Mr. S. is a 23¬year¬old male who sustained a traumatic brain injury as an unrest

Question

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, 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 ventriculostomy 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.

Questions:

Based on the information provided, what is Mr S's preoperative Glascow Coma Score? What is the significance of this number? How should the nurse describe this to the family?
What is the cause of his pupillary changes?
Which of his post¬operative findings are of concern?
Why is the 3% saline ordered? How will the nurse know if it is effective?

Explanation / Answer

Mr S's preoperative GlasgowComa Score is 5. The significance of this number is, the brain injury is severe with less prognosis.

Nurses need to understand the parent's expectation of caring in the acute care so that they can modify their attitudes, beliefs, and behaviors to adjust the family needs. Parents should be involved in the care of the loved ones and their grief should be respected and they should also be involved in decision making. The nurse should provide emotional support, psychological and physical environment for the family.

Pupillary changes are reactivity is an only indication of increased intracranial pressure (ICP).

3 percent saline (Hypertonic saline) is ordered as it is important in countering hyponatremia in the brain. Low serum sodium level after traumatic brain injury can lead to extracellular volume depletion, cerebral ischemia, and cerebral edema. This can all result in an increase in ICP.

Reduced ICP, Cerebral edema and cerebral ischemia will let the nurse know that the treatment is effective.

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