Question

32) 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).

32.1) Mention your interpretation briefly.

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

Answer 1

Glass gow coma scale consists

Eye response

4- open spontaneously

3-open to verbal command

2-open to pain

1-No eye opening

verbal response

5-oriented

4-confused

3-Inappropriate words

2-Incomprehensible sounds

1-no verbal response

Best motor response

6-obey command

5-localising pain

4-withdrawal from pain

3-flexion to pain

2-extension to pain

1-No motor response  

Here patient has E2M3V1

means the score is 5 which indicate severe head injury.

Generally it classified as :

Severe with GCS<8

Moderate GCS 9-12

Minor GCS >13

E2 indicate eye open to pain stimulus.

M3 indicate abnormal flexion to pain

V1indicate no verbal response

2.Intervention in nursing

Airway, respiration, and circulation identification to improve oxygenation and perfusion.

The head should be 30 degrees and the midline location elevated.

Told immediately of Doctor Do's CT scan.

Hemorrhage and hypotension blood products are best attributable to Brai injury. Fluids from colloids are contraindicated. The causes of cerebral edoema are aggravated by hypotonic regular saline and ringer lactate, so they should be prevented.

Epinephrine ir or epinephrine administration as prescribed with near follow-up.

Ventilation and the control of airways. Artificial airway indication, if the GCS score is less than 8.