Case for Icp

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The nurse is caring for a middle-aged adult male client who is presenting to the emergency department with a severe headache, neck pain, and vomiting several hours after being involved in a motor-vehicle collision. The client is responding appropriately to verbal stimuli and is moving all extremities to command and contusions are noted around the cranium and left orbit. Questions: 1. Which assessments should the nurse perform at this time? List 3 assessments with rationales. 1. Assess vital signs, cranial nerves, and GCS to see if there is any involvement from the accident, a non-reactive pupil can indicate a bleed in the brain needing attention. A baseline GCS can help determine if the patient is improving or worsening. A score of 8 or higher indicates a better chance of survival. 2. Check to see if there is CSF leakage from the nose or ear because this would confirm a fracture and is associated with a tear in the Dura. 3. Assess if there are any lacerations on the scalp and obtain details from him, such as next of kin, allergies, current medications, etc. This way if the patient declines, information is provided to the HCP and treatment becomes easier (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1439-1445). 2. Two hours later, the client becomes less responsive to verbal stimuli, the blood pressure is elevated and the client is not able to move extremities against gravity or resistance. What should the nurse do next? Explain your rationale. o Administer oxygen through a non rebreather mask to ensure patient is getting enough oxygen to his brain. Then I’d establish two large bore catheter IV sites and prepare for surgical intervention as I’d suspect an epidural hematoma, which needs surgery to be removed. Managing the increased intracranial pressure would also be a necessity (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1441).

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