NUR463 Neuro Case study PDF

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NUR 463 Neurological Case Study Name: Date: November 17, 2017 Mr. S. is a 23-year-old male who sustained a traumatic brain injury as an unrestrained driver in a motor vehicle crash. On admission, his blood pressure (BP) was 158/72 mm Hg, heart rate (HR) 46 beats per minute, respiratory rate (RR) 28 breaths per minute, and temperature 96.2° F (35.6° C). His neurological exam reveals that his right pupil is at 6 mm and reacts sluggishly; his left pupil is 4 mm and reacts briskly. He is nonverbal, extends his arms bilaterally to pain, and opens his eyes minimally to pain. He is quickly intubated and placed on mechanical ventilation. A computed tomography (CT) scan is done, which reveals a large right subdural hematoma with cingulate herniation from right to left, as well as right-sided uncal herniation. He is taken to surgery emergently for a craniotomy to remove the subdural hematoma. After surgery, he arrives in the critical care unit with a ventricular catheter to measure intracranial pressure (ICP). His initial ICP is 24 mm Hg, BP 130/67 mm Hg, mean arterial pressure (MAP) 88 mm Hg, HR 54 beats per minute, RR 12 breaths per minute (controlled ventilation), and temperature 96.1° F (35.5° C). His current Glasgow Coma Scale (GCS) score is 3, but the anesthesiologist did not reverse the anesthesia, choosing to allow it to wear off gradually. He has orders for 3% saline at 20 mL/hr intravenously. 1. Based on the information provided, what is Mr. S.’s preoperative GCS? What is the significance of this number, and how would the nurse describe this to his family? Mr. S.’s preoperative GCS score was five. He received a one for being nonverbal, a two for opening his eyes minimally to the response of pain and another two for extending his arms to pain which indicates decerebrate posturing. Based on his score of five, Mr. S would be described as in a comatose state. I would explain to the family that this scale is a

neurological assessment that ranges from 3-15, with 3 being the worst and 15 the best possible outcome. I would explain that it is based on three evaluations including eye response to stimuli, verbal response to stimuli and motor response to stimuli. 2. Anatomically, what is the cause of his pupillary changes? The pupillary changes are due to the subdural hematoma on the right side of the brain which is causing increased ICP. This increase in pressure is most likely pressing on the cranial nerve III, the oculomotor, which would result in the pupillary response he is demonstrating. 3. Which of his postoperative findings are of concern? His ICP is 24, when the normal is 5-15. So he has increased pressure in his brain. His GCS also went down and is now 3, which indicates a worsening in his condition because now he is in a more comatose state. 4. Why is the 3% saline ordered, and how will the nurse know if it is effective? This solution is a hypertonic solution which will help prevent cerebral edema. They’ll know if the treatment has been effective based on his vital signs. His blood pressure would stabilize and his ICP would decrease...