AT&T; LTE 3:23 PM X Neurological Disorders Case Study SCENARIO JUR. is a 28-year

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AT&T; LTE 3:23 PM X Neurological Disorders Case Study SCENARIO JUR. is a 28-year-old man who was doing home repairs. He fell from the top of a 6- foot stepladder, striking his head on a large rock. He experienced momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right demporal area. The neighbor drove him to the emergency department (ED) of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room 1. What assessment data should the nurse obtain? 2. List at least five components of a neurologic examination. 3. What is the most sensitive indicator of a neurologic change? CASE STUDY PROGRESS The nurse completes the neurologic examination and find the following: Glasgow Coma Scale (GCS) 15: pupils equal, round, react to light (PERRL): and full sensation intact JR. complains of (C/O) a headache and is becoming increasingly drowsy. As the radiology technician performs a portable cross-table lateral cervical spine (C-spine) x-ray, J.R. begins to speak incoherently and appears to drit off to sleep. 4. What is the next action that the nurse should take? CASE STUDY PROGRESS JR. has become unresponsive to verbal stimul and responds to painful stimuli by abnormally flexing his extremities (decorticate movement). He has no verbal response. The right pupl is larger than the left and does not respond to light Open With Print

Explanation / Answer

1.Initial assessment is assessing the consiousness , breathing and circulation.Then vital signs and GCS.

2.i).cranial nerve assessment.

ii).Pupilary response

iii).Muscle power

iv).Muscle tone

V).Mental status examination.

3.Important indicator is GCS

4.It may be due to the increasing ICP due to trauma hence bed end should be elevated for 45 degree and immediately inform to the physician for further management.

5.E1V1M5 GCS -7/15.Symptoms indicate ICP increase.

6.Poor GCS indicates patient having poor consciousness hence nurse should monitor vital signs note for any changes.

Maintain head end elevation at 45 degree.

Maintain adequate fluids for the patient.

7.Normal ICP ranges between 7-15mmHg.ICP should be maintained in the normal range to maintain the normal cerebral perfusion pressure (CPP).Changes in ICP cause changes in CPP .poor perfusion results in ischemia and infraction of brain cells.

8.Headache, papilledema,loss of consciousness,Increased blood pressure, decorticate and decerebrate postures in severe brain affects.

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