Head Trauma Case Study NUR 401

Scenario: 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 a momentary loss of consciousness. By the time his neighbor ...

Scenario: 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 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. ⦁ What steps will you take to assess J.R.? ⦁ First I would assess his airway to make sure it is patent and nothing is prohibiting him from getting air in ⦁ The I would assess his breathing to see if he is in distress, listen to lung sounds, count respirations, and assess chest expansion ⦁ Check Circulation assessing blood loss from laceration, by feeling for pulses, cap refill, checking for cyanosis and checking BP ⦁ Lastly I would perform Glasgow coma scale to assess LOC ⦁ List at least five components of a neurologic examination. ⦁ Level on consciousness ⦁ Motor function ⦁ Pupillary function ⦁ Respiratory function ⦁ Vital signs ⦁ What types of injuries may J.R. have sustained? ⦁ Due to blunt trauma from J.R. falling from a ladder and hitting his head on a rock he may have sustained some type of traumatic brain injury such as skull fracture, concussion, contusion, or cerebral hematoma. ⦁ What complication is common to each of these diagnoses (listed in #3) concerns you most? ⦁ These injuries run the risk of increasing intracranial pressure ⦁ Identify at least six findings that would indicate this complication (listed in #4) is occurring. ⦁ Changes in LOC ⦁ Changes in speech ⦁ Vomiting ⦁ Changes in vitals: increased SBP, decreased pulse, decreased respirations ⦁ Headache ⦁ Changes in pupillary functions: impaired eye movements, papilledema ⦁ What is the most sensitive indicator of neurologic change? ⦁ The most sensitive indicator of neurologic change would be a change in level of consciousness. This is because a patients level of consciousness deteriorates before any other neuro changes are noticed. Case Study Progression 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 (VS) 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. ⦁ What are the next actions you will take? ⦁ My next action would be to try to arouse/ wake up J.R. Next I would reassess J.R. by repeating GCS and vital signs. I would also assess for the oculocephalic reflex to see if J.R. is experiencing some brainstem injury. Case Study Progression While waiting for the physician to arrive, you find that J.R. has become 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. ⦁ What is this response called and what does it signify? ⦁ The position is known as decerebrate posturing. ⦁ Decerebrate occurs when there is a lesion on the brainstem this signifies that there is severe brain damage present. ⦁ Calculate J.R.'s GCS score. Describe the clinical implications of this score. ⦁ Glasgow coma scale is a tool used for assessing level of consciousness. This score is based on eye opening, verbal response and best motor response. Lowest score to attain is 3 which signifies that patient is incompetent and in a coma , the highest score is 15. ⦁ J.R. has a GCS of 4. This is because he got 1 for eye opening response due to no eye opening regardless of stimulation; 1 for verbal response due to no verbalization despite stimulation; 2 for best motor response due to decerebrate posturing in response to noxious stimuli. ⦁ What is the likely cause