John Wiggins - Concepts of Nursing III PDF

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Concepts of Nursing III...

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John Wiggins Room 301 John Wiggins, age 36, has been admitted for a possible concussion from an ATV rollover without a helmet three days ago. He is alert and cooperative but does complain of a consistent headache and nausea. Upon admission, he had a blood-alcohol level of 0.09. His vital signs are normal and are being taken with Neuro checks q 2 hours. His Glasgow coma scale is 15. He admits to drinking a 6-pack of beer a day. Category Intracranial regulation Sensory perception Cognition

Your response Yes Yes Yes

Grief Functional ability

No Yes

Coping

No

Explanation The patient has a potential for intracranial hemorrhage The patient has an elevated blood alcohol level and has a possible concussion Continuous assessment of his cognition as deficits may be an indication of an evolving neurological injury No indication at this time Continuous assessment of his mobility as deficits may be an indication of an evolving neurological injury No indication at this time

Scenario 1 You are gathering supplies to complete an initial neurological assessment on Mr. Wiggins.

You correctly selected 2 out of 5 actions:

Correc Your t Answe Answe Stat r r us Label No Yes Penlight

No

Yes

No

Yes

No

No

No

No

Explanation The penlight is used to assess pupillary reflex Cotton swab Light touch and corneal reflex Tongue blade Gag reflex and can be broken in half to provide sharp or 2point reflex Stethoscope Not indicated for a neurological examination, no auscultation necessary Sphygmomanome Not indicated for an initial neurological ter examination where there is no concern for Cushing`s reflex/triad

Scenario 2 Upon examination, you found that the patient's pupillary were not equal bilaterally.

You correctly selected 2 out of 5 actions: Correc Your t Answe Answe Stat r r us Label No Yes Notify the healthcare provider of finding immediately No Yes Document size and reaction time of each pupil

No

Yes

No

No

Explanation Possible intracranial bleed, emergency intervention may be necessary Dilated pupils and decreased reaction time may be an indication of increased intracranial pressure Ask the patient if Slightly unequal pupil a healthcare size can be a normal provider has noted finding, but a sluggish unequal pupils reaction may be before related to drugs or increased intracranial pressure Put the patient in This would increase reverse intracranial pressure Trendelenburg on the brain position to decrease intracranial

Correc Your t Answe Answe Stat r r us No

No

Label pressure Tell the patient this is normal and will resolve itself in a few days

Explanation Inappropriate as findings may indicate a neurological condition

Scenario 3 After notifying the healthcare provider of your findings, you return to the room to reassess Mr. Wiggins. You find that he has become drowsy and slightly confused. Perform a Mini-Mental State Examination

You correctly selected 2 out of 5 actions: Correc Your t Answe Answe Stat r r us Label Explanation No Yes Assess patient`s This is a primary orientation to neurological time and date assessment and the first question in a MiniMental State Examination No Yes Have the patient Part of the Mini-Mental

Correc Your t Answe Answe Stat r r us

No

Yes

No

No

No

No

Label Explanation listen carefully State Examination as to 3 words and short-term memory loss repeat them to is an indication of a you neurological deficit Have patient Inability to identify a identify simple object, such as a name/object you pencil or paper, are holding indicates a neurological deficit. This is part of the Mini-Mental State Examination Have the patient While this examination close his eyes can identify a and alternate neurological deficit, it is touching their often used to determine index fingers to drug/alcohol use or their nose sleep deprivation. It is not part of the MiniMental State Examination Have the patient This test is used to draw a clock assess dementia and/or with hands at 3 delirium. This is not part o`clock of the Mini-Mental State Examination.

Scenario 4 Mr. Wiggins's level of consciousness has deteriorated throughout the day. During his initial assessment, his Glasgow Coma Scale was 15. The healthcare provider asks what his current Glasgow Coma Scale is, you report his Glasgow Coma Scale is now 11. What part(s) of the GCS should be included?

You correctly selected 2 out of 5 actions: Correc Your t Answe Answe Stat r r us Label Explanation No Yes The patient opens Eye-opening is the his eyes to first test in the speech Glasgow Coma Scale with a score of 1-4 A best verbal No Yes The patient is confused and/or response is the second assessment in uses the Glasgow Coma inappropriate Scale with a score of words 1-5 No Yes The patient has The best motor difficulty obeying response is the third test in the Glasgow commands but Coma Scale with a localizes pain score of 1-6 No No Assess the Not part of the patient`s pupil Glasgow Coma Scale response Not part of the No No The patient has decreased deep Glasgow Coma Scale tendon responses

Scenario 5

You have reported the decreased Glasgow Coma Scale to the Provider. They are on their way in. Select appropriate interventions in the meantime.

You correctly selected 1 out of 5 actions: Correc Your t Answe Answe Stat r r us Label No Yes Provide one-toone care until the Provider arrives No Yes Elevate the head of the bed 30 degrees No Yes Ensure side rails are up and the bed is in the lowest position No Yes Ensure patient is NPO untiled advised otherwise No

No

Explanation The patient`s Glasgow Coma Scale has deteriorated and is a fall risk To reduce intracranial pressure The patient is a fall risk – facilitates keeping the patient in bed

To prevent aspiration as the Glasgow Coma Scale drops (less than 8, intubate). Likelihood of impending surgery Check The patient must orthostatic sit/stand to accomplish blood pressures this...