(page 325, Signs and Symptoms: A 2-in-1 Reference for Nurses
under the listing for "headache")
"In some patients, intracerebral hemorrhage produces a severe generalized headache. Signs and symptoms vary with the size and location of the hemorrhage. A large hemorrhage may produce a rapid, steady decrease in LOC, perhaps resulting in coma. Other common findings include hemiplegia, hemiparesis, abnormal pupil size and response, aphasia, dizziness, nausea, vomiting, seizures, decreased sensation, irregular respirations, positive Babinski's reflex, decorticate or decerebrate posture, and increased blood pressure."
(page 400, Signs and Symptoms: A 2-in-1 Reference for Nurses
under the listing for "decreased level of consciousness")
"Intracerebral hemorrhage, a life-threatening disorder, produces a rapid, steady loss of consciousness within hours, commonly accompanied by severe headache, dizziness, nausea, and vomiting. Associated signs and symptoms vary and may include increased blood pressure, irregular respirations, Babinski's reflex, seizures, aphasia, decreased sensations, hemiplegia, decorticate or decerebrate posture, and dilated pupils."
The patient should be evaluated by the Glasgow Coma Scale on a regular ongoing basis. I would say that keeping the HOB elevated at all times is an arbitrary thing and only absolutely necessary if the patient starts to show signs of a decreasing level of consciousness. You can certainly keep his head elevated while you are on duty and caring for him if you like. I don't see that it would cause any harm. However, for care planning purposes I would write a nursing intervention to observe this patient for the signs and symptoms that are listed in the above information. The minute this patient shows any evidence of drowsiness, somnolence or stupor I would get his head elevated. You might amend your order to say: HOB up 30 degrees at all times if patient becomes drowsy, somnolent, stuporous or has a Glasgow Coma Scale score of 7 or below and cannot be aroused.
The emergency actions listed for decreased level of consciousness are
- keep the airway open
- elevate the head of the bed 30 degrees
- turn the head to the side if there is no spinal injury
- prepare to suction airway and support breathing