Caring for a patient with a traumatic brain injury

Opioids, sedatives, osmotic diuretics, hypertonic saline solutions, and barbiturates are drug classes that may be used to normalize ICP and prevent secondary injury. The nurse is caring for a patient with a traumatic brain injury.  Give one example from each class, prioritize three nursing considerations for each and prioritize the order of administration.

Karen is a 40-year-old married mother of a 4 and 10-year-old. She was an unbelted passenger in a single car roll over. She was found outside the car complaining of severe head and neck pain. She is brought to the ED via EMS in C-spine precautions. She has bruising under her eyes and over the left mastoid bone. BP 165/36, HR 51, RR 24, O2sat 92% on 4 L NC. She has an 18 gauge IV in her R AC.

1. Prioritize your specific assessment (do not put “assess respiratory status”). Describe specifically what you will assess; chest symmetry, lung sounds, etc. of this patient in order of priority 1-10.

1. Determine Karen’s GCS using the assessment data below:

__________ .

Karen’s eyes open in response to verbal stimuli
Karen is oriented to person only
Karen pulls her arm away and she moves her arm in response to a needle prick

1. Karen requests something for her headache. Which medication(s) are appropriate for the nurse to administer to Karen for her complaint of headache?

1. Mr. Smith is a 23-year-old male who sustained a traumatic brain injury as an

unrestrained driver in a motor vehicle crash. On admission, his blood

pressure (BP) was 158/32 mm Hg, heart rate (HR) 46 beats per minute,

respiratory rate (RR) 28 breaths per minute, and temperature 96.2° F

(35.6° C). His neurological exam reveals that his right pupil is at 6 mm and

reacts sluggishly; his left pupil is 4 mm and reacts briskly. He is nonverbal,

extends his arms bilaterally to pain, and opens his eyes minimally to pain.

1. What is the clinical significance of Mr. Smith’s blood pressure?

1. Determine Mr. Smith’s GCS using the assessment data above:

____________

1. What does Mr. Smith’s GCS indicate in terms of his probable outcome?

1. Joan Walkeris an 84-year-old female who has had a productivecough of green phlegm that startedfour days ago thatpersists. She wasstarted three daysago on prednisone 40 mg PO daily and azithromycin 250 mg PO x5 days by her clinic physician. She had a fever yesterday of 102.1, so she was admitted to the med-surg unit with a diagnosis of pneumonia. At 0330, the nurse hears a loud crash in Ms. Walker’s room. You rush in and find her lying on the floor. She states she fell trying to use the BSC. The patient is alert and oriented and denies pain anywhere. She says she’s fine and not hurt at all. The nurse assesses the patient and finds no evidence of injury. VS and assessment are unchanged from the earlier shift assessment.  Prioritize how the nurse should handle this situation.