Question

please use complete sentences.

You are working in an ER when a family is admitted after a multiple motor vehicle accident. The parents have minor injuries. They have a 3-month-old infant that was in a car-seat and a 4-year-old that was wearing a seat belt.

The 3-month-old is crying. Her vital signs are HR 165, B/P 70/35, RR 60. Are these within normal limits? Are you concerned about the infant from the vital signs?

The 4-year-old has a bruise on her left temple. She is lethargic, arouses with stimulation, and asks for her mom. Her vital signs are HR 140, B/P 91/52, RR 20, and Glascow Coma Scale (GCS) 13. As you continue to assess her, she becomes unconscious and her GCS is now 9.

What are your priority nursing interventions?

A CT shows a subdural bleed and she is transferred to the ICU. Her intracranial pressure (ICP) is 10.

Is this within normal limits? What are you concerned about with this pressure?

What is a priority nursing diagnosis with interventions and rationales?

What are your priority concerns with an increased ICP?

What are collaborative departments that will be involved in her care?

Answer 1

No three month old childrens's vitals are not in normal range.her diastolic b.p should be 50 to 65 range.but it is less than normal.while,her respiratory rate is very high from normal range(30-45).Thus,i am worried about her condition.

Priority nursing interventions for 4 year old

1)patients airway should be maintained

A)head end elevate at 30 to 45 degree

B)do suctionig

C)arrange for endotracheal intubation

2)prevent the child from falling

A)use bed with side rails

B)restrains

3)start i.v line to maintain hydration status

4)foleys catheterization to tackle urinary retention

5)ryles tube insertion to provide feeding

Her intracranial presure is increased as normal value of icp in children is 3 to 7.increased intracranial pressure indicates brain injury or swelling in the brain cells.thus,it is a life threatening condition.it should be treated immediately.therefore,i am concerned about her condition.

Nursing diagnosis:::ineffective cerebral perfusion related to raised intra cranial presure

Nursing interventions::1)head end of the bed should be elevated 30 to 45 degree to reduce icp

2)restrains should be applied to limit the movement.movement of the body can increase incp.

3)suction the airway if necessary

4)administer medications and fluids according to doctors order

5)provide calm and quite enviroment

Assess vital signs frequently

Head foot physical examination

Neurological assessessment should be done in every hour

Notify the signs of seizures

Prevent patient from falling

Maintain hydration status

Indwellung catheterisation

Patient should be kept in calm and quite room with no noises and light

Physician,Neurologist,physiotherapist,dietitian,nurses,pharamacist are the team who should take care of her and be involved in her treatment .