Nursing Case Study for Head Injury
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Outline
Chad is a 22-year-old male patient brought to the emergency room after falling from a hotel balcony. He was visiting a resort town and, on a dare, tried to jump from one balcony to another falling three stories. Upon arrival to the ER, he is awake, alert, oriented x 4. There are various scrapes and bruises from head to toe noted upon triage and a large bump near his right temple
What assessments and initial check-in activities should the nurse perform to best assist the patient and law enforcement?
Question - What orders does the nurse expect the provider to give?
Question - What should the nurse be cognizant of caring for this patient?
After screening and assessing the patient, the nurse has the following data.
The patient is able to follow instructions and complains of generalized pain but moves all extremities. His protective cervical spine collar remains in place, and he has 18 G IVs in each arm. Pupils are equal and reactive but sluggish. He converses appropriately, opening his eyes spontaneously when addressed. He is cleared to go to radiology for CT.
BAC: 0.5 percent
UDS: NO INDICATION of amphetamines, methamphetamines, benzodiazepines, barbiturates, marijuana, cocaine, PCP, methadone, opioids (narcotics)
CBC: WNL
CMP: WNL
EKG: sinus rhythm, no ectopy noted
BP 120/70 SpO2 98% on Room Air
HR 62 bpm and regular Ht 175 cm
RR 12 bpm Wt 75 kg
Temp 36.9°C
What is the patient’s current GCS score? Why is this important before going to the radiology department?
Radiology calls the ER at the conclusion of the diagnostic studies. The tech says, “The patient got this weird look on his face and is slow to answer our questions. He also talks like he is drunk. Please come get him.”
What should the RN do now?
Neuro check gives a new GCS of 10. His eyes are closed and only open with noxious stimuli. His speech is garbled and he answers questions inappropriately although he still knows his name. He moans and moves his hand away when painfully stimulated but does not follow commands.
What is a complication may this patient be experiencing?
Are there new orders the nurse might anticipate and/or suggest?
The nurse receives orders to transfer the patient to an inpatient progressive care unit.
What is the best way to give report from one unit to another?
After giving a report, the nurse notes that Chad is once again able to follow commands and seems more alert. He says he does not remember going to radiology and complains of a dull headache rated 3/10 on a 1-10 scale with 10 being the worst. His transfer is completed without incident. The nurse documents he is fully alert and oriented x 4 prior to transfer.
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Transcript
Hey everyone. My name is Abby. We’re going to go through a case study for head injury together. Let’s get started. In this scenario, Chad is a 22-year-old male who arrives at the emergency room after falling from a hotel balcony. He was visiting a resort town and, on a dare, tried to jump from one balcony to another falling three stories. Upon arrival at the ER, he is alert and oriented times four. There are various scrapes and bruises from head to toe that were noted upon triage and a large bump near his right temple. Now that we have this information, let’s go to our critical thinking checks number one, two, and three below.
Great job. After screening and assessing the patient, the nurse has the following data: The patient is able to follow instructions and complains of generalized pain, but he moves all extremities. His protective cervical spine collar remains in place, and he has 18-gauge IVs in each arm. His pupils are equal and reactive, but sluggish. He converses appropriately, opening his eyes spontaneously when addressed and he is clear to go to radiology for CT.
Let’s take a look at these labs: His blood alcohol content written here for BAC is 0.5%. His urinary drug screening UDS has no indication of amphetamines, methamphetamines, benzodiazepines, barbiturates, marijuana, cocaine, PCP, methadone, or opioids, also known as narcotics. His complete blood count or CBC is within normal limits. He also has a CMP that was taken, and those values are also within normal limits. His EKG shows that he’s in sinus rhythm and no ectopy is noted. As far as his vital signs go, his blood pressure is 120/70 mmHg, his heart rate is 62 beats per minute with a regular rhythm, and a respiratory rate of 12. His temperature is 36.9 degrees Celsius and his saturation on room air at 98%. We also got a height and weight height of 175 centimeters and a weight of 75 kilograms. Now that we have all of this information, let’s go to our critical thinking check number four below.
Excellent work. Radiology calls the ER. At the conclusion of the diagnostic studies, the tech says, “The patient got this weird look on his face and is slow to answer our questions. He also talks like he is drunk. Please come get him.” Let’s take a look at critical thinking check number five below.
Great job. The latest Neuro check gives a new GCS of 10. His eyes are closed and only open with noxious stimuli. His speech is garbled, and he answers questions inappropriately although he still knows his name. He moans and moves his hand away when painfully stimulated but does not follow commands. With this in mind, let’s take a look at our critical thinking checks number six and number seven below.
Great job. The nurse receives orders to transfer the patient to an inpatient progressive care unit. With all of this information, we can now take a look at critical thinking check number eight below.
Great job, everybody. After giving a report, the nurse notes that Chad is once again able to follow commands and seems more alert. He says he does not remember going to radiology and complains of a dull headache rated 3/10 on a 1-10 scale with 10 being the worst. His transfer is completed without incident. The nurse documents that he is fully alert and oriented times four prior to the transfer.
That’s all for this case study. Good job. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you all. Now, go out and be your best selves today and as always, happy nursing!
Reference:
For condition: from uptodate.com: Acute mild traumatic brain injury (concussion) in adults
Authors:Randolph W Evans, MD, FAANChristopher T Whitlow, MD, PhD, MHASection Editors:Michael J Aminoff, MD, DScMaria E Moreira, MD (last updated March, 2021)
Shahid, S., Thomas, S. Situation, Background, Assessment, Recommendation (SBAR) Communication Tool for Handoff in Health Care – A Narrative Review. Saf Health 4, 7 (2018). https://doi.org/10.1186/s40886-018-0073-1O
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Nursing Case Studies
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.
We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
