Question

Adam is a 28-year-old male that was doing home repairs when he fell off the top of an 8 foot ladder hitting his head on a large rock. The event was witnessed by a neighbor who reports a loss of consciousness (LOC) for approximately 30 seconds. The patient is now awake with profuse bleeding from a temporal area laceration.

1. Since you can see that the patient is awake and breathing, what are the very first two simultaneous things you will do for this patient?

2. How will you assess Adam?

3. What are at least 5 components of a neurological exam?

4. What possible injuries may Adam have sustained?

5. What complications are common to each of those injuries mentioned above?

6. What are 6 possible findings that you may see on Adam that would indicate a possible complication is occurring?

Adam had previously been awake with vital signs within normal limits. While getting a chest X-ray he complains of a headache and appears drowsier. As you start to ask him more questions his speech becomes incoherent and he becomes unresponsive.

7. What is your number one assessment to make at this time?

Upon further assessment you find his pupils to be unequal and only one responds to light. Patient is only responding to painful stimuli and is exhibiting decorticate posturing.

8. What is most likely the cause of Adam’s change in condition?

9. What are your nursing priorities at this time?

A reassessment of his vitals show that his BP remains WNL, his heart rate is mildly elevated at 110, his respirations are 9 and his oxygen saturation is 91%.

10. What is your concern and why?

The ED physician orders the following: ● Foley Catheter ● NG Tube to low intermittent suction ● STAT CT ● Intubation ● Normal Saline @ 100ml/hr ● STAT Trauma labs ● 160g Mannitol IV STAT over 30mins ● 1360mg Phenytoin IV STAT over 30mins then 100mg IV TID

11. Outline a plan for implementing these orders

Answer 1

1. ANSWER:

As the patient is awake and breathing, but he is having profuse bleeding at the temporal area. The very first simultaneous things that has to be done for the patient is to stop bleeding to reduce the risk of head injury. Bleeding can be stopped by applying pressure over the injured area with a clean cloth or cotton or gauze pieces. The second thing that has to be done is call for emergency help or calling to the ambulance to help out the patient.

2. ANSWER:

Adam has a head injury because of fall down with profuse bleeding, in this stge assessment of patient is very important to rule out further complications. Assessment includes monitoring of vital signs, using of glasgowcoma scale to assess the level of consciousness, monitoring airway and breathing pattern, assessing of hemorrhage level, performing of neurological examination can be done to checkout neurological functioning in the body.

3. ANSWER:

Neurological examination is performed to assess the functioning of nervous system which includes sensory and motor responses in the body. The components of neurological examination includes:

1. Cranial nerves

2. Reflexes

3. Mental status

4. Sensory

5. Coordination and gait

These are the components of neurological examination.