Question

Mr Reynold had undergone craniotomy and he is on 2nd post op day. You are there to take over the client from the staff of previous shift. Answer the following question based on the scenario. On assessing the level of consciousness of Mr Reynold, you got a score of E2M3V1, which is entirely different from the previous reading (E4M4V3).

QUESTION 1.) Mention your interpretation.

QUESTION 2.) Describe how you would respond in this situation as an enrolled nurse (in 40-50 words).

Answer 1

1. E2M3VI indicate Glasgow coma scale(GCS) of 6,Eye-2,Motor -3 and Vision-1.GCS is commonly used to describe the level of consciousness especially in case of traumatic brain injury.GCS scoring system is atotal scor of 15 points.

Eye opening

• 4=spontaneous
• 3= to sound
• 2=to pressure
• 1=none

Verbal response

• 5=oriented
• 4=confused
• 3=words ,not coherent
• 2=sounds
• 1=none.

Motor Response

• 6=obeys command
• 5=localizing
• 4=normal flexion
• 3=abnormal flexion
• 2=extension
• 1=none

The summing of the score is important ,for eg E2M3V1=6,E4M4V3=11

Severe brain injury GCS is 8 or less

Moderate GCS 9-12

Mild GCS 13-15

In this case the patient had a GCS of 11 ie the patient had only mild brai injury,but after sometime GCS decreased to 6 which shows that the condition of the patient is deteriorating and leading to severe brain injury.

2.A score lower than 8 indicate the patient is in coma

• In this situation maintain mechanical ventilation .
• Monitor BP,pulse and Heart sounds
• Assess the respiratory and circulatory status.
• Suction fluids from the airway as needed.
• Place the client in a smi fowlers position.
• Change the position of the patient every 2 hrs.
• Assess for edema.
• Monitor for dehydration.
• Monitor intake and out put chart
• Maintain NPO status until consciousness required.
• Provide intravenous or enteral feedings.
• Assess the bowel sounds.
• Monitor the status of skin integrity.
• Provide frequent mouth care.
• Assess the neurologicalstatus frequently.
• Initiate measures to prevent skin break down.
• Initiate physical therapy as appropriate.
• Avoid restraints.
• Remove dentures and contact lenses if present.