NERVOUS SYSTEM ALTERATION CASE DISCUSSION:
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.
No citations are needed.
