A client with a right temporal lobe lesion is displaying Cheyne-Stokes respirations. The nurse recognizes:
1. This client requires surgical decompression of the brain.
2. There is no medical treatment appropriate for this symptomology.
3. The next likely sign will be sluggish pupil reaction ipsilaterally.
4. This type of brain pathophysiology is usually self-limiting.
This client requires surgical decompression of the brain.
Rationale: This client is experiencing a symptom of uncal herniation. Late signs include altered respiratory patterns, such as Cheyne-Stokes respirations. Urgent surgical intervention to decompress the brain is often the treatment of choice. Often, the first sign of impending uncal herniation is a sluggishly reactive pupil on the ipsilateral (same) side of the lesion. Herniation syndromes are life-threatening neurological emergencies that, left untreated, can progress rapidly to death.
Step of the Nursing Process: Assessment
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