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Case Study #1 – Jordan Johnson
Temp 97.2°F (36.2°C), HR 60, BP 122/75 (91), RR 16, Oxygen 
Saturation 97% on (these are ventilator settings 50% FIO2; SIMV 
12; TV 800); Eyes open to painful stimuli, pupils equal but sluggish 
to respond to light, 3 mm; No attempt to track with eyes; Does not 
appear to recognize his mother; Withdraws arms away from pain. 
No spontaneous movement of lower extremities. Intracranial 
pressure monitor zeroed. Intracranial pressure (ICP) = 16 mmHg 
per subdural screw (bolt) monitor.

Calculate the Glasgow Coma Scale 

 

What assumptions can the nurse make, based on the GCS?

The nurse recognizes the signs of increased intracranial pressure from the baseline assessment. Which 
assessment finding(s) support(s) this assumption?

Identify the Top 3 Priority actions the nurse should take.
1.
2.
3.

SCIENCE
HEALTH SCIENCE
NURSING

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