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.?
 First I would assess his airway to make sure it is patent and nothing is
prohibiting him from getting air in
 The I would assess his breathing to see if he is in distress, listen to
lung sounds, count respirations, and assess chest expansion
 Check Circulation assessing blood loss from laceration, by feeling for
pulses, cap refill, checking for cyanosis and checking BP
 Lastly I would perform Glasgow coma scale to assess LOC

2. List at least five components of a neurologic examination.
 Level on consciousness
 Motor function
 Pupillary function
 Respiratory function
 Vital signs


3. What types of injuries may J.R. have sustained?
 Due to blunt trauma from J.R. falling from a ladder and hitting his
head on a rock he may have sustained some type of traumatic
brain injury such as skull fracture, concussion, contusion, or
cerebral hematoma.


4. What complication is common to each of these diagnoses (listed in #3)
concerns you most?
 These injuries run the risk of increasing intracranial pressure

5. Identify at least six findings that would indicate this complication
(listed in #4) is occurring.
 Changes in LOC



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,  Changes in speech
 Vomiting
 Changes in vitals: increased SBP, decreased pulse, decreased
respirations
 Headache
 Changes in pupillary functions: impaired eye movements,
papilledema


6. What is the most sensitive indicator of neurologic change?
 The most sensitive indicator of neurologic change would be a
change in level of consciousness. This is because a patients level
of consciousness deteriorates before any other neuro changes
are noticed.


Case Study Progression
You complete your neurologic examination and find the following: Glasgow Coma
Scale (GCS) score of 15; pupils equal, round, reactive to light; and full sensation
intact. J.R. complains of a headache and is somewhat drowsy. His vital signs (VS) are
120/72, 114, 30, 98.7 ° F (37.1 ° C) and Spo2 94%. As the radiology technician
performs a portable cross-table lateral cervical spine x-ray examination, J.R. begins
to speak incoherently and appears to drift off to sleep.


7. What are the next actions you will take?
 My next action would be to try to arouse/ wake up J.R. Next I
would reassess J.R. by repeating GCS and vital signs. I would also
assess for the oculocephalic reflex to see if J.R. is experiencing
some brainstem injury.

Case Study Progression
While waiting for the physician to arrive, you find that J.R. has become unresponsive
to verbal stimuli. The right pupil is larger than the left and does not respond to light.
J.R. responds to painful stimuli in the manner shown in the illustration.




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