Question

10) Mr Reynold had undergone craniotomy and he is on 2nd post op day. You are there to take over the client from the staff of previous shift. Answer the following question based on the scenario. On assessing the level of consciousness of Mr Reynold, you got a score of E2M3V1, which is entirely different from the previous reading (E4M4V3). 10.1) Mention your interpretation.

10.2)   Describe how you would respond in this situation as an enrolled nurse (in 40-50 words).

Answer 1

Glass gow coma scale consists

Eye response

4- open spontaneously

3-open to verbal command

2-open to pain

1-No eye opening

verbal response

5-oriented

4-confused

3-Inappropriate words

2-Incomprehensible sounds

1-no verbal response

Best motor response

6-obey command

5-localising pain

4-withdrawal from pain

3-flexion to pain

2-extension to pain

1-No motor response  

Here patient has E2M3V1

means the score is 5 which indicate severe head injury.

Generally it classified as :

Severe with GCS<8

Moderate GCS 9-12

Minor GCS >13

E2 indicate eye open to pain stimulus.

M3 indicate abnormal flexion to pain

V1indicate no verbal response

Nursing intervention

• Recognize airway, breathing and circulation to optimize oxygenation and perfusion.
• Head should be elevated 30degree and midline position.
• Immediately informed to doctor Do CT scan.
• Brai injury may be due to hemorrhage and hypotension blood products are best. Colloid fluids are contraindicated. Hypotonic normal saline and ringer lactate exacerbate the conditions cerebral edema so it should be avoided.
• Administration of epinephrine ir nor epinephrine as prescribed with close monitoring.
• Ventilation and airway management. Indication of artificial airway if GCS score less than 8.