What is the nursing priority when caring for a client with severe hemiplegia and fixed, dilated pupils due to a gunshot wound?

In the context of caring for a client with severe hemiplegia and fixed, dilated pupils due to a gunshot wound, monitoring respiratory rate is crucial. This condition suggests significant neurological compromise, potentially affecting brain areas responsible for autonomic functions, including breathing.

After a gunshot wound, there may be swelling or damage to the brain, which could lead to respiratory failure if the areas controlling respiratory drive are impacted. Fixed and dilated pupils are typically indicative of increased intracranial pressure or severe brain injury, both conditions that may affect the client’s ability to maintain adequate ventilation. Therefore, vigilance in monitoring the respiratory rate is essential, as any deterioration in breathing could quickly lead to inadequate oxygenation and potentially life-threatening complications.

While monitoring blood pressure, assessing the level of consciousness, and checking limb mobility are also important nursing assessments in caring for such a client, they do not take precedence over ensuring respiratory function. A compromised respiratory rate can significantly affect other bodily systems, making it the priority in urgent care settings.