Question

D.G., a 19-year-old man, was brought to the emergency department after a motor vehicle accident in which he was the driver. He is transferred to the neuro-trauma intensive care unit with a diagnosis of traumatic brain injury (TBI).

Subjective Data

• Multiple family members and friends in the waiting room
• D.G.’s girlfriend died on scene
• Hospital chaplain present

Objective Data

Physical Examination

• Glasgow Coma Scale score, 4
• Neurologic Assessment:
  • Pupils 4 mm and sluggish
  • Decerebrate posturing
  • Periorbital ecchymosis
• Clear drainage from nares is positive for glucose

Diagnostic Studies

• Computed tomography (CT) scan: subdural hematoma compressing the ipsilateral ventricle and causing a midline shift

Interprofessional Care

• Admission orders include:
  • Multiple line placements: arterial monitoring, central venous pressure line, ventriculostomy, and jugular bulb oximetry
  • Keep cerebral perfusion pressure (CPP) greater than 70 mm Hg
  • Begin standing orders for proprofol, midazolam, ranitidine, and phenytoin
  • Continuous cardiac monitoring
  • Urinary catheter with strict I & O measurements
  • Neuro checks every hour
  • Monitor lab values (arterial blood gases, complete blood count, electrolytes) every morning

Question

1. List at least three nursing diagnoses for D.G, including all three aspects. including as evidenced by
2. What are two potential complications (not symptoms) associated with this case?
3. What type of IV line would be used for D.G. and why?

Answer 1

Let's analyse the condition

• GCS score 4 indicates severe brain injury
• Decerebrate posturing indicates brain stem damage , specifically damage below the level of the red nucleus.
• Sluggish pupil may be an early focal sign of an expanding intracranial lesion and increased intracranial pressure.
• Periorbital ecchymosis is symptom seen in severe brain injury
• Clear drainage from nares positive for glucose means there is leakage of CSF
• The subdural hematoma and midline shift is often associated with high intracranial pressure which is deadly. Midline shift is a measure of ICP

Nursing diagnosis:

1. Impaired gas exchange related to decreased level of consciousness and weakness
2. Altered thought process related to head injury
3. imapired physical mobility related to hemiplegia
4. Lack of motor function or paralysis or coma due to brain stem damage

Complications:

Longterm impairments in 1) cognition 2) physical skills 3) emotional or behavioural functions.

I V line used in traumatic brain injury :

Hypertonic saline may be used in patients with severe TBI. 0.9% normal saline or even 3% NS should be considered if a crystalloid is chosen.
Hypotonic , low sodium and dextrose containing fluids should be avoided.