HESI Patient Review 6 Micheal Dunne PDF

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HESI Patient Review: Adult Health – Neurological Health Problems – Michael Dunne (29-year-old man on a neurology unit with head injury) You are a nurse working the evening shift on a Neurology Unit. You make rounds on your patients after receiving report. One of your patients is 29-year-old Michael Dunne. He was brought to the Emergency Department (ED) after being hit on the right side of the head with a baseball. He had "blacked out" for about a minute. On awakening, he complained of dizziness. Mr. Dunne has just arrived from the Emergency Department (ED). His admitting diagnosis is traumatic head injury with concussion, and scalp laceration. In the ED, the scalp laceration was closed with 12 sutures. Skull xrays are negative for fracture. The CT results indicated some minor swelling on the right side. Glasgow Coma Scale (GCS) score, as reported on the ED Transfer Note, is 14, with disorientation to time and place. During your rounds, you briefly assess Mr. Dunne. You make sure Mr. Dunne's bed is in the low position. Mr. Dunne's drowsy state makes it easy for him to fall out of bed. 

You recall what you know about a concussion. Which of the following best describes this type of head injury? o Movement of brain tissue in the skull  A concussion is a closed head injury, and is usually a result of blunt impact to the head. Damage occurs to brain tissue as it bounces, twists, and/or turns within the skull. Depending on the severity of impact, damage may be mild and symptoms may be temporary, or damage may be severe and symptoms may be persistent. A transient loss of unconsciousness or "dazed" appearance typically follows. Memory loss of events preceding the injury (retrograde amnesia) and following the injury (anterograde amnesia) is common. o Tearing of brain tissue with intracerebral bleeding  An intracranial laceration, not a concussion, involves tearing of brain tissue. It usually is a result of a penetrating head injury, such as from a bullet. It often leads to intracerebral bleeding. o Collection of blood between the dura mater and arachnoid mater  A subdural hematoma, not a concussion, is a collection of blood in the subdural space between the dura mater and the arachnoid layer of the meningeal covering of the brain. A subdural hematoma can be a consequence of a closed head injury or a penetrating head injury. It is usually a result of a venous bleed and therefore is slow to develop into a large mass. Injury resulting in subdural hematoma can be life-threatening because of mass effect on brain tissue and rise in intracranial pressure. o Collection of blood between the dura mater and the skull  An epidural hematoma, not a concussion, is a collection of blood between the dura mater and the skull. An epidural hematoma can be a consequence of a closed head injury or a penetrating head injury. Bleeding is usually arterial, but can be venous. If arterial, the hematoma develops rapidly. Patients often present unconscious, although a brief "lucid interval" often occurs after the head injury and lasts about a minute. This is followed by a decrease in level of consciousness and progression to coma. Injury resulting in epidural hematoma can be life-threatening because of mass effect on brain tissue and rise in intracranial pressure. Prompt surgical intervention is needed.

Mr. Dunne has been hospitalized for observation, to ensure that his condition stabilizes and his injuries are not more serious. Throughout his stay, his condition will be closely monitored. 

You will work on Mr. Dunne's plan of care later. Right now, you make a mental note of problems applicable to Mr. Dunne at this time. These include: o Risk for Injury

a traumatic head injury with scalp laceration and brain concussion. He is drowsy and disoriented. Mr. Dunne is at Risk for Injury due to his drowsy state and disorientation associated with his head injury. Nursing measures are indicated to insure Mr. Dunne is safe and does not sustain injuries. Frequent observation and assessment and keeping the bed in the low position are important. Activity Intolerance  Because of his head injury, Mr. Dunne's activity will be restricted for at least a few days. His ability or inability to tolerate activity is not a consideration at this time. Impaired Skin Integrity  The laceration should be kept clean and protected from injury and should be checked for signs of infection. Impaired Home Maintenance 

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The primary focus of your care with Mr. Dunne involves safety measures and observation. After head injury, observation for signs of increased intracranial pressure (ICP) is critical. 

