Melvin Strong, a 19-year-old patient, presents to the emergency department after being ejected from an automobile. He has a back board with a cervical collar in place. The EMT stated that when he saw the patient, the patient was unconscious but quickly gained consciousness and was oriented ×3, talking, and able to move all four extremities. Within 5 minutes, the patient became unable to be aroused, opened his eyes only to painful stimuli, made incomprehensible sounds, and withdrew from pain. The vital signs are: temperature, 100°F, blood pressure, 180/50 mm Hg; heart rate, 50 bpm; respiratory rate, 14 breaths/min. The left antecubital IV site has NS at 125 mL/hr. The EMT stated that the patient complained of a severe headache and had an episode of projectile vomiting before the neurologic decline. The patient’s breathe smells like alcohol. When the patient arrived, the nurse noted that the patient’s pupils were unequal—the right pupil was larger than the left pupil—but both pupils reacted to light accommodation. 1. What do the assessment findings suggest? 2. What signs and symptoms does the patient exhibit related to increased intracranial pressure? 3. What medical and surgical treatment does the nurse anticipate for the patient? 4. What Glasgow Coma Scale (GCS) did the patient have initially at the scene of the accident? What GCS did the patient have when he began deteriorating neurologically? 5. What nursing interventions should the nurse provide?
1. On arrival to the emergency within five minutes patient
- became unable to be aroused
- opened his eyes on painful stimuli only E3
- made incomprehensible sound V5
- withdraw from pain M4
Vital signs were :-
Temperature - 100°F
Blood pressure - 180/50mmhg
Heart rate - 50bpm
Respiratory rate - 14 breaths per min
His GCS was E3V5M4
2. The signs and symptoms of ICP are :-
- projectile vomiting
- severe headache
- altered mental status
- Cushing triad of bradyapnea, bradycardia,and hypertension.
3. Medical and surgical treatment that should be provided to the patient are:-
- evacuation of mass lesion
- maintain euvolemia
- hyperosmolar therapy.
- ventriculostomy to drain CSF and lumbar drain .
- maintaining 30 degree of bed
- maintaining normocarbia
- normothermia
- sedation and analgesics
- seizure management and prophylaxis
- barbiturates and mild /moderate hypothermia for refractory intracranial hypertension.
4. Glasgow Coma Scale for this patient when he was brought to the emergency is less than 8 and then after 5 min it was 12 ( E3V5M4 .)
E 3- open his eyes on painful stimuli
V5 - incomprehensive sounds
M4- withdraws pain
Melvin Strong, a 19-year-old patient, presents to the emergency department after being ejected from an automobile....
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