Reference no: EM133618794

Problem

Case Study TBI Part 1 History & Physical PMH: Exercise induced asthma, PSH: Tonsillectomy Allergies: Penicillin-Hives Presented to the ER via EMS fell off 4 ft platform hitting the back of her head. Witnesses report loss of consciousness for about 3 minutes. EMS arrived within 5 minutes after fall. Drowsy, restless, vomited X 1 prior to arrival. CT Scan of head ordered. Vital Signs 0815 0830 0915 Temperature 98.3 oral 98.9 oral 99.8 oral Respiratory Rate 18 16 14 Heart Rate 98 bpm 89 bpm 62 bpm Blood Pressure 136/85 140/74 154/60 Oxygen Saturation 97% RA 97% RA 95% RA Pain 9/10 back of head 9/10 back of head 10/10 back of head Nurses' Notes 0815: Client arrived via ambulance with c-collar on, backboard in place. According to EMS report client fell off a 4 ft platform and struck the back of her head. Co-workers witnessed fall and reported loss of consciousness for 2-3 minutes. Client is arousable but lethargic, PEARL, 2mm. Slurred speech, oriented to person & place, Client has poor attention and needs repeated direction for response. GCS: 13, IV with 18 gauge started in left antecubital with D5W at 100ml/hr. Skin clammy with pallor. No recollection of events. Bruising on the back of head. vomited brown tinged mucous. 0830: Client continued to be arousable but lethargic, PEARL, 2mm. Slurred speech, oriented to person, place, and events, delayed response to verbal response. Client has poor attention. GCS: 13, Lungs clear bilaterally, nonlabored breathing, less than 3 sec cap refill, Abdomen soft nontender with positive bowel sounds, + pedal pulses, no edema, Ondansetron 4mg IVP administered. 0835: Client transported to CT scan with RN to monitor. 0915: Client arrived back from CT scan. Client appears more confused, oriented to person only, more difficult to arouse. Does not follow simple commands or respond to questions. Eyes open and responds only to pain. GCS: 10. Pupils react sluggishly bilaterally, 2mm. Laboratory Results 0820 Reference Ranges WBC 11,430 microliter 4,500-11,000 microliter Hgb 10.9 g/dL 12.1-15.1 g/dL Hct 31.4% 36-48% Platelet 164,000 mm3 150,000-400,000 mm3 Client Name: Lilly Roberts DOB: Age: 3/5/20XX 21 years old Gender: Pronouns: Female She/her NUR 217 March 2023 Na 140 mEq/L 135-145 mEq/L K 3.6 mEq/L 3.6-5.2 mmol/L Cl 104 mEq/L 96-106 mEq/L BUN 18 mg/dL 6-24 mg/dL Creat 1.0 mg/dL 0.7-1.2 mg/dL eGFR 109 ml/min/1.73m2 Greater than 90 ml/min/1.73m2 Total CO2 24 mEq/L 23-29 mEq/L Glucose, nonfasting 105 mg/dL 70-99 mg/dL Imaging 0915 CT scan of head: 5 cm subdural hematoma in the left parietal region. Possible focus of hemorrhage (2 cm) in right frontal lobe. There is a midline shift of 6mm. Answer the following questions for TBI Case Study:

A. What assessment findings do you have immediate concerns about?

B. Why do you have concerns about these findings? What do these findings indicate?

C. What findings need to be addressed first, second, and third? Explain why prioritized the
findings in this order.

D. What orders are anticipated for this client?

E. What nursing interventions should be initiated for this client?

F. What signs would indicate that the client is improving or declining?