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
1
, 5. Identify at least six findings that would indicate this complication (listed in #4)
is occurring.
• Changes in LOC
2
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
1
, 5. Identify at least six findings that would indicate this complication (listed in #4)
is occurring.
• Changes in LOC
2
