Reference no: EM133502893

Case Scenario:

Amy Braden, age 24, was in the passenger seat of a car driven by her boyfriend when they were hit from behind by a truck whose brakes failed. Amy was wearing a seat belt, but hit her head on the dashboard. When the paramedics arrived, she was unconscious with significant head and facial bleeding. Her boyfriend had minor injuries, and is also being treated in the emergency department.

This activity contains 6 questions:

The nurse in the ED takes Amy's vital signs that reveal; T 36.1°C., P 88, R 22, and BP 108/58. Amy begins to show signs of arousal, and the nurse assesses her neurological function by using the Glasgow Coma Scale.

What is this scale, and how does the nurse use this scale in their assessment?

Amy's total score on the Glasgow Coma Scale prior to arrival in the ED was 3, while the current score is 7. The assessment reveals the following: Eye-opening response: 2 (Responds to painful stimuli.) Best motor response: 3 (Responds to stimuli by abnormal flexion.) Best verbal response: 2 (Responds to stimuli by incomprehensible sounds.)

What is the nurse's interpretation of the meaning of her scores?

Amy is sent for an MRI of the brain. What does the nurse understand as the reason for this test, and what data is it expected to reveal?

The MRI results reveal that Amy has not suffered a fracture or brain hemorrhage; however, she does have brain edema from the injury. Amy's V.S. remain stable; her oxygen saturation level is 93% on 2L of O2.

Given this data, what is the nurse's primary concern?

When Amy regains consciousness, what other areas of neurological functioning does the nurse need to assess?

Suppose Amy's condition worsened, and increased cerebral edema led to dysfunction of the brainstem. What are the most important deficits to which the nurse should be alert in this situation?