head injury and possible temporal skull fracture case study

QUESTION

a young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs include temperature 99 degrees Fahrenheit, the pulse is 100 bpm, RR is 18 breaths/min, and bp 140/70 mm hg. the nurse should report which changes should occur to the healthcare provider? select all that apply.

-increasing diastolic blood pressure

-tachycardia

-decreasing systolic blood pressure

-decreasing urinary output

-bradycardia

-widening pulse pressure

ANSWER

When a young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident, close monitoring of vital signs is crucial to detect any changes that may indicate worsening condition or complications. In this case, the nurse should report the following changes to the healthcare provider:

Increasing diastolic blood pressure: An increasing diastolic blood pressure may indicate a rise in intracranial pressure (ICP) and could be a sign of worsening head injury. It is important to monitor ICP as elevated levels can lead to further brain damage.

Tachycardia: Tachycardia, or an elevated heart rate, can be a response to stress or pain associated with the head injury. However, it may also indicate inadequate cerebral perfusion or other complications. Reporting tachycardia helps the healthcare provider assess the patient’s cardiac status and overall condition.

Decreasing systolic blood pressure: A decreasing systolic blood pressure may indicate decreased cardiac output and impaired perfusion. This can be a concern for cerebral perfusion and overall tissue oxygenation. Prompt reporting of this change is necessary for appropriate management.

Decreasing urinary output: A decrease in urinary output may indicate decreased renal perfusion, which can be a result of decreased cardiac output or hypovolemia. This change in urinary output can be an early sign of inadequate tissue perfusion and should be promptly reported to the healthcare provider.

It is important to note that bradycardia and widening pulse pressure are not listed as changes to report in this scenario. Bradycardia is less likely to occur in the setting of a head injury, and widening pulse pressure may be a compensatory response to increased ICP. However, the nurse should still monitor these parameters and consider them within the context of the overall clinical picture.

By promptly reporting these changes to the healthcare provider, appropriate interventions and further assessments can be initiated to ensure the patient’s safety and optimize their care. Timely communication between the nurse and the healthcare provider is essential in managing patients with head injuries to prevent complications and promote recovery.