A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take?

Question

A client with blunt head injury is admitted for observation, including hourly neurologic checks.  At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen.  At 02:00 AM, the client appears to be sleeping.  Which action should the nurse take?

Quizplus · Accepted Answer

Serial neurologic assessments are important as neurologic abnormalities are often initially subtle, making it important to note the trend. Interventions for neurologic issues are most effective when made early. A neurologic assessment includes: Glasgow Coma Scale (GCS)-best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive). Pupils-equal, round, response to light, and accommodate (PERRLA) Motor-strength and movement in all four extremities Vital signs-especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP). This client is not admitted in the hospital to get a good night sleep. The client is admitted due to the need for serial neurologic assessments by a professional nurse, and that is the priority. (Option B) Although pain relief has probably been achieved, this option does not reflect any neurologic assessment. One of the early signs of increased ICP is change in level of consciousness. This option does not assess the client's arousability. (Option C) Checking the respiratory rate and characteristics is part of the neurologic assessment. However, this alone is insufficient for assessing a neurologic status after a blunt head injury. (Option D) It is good to awaken the client, but paresthesia is part of a neurovascular assessment. Neurovascular assessment, commonly known as the 5 Ps, consists of paresthesia, pain, pallor, paralysis, and pulselessness. A neurovascular assessment is used when circulation is a primary concern. It is not the primary neurologic assessment needed in a closed head injury. Educational objective: Clients must be awakened for a prescribed, necessary neurologic assessment. A neurologic assessment consists of GCS, PERRLA, movement and strength of the extremities, and vital signs.

A Client with Blunt Head Injury Is Admitted for Observation