Question

Mary is a 22-year-old college student who received a head injury in an automobile accident. She was healthy before her accident. The emergency medical services team brought her to the emergency department (ED). She is stabilized in the ED, cervical spine injury is ruled out, and she is admitted to the neurologic intensive care unit. She is confused and groggy and has leakage of CSF from one ear and irregular respirations.

1. What evaluations would you perform?
2. What specific nursing measures would you include in your care plan concerning the leaking CSF?
3. What measures would you take to provide appropriate respiratory care?

Answer 1

Answer 1

The evaluations that would be performed are:

• Physical examination that should include detailed neurological examination
• Myelogram
• A radiograph that include all cervical to T1 vertebrae and should cover anterior, posterior and oblique view and take open mouth radiograph
• CT cisternogram, and pledget study for CSF leak
• Glasgow's coma scale

Answer 2

The nursing measures that can be included in the careplan are:

• Provide bedrest
• Avoid coughing and sneezing, nose blowing and yawning
• Avoid straining and use laxatives
• Do not lift heavy weights
• Avoid bending and lifting

Answer 3

Involvement of C3 and C4, C5 leads to respiratory problems

If the patient have severe respiratory problems, tracheostomy can be performed

If the irregular breathing is due to loss of diaphragm function, then a pacing system to stimulate diaphragm can be used

Provide respiratory muscle training regimens

Administer oxygen as per requirement

The drugs like theophylline can help to improve respiratory motor output in this condition