10/16/24, 1:37 NUR2214 C Case study – traumatic brain
PM injury
NUR2214C
Case study – traumatic brain injury
Meet the Client
A group of adolescents has gathered at a park drinking beer. At the end of the outing, they get into an
automobile driven by one of the teens. Before even getting out of the park, the teen driver hits a tree
and the air bags are deployed. Looking around, everyone seems alright except the unconscious teen in
the passenger seat who was not wearing a safety belt. The group decides to drop their friend off at
the local hospital emergency department, hoping to avoid getting in trouble for underage drinking.
Section 1 – Traumatic brain injury
1. The unconscious client is hurriedly brought into the ED, and several nurses begin
assessments. Which assessment techniques are used to determine if this client has a
traumatic brain injury? (SATA)
• Assess for tinnitus or hearing difficulty. These are manifestations of a basilar skull
fracture.
• Observe the area behind the client’s ears. Battle’s sign refers to ecchymosis behind the
ears, and it is a common manifestation of a traumatic brain injury.
• Observe the area around the client’s eyes. Periorbital ecchymosis, also called “raccoon
eyes,” is a common manifestation of a basilar skull fracture along with a positive Battle’s
sign.
• Check the client’s ear cavity for leaking fluid. Otorrhea is cerebrospinal fluid leakage
from the ear and generally confirms that the fracture has transversed the dura.
The nurse is concerned about the rhinorrhea that the client is experiencing.
2. What method can the nurse use to determine if the drainage is CSF?
• Observe for a halo around a spot of drainage. When a drop of the drainage is placed on
a white dressing, the CSF will separate from the blood and form a “halo” around the
blood. Other measures the nurse can use include observing the appearance of the
drainage and using a dextrostick to assess for the presence of glucose in the drainage.
CSF is clear. However, the CSF may be mixed with blood, so appearance alone may not
be a true indicator of CSF. CSF contains glucose, unlike normal nasal drainage. However,
a false positive for glucose may be obtained if the CSF is mixed with blood, since blood
also contains glucose.
Section 2 – Nursing plans and interventions
The nurse applies a sterile nasal drip pad and initiates interventions to prevent increased intracranial
pressure (ICP).
3. Which nursing intervention should be initiated to prevent increased ICP for this client?
• Keep the head of the bed elevated at 30 degrees. Activities such as performing a
Valsalva maneuver, coughing, and vomiting should be prevented, since they may cause
an increase in ICP. In addition, the client should be positioned with the head of the bed
elevated about 30 degrees, and neck flexion and extension should be avoided.
about:blan 1/
k 6
, 10/16/24, 1:37 NUR2214 C Case study – traumatic brain
PM injury
4. The client is awake and requests something for a headache. Which medication is best for
the nurse to administer?
• Acetaminophen. This is the best choice, because acetaminophen is a non-opioid
analgesic, and it will not cause CNS depression.
Section 3 – Glasgow Coma Scale (GCS)
5. Which components are measured by the GCS?
• Verbal response, motor response, and eye opening. The GCS measures responses that
are spontaneous and completely oriented to responses only from noxious stimuli to no
response at all. The client is observed for abnormal decorticate (flexor) and decerebrate
(extensor) posturing as part of the motor response to a stimulus.
Section 4
The client is medicated and reports that the headache is relieved. The nurse continues to monitor the
client’s vital signs and neurological status is assessed using the GCS. The nurse’s assessment findings are
as follows: Client’s eyes open in response to verbal stimuli. Client is oriented to person only. Client pulls
arm away and moves arm in response toa needle prick.
6. What is the GCS rating obtained in this assessment?
• 11
about:blan 2/
k 6
PM injury
NUR2214C
Case study – traumatic brain injury
Meet the Client
A group of adolescents has gathered at a park drinking beer. At the end of the outing, they get into an
automobile driven by one of the teens. Before even getting out of the park, the teen driver hits a tree
and the air bags are deployed. Looking around, everyone seems alright except the unconscious teen in
the passenger seat who was not wearing a safety belt. The group decides to drop their friend off at
the local hospital emergency department, hoping to avoid getting in trouble for underage drinking.
Section 1 – Traumatic brain injury
1. The unconscious client is hurriedly brought into the ED, and several nurses begin
assessments. Which assessment techniques are used to determine if this client has a
traumatic brain injury? (SATA)
• Assess for tinnitus or hearing difficulty. These are manifestations of a basilar skull
fracture.
• Observe the area behind the client’s ears. Battle’s sign refers to ecchymosis behind the
ears, and it is a common manifestation of a traumatic brain injury.
• Observe the area around the client’s eyes. Periorbital ecchymosis, also called “raccoon
eyes,” is a common manifestation of a basilar skull fracture along with a positive Battle’s
sign.
• Check the client’s ear cavity for leaking fluid. Otorrhea is cerebrospinal fluid leakage
from the ear and generally confirms that the fracture has transversed the dura.
The nurse is concerned about the rhinorrhea that the client is experiencing.
2. What method can the nurse use to determine if the drainage is CSF?
• Observe for a halo around a spot of drainage. When a drop of the drainage is placed on
a white dressing, the CSF will separate from the blood and form a “halo” around the
blood. Other measures the nurse can use include observing the appearance of the
drainage and using a dextrostick to assess for the presence of glucose in the drainage.
CSF is clear. However, the CSF may be mixed with blood, so appearance alone may not
be a true indicator of CSF. CSF contains glucose, unlike normal nasal drainage. However,
a false positive for glucose may be obtained if the CSF is mixed with blood, since blood
also contains glucose.
Section 2 – Nursing plans and interventions
The nurse applies a sterile nasal drip pad and initiates interventions to prevent increased intracranial
pressure (ICP).
3. Which nursing intervention should be initiated to prevent increased ICP for this client?
• Keep the head of the bed elevated at 30 degrees. Activities such as performing a
Valsalva maneuver, coughing, and vomiting should be prevented, since they may cause
an increase in ICP. In addition, the client should be positioned with the head of the bed
elevated about 30 degrees, and neck flexion and extension should be avoided.
about:blan 1/
k 6
, 10/16/24, 1:37 NUR2214 C Case study – traumatic brain
PM injury
4. The client is awake and requests something for a headache. Which medication is best for
the nurse to administer?
• Acetaminophen. This is the best choice, because acetaminophen is a non-opioid
analgesic, and it will not cause CNS depression.
Section 3 – Glasgow Coma Scale (GCS)
5. Which components are measured by the GCS?
• Verbal response, motor response, and eye opening. The GCS measures responses that
are spontaneous and completely oriented to responses only from noxious stimuli to no
response at all. The client is observed for abnormal decorticate (flexor) and decerebrate
(extensor) posturing as part of the motor response to a stimulus.
Section 4
The client is medicated and reports that the headache is relieved. The nurse continues to monitor the
client’s vital signs and neurological status is assessed using the GCS. The nurse’s assessment findings are
as follows: Client’s eyes open in response to verbal stimuli. Client is oriented to person only. Client pulls
arm away and moves arm in response toa needle prick.
6. What is the GCS rating obtained in this assessment?
• 11
about:blan 2/
k 6
