Question

J.R. is a 28-year-old man who presented with a traumatic brain injury (TBI) after being in a motor vehicle crash. He was not wearing a seatbelt and his head hit the windshield. He experienced a loss of consciousness for an unknown length of time. Upon arrival he is groggy and doesn’t remember anything about the accident. VS upon admission: BP 130/70, Pulse 114, Resp 28, Spo2 96%.

1. Describe 5 components of the neurologic examination, include the GCS as one.
2. TBI patients are at risk of developing increase intracranial pressure (ICP). What would indicate this complication is occurring with J.R.?
3. What interventions are indicated to prevent ICP for patients with brain injury? Describe at least 5 including positioning.
4. Detail the respiratory assessment you will perform for this patient, why is this assessment so important?

45 minutes later your assessment reveals VS BP 160/62, Pulse 58, Resp 12, Spo2 94%.

5. What complication could be occurring to cause this change in VS?

Answer 1

# 5 components of the neurologic examination include :-

1- Emotional state (external mood) - natural, flat, anxious, angry, or irritable

2- Language ability - (spoken and written) understands and communicates clear, slurred... any type of Aphasia

Impact on Lifestyle - Role in home, society and community

3 - Level of consciousness - is client alert and able to follow commands.if not, Glasgow Coma Scale (eye, verbal, and motor) noxious stimuli is applied 1st (Centrally - trapezius pinch, mandible pressure, supra orbital pressure or sternal rub 2nd Painful stimuli or peripherally - nailbed pressure, nipple twist, testicular pressure or hair pulling)

4 - Cranial Nerves

Motor ability - Atrophy

gradual loss of muscle or flesh usually because of disease or lack of usage or Tremors/Tics, abnormalities in tone Spasticity (increased muscle tone, Rigidity (resistance to passive stretch), and Flaccidity (lack of muscle tone, limb, floppy).

Romberg Test - screening test for balance (seated or standing) eyes closed and open for 20 seconds - stand close for support > slight swaying is normal > break in stance is abnormal = + Romberg test

Sensory system - knowing dermatomes (Fig. 65-9, pg. 1915) that represent distribution of the peripheral nerves that arise from spinal cord SC.

Tactile sensation (touching area with cotton tip), Pain/Temp. transmitted together in lateral part of SC (hot/cold - pain sharp/dull), Vibration/Proprioception transmitted together posterior part of SC (Tuning fork on bony prominence > explain sensation or notify when ceases).

Close both eyes explain which direction great toe or index finger alternately moved up and down. Agnosia - inability to recognize objects

5 - Reflexes - classified as deep tendon, superficial or pathologic. DTR are graded on scale 0-4, (0 = no response, 2+ = normal, 4+ Hyperactive).

# Indications of raised ICP are :-

headache

nausea

vomiting

increased blood pressure

Decreased heart rate

Decreased respiratory rate

decreased mental abilities

confusion about time, and then location and people as the pressure worsens

double vision

pupils that don’t respond to changes in light

shallow breathing

seizures

loss of consciousness

coma

# Intervention to prevent raised ICP are :-

- Keep head of bed slightly elevated and the head in midline (straight). For clients with a basal skull fracture, keep bed flat.

- Limit movement, space essential nursing tasks, and reduce or eliminate environmental stimuli (e.g., loud noise, bright lights).

- Avoid extreme hip flexion.

- Keep client quiet. Change position with assistance and use a turning sheet. Avoid range-of-motion (ROM) exercises until ICP approaches normal unless ordered otherwise by the physician.

- Administer reduced fluid volumes at an even rate for 24 hours. Give diuretics as prescribed; note client's response to therapy.

- Hyperventilate the mechanically ventilated client briefly according to medical orders.

- Suction the airway only when necessary.

- Give 100% oxygen before and after suctioning when it is required.

- Keep suctioning brief, without exceeding 10-15 seconds per pass of the catheter.

- Administer a prescribed stool softener.

- Ensure that a gastric tube used for decompression or nourishment remains patent.

- Administer prescribed medications if vomiting or persistent coughing occur.

# The respiratory assessment done in patients with increased ICP is assessment of respiratory rate because bradyapnea is one of the sign of raised ICP . Cushing's traid is the main sign of increased ICP , it includes hypertension , bradyapnea , bradycardia .

# After 45 minutes of reassessment it reveals the above mentioned vital signs which clearly states that ICP has increased . Its visible by the Cushing's triad .