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NUR 401 NEW UPDATE Head Trauma Case Study
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NUR 401 NEW UPDATE Head TraumaCase Study
Scenario: J.R. is a 28-year-old man who was doing home repairs. He fell from the
top of a 6-foot stepladder, striking his head on a large rock. He experienced a
momentary loss of consciousness. By the time his neighbor got to him, he was
conscious but bleeding profusely from a laceration over the right temporal area. The
neighbor drove him to the emergency department of your hospital. As the nurse,
you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a
treatment room.
1. What steps will you take to assess J.R.?
a. Primary Survey: ABCDE (with a focus on D with possible head trauma)
i. Airway- Make sure he has a patient airway
ii. Breathing- Make sure that the patient is able to breathe on his
own and that he is getting oxygen to his system based on
color or breathing efforts.
iii. Circulation- Making sure that he is perfusing all his tissues
in his body. I would assess his laceration for any signs of
hemorrhage.
iv. Disability- I would assess his neuro status due to falling.
I would check his brain function along with sensation
and movement of extremities. (C-spine collar already in
place)
v. Exposure- I would review his body for any other injuries
that are not obvious from the story
b. Secondary Survey: Get a history of the events leading up to his fall,
any other medical history, vital signs, and any diagnostic test and
monitors as ordered
2. List at least five components of a neurologic examination.
1. Level of Consciousness
2. Motor Function
3. Pupillary Function
4. Respiratory Function
5. Vital Signs
3. What types of injuries may J.R. have sustained?
1. Skull Fracture
2. Concussion
3. Contusion
4. Cerebral hematoma (Leaning this way due to laceration)
a. Epidural
b. Subdural
NUR 401 NEW UPDATE Head Trauma
Case Study
, NUR 401 NEW UPDATE Head Trauma
Case Study
c. Subarachnoid
4. What complication is common to each of these diagnoses (listed in
#3) concerns you most?
All these injuries are at risk for developing an increase in intracranial
pressure
5. Identify at least six findings that would indicate this
complication (listed in #4) is occurring.
1. Change in LOC
2. Change in vitals
a. Decreased RR
b. Increased BP
c. Decreased HR
d. Increased T
3. Headache
4. Vomiting
5. Pupillary changes
6. Changes in Speech
7. Posturing
6. What is the most sensitive indicator of neurologic change?
Change in the patient’s level of consciousness
Case Study Progression
You complete your neurologic examination and find the following: Glasgow Coma
Scale (GCS) score of 15; pupils equal, round, reactive to light; and full sensation
intact. J.R. complains of a headache and is somewhat drowsy. His vital signs (VS) are
120/72, 114, 30, 98.7 ° F (37.1 ° C) and Spo2 94%. As the radiology technician
performs a portable cross-table lateral cervical spine x-ray examination, J.R. begins
to speak incoherently and appears to drift off to sleep.
7. What are the next actions you will take?
I would call the physician since his LOC seems to be changing. As I am
waiting, I would check his airway to make sure it was patent and that he was
breathing. I would then perform mini neuro checks to monitor his status.
Case Study Progression
While waiting for the physician to arrive, you find that J.R. has become unresponsive
to verbal stimuli. The right pupil is larger than the left and does not respond to light.
J.R. responds to painful stimuli in the manner shown in the illustration.
NUR 401 NEW UPDATE Head Trauma
Case Study
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