SuperHumanOkapiMaster471
Please fill out this case study using the same format. Thanks …
Please fill out this case study using the same format. Thanks
Jeff Dickson is a 15-year-old male brought to the emergency department by his parents. They report Jeff fell from his skateboard yesterday morning on the way to school. He was not wearing a helmet. At the time of the fall there was no loss of consciousness, but he had a few facial, arm and knee abrasions. He went to the school nurse who cleaned his wounds and sent him to class. Last evening Jeff complaints were generalized stiffness and a headache. This morning he was lethargic, nauseated and the headache persisted.
Upon admission to the ED, Jeff is awake, but lethargic. He knows his name, and recognizes his parents. He does not know the day of the week. He has no memory of the accident.
He is scheduled for a CT scan of the head.
PMH: none, up to date on all vaccines, NKDA, No medications.
SH: active teenager, soccer and basketball player in the intermural teams
1. After reviewing the client information, highlight parts of the paragraph that are most concerning (cues).
2. What is the clinical significance (analyze) of the cues highlighted?
Current VS Clinical Significance
T: 98.2 F/37.3 C BP: 112/64
HR: 68 (regular)
RR: 14 (regular)
SaO2: 99% RA
Pain: global head ache, 4/10
Neuro: Oriented to person and place. PERRLA 4 mm. Slow to respond. Obeys commands, falls asleep unless spoken to. Ecchymosis bilateral under eyes and behind left ear.
Glasco coma scale is _____
Cardiac: sinus rhythm, RRR, w/o R/M/G, Saline lock in left hand.
Resp: clear bilaterally
GI: BS x 4 quadrants
GU: no abnormality noted, has not voided
Skin:numerous superficial abrasions on both forearms, and right leg. Large superficial abrasion on right forehead at the hairline.
The MD gives orders:
IVF NS @ 50 ml/hr.
levetiracetam 40mg/kg IV infusion in 100 mL 0.9% sodium chloride over 15 minutes. Client weight 145 lbs.
lorazepam 2 mg IV PRN for seizures may repeat in 5 minutes if seizure persists
NPO
3. How many mg(s) is the bolus dose? Round to the whole number.
4. What rate will you program on the pump for the levetiracetam infusion?
You leave the room to check if the levetiracetam is up from the pharmacy. Jeff’s mother rushes out of the room frantic and tells you Jeff has vomited. You enter the room and begin assessing.
He is arousable to pain, mumbles incomprehensible words after repeated requests, and moves a finger when asked to squeeze your hand.
While assessing vital signs, you notice fasciculations of his right hand. When you place the BP cuff, Jeff arches his body; all extremities rigidly extend for approximately 10 seconds, followed by rhythmic muscle contractions. His face is dark red, and he is apneic while rigid and incontinent of urine.
5. For each action below, use an X to specify whether the action would be Indicated, (appropriate or necessary), Contraindicated (could be harmful), or Non-essential (makes no difference or is not necessary) for the client’s care at this time?
Nursing Action Indicated Contraindicated Non-essential
Assess airway
Monitor RR and work of breathing
Turn to left side
Assess LOC and recall of event
Educate about helmet safety
Re-orient
Administer phenytoin po STAT
Administer lorazepam IVP
Restrain the client to prevent injury
Remain with the client
Check levetiracetam serum levels
Suction mouth
Call for assistance
6. What should be noted/documented about the seizure? List a minimum of 6.
7. What are priority assessments during the postictal stage? List a minimum of 6.
Jeff is taken to CT scan where it reveals a basilar skull fracture.
He is taken to emergency surgery for a decompressive craniotomy with bone flap, external ventricular drain (EVD) placement, sedated, vented and subsequently transferred to the PICU.
8. Indicate which nursing action listed below is appropriate for the potential complication. Note, not all the nursing actions will be used.
Nursing Actions
Apply SCD’s &TED hose
Apply warm blankets
Lock HOB controls
Insert Foley catheter
Perform mental status checks hourly
Monitor VS Q 15 minutes
Apply continuous capnography
ABG monitoring
Maintain EVD at consistent height
Potential complication Appropriate nursing action for potential complication
Rapid ICP changes
Increased ICP
Impaired gas exchange
Hypothermia
Venous thromboembolism
9. List signs and symptoms of increased intracranial pressure (IICP).
10. For the below table note which action contributes to
increased or decreased/maintaining ICP by placing an X in the appropriate column.
Action Increase Decrease/Maintain
Cluster care
HOB 30-35 degrees
Hyperventilation
Maintain low stimulation environment
Maintain oxygenation
Midline position of the head
Prone position
Temp. 101. 6 F
Tracheal suctioning
Vagal nerve stimulation
Volume overload
Vomiting
Terms:
Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.
Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.
Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.
Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.
Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state.
Coma is a state of unarousable unresponsiveness.
https://www.ncbi.nlm.nih.gov/books/NBK380/
