Comprehensive Nursing Management in Neurological Assessment and Head Injury Care

QUESTION

Questions to prepare:

What are the key elements in a performing a complete neurological assessment?

What assessment findings are considered early and late signs of increased ICP?

Your patient starts complaining of difficulty breathing. You perform a focused assessment and check their vital signs: BP 160/72, HR 108, RR 35, and SpO2 91%. You have placed the patient on oxygen with no improvement. You have paged the Provider several times and they reply, “I’m with another patient, I’ll get there when I get there. Please stop paging me.” Which TeamSTEPPS tool will you use to support your argument?

What is the priority nursing management of the patient with a head injury?

How would you know if intubation is indicated for a patient with a head injury? How would you prepare for intubation?

What steps should the nurse take when receiving a verbal or phone order from a Healthcare provider?

Famotidine is ordered IVPB for a critically ill patient with head injury. What is the most likely indication in this situation?

Mannitol is a diuretic. Why is it given to patients with elevated intracranial pressure?

Caution is required if giving Mannitol to

ANSWER

Comprehensive Nursing Management in Neurological Assessment and Head Injury Care

Introduction

Neurological assessments and head injuries demand a systematic approach and informed decision-making by nurses. In this essay, we will explore key elements in performing a complete neurological assessment, assessment findings related to increased intracranial pressure (ICP), strategies to support nursing arguments within a healthcare team, priority nursing management for head injuries, indications for intubation, steps for receiving healthcare provider orders, and the use of medications like famotidine and mannitol in patients with head injuries.

Key Elements in Neurological Assessment
Mental status evaluation, including level of consciousness and orientation.
Cranial nerve assessment for sensory and motor functions.
Motor function assessment, evaluating muscle strength and tone.
Sensory function assessment, including response to stimuli.
Reflex assessment, such as deep tendon reflexes.
Gait and coordination assessment to detect balance and coordination issues.

Early and Late Signs of Increased ICP
Early signs include headache, nausea, and vomiting.
Late signs encompass altered mental status, pupillary changes, bradycardia, and hypertension.

Using TeamSTEPPS to Support Arguments
The “Assertive Statement” tool can be employed in this situation. It allows the nurse to assert the need for urgent attention and express concerns about the patient’s deteriorating condition while maintaining a respectful tone.

Priority Nursing Management of Head Injury
Ensure airway, breathing, and circulation (ABCs) stability.
Implement measures to reduce ICP, such as elevating the head of the bed and administering osmotic diuretics like mannitol.
Frequent neurological assessments to monitor changes in mental status and signs of ICP.
Maintain cervical spine precautions if there’s concern about associated trauma.

Indications and Preparation for Intubation
Intubation may be indicated if the patient’s airway is compromised, or their level of consciousness deteriorates.
Prepare for intubation by ensuring necessary equipment, medications, and skilled personnel are available. Preoxygenate the patient to maximize oxygen reserves.

Receiving Verbal or Phone Orders from Providers
Clearly document the order, including date, time, and the complete order details.
Repeat the order back to the provider for verification.
Obtain a written order as soon as possible and ensure it matches the verbal order.

Famotidine Indication
Famotidine may be ordered to reduce gastric acid secretion in critically ill patients, especially those with head injuries, to prevent stress ulcers.

Mannitol Use in Elevated ICP
Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid from brain tissue into the bloodstream. It also improves cerebral perfusion.

Caution with Mannitol
Caution is required when giving mannitol to patients with pre-existing renal conditions, dehydration, or heart failure, as it can exacerbate these conditions.

Conclusion

Comprehensive nursing management in neurological assessment and head injury care involves systematic assessments, prompt recognition of changes in ICP, effective communication within healthcare teams, and the appropriate use of medications. Nurses play a critical role in advocating for and delivering safe and efficient care to patients with head injuries and neurological concerns.