You will be especially alert for any signs of increased intracranial pressure (ICP) when caring for Mr. Dunne. After head injury, if ICP increases, the increase is usually a result of: o Inflammation  Tissue injury causes inflammation, with increased capillary permeability and movement of fluid into the affected area. The skull is a non-compliant cavity filled to capacity with brain, blood, and cerebrospinal fluid. Anything that increases volume or mass within the cavity can cause intracranial pressure (ICP) to increase. o Infection  can increase secondary to infection. However, infection is not common after head injury. o bleeding  Bleeding associated with head injury can increase the volume of the contents of the closed cranial cavity, increasing intracranial pressure (ICP). The skull is a non-compliant cavity filled to capacity with brain, blood, and cerebrospinal fluid. Anything that increases volume or mass within the cavity can cause ICP to increase. o cerebral ischemia  does not increase secondary to cerebral ischemia, although ICP can affect cerebral blood flow. o cerebral infarction  does not increase secondary to brain infarction. Brain infarction (tissue necrosis) usually is not associated with head injury.

Head injury, the direct result of trauma, damages the brain. Secondary brain injury can occur as a result of increased intracranial pressure (ICP), and problems it can cause, such as cerebral ischemia. Measures to avoid increases in ICP are critical. Assessments for early detection of increasing ICP are also critical. Increased pressure on delicate cerebral cells, and cerebral ischemia, can interfere with cerebral function and result in neurologic deficits that can be observed. After your brief rounds, you note in Mr. Dunne's medical record that hourly neuro checks are ordered. Frequent neuro checks are designed to quickly identify changes that might indicate increasing ICP or alterations in brain function. The neuro check protocol you follow includes assessment of vital signs, level of consciousness, pupil reaction to light, and motor strength. 

To insure early recognition of increased intracranial pressure (ICP), which of the following assessments is MOST IMPORTANT? o Vital signs

Breathing pattern, heart rhythm, and blood pressure changes occur with neurological deterioration. Although vital signs should be frequently monitored in all patients with head injury, another assessment is more critical in detecting early increases in intracranial pressure (ICP). Level of consciousness  A decreasing level of consciousness (LOC) is often the first indication that intracranial pressure (ICP) is increasing. Level of consciousness, or arousability, is a state of awakeness and ability to interact with the environment. Level of consciousness is optimal when cerebral metabolism and cerebral blood flow are normal. When cerebral metabolism or cerebral blood flow are not normal, neurological deterioration occurs, and level of consciousness decreases. Decreasing level of consciousness is the best indicator of neurological deterioration. Pupil reaction to light Motor strength 

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The Glasgow Coma Scale (GCS) is one source of data regarding level of consciousness. Use of the Glasgow Coma Scale (GCS) allows for standardized neurological assessment and reporting of arousal and awareness. Serial assessments allow for identification of subtle changes over time. Scoring with the Glasgow Coma Scale (GCS) is on a scale of 3 to 15. A Glasgow Coma Scale (GCS) score of 15 is normal and suggests that the brain is fully functioning. It indicates that a person's eyes open spontaneously, he is alert and oriented, and is able to physically respond appropriately to verbal commands. The Glasgow Coma Scale (GCS) should be used in conjunction with other neurological examinations. The Glasgow Coma Scale (GCS) is not sensitive for evaluation of altered sensorium or focal or lateral neurologic deficits. Many patients with a high Glasgow Coma Scale (GCS) score have serious brain damage requiring intervention. Astute, ongoing assessment of Mr. Dunne is critical. Neurologic deterioration with onset of symptoms could happen quickly. To determine Mr. Dunne's best verbal response using the Glasgow Coma Scale, you assess his orientation. The nurse in the Emergency Department (ED) reported that Mr. Dunne was disoriented to time and place. From this you infer that he remained oriented to person. Orientation is assessed by evaluating a person's ability to respond appropriately to questions about who he is (orientation to person), where he is (orientation to place), and what time it is (orientation to time). When orientation is documented, the status of each should be noted, although often only negative findings are mentioned, and positive findings are inferred. Often, with deteriorating mental function, orientation to time is lost first, followed by orientation to place, and finally, disorientation to person occurs. Mr. Dunne's first name is Michael, but everyone calls him Mickey. When you call him by this name he turns to you. However, when you ask him his name, his response, though accurate, is slurred. Initially, Mickey does not know where he is, but after some leading questions, he does answer correctly. He does not know the time of day.Using the Glasgow Coma Scale, you assign Mickey a score of 4 out of 5 for his verbal response (confused conversation). Mickey is not fully alert. His level of consciousness is decreased. Although Mickey is arousable, he is drowsy. Also, he is not fully oriented to time, place, and person. Mickey is best described as being lethargic (abnormally drowsy). Stupor is characterized by confusion in a patient who is responsive only to repeated stimulation and who otherwise remains in a deep sleep. Mickey, although not fully oriented, is easily arousable. A semi-comatose state is characterized by the absence of verbal responses and inappropriate responses to painful stimuli. 

