Question

8. A client returned from theatre 20 minutes ago post bowel surgery with a GCS of 15. On examination of this client you find |that their GCS has dropped to 10. 8.1 What will you do? 8.2 What are the possible causes? 8.3 List 4(four) members of the Emergency Response Team

Answer 1

The Glasgow Coma Scale (GCS) is the common neurologic assessment tool in the head injury patients, especially those in the intensive care units. It is used to test the verbal, motor, and eye response.

The patients with a GCS score of 12 to 15 indicate that there is no requirement for ICU (intensive care unit) admission. The GCS score ranging from 9 to 12 indicate moderate coma. A GCS score of below nine (9) indicates the need for endotracheal intubation, and ventilator support. The patient is generally in severe coma.

8.1).

In the given case, the patient’s level of consciousness assessed as per GCS is, 10, which indicates moderate coma. So, the nurse should immediately check for any major bleeding sites, and the ventilation. An alert should be sent immediately to the emergency medical department. In the mean while, the nurse have to check the ABCD (Airway, Breathing, Circulation, and Disability)

8.2).

The possible causes in this case include, hemorrhage, drug overdose, and inadequate tissue perfusion and airways.

8.3).

The four members of emergency medical care required in this case are,

• General physician
• Neurologist
• Registered nurse
• Surgeon who performed the surgery