A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A. Count the rate to be sure the ventilations are deep enough to be sufficient.
B. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.
C. Call the physician to adjust the ventilator settings.
D. Check deep tendon reflexes to determine the best motor response.
Correct Answer: B. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.
Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease.
Option A: Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Changes in blood pressure, compare BP readings in both arms. Respirations, noting patterns and rhythm (periods of apnea after hyperventilation), Cheyne-Stokes respiration. Irregularities can suggest location of cerebral insult or increasing ICP and need for further intervention, including possible respiratory support.
Option C: Maintain bedrest, provide a quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures. Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.
Option D: Checking deep tendon reflexes is one part of the GCS analysis. Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity. Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP or cerebral injury, requiring further evaluation and intervention.
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