INSTRUCTIONS: 1. All s apply to this case study. Your… INS
INSTRUCTIONS: 1. All s apply to this case study. Your… INSTRUCTIONS:1. All s apply to this case study. Your responses should be detailed and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. ScenarioJ.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. Differentiate between a primary and secondary head injury.2. What steps will you take to assess J.R.?3. List at least five components of a neurologic examination. 6 Emergency4. What is the most sensitive indicator of neurologic change?5. What are the next actions you will take?You find that J.R. has become unresponsive to verbal stimuli and responds to painful stimuli by abnormally flexing his extremities (decorticate movement). He has no verbal response. The right pupil is larger than the left and does not respond to light. 6. What is J.R.’s GCS score at this time? Indicate what this means.7. You summon the physician. Based on the GCS score, what are the next steps you will take?8. What is a normal intracranial pressure (ICP), and why is increased ICP so clinically important?9. Identify at least five signs and symptoms of increased ICP.10.The physician orders a 25% mannitol solution IV. What is mannitol, and why is it being administered to J.R.?J.R. is transported to radiology for a CT, where he is found to have a large epidural hematoma on the right with a hemispheric shift to the left. He will be taken straight to the operating room (OR) for evacuation of the hematoma. While enroute from the CT scan to the OR, the physician instructs the respiratory therapist to initiate hyperventilation of the patient to “blow off more CO2.” 11.What is the rationale for this action?12.While he is in surgery, J.R.’s family arrives at the ED with their faith healer. They ask that their faith healer anoint J.R. and pray over him. What should the nurse say? After J.R.’s surgery he is admitted to the neurological intensive care unit (NICU). 13.What assessment indicators will be closely monitored in J.R.?14.J.R. has ICP monitoring in place with an intraventricular catheter. Nursing interventions related to J.R.’s are while the catheter is in place include: (Select all that apply.) a. Continuously monitoring the ICP waveforms.b. Using aseptic technique when setting up the device.c. Maintaining a cerebral perfusion pressure of 60 mmHg.d. Leveling the transducer even with the foramen of Monroe.e. Administering prophylactic antibiotic therapy.f. Notifying the physician if the ICP is greater than 30 mm Hg.15.List four medication classifications that NICU nurses could use to decrease or control increased ICP and the rationale for using each.16.Explain at least eight independent nursing interventions and the rationale for each that would be used to prevent increased ICP in the first 48 postoperative hours.17.Given the above case make an integrated pathophysiology, taking into consideration the diagnostic examinations and therapeutics (medications). Please use the format for the pathophysiology. DISEASE PROCESS – will indicate mode of entry (if applicable), organs involve or affected; described in diagram and narrative form the pathogenesis of a disease, the biological mechanism (or mechanisms) progress of disease showing its morphological features or that leads to the diseased state. SYMPTOMATOLOGY – can be multiple. Should include the positive and negative pertinent findings.Each sign and symptom should yield to a specific assessment/diagnostics and possibly management. DIAGNOSTICS/ LABORATORY CONFIRMATORY TEST – should be based on the signs and symptoms and the specific stage of disease process, and this will include a. Physical Assessment of the affected system. b. Medical Diagnostics may include IDEAL or potential diagnostic procedures. c. Nursing Diagnosis (NANDA) MANAGEMENT a. Medical – includes procedures ( ex. NGT, intubation, suctioning, BT,etc.) and drugs (including IV, parenteral feeding, ) b. Surgical – if there is c. Nursing – nursing interventions based on the formulated nursing diagnosis PROGNOSIS The predicted outcome of a disease and the chance of recovery if treatment is applied and if no treatment has been initiated to the patient. 18.Formulate 2 NCP for the above case. Health Science Science Nursing BSN 15
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