Question

your patient is a pedestrian struck by a car and thrown 35 feet. they were unconscious at the scene but became responsive with initial and subsequent glasgow coma scale (gcs) scores of 13 (e-3, v-4, m-6). the patient has bilateral subdural hematomas and is awaiting transfer to the icu. your next assessment reveals a gcs of 9 (e-2, v-2, m-5). what is the priority nursing intervention?

Answer 1

The priority nursing intervention for a patient with a deteriorating GCS score is to reassess ABC's, prepare for possible intubation, notify the physician urgently, and continuously monitor the patient's neurological status. Immediate actions are crucial as they may significantly influence the patient's outcome.

Step-by-step explanation:

Prioritizing Nursing Interventions for a Traumatic Brain Injury Patient

The priority nursing intervention when presented with a patient whose Glasgow Coma Scale (GCS) has dropped from 13 to 9 is to immediately reassess the patient's airway, breathing, and circulation (the ABC's of basic life support), and be prepared for rapid intubation or ventilation assistance if required. This significant decrease in the GCS score indicates that the patient's neurological status is deteriorating, possibly due to increased intracranial pressure from the bilateral subdural hematomas. Notifying the physician urgently and preparing for potential interventions, such as administering osmotic diuretics like mannitol to reduce intracranial pressure, are also critical steps. Continuous monitoring of GCS, vital signs, pupil size, and reactivity is essential, and positioning the patient to avoid neck flexion, which can further impede venous drainage from the brain, may be beneficial.

Rapid assessment of neurological function is critical in an emergency situation because it helps identify the severity and progression of a brain injury, allows for immediate intervention that can prevent further damage, and aids in making crucial decisions regarding patient management and potential need for immediate imaging or surgery.

Answer 2

The priority nursing intervention would be to ensure the patient's airway is open and protected, notify medical teams of the GCS change, monitor for signs of raised intracranial pressure, prepare for neuroimaging, and expedite ICU transfer.

Step-by-step explanation:

If your patient, who suffered a pedestrian accident, shows a decreasing Glasgow Coma Scale (GCS) score from 13 to 9 after bilateral subdural hematomas with a pattern of E-2, V-2, M-5, the priority nursing intervention would be to ensure the patient's airway is open and protected because a GCS of less than 9 typically indicates the need for intubation to maintain airway patency and prevent further harm. In conjunction with this, the nurse should promptly notify the attending physician or emergency medical team of the change in the patient's neurological status, as this change could signify potential for rapid deterioration. Additionally, monitoring for other signs of raised intracranial pressure, preparing to assist with neuroimaging (CT or MRI scans), and ensuring swift transfer to the ICU are critical steps in managing the patient's care.

Reasons for Priority Nursing Intervention

• Maintaining an open airway is crucial as the patient's ability to protect their own airway is compromised with a lowered GCS.
• A decreasing GCS indicates possible increasing intracranial pressure or brain herniation, which requires immediate medical attention.
• Neuroimaging is pivotal in assessing the extent and progression of the injury.

Overall, the rapid assessment and response to changes in neurological status could be lifesaving and may prevent further brain injury.