NUR 401 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, ...
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
1
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