Hinkle CSA Ch 68 - Ch review - Brunner and Suddarth\'s Textbook of Medical-Surgical Nursing PDF

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Suggested Answers to Case Study, Chapter 68, Management of Patients With Neurologic Trauma

1a. What do the assessment findings suggest? The symptoms suggest a traumatic brain injury and, more specifically, an epidural hemorrhage. The increased intracranial pressure from the arterial bleed causes the quick changes in the neurologic status. 1b. What signs and symptoms do the patient exhibit related to increased intracranial pressure?      

Altered level of consciousness: coma state as reflected by the Glasgow Coma Scale (GCS) of 8 Projectile vomiting Widening pulse pressure Bradycardia as reflected by the heart rate Hyperthermia as reflected by the temperature Unequal pupils

1c. What medical and surgical treatment does the nurse anticipate for the patient?  

CT scan without contrast to locate the bleed and then the patient will be taken to the operating room quickly to evacuate and stop the hemorrhage and decrease the increasing intracranial pressure. Draw labs stat as ordered: CBC, coagulation profile, renal/metabolic profile, type and cross, ETOH level.

1d. What GCS did the patient have initially at the scene of the accident? What GCS did the patient have when he began deteriorating neurologically? GCS = 15 initially E- 2, V-2, M-4 = 8 is the score when the patient began deteriorating neurologically. 1e. What nursing interventions should the nurse provide?

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Maintain a patent airway. Monitor for further changes in the neurologic status and cranial nerve deficits, vital signs, and GCS. Institute measures to decrease intracranial pressure.

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Provide seizure precautions.

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2a. What clinical management should the nurse anticipate for the patient? 

Atropine is provided IVP to speed up the heart rate and increase the cardiac output. The goal is to keep the heart rate at 60 to 100 bpm.

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Large volumes of fluids—normal saline—are used to restore hemodynamic stability. Vasopressors, such as norepinephrine, are used as a titrated IV drip to keep the systolic blood pressure in the range of 90 to 100 mm Hg. Treat the paralytic ileus with a nasogastric tube to decompress the stomach and to prevent risk for aspiration while the patient is in neurogenic shock and ileus is common. Monitor for neurogenic bladder. Assess for urinary retention and bladder overdistension Treat the underlying cause, which is the spinal cord injury, through mobilization and decompression of the spinal cord injury. Methylprednisolone is used to decrease inflammation. Maintain skin integrity.

2b. What are signs that the neurogenic shock is resolving?   

Return of reflexes Development of hyperreflexia instead of flaccidity Return of ability to empty bladder, which depends on the level of the injury...