An elderly client with mild dementia and confusion has sustained an unwitnessed fall. The nurse is...

An elderly client with mild dementia and confusion has sustained an unwitnessed fall. The nurse is performing hourly neuro check as ordered by the provider. Which of these findings should be reported to the charge nurse immediately?

1. A change in BP 125/75 to 118/86

2. A glasgow coma scale of 14

3. A New onset of lethargy

4. Pupil size of 4 mm in both eyes

Expert Solution

Answer. Option 1. A Change BP 125/75 to 118/86

Option 1 is correct as Change BP 125/75 to 118/86 indicates the drop in blood pressure after the fall. This hypo-tension in older adults or elderly patient dementia and confusion indicates the lack of adequate blood supply t the brain and this can cause serious conditions leading to neural issues, functional issues, reduced cardiac output, weakness, etc. The drop in blood pressure gives us empirical evidence of the findings should be reported to the charge nurse immediately suggesting a serious change in health condition of the older adult.

Option 2 is incorrect as glasgow coma scale of 14 correlates to a normal reading in the person and the person is safe and fine without coma

Option 3 is incorrect as new onset of lethargy can indicate change in health condition but the evidence in especially older adults cannot be quantified and directly linked to the neuro check parameters and hence as compared to drop in blood pressure in option 1, this option does not have the impact reporting criteria

Option 4 is incorrect as Pupil size of 4 mm in both eyes 2.5 - 5.0 mm in diameter and the size of 4mm is normal and does not need to be reported.

Nightingale answered 1 year ago

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