J.R. is a 28-year-old man who was doing home repairs. He fell from…

Question Answered step-by-step J.R. is a 28-year-old man who was doing home repairs. He fell from… 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.What steps will you take to assess J.R.?List at least five components of a neurologic examination.What types of injuries may J.R. have sustained?What complication common to each of these diagnoses concerns you most?Identify at least six findings that would indicate this complication is occurring.What is the most sensitive indicator of neurologic change?Case Study ProgressYou complete your neurologic examination and find the following: Glasgow Coma Scale (GCS) score of15; pupils equal, round, reactive to light; and full sensation intact. J.R. complains of a headache and issomewhat 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.What are the next actions you will take?Case Study ProgressWhile 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 themanner shown in the illustration.Illustration view link is attached: https://ibb.co/3my7bRVWhat is this response called and what does it signify?Calculate J.R.’s GCS score. Describe the clinical implications of this score.What is the likely cause of the change in J.R.’s neurologic status?What are your nursing priorities at this time?What immediate actions will you take?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 ProgressThe physician arrives and gives the orders shown in the chart.Chart ViewPhysician’s OrdersInsert Foley catheterInsert nasogastric tube to continuous low wall suctionIntubate: Vent settings assist-control 16, VT 900 mL, Fio2 0.5, PEEP (positive end-expiratorypressure) 3 cmIV fluid 0.9% normal saline at 100 mL/hr (keep it at 10ml hour since there is no indication that he needs fluid)160 g Mannitol IV STAT over 30 minutesPhenytoin (Dilantin) 1360 mg IV STAT over 30 minutes, then 100 mg IV tidSTAT CT scanSTAT trauma labs: CBC, CMP, UA, type and cross, PT/INR and PTT, ABGs, toxicology screenOutline a plan for implementing these orders.What is Mannitol, and why is it being administered to J.R.? What must you consider when administering this medication?What is the expected outcome associated with administering phenytoin to J.R.?Case Study ProgressJ.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.How should you respond?Case Study ProgressPostoperatively J.R. is admitted to the neurologic ICU.What assessment indicators will be closely monitored in J.R.?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. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)