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Scenario: Your patient has sustained a closed head injury in an automobile accident and was admitted to the ICU

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Scenario: Your patient has sustained a closed head injury in an automobile accident and was admitted to the ICU. The priority nursing problem on the care plan is potential for injury due to possible increased intracranial pressure.

1. Write two appropriate expected outcomes for this diagnosis for this patient.

 a. ____________________________

b. ____________________________

2. Nursing interventions that would be carried out to help the patient achieve the expected outcomes would be:    ____________________________    ____________________________    ____________________________

3. Criteria by which you would evaluate whether the expected outcomes have been met are:    ____________________________    ____________________________

 

PRIORITY SETTING

 You are assigned the following patients:

a. Mr. Hopper, age 23, who has a C-5 injury sustained in a diving accident and is in cervical tongs and on a specialty bed.

b. Ms. Hernandez, age 48, who has a ruptured disk at L-5. She has just had a diskectomy this morning.

c. Ms. Chinn, age 72, who suffered a back injury and a pelvic fracture in an automobile accident. She is on bedrest and has paresthesia in her right leg and foot.

Mr. Hopper is complaining of muscle spasms and pain.

Ms. Hernandez calls complaining of nausea.

Ms. Chinn calls and asks for help, explaining that she has experienced some incontinence and the bed is wet. In which order would you attend to these patients' needs?

__________

 

Multiple choice questions

 Choose the best answer(s) for the following questions.

1. Discharge teaching for the patient who has sustained a concussion should include instructions to:

a. take the prescribed analgesic for headache every 4 hours.

b. lie down flat at home and move around as little as possible.

c. force fluids to prevent dehydration and infection.

d. report immediately any severe headache or persistent vomiting.

 

2. Planning for the patient who has sustained a spinal injury would include listing which nursing problem as the highest priority in the care plan?

a. Altered sensory perception due to spinal contusion

b. Potential for infection due to trauma to spinal column

c. Incontinence due to paraplegia

d. Potential for injury due to inability to move

 

3. The first priority in assessing the patient with head trauma at an accident scene is determining:

a. whether spinal injury is present.

b. the level of consciousness using the Glasgow coma scale.

c. whether the airway is patent.

d. whether hypotension is present.

 

4. Mary took a fall while skiing and bumped her head on a small tree. She got right up and stated that she was fine. However, shortly afterwards Mary began suffering from a headache. What should her family do?

a. Give Mary two Tylenol and see if it resolves the headache.

b. Give Mary two ibuprofen because it would help reduce any inflammation Mary is experiencing.

c. Call 911 as Mary experienced a head injury earlier and may be developing complications such as a subdural hematoma.

 d. Wait to see if any other symptoms such as nausea and vomiting develop, and if they do, take her to an urgent care center.

 

5. Mannitol is an osmotic diuretic that helps decrease ICP. Nursing interventions for the patient receiving this drug include: (Select all that apply.)

 a. monitor intake and output.

b. observe for chest pain.

c. monitor for increasing salivation.

d. watch for electrolyte imbalances.

e. check skin turgor.

 

6. A patient with a daughter who is engaged to be married suffered an accident that left him paraplegic. What comment indicates the patient is in the stage of bargaining?

a. "I am saddened that I will miss being able to dance with my daughter at her wedding."

b. "I do not deserve to be paralyzed for my daughter's wedding!"

c. "If God will let me just walk my daughter down the aisle for her wedding, I'll never complain about being in this chair again!"

d. "Maybe I will be able to have special braces so that I will be able to operate a Segway as a way of 'walking' my daughter down the aisle."

 

7. Mr. Pineda suffered a closed head injury and has increased ICP. The health care provider has prescribed mannitol 1 g/kg IV every 6 hours. Mr. Pineda weighs 194 lbs. How many grams of mannitol would be the correct dose to be given every 6 hours? _____ g

 

8. What is a priority nursing intervention for the patient with a spinal cord injury who is quadriplegic?

a. Preventing overdistention of the bladder

b. Assessing skin integrity every shift

c. Using an abdominal binder to raise blood pressure

d. Providing frequent massage of the legs

 

9. Autonomic dysreflexia can lead to:

a. heat stroke from loss of thermoregulation.

b. paralytic ileus.

c. severe muscle cramps.

d. severe hypertension.

 

CRITICAL THINKING ACTIVITIES

Scenario A:

Mr. Schultz sustained a head injury in a bicycle accident. He was admitted to the ICU from the emergency department as his level of consciousness was decreasing. He is arousable, but very drowsy. His vital signs are BP 132/84, P 78, R 16, T 98.8° F (37.1° C). Vital and neuro signs are ordered every hour. A pulse oximeter is attached and he is placed on a cardiac monitor.

1. He had a head CT without contrast in the ED. What information is obtained from this test?    His pulse pressure shows widening after 3 hours and he is more difficult to arouse.

2. What medications would you expect he might receive?    His condition worsens and one pupil begins to dilate. He is placed on mechanical ventilation.

3. When suctioning his endotracheal tube, why is it especially important to oxygenate him thoroughly beforehand?

 

 Scenario B:

Mr. Schultz was found to have a subdural hematoma. A craniotomy was performed and the hematoma evacuated. You are caring for him postoperatively.

1. What would you pay particular attention to when positioning him?

2. Why is it important to maintain a quiet, nonstimulating atmosphere for this patient?

3. Besides increasing ICP, what is the next complication against which you would direct your nursing care?

 

Directions: Fill in the blanks with the correct words from the Vocabulary Building Glossary to complete the statements.

1. Bleeding into the brain is a(n) _____ factor for an increase in ICP.

2. The patient who has a spinal cord injury is repositioned on the side by _____ him as a single unit.

3. Mr. Eagle hit his head hard on the windshield, his head bounced backwards, and he ended up with an injury on the front of the brain and a(n) _____ injury on the back of the brain.

4. _____ odors in the room of a patient after brain surgery may cause the ICP to rise.

5. A reaction seen with autonomic dysreflexia is _____ on the skin.

 

 COMMUNICATION EXERCISE

Dialogue Practice  

what you might say to the mother of a 16-year-old boy who suffered a head injury to reassure her and involve her in the plan to help her son. Cover why she shouldn't try to keep him awake (sleep is helpful for healing, but he will be aroused periodically to check the level of consciousness). Explain to her how she can help with passive range-of-motion exercises and with keeping his hands in good anatomic position.

Documentation

Document what you told her below. ____________________________

 

 

COMMUNICATION EXERCISE 2

Dialogue Practice

Directions:

Discuss with a partner.

A. With a partner, use the guidelines in the Focused Assessment to perform an assessment. Practice asking each question. Practice charting your assessment.

B. As a second-language learner, do you think the steps to help an aphasic person (self-talk, parallel talk, expansion, and modeling) would help someone learning a new language? Why or why not? What happens in each of the steps?