Assignment
Scenario
J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot (1.8 metres) stepladder, striking his head on a rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.
I. What steps will you take to assess J.R.?
II. List at least 6 components of a neurologic examination.
III. What types of injuries may J.R. have sustained?
IV. Differentiate between primary and secondary head injury.
V. What complication common to each of these diagnoses concerns you most?
VI. Why is this complication clinically important?
VII. Name at least 6 findings that would indicate this complication is occurring.
VIII. Which one is the most sensitive indicator of neurologic change?
CASE STUDY PROGRESS
You complete your neurologic examination and find the following: Glasgow Coma Scale (GCS) score of 15; pupils equal, round, reactive to light; and full sensation intact. J.R. complains of a headache and is somewhat drowsy. His vital signs are 120/72, 114, 30, 98.7° F (37.1° C), and Spo2 94%. As the radiology technician performs a portable cross-table lateral cervical spine x-ray examination, J.R. begins to speak incoherently and appears to drift off to sleep.
I. What are the next actions you will take?
CASE STUDY PROGRESS
While waiting for the provider to arrive, J.R. becomes unresponsive to verbal stimuli. The right pupil is larger than the left and does not respond to light. J.R. responds to painful stimuli in the manner shown in the illustration.
I. What is this response called and what does it signify?
II. Calculate J.R.'s GCS score. Describe the clinical implications of this score.
III. What is the most likely cause of the change in J.R.'s neurologic status?
IV. What are your immediate nursing priorities?
V. What immediate actions will you take?
VI. His vital signs are now 160/72, 64, 10, 98.7° F (37.1° C), and Spo2 94%. What is your concern and why?
CASE STUDY PROGRESS
The provider arrives and gives the orders shown in the chart.
Chart View
Physician's Orders
Insert indwelling urinary catheter
Insert nasogastric tube to continuous low wall suction
Intubate: Vent settings assist-control 16, VT 900 mL, Fio2 0.5, PEEP (positive end-expiratory pressure) 3 cm
IV fluid 0.9% normal saline at 100 mL/hr
160 grams Mannitol IV STAT over 30 minutes
Phenytoin 1360 mg IV STAT over 30 minutes, then 100 mg IV every 8 hours
STAT CT scan
STAT labs: CBC, CMP, UA, type and cross, PT/INR and PTT, ABGs, toxicology screen
I. Outline a plan for implementing these orders.
II. What is mannitol, and why is it being given to J.R.?
III. What is the expected outcome associated with administering phenytoin to J.R.?
CASE STUDY PROGRESS
J.R. goes to radiology for a CT scan, which shows a large epidural hematoma on the right with a hemispheric shift to the left. He is taken straight to the operating room for evacuation of the hematoma. While he is in surgery, J.R.'s family arrives with their chaplain. They ask if they can anoint J.R. and pray over him.
I. How should you respond?
CASE STUDY PROGRESS
Postoperatively J.R. is admitted to the neurologic ICU.
I. What assessment indicators will be closely monitored in J.R.?
II. An appropriate nursing intervention for J.R. to promote cerebral tissue perfusion is:
i. Avoiding passive range-of-motion exercisesb. Repositioning him every 4 to 6 hours, using logrollingc. Limiting endotracheal suctioning to no longer than 15 secondsd. Clustering nursing activities so he has periods of uninterrupted rest
III. The best way to position J.R. is to:
i. Elevate the head of the bed to 30 degrees.
ii. Keep him flat with his hips slightly flexed.
iii. Place him on the right side with his head flexed.
iv. Turn his head from side-to-side to decrease aspiration risk.
IV. Name 4 independent nursing interventions that would be used to control environmental stimuli during the first 48 postoperative hours.
V. What measures will be used to prevent J.R. from developing hyperthermia? Why are these important?
VI. What outcome criteria would determine whether the independent nursing measures for J.R. were effective?