A 42 year-old-female client was involved in

A 42 year-old-female client was involved in a motor vehicle crash. The client was an unrestrained passenger in a car which swerved off the road and struck a tree. She was ejected from the car and was found unconscious by EMS providers. After being placed on a spinal board and in a C-collar, she was transferred by helicopter to the nearest trauma center. She was slightly combative and unresponsive to commands at arrival. Her pupils were reactive bilaterally; however, the left pupil was more reactive than the right pupil. The left pupil was 4 mm in size and the right pupil was 3 mm in size. The client would open her eyes only to painful stimuli. Her respiratory rate was 40 breaths/minute and labored. Other diagnostic data includes: Blood pressure: 90/40 mm Hg, heart rate: 100 beats per minute, respirations: 40 breaths per minute, temperature 98.0oF. Upon arrival to the emergency department, an endotracheal tube was placed, and mechanical ventilation was started. Additional treatment included placement of a subclavian central line, arterial catheter, and foley catheter. The client is withdrawing to painful stimuli only in the upper extremities. She has exhibited no movement of her lower extremities. X-rays of the cervical, thoracic, and lumbar spines showed partial transection and fractures of T6-8. The client’s CT scan of the head revealed a left temporal contusion with a midline shift of brain structures and a left temporal parietal subdural hematoma. The client was transferred to the operating room where a craniotomy was performed to remove the hematoma. What is a craniotomy? Why is it being done in this case? Discuss management of a patient post craniotomy. Where can hematomas occur with head injuries? What are symptoms of increased intracranial pressure? What symptoms is this client exhibiting to support the diagnosis? What is the general cause of increased intracranial pressure in patients with head injuries? After surgical removal of the hematoma, the client was transferred to the intensive care unit. An intracranial pressure monitoring device was placed. The following were her diagnostic data after surgery: ICP: 25 mm Hg, blood pressure: 130/88 (90) mm Hg, heart rate: 100 beats per minute, respirations: 12 breaths per minute, temperature: 100oF, pH 7.40, PCO2: 43, PaO2: 434, HCO3: 20.4. Ventilator settings were as follows: SIMV, tidal volume: 700, rate 12 breaths per minute, FiO2: 100%, peep: 5 cm H2O, pressure support: 10 mm Hg As the client recovered from general anesthesia, she opened her eyes to painful stimuli and exhibited abnormal general flexion to pain in her upper extremities. Over the next two hours, the client’s temp rose to 101oF, her blood pressure decreased to 110/70 (60) mm Hg and her ICP rose to 30 mm Hg. Her serum osmolarity was 282, potassium level was 3.9 mEq/L, and sodium level 139 mEq/L. What do you anticipate is happening? What is her CPP? What does CPP indicate? What should it be? What is her GCS? Discuss the significance of posturing such as abnormal flexion and extension. What do the arterial blood gas results indicate? What would you do to her vent settings? What does hyperventilation do? What is the desired range for PCO2 in head injury patients? What are your priorities? What is the difference between a subarachnoid bolt and an intraventricular catheter? What are the nursing considerations of each? Postoperative orders include the following: Fluid restriction to maintain patient’s osmolality between 305-315 Mannitol 25-50 gms every six hours intravenous bolus for serum osmolality < 300 Check serum osmolality, basic metabolic profile every six hours Levitiracetam 500 mg intravenously twice daily Norepinephrine infusion at 0.2 mcg/kg/minute, titrate to maintain mean arterial pressure >70 mm Hg and cerebral perfusion pressure > 70 mm Hg What are the rationales for these orders? What do you suspect with her lowering blood pressure? What complications can arise? Discuss the medical management and nursing interventions for a patient with a head injury and increased intracranial pressure. What are the leading causes of head injuries? Differentiate the different types of head injuries. Differentiate the types of skull fractures associated with head trauma. What are special considerations for patients with basilar skull fractures? What is a coup-contrecoup injury with traumatic head injury? The client’s intracranial pressure remained elevated for more than 72 hours, then gradually stabilized. Once stabilized, she was taken to the operating room for a spinal fusion of T6-8. After spine stabilization, she remained paralyzed from the waist down. Discuss common causes of spinal cord injuries. What were this client’s risk factors? Discuss the difference between complete and partial transection of the cord. What are your emergency assessments and treatments for a spinal cord injury patient? How does this client having a traumatic brain injury complicate the situation? What is the treatment of a cervical spine injury? What is the surgical and nonsurgical treatment for thoracic and lumbar spine fractures? Discuss postoperative interventions. What long term complications can occur from immobilization due to spinal cord injury and how do you prevent those from occurring? Compare and contrast spinal shock and autonomic dysreflexia. What are they? Why do they occur? What is the treatment?

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