Page 274 - Critical Care Nursing Demystified

Chapter 5 CARE OF THE PATIENT WITH NEUROLOGICAL NEEDS 259

CASE STUDYY
C A S E S T UD
5 An 84-year-old pleasantly smiling female arrives independently to the Emer-
gency Room with the chief complaints of “double vision, severe and worsening
headache for 1 week.” She is awake, alert, and admits to no recent falls or injuries. She
has been taking antihypertensive medications for the past 20 years. Vital signs are T:
100, P: 84, R: 16, and BP: 150/80. Within minutes of her initial assessment, the patient’s
condition begins to rapidly decline. Vital signs are now T: 101.8, P: 70, R: 12, and BP:
210/60. The patient’s gaze is now dysconjugate and verbal responses to questions
and commands are nonexistent. Vital signs indicate Cushing’s triad, with a widening
pulse pressure of 150. Her daughter arrives and provides the information that 1 week
ago, as her mother was cleaning a chandelier, she fell off of her dining room table
and struck her head on a corner of the table.

QUESTIONS
What additional nursing considerations and interventions would be indicated
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