The client is hypotensive, so the nurse assesses the client's craniotomy dressing; it is dry and intact. The nurse turns the client and sees that the pad under the client is soaked with blood
Choose suitable nursing interventions and rank them in order. 1. Lower head of the bed.
2. Apply pressure to the site.
3. Increase intravenous fluids.
4. Assess remaining vital signs.
5. Increase supplemental oxygen.
6. Perform neurological assessment.
3, 4, 5, 6
3. Because the client is hypotensive, suitable nursing interventions include increasing IV fluids to restore perfusion, especially important after a craniotomy, to maintain cerebral perfusion.
4. The nurse completes the remaining vital signs because they reveal important supplementary information about the cardiovascular, respiratory, and neurological status of the client.
5. Increasing supplemental oxygen is a suitable nursing response to hypotension with bleeding because the system is hypoxic from loss of oxygen-carrying capacity of the blood.
6. A neurological assessment is important to compare with baseline data and evaluate the degree of intracranial pressure and cerebral function.
1. The nurse avoids lowering the head of the bed in the face of hypotension for a client after a craniotomy because increased intracranial pressure is a postoperative risk. If the increase in intracranial pressure is excessive, the brain can herniate and lead to client death.
2. Applying pressure to the bone flap of the craniotomy can lead to impaired cerebral perfusion and stroke.
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