A client is admitted with signs of a stroke (CVA). On admission, vital signs were: blood pressure 128/70, pulse 68, and respirations 20, pupils equal and reactive, client awake and responding to verbal stimuli
Two hours later the client is not awake but is easily aroused, has a blood pressure of 140/70, pulse 52, respirations 18, and the left pupil is now slower than the right pupil in reacting to light. These findings are a result of: 1. Increased intracranial pressure.
2. Impending brain death.
3. Reperfusion injury.
4. Normal stabilization poststroke.
Increased intracranial pressure.
Rationale: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP) and require notification of the health care provider. The most current assessment findings indicate that the client's condition is becoming more unstable. Brain death is diagnosed by lack of brain waves and inability to maintain vital function. Reperfusion injury results in further injury to already damaged tissue that is compromised, and may be seen most often with thrombolytic therapy.
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