NR 340 Week 7 Case Study 2020; Neuro

NR 340 Week 7 Case Study 2020; Neuro

Critical Care Case Study

Ms. J, a 27 year-old right-handed patient, was involved in a motor vehicle collision.  Ms. J was an unrestrained passenger in a car that swerved off the road and struck a tree.  She was ejected from the car and was found unconscious by the emergency medical service personnel. 

After being placed on a spinal board and placed in a cervical collar, she was transported by helicopter to the nearest trauma center.  She is somewhat combative and was not following commands at arrival.  Her pupils are reactive bilaterally left>right.  Her respiratory rate is 40 breaths per minute and labored.  She was intubated and placed on mechanical ventilation.  Additional treatment includes a right subclavian triple lumen catheter, arterial line, and foley catheter placement.  Initial evaluation of her cervical spine revealed no abnormal findings and the backboard and collar were discontinued.  Ms. J’s diagnostic data is as followed:

B/P- 90/40 mmHg

Heart rate- 100bpm

Respirations 40 breaths/minute

Temperature 36.7 degrees C (98 degrees F)

Pupils reactive left>right

Glasgow Coma Scale 9

Ms. J’s initial CT scan of the head revealed left temporal cerebral contusion with a midline shift of brain structures.  The CT scan revealed a left temporal parietal subdural hematoma.

Ms. J was taken to surgery for evacuation of the hematoma and placement of an ICP monitoring device.  She was transferred to critical care and intubation and mechanical ventilation was continued.  The following is her diagnostic data after surgery.

ICP- 25 mmHg

B/P 130/88 mmHg

Heart rate- 100 bpm

Respirations 12 breaths per minute

Temperature 37.8 degrees C (100 degrees F) pH 7.48

PaCO2- 40 mmHg PaO2- 434 mmHg

HCO3- 20.4 mmol/L

Ventilator settings are as followed:

Tidal Volume- 700 mL Rate 12 breaths/minute

FiO2 100%.

As Ms J, recovered from anesthesia, she opened her eyes to speech, and exhibited abnormal general flexion to obtain a Glasgow coma scale of 8.  Over the next 2 hours, Joyce’s body temperature increased to 38.3 degrees C (101 degrees F).  Despite interventions, Ms J’s ICP remained elevated.  Her serum osmolality was 282 mOsm/L. K level was 3.9 mmol/L and Sodium level was 139 mmol/L. Post-operative orders include the following:

Fluid restriction to maintain patient’s osmolality between 305-315 mOsm/L

Mannitol 25g IV times one now

Phenytoin (Dilantin) 100 mg IV every 6 hours

Ms. J’s ICP remained elevated for more than 72 hour, then gradually her pressure stabilized.  After 2 weeks in the intensive care unit, Ms J was transferred to a neurologic step-down unit and then to a head injury rehabilitation unit. 

1.       Identify the leading causes of head injury.

Ms. J sustained her head injuries from being ejected from the motor vehicle upon the car making impact with the tree.

2.       What was the rationale of placing Ms. J on a backboard and cervical collar?

Ms. J was placed on a backboard and in a cervical collar to stabilize her spine to prevent any further injury to her spinal cord.

3.       What is the Glasgow Coma Scale?  How is the scale helpful?