Richard Hammond is a 48-year-old male who sustained a traumatic brain injury as a result of crashing a high speed jet powered car. On admission, his blood pressure (BP) was 158/72 mm Hg, heart rate (HR) 46 beats per minute, respiratory rate (RR) 28 breaths per minute, and temperature 96.2° F (35.6° C). His neurological exam reveals that his right pupil is at 6 mm and reacts sluggishly; his left pupil is 4 mm and reacts briskly. He is nonverbal, extends his arms bilaterally to pain, and opens his eyes minimally to pain. He is quickly intubated and placed on mechanical ventilation. A computed tomography (CT) scan is done, which reveals a large right subdural hematoma with cingulate herniation from right to left, as well as right-sided uncal herniation.
He is taken to surgery emergently for a craniotomy to remove the subdural hematoma. After surgery, he arrives in the critical care unit with a ventricular catheter to measure intracranial pressure (ICP). His initial ICP is 24 mm Hg, BP 130/67 mm Hg, mean arterial pressure (MAP) 88 mm Hg, HR 54 beats per minute, RR 12 breaths per minute (controlled ventilation), and temperature 96.1° F (35.5° C). His current Glasgow Coma Scale (GCS) score is 3, but the anesthesiologist did not reverse the anesthesia, choosing to allow it to wear off gradually. He has orders for 3% saline at 20 mL/hr intravenously.
QUESTIONS FOR CONSIDERATION AND CARE PLANNING:
- Based on the information provided, what is Mr. Hammond’s preoperative GCS calculation?
- What is the significance of this number and how would the nurse describe this to two concerned gentlemen waiting to hear his condition and prognosis?
- Anatomically, what is the cause of his pupillary changes?
- Which of his postoperative findings are of the greatest concern?
- Why is the 3% saline ordered, and how will the nurse know if it is effective?
- Five extra points awarded if you can name the two gentlemen AND state under what circumstances you could share this information as stated in question #2.
Rubric
Neuro Case with EC
| Criteria | Ratings | Pts | |
|---|---|---|---|
| This criterion is linked to a Learning Outcome Accuracy, Clarity and Brevity The written responses are brief and to the point. No non-essential information is included while all pertinent data is present. Primary assessment of the case study is correct. | 100 ptsFull MarksClear and accurate responses are provided without extra information. All questions accurately addressed.80 ptsMost CreditNo more than one response is missing vitally important data. No more than one response contains non-essential information to a significant degree.60 ptsPartial CreditNo more than two responses are missing vitally important data. No more than two responses contain non-essential information to a significant degree. Primary identification of condition is incorrect.0 ptsNo CreditIncorrect primary assessment of the case study. Not submitted on time. Multiple instances of missing vital information needed to address the situation in the case study. | 100 pts | |
| This criterion is linked to a Learning OutcomeExtra Point Name the two gentlemen and how you can share the info. | 5 ptsFull MarksBoth names (first and last). Under what circumstance may the nurse share info?0 ptsNo MarksAny missing data. | 5 pts | |
| Total Points: 105 | |||
Requirements: 5-6 SENTENCES PER QUESTION
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