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1. Check for pupil size and reaction Pinpoint and noresponsive pupils
to light (penlight). Pupils that fixed (nonreactive) and
dilated pupils (poor prognostic
sign)
Ovoid pupil- midstage between
normal and dilated pupil size
Uneven pupils
Loss of light reaction
GASTROINTESTINAL o Constipation
1. Inspect the abdomen for Projectile vomiting o Imbalance nutrition
distention Constipation less than body
2. Auscultate bowel sounds Bowel incontinence requirements
Paralytic ileus
INTEGUMENTARY Pressure ulcers o risk for impaired skin
1. Inspect the skin integrity integrity
and character.
GENITOURINARY
1. Record Intake and output Urinary incontinence