Scenario #1-
Question Answered step-by-step Scenario #1- Mr. Doe is a 74 y/o male that was admitted to your hospital unit for diagnostic testing. He has a known brain tumor and is having further diagnostic studies tomorrow morning. He came through the ER this morning with complaints of feeling weaker than usual and headaches for the last week. Upon physical assessment he was alert and oriented x 3 with normal speech pattern, pupils round, equal, and reactive to light. He was able to move all extremities equally on both sides but reports generalized weakness. No further neurological deficits were noted. He reports a mild headache of a 3/10 on the pain scale. He just completed dinner and tolerated it well. Vital signs upon assessment were T-98.2 P-72 R-18 B/P- 132/76 A few hours later, your nursing assistant informs you that Mr. Doe has just vomited and is requesting the nurse. Upon assessment you find Mr. Doe does not want the lights turned on as he states the lights are “bothering him” and he is lying flat in the bed with the pillow over his face. He complains of an increased headache rating his pain a 10/10. What should be your nursing actions at this point? Upon further assessment, you find that Mr. Doe is speaking more slowly than earlier in the day. His pupils are slightly different with one at a 3mm measurement and one at a 5mm measurement. Both are reactive to light, but the left is slower to constrict with light. During your assessment, Mr. Doe does not demonstrate any difference in his strength to the upper and lower extremities. He does however have another episode of vomiting. His vital signs areT-98.4 P-60 R-16 B/P- 168/78What might you consider is happening with Mr. Doe? What does his blood pressure (in combination with his symptoms) possibly indicate? What will be your nursing actions at this point? What type of medications might you expect the physician to order? What diagnostic testing might you expect the physician to order? What neurological condition may happen if Mr. Doe isn’t treated fairly quickly? What could ultimately happen to Mr. Doe if he is left untreated? Based upon what is happening with Mr. Doe what safety interventions will you put into place? Health Science Science Nursing NUR 230 Share QuestionEmailCopy link Comments (0)
