NURS 392Module 9 Case Study

Patient Profile D.G., a 19-year-old male, was brought to the emergency department following a motor vehicle accident (primary ICP) in which he was the driver. He is transferred to the Neuro-Trauma Intensive Care Unit with a diagnosis of traumatic brain injury. Subjective Data  Multiple family members and friends in the waiting room  D.G.'s girlfriend died on scene  Hospital chaplain present Objective Data Physical Examination  Glasgow coma scale 4 o Less than 8!! In coma  Neurologic Assessment: o Pupils 4 mm and sluggish  Normal pupil size in adults varies from 2-4mm.  Sluggish responses indicate early pressure on CN III. o Decerebrate posturing  Extension – stage 4 ICP o Periorbital ecchymosis  Raccoon eyes – basilar skull fracture.  Clear drainage from nares is positive for glucose o Indicates CSF leaking from the nose; generally associated with a tear in the dura and subsequent leakage of CSF with basilar skull fracture; confirms the fracture has traversed the dura; increases risk for meningitis Diagnostic Studies  Computed tomography (CT) scan  Subdural hematoma compressing the ipsilateral (same side as the bleed) ventricle and causing a midline shift (brain moves away from the side of the lesion, drifting away from midline) Collaborative Care  Admission orders include: This study source was downloaded by from CourseH on :04:43 GMT -05:00 o Multiple line placements: Arterial monitoring, central venous pressure line, ventriculostomy, and jugular bulb oximetry  Arterial monitoring – direct measurement of BP; measures O2 and CO2 concentration in the blood;  CVP line – measures pressure of the blood as it returns to the heart  Ventriculostomy – gold standard; direct pressure within ventricles  Jugular bulb oximetry – measurement of jugular venous O2 saturation, indicating total venous brain tissue extraction of oxygen; measure of cerebral supply/demand (normal 55-75%; 50% impaired cerebral oxygenation)  o Keep cerebral perfusion pressure (CPP) 70 mm Hg o Begin standing orders for:  propofol (Diprivan) – IV anesthetic sedative (pg. 1367)  midazolam (Versed) – light sedation  ranitidine (Zantac) – proton pump inhibitor (used to protect stomach from stress response and increased acid secretion)  phenytoin (Dilantin) – anti-epileptic (anticonvulsant) o Continuous cardiac monitoring (monitor for V/S changes, which can indicate worsening ICP) o Urinary catheter with strict I&O measurements (monitor for insensible losses and fluid/electrolyte imbalances) o Neuro checks every hour (assess for decreased LOC, pupillary dilation, etc.)