Mickey has slurred speech. Mickey's slurred speech indicates that: o aphasia is present  Aphasia is not characterized by slurred speech. Aphasia, an inability to communicate, can be expressive or receptive. In expressive aphasia, a patient cannot identify the words with which

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to express himself verbally and/or in writing. In receptive or sensory aphasia, a patient cannot understand written and/or spoken words. Mickey's thought processes are not normal  Mickey's thought processes may or may not be impaired. Mickey has altered perception  Perception involves interpretation, not expression. Broca's motor speech area of the brain is affected  Slurred speech occurs secondary to Broca's motor speech area of the brain being affected. It can be a sign of increasing intracranial pressure (ICP).

You assess Mickey's motor response bilaterally. He is able to follow your verbal commands and move as directed without difficulty, although his responses are slow. He is able to localize pain. You continue with your assessment of Mickey. You test his muscle strength by having him push his extremities against your hands. You note significant weakness on Mickey's left side. This is a new finding. As you prepare to check Mickey's eyes, he complains of a dull headache. This is also a new finding. 

What should you do? o Report Mickey's headache to the physician stat  While the onset of Mickey's headache is significant and should be reported, it would be more appropriate to complete your neurological assessments before contacting the physician. o Complete Mickey's neuro assessment by checking his eyes  should be completed before contacting the physician. Data provided through pupil assessment is important in evaluating neurological status.

You observe Mickey's eye-opening ability. Mickey spontaneously opens his eyes. 

You also examine Mickey's pupils. You check for pupil reaction to light. In preparing for this, you do which of the following? o Place Mickey in the Trendelenburg position  this position would be unsafe! Intracranial pressure (ICP) would increase with Mickey in the Trendelenburg position! o Dim the lights in Mickey's room  After the lights are dimmed, a bright light should be directed into the eye. The normal response is brisk pupil constriction in response to light. Each eye should be checked separately. Pupils should be equal in size and react to light at the same, quick rate. Mickey's pupils are equal in size and react equally to light with constriction. o Increase the lighting in Mickey's room o Instill fluorescein stain into the conjunctival sac of Mickey's right eye o Plan to check pupil response to light in Mickey's right eye only

You notify the physician about Mickey's slow motor responses and weakness on the left side, and onset of headache. He will see Mickey shortly. 

Mickey's wife, who has just arrived, asks if the physician will order some medication for Mickey's headache. You advise her that: o the physician will probably prescribe a strong narcotic analgesic to help alleviate Mickey's headache o the physician may order a mild analgesic such as acetaminophen to help alleviate Mickey's headache  The physician might order a mild analgesic to alleviate Mickey's headache pain. Narcotics would not be ordered. They could mask signs and symptoms that are important indicators of neurological status.

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o Mickey will probably have a headache for a few weeks It is apparent that Mickey's condition is subtly changing. Which of the following nursing measures is indicated? o Make sure the head of Mickey's bed is elevated  Mickey is exhibiting signs and symptoms of increased intracranial pressure (ICP). The head of his bed should be elevated to promote venous outflow from the brain and help minimize ICP. Head of bed elevation at 30-45 degrees is generally recommended. o Apply soft restraints on Mickey's wrists  would not be wise and is not indicated. If Mickey fought the restraints, this could result in an increase in ICP. This should be avoided. o Ask Mickey to void  Although a distended bladder can increase ICP, it is unlikely that asking Mickey to void would reduce ICP. o Encourage Mickey to stay awake and talk with his wife  Encouraging Mickey to stay awake would not reduce ICP. Onset of left-side weakness in Mickey suggests: o an undiagnosed head injury in the left side of his brain  A head injury in the left side of the brain would cause right-side paresis, not left-side paresis. Motor function, when impaired, usually occurs contralateral to brain injury. Motor function impairment may involve hemiparesis (weakness) or hemiplegia (paralysis). It would not be unusual for a person to develop hemiparesis or hemiplegia on his left side as a consequence of a right-side head injury. o a concurrent spinal cord injury  Motor function can be impaired as a consequence of brain or spinal cord injuries. Hemiparesis or hemiplegia can occur without injury to the spinal cord. There is no evidence of spinal cord injury. o expanding injury to the right side of the brain  Motor function, when impaired, usually occurs contralateral (on the opposite side) to brain injury. Motor function impairment may involve hemiparesis (weakness) or hemiplegia (paralysis). An expanding hematoma, a consequence of right-head trauma, could result in progressive weakness and paralysis on the left side. o injury to the muscles on the left side of his body

