Acute Head Injury

Please provide complete, thorough, and detailed answers to all questions in the case study. Multiple-choice answers should include the correct choice and rationale for that choice and/or rationale why other choices are incorrect.


Case Study Acute Head Injury


Difficulty: Advanced

Setting: Hospital

Index Words: head injury, trauma, crisis management, neurologic assessment

Giddens Concepts: Clinical Judgment, Culture, Intracranial Regulation

HESI Concepts: Assessment, Clinical Decision Making, Culture, Intracranial Regulation, Nursing Interventions






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.

· Scenario



1. What steps will you take to assess J.R.?








2. List at least five components of a neurologic examination.









3. What types of injuries may J.R. have sustained?







4. What complication common to each of these diagnoses concerns you most?







5. Identify at least six findings that would indicate this complication is occurring.



Part 1 Medical-Surgical caSeS






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6. What is the most sensitive indicator of neurologic change?






Case Study Progress

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?






Case Study Progress

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.


8. What is this response called and what does it signify?







9. Calculate J.R.’s GCS score. Describe the clinical implications of this score.











10. What is the likely cause of the change in J.R.’s neurologic status?







11. What are your nursing priorities at this time?







12. What immediate actions will you take?







13. His vital signs are now 160/72, 64, 10, 98.7 ° F (37.1 ° C), and Spo2 94%. What is your concern and why?

Case Study Progress

the physician arrives and gives the orders shown in the chart.



Physician’s Orders

Insert Foley catheter

Insert nasogastric tube to continuous low wall suction

Intubate: Vent settings assist-control 16, V 900 mL, Fi


o 0.5, PEEP (positive end-expiratory


pressure) 3 cm

IV fluid 0.9% normal saline at 100 mL/hr 160 g Mannitol IV STAT over 30 minutes

Phenytoin (Dilantin) 1360 mg IV STAT over 30 minutes, then 100 mg IV tid STAT CT scan

STAT trauma labs: CBC, CMP, UA, type and cross, PT/INR and PTT, ABGs, toxicology screen

Chart View



14. Outline a plan for implementing these orders.








15. What is Mannitol, and why is it being administered to J.R.?








16. What is the expected outcome associated with administering phenytoin to J.R.?

Case Study Progress

J.R. is transported to radiology for a Ct scan; he is found to have a large epidural hematoma on the right with a hemispheric shift to the left. He is taken straight to the operating room for evacuation of the hematoma. While he is in surgery, J.R.’s family arrives with their faith healer. they ask that their faith healer anoint J.R. and pray over him.




17. How should you respond?











Case Study Progress

Postoperatively J.R. is admitted to the neurologic ICU.


18. What assessment indicators will be closely monitored in J.R.?







19. Identify eight independent nursing interventions and the rationale for each that would be used to prevent increased intracranial pressure (ICP) in the first 48 postoperative hours.