11/17/23, 11:19 AM Unfolding Case Study Traumatic Brain Injury
Unfolding Case Study- Traumatic Brain Injury
A 51-year-old male client who sustained a closed head injury was brought to the emergency department
(ED) this morning by emergency medical services (EMS). The client was accompanied by his wife who
reported that he fell from a ladder while trying to clean the gutters on their house. On arrival to the
hospital, the client was alert and responding appropriately to questions wearing a neck collar that was
applied by first responders for neck stabilization. Vital signs: temperature= 98.7 º F (37º C), apical heart
rate= 78 beats/min and regular, respirations=18 breaths /min, blood pressure (BP)= 126/78 mm Hg,
Oxygen saturation is 95% on room air. The client reported a mild headache of 3/10 on a 0 to 10 pain
intensity scale. Cardiac monitor reading revealed normal sinus rhythm. The client denied nausea or
vomiting. Glasgow Coma Scale score= 15; PERRLA. In addition to routine lab work, a computed
tomography (CT) scan of the brain and cervical and spinal x-rays were performed. The CT scan of the
brain showed regions of hypodensity. Two hours later, the client was transferred to the acute
neurological unit. The unit admission assessment was the same as the baseline assessment in the ED.
The client was placed on bedrest with the head of the bed elevated, and a lunch tray was requested.
1. Highlight the client findings below that are of immediate concern to the nurse.
The nurse performs a neurological check on the client about an hour after lunch. Vital signs:
Temperature= 98.8º F (37.1º C), apical Heart Rate= 60 beats/min, and regular Respirations= 16 breaths/
min, Blood pressure= 142/68 mmHg, Oxygen saturation is 92% on RA. The client reports a headache of
5/10 on a 0 to 10 pain intensity scale and has a new onset of nausea. Glasgow Coma scale= 12. The client
seems sleepy and confused as to where he is, but he responds to localized painful stimuli and opens his
eyes in response to sound. Slight pupil dilation is noted in the right eye.
2. Choose the most likely options for the information missing form the statement below by selecting
form the lists of options provided.
The nurse recognizes that the client’s decline in neurological status is likely the result of
_______1______2_____caused by _________2__3_________.
Option for 1 Option for 2
Dehydration Hospitalization
Increasing intracranial pressure Low oxygen saturation
Sensory deprivation Intracranial bleeding
Hypoxia Hypertension
Increasing headache pain Inadequate fluid intake
about:blank 1/3
Unfolding Case Study- Traumatic Brain Injury
A 51-year-old male client who sustained a closed head injury was brought to the emergency department
(ED) this morning by emergency medical services (EMS). The client was accompanied by his wife who
reported that he fell from a ladder while trying to clean the gutters on their house. On arrival to the
hospital, the client was alert and responding appropriately to questions wearing a neck collar that was
applied by first responders for neck stabilization. Vital signs: temperature= 98.7 º F (37º C), apical heart
rate= 78 beats/min and regular, respirations=18 breaths /min, blood pressure (BP)= 126/78 mm Hg,
Oxygen saturation is 95% on room air. The client reported a mild headache of 3/10 on a 0 to 10 pain
intensity scale. Cardiac monitor reading revealed normal sinus rhythm. The client denied nausea or
vomiting. Glasgow Coma Scale score= 15; PERRLA. In addition to routine lab work, a computed
tomography (CT) scan of the brain and cervical and spinal x-rays were performed. The CT scan of the
brain showed regions of hypodensity. Two hours later, the client was transferred to the acute
neurological unit. The unit admission assessment was the same as the baseline assessment in the ED.
The client was placed on bedrest with the head of the bed elevated, and a lunch tray was requested.
1. Highlight the client findings below that are of immediate concern to the nurse.
The nurse performs a neurological check on the client about an hour after lunch. Vital signs:
Temperature= 98.8º F (37.1º C), apical Heart Rate= 60 beats/min, and regular Respirations= 16 breaths/
min, Blood pressure= 142/68 mmHg, Oxygen saturation is 92% on RA. The client reports a headache of
5/10 on a 0 to 10 pain intensity scale and has a new onset of nausea. Glasgow Coma scale= 12. The client
seems sleepy and confused as to where he is, but he responds to localized painful stimuli and opens his
eyes in response to sound. Slight pupil dilation is noted in the right eye.
2. Choose the most likely options for the information missing form the statement below by selecting
form the lists of options provided.
The nurse recognizes that the client’s decline in neurological status is likely the result of
_______1______2_____caused by _________2__3_________.
Option for 1 Option for 2
Dehydration Hospitalization
Increasing intracranial pressure Low oxygen saturation
Sensory deprivation Intracranial bleeding
Hypoxia Hypertension
Increasing headache pain Inadequate fluid intake
about:blank 1/3
