Head Trauma Case Study-J.R

Head Trauma Case Study-J.R Head Trauma Case Study NUR 401 Scenario: 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. 1. What steps will you take to assess J.R.? a. Primary Survey: ABCDE (with a focus on D with possible head trauma) i. Airway- Make sure he has a patient airway ii. Breathing- Make sure that the patient is able to breathe on his own and that he is getting oxygen to his system based on color or breathing efforts. iii. Circulation- Making sure that he is perfusing all his tissues in his body. I would assess his laceration for any signs of hemorrhage. iv. Disability- I would assess his neuro status due to falling. I would check his brain function along with sensation and movement of extremities. (C-spine collar already in place) v. Exposure- I would review his body for any other injuries that are not obvious from the story b. Secondary Survey: Get a history of the events leading up to his fall, any other medical history, vital signs, and any diagnostic test and monitors as ordered 2. List at least five components of a neurologic examination. 1. Level of Consciousness 2. Motor Function 3. Pupillary Function 4. Respiratory Function 5. Vital Signs 3. What types of injuries may J.R. have sustained? 1. Skull Fracture 2. Concussion 3. Contusion 4. Cerebral hematoma (Leaning this way due to laceration) a. Epidural b. Subdural