Client: 19-year-old Justin was involved in a MVA head-on collision…

Question Answered Client: 19-year-old Justin was involved in a MVA head-on collision… Client: 19-year-old Justin was involved in a MVA head-on collision while coming home from work. Justin is captain of the football team and has a history of multiple concussions. Client arrived at the Emergency Department by ambulance. Justin’s mom and sister have arrived.Current Vital signs: 97.1 temp, HR 65, BP 132/70, RR 16, Oxygen Saturation 96% on 50% FIO2Assessment: Eyes open to painful stimuli, pupils equal but sluggish to respond to light, 3mm, no attempt to track with eyes, does not appear to recognize his family. Withdraws from pain, no spontaneous movement of lower extremities. Sounds are made but no words. 1.     According to the Glasgow Coma Scale how would the nurse rate Justin’s condition? What score would you give him upon admission?1.     What assumptions can the nurse make based on the GCS score?  2.     What are risk factors for head injury? How does Justin fall into this population?  3.     What signs of increased intracranial pressure does the nurse recognize from the baseline assessment? What are other expected clinical manifestations of increased ICP?  4.     What are priority interventions should the nurse provide for the client with ICP? What will the nurse assess and monitor for frequently? 5.     What is the reasoning behind giving each of these medications for ICP? What are nursing interventions to consider for each? Mannitol PhenytoinLabetalolBarbituatesOpoids 0830: An intracranial pressure (ICP) (intraventricular catheter) monitor is placed via a burr hole- ICP=16 mmHg per ventriculostomy monitorUpdated Nursing Notes0900 Temp 101.6, ICP = 17 mmHg1000 Temp 102.4, HR 50, RR12, BP 162/68, ICP 20. Resting, Respirations irregular1100 Pupils 5 mm Fixed. Does not open eyes to painful stimuli, Vocalization does not occur, decorticate posturing is noted. ICP =22Stat CT Report: Absence of sulcal markings and poor differentiation of white and gray matter from diffuse bilateral cerebral hemispheric edema. Brain stem encroachment noted6.     What is the current GCS score?  7.     Correlate the current vital signs to Cushings Triad. What does this mean?  8.     What are possible complications of the intraventricular catheter pressure monitor? What should a nurse know about setting up and maintaining this system? (https://youtu.be/MPpH8MnXhb8)**Orders Received: Mannitol 20% 0.5 g/kg IV infused over 60 minutes**9.     What is the dose of Mannitol he should receive? How many total ml should be given? What is the rate to set the IV pump at? Justin’s current weight is 80 kg. a)     ______grams    b)     ______ml c)     ______ml/hr (pump rate)d)     If the Mannitol was given IV push, what special consideration is necessary when drawing it up?e)     How does Mannitol work in the body?  1.     Explain the pathophysiology of herniation of the brainstem: 2.     What are the signs and symptoms of brain herniation? 3.     How actions can a nurse take that might decrease ICP and prevent brain herniation in the client with head injury?  Updated Nursing Notes:0100 ICP = 19 mmHg, Eyes open with nail bed pressure, Moans intermittently, & physical withdrawal from pain 4.     What was the GCS at 0100?  0130 The client experienced a sudden loss of consciousness and emitted a loud cry. Rigid muscle movement was noted with arms and legs extended; jaw was clenched shut, pupils fixed and dilated, urinary incontinence, and breathing ceased and the client became cyanotic for approximately 15 seconds. This was followed by convulsive movements alternative with relaxation. Hyperventilation occurred, eyes rolled back, and frothing was noted at the mouth. This lasted for 90 seconds and was followed by somnolence.  5.     How do seizures effect to ICP? 6.     What are key observations noted with a tonic-clonic seizure?  7.     What are the priority actions during and after the seizure? 8.     What are the stages of a seizure? What should the nurse document regarding the seizure? 9.     What are seizure precautions? 10. How can the nurse support the client’s family?  11. What is an ideal outcome for Justin? Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

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