Case Study Progression Assignment Help: How to Answer This Question
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Original Question
CASE STUDY PROGRESSION As Lakisha reminisces about his years playing football, she says, “At the time I thought that it was so painful and unfair that Jordan had to experience that. I now realize that this head injury from the automobile accident is much worse! I wish that Jordan would wake up and come off the breathing machine.” Name: Jordan Johnson Allergies: NKDA Age: 19 years Code Status: Full code Health Care Provider: Susan Hartman, MD NURSING NOTE October 25, 2021 Temp 97.2°F (36.2°C), HR60, BP 122/75(91), RR 16,SpO2 97%on 50% FIO2; SIMV 12; TV800; Eyes open to painful stimuli, pupils equal but sluggish to respond to light, 3 mm; No attempt to track with eyes; Does not appear to recognize his mother; Withdraws arms away from pain. No spontaneous movement of lower extremities. Intracranial pressure monitorzeroed. Intracranial pressure (ICP) = 16 mmHg per subdural screw (bolt)monitor. Glasgow Coma Scale (GCS) Behavior Response Eye-Opening 4. Spontaneously 3. To speech 2. To pain 1. No response Total Score Best Score: 15 Comatose: 8 or less Unresponsive: 3 Verbal 5. Oriented to time, person and place 4. Confused 3. Inappropriate words 2. Incomprehensible sounds 1. No response Motor 6. Obeys command 5. Moves to localized pain 4. Flex to withdraw from pain 3. Abnormal flexion 2. Abnormal extension 1. No response QUESTION #4 (2 Points) The nurse completes the neurological assessment on Jordan. How should the nurse rate his condition using the information and the Glasgow Coma Scale (GCS) provided above? 3 5 7 9 QUESTION #5 (2 points) What assumptions can the nurse make, based on the GCS? The number fluctuates hourly and is inaccurate. The number shows a minimal amount of brain damage. Jordan’s number correlates with severe brain injury. Jordan will likely make a full recovery. QUESTION #6 (4 points) The nurse recognizes the signs of increased intracranial pressure from the baseline assessment. Which assessment finding(s) support(s) this assumption? (SELECT ALL THAT APPLY.) Heart rate 58 beats per minute. Widened pulse pressure. Decreased mental abilities. Intracranial pressure of 16 mmHg. Temperature QUESTION #7 (2 points totals) (1 point for correct answer / 1 for proper rationale) The nurse has each of these medications prescribed. Which medication should the nurse hold and why? Mannitol 5% 1.5 g/kg IV once, infuse over 30 minutes. Phenobarbital 2 mg/kg IV Q 24 hours. Acetaminophen 650 mg PR Q 4 hours PRN Labetalol 20 mg IV PRN Q 10 mins for SBP >180 Why should the medication be held?
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