NURS 4700 Case study Head Injury
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NURS 4700 Case study Head Injury
NURS 4700
Lesson #9
Head Injury, Stress and Adaptation
In Class Learning Patient Care Scenario:
Meet your patient J.R.
NURS 4700 Case study Head Injury
J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a large rock. He experienced 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 (ED) 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.
- Describe the term primary head injury
- Describe a secondary head injury
- What steps should you take to assess J.R.?
- List at least five components of a neurologic examination
- What is the most sensitive indicator of neurologic change?
NURS 4700 Case study Head Injury
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Case study progress
You complete your neurologic examination and find the following: Glasgow Coma Scale (GCS) 15; pupils equal, round, react to light (PERRL); and full sensation intact. J.R. complains of (c/o) a headache and is becoming increasingly drowsy. As the radiology technician performs a portable lateral cervical spine (C-spine) x-ray, J.R. begins to speak incoherently and appears to drift off to sleep.
- What is the next action you would take?
NURS 4700 Case study Head Injury
Case study progress
You find J.R. has become unresponsive to verbal stimuli and responds to painful stimuli by abnormally flexing his extremities (decorticate movement). He has no verbal response. The right pupil is larger than the left and does not respond to light.
- What is J.R.’s GCS score at this time? Indicate what this means.
- Based on his GCS score, what are the next steps you should take? The physician already has been summoned.
- What is a normal ICP, and why is increased ICP so clinically important?
- Identify at least five signs and symptoms (S/S) of increased ICP
- The physician orders a 25% mannitol solution IV. What is mannitol, and why is it being used on J. R.?
NURS 4700 Case study Head Injury
Case study progress
- R. is transported to radiology for a CT, where he is found to have a large epidural hematoma on the right with a hemispheric shift to the left. He will be taken straight to the operating room (OR) for evacuation of the hematoma. While en route from the CT scan to the OR, the physician instructs the respiratory therapist to initiate hyperventilation of the patient to “blow off more CO2”
- What is the rationale for this action?
- What nursing interventions are important when caring for a patient with increased ICP?
- After J. R.’s surgery he is admitted to the ICU. List four medication classifications that the ICU nurse could use to decrease or control increased ICP.
- Jennet et al. (1981, as cited in Kneafsey & Gawthorpe, 2004) state “…psychological and psychiatric problems exceed physical problems as causes of morbidity and disability following acquired brain injury, and frequently remain unrecognized and untreated…” (p. 604). Outline some of the known long term consequences of head injury.
- Life after a head injury has been shown to be stressful for the caregiver and the individual who has sustained the head injury. What are some general strategies for coping with stress?
NURS 4700 Case study Head Injury
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