The physician arrives and performs a thorough neurological assessment on Mickey. 

Among other findings, the physician determines that pupil response to light is not normal in one of Mickey's eyes. Pupil changes that happen as a result of brain injury occur ______________ to the site of brain injury. o Ipsilateral  Pupil changes that happen as a result of brain injury occur ipsilateral (on the same side) to the site of brain injury. The oculomotor, or third cranial nerve, controls pupil response. o Contralateral  Pupil changes that happen as a result of brain injury do not occur contralateral (on the opposite side) to the site of brain injury.

Mickey's right pupil is 6 mm in size compared with his left, which is 3 mm. His left pupil reacts quickly to light while his right pupil reacts sluggishly to light. A pupil size of 4 mm is usually normal. Pupil size larger than 5 mm may be abnormal (dilated). Pupil size smaller than 3 mm may be abnormal (constricted). The physician suspects that Mickey has an expanding hematoma secondary to a brain contusion. He orders a stat computed tomography (CT) scan to confirm the diagnosis and pinpoint the location of the hematoma. You stay at Mickey's bedside, monitoring his status continuously. You take Mickey's temperature, knowing that temperature regulation may not be normal because of Mickey's increasing intracranial pressure (ICP).

Increased pressure on the hypothalamus may interfere with Mickey's ability to maintain a normal body temperature. Mickey's temperature is 99.7 degrees F (37.6 degrees C). You remain alert for temperature elevations. Cerebral metabolic demand increases rapidly with temperature elevations. You recheck Mickey's pulse and blood pressure, which you've been monitoring frequently. A gradual increase in Mickey's pulse rate and blood pressure is apparent. 

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You know that these changes in vital signs (gradual increase in pulse rate and blood pressure) reflect: o early compensatory mechanisms in response to increased intracranial pressure (ICP)  With an elevated intracranial pressure (ICP), cerebral perfusion is initially increased. As ICP increases, cerebral perfusion decreases. Tachycardia and a rising systolic blood pressure occur as compensatory mechanisms aimed at maintaining cerebral perfusion. If increased intracranial pressure persists, compensatory mechanisms will begin to fail. As the intracranial pressure increases, the client will exhibit irregular respirations (Cheyne-Stokes), bradycardia and a widening pulse pressure (Cushing's triad). The widening pulse pressure usually occurs because the systolic pressure elevates, while the diastolic is unaffected. o failure of compensatory mechanisms in response to increased intracranial pressure (ICP)  If increased intracranial pressure persists, compensatory mechanisms will begin to fail. As the intracranial pressure increases, the client will exhibit irregular respirations (Cheyne-Stokes), bradycardia and a widening pulse pressure (Cushing's triad). The widening pulse pressure usually occurs because the systolic pressure elevates, while the diastolic is unaffected. o abnormal sympathetic nervous system responses to increased intracranial pressure (ICP)  Tachycardia and a rising systolic blood pressure occur as normal, not abnormal, compensatory sympathetic nervous system responses when intracranial pressure (ICP) increases. o abnormal parasympathetic nervous system responses to increased intracranial pressure (ICP)  Tachycardia and a rising systolic blood pressure occur as normal sympathetic, not parasympathetic, nervous system responses when intracranial pressure (ICP) increases. You are careful to avoid unnecessary increases in Mickey's intracranial pressure (ICP). Which of the following nursing interventions are aimed at preventing/controlling increases in ICP? o Maintaining head of bed elevation  head elevated should promote cerebral venous outflow and help decrease intracranial pressure (ICP). ...