Melvin Strong- TCI PDF

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Summary

Homework...

Description

Melvin Strong, a 19-year-old patient, presents to the emergency department after being ejected from an automobile. He has a back board with a cervical collar in place. The EMT stated that when he saw the patient, the patient was unconscious but quickly gained consciousness and was oriented ×3, talking, and able to move all four extremities. Within 5 minutes, the patient became unable to be aroused, opened his eyes only to painful stimuli, made incomprehensible sounds, and withdrew from pain. The vital signs are: temperature, 100°F, blood pressure, 180/50 mm Hg; heart rate, 50 bpm; respiratory rate, 14 breaths/min. The left antecubital IV site has NS at 125 mL/hr. The EMT stated that the patient complained of a severe headache and had an episode of projectile vomiting before the neurologic decline. The patient’s breathe smells like alcohol. When the patient arrived, the nurse noted that the patient’s pupils were unequal—the right pupil was larger than the left pupil—but both pupils reacted to light accommodation.

a. What do the assessment findings suggest? The patient has an increased intracranial pressure caused by a hemorrhagic stroke b. What signs and symptoms does the patient exhibit related to increased intracranial pressure? Changes in LOC, pupillary changes, high BP, low pulse, headache , vomiting. c. What medical and surgical treatment does the nurse anticipate for the patient? Medical treatment: fresh frozen plasma, vitamin K, hemodialysis, , oral activated charcoal, prothrombin complex concentrates, recombinant activated factor VII Surgical treatment: craniotomy, stent or coil placement d. What Glasgow Coma Scale (GCS) did the patient have initially at the scene of the accident? What GCS did the patient have when he began deteriorating neurologically?  Initially:14 

Later:8

e. What nursing interventions should the nurse provide? 

Optimizing cerebral tissue perfusion by implementing aneurysm precautions

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Relieving anxiety

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Monitoring and managing potential complications which are vasospasm, seizure, hydrocephalus, rebleeding, hyponatremia.

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Promoting home and community base care by educating patient about self-care, continuing care...