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Case Study #1 – Jordan Johnson
Temp 97.2°F (36.2°C), HR 60, BP 122/75 (91), RR 16, OxygenÂ
Saturation 97% on (these are ventilator settings 50% FIO2; SIMVÂ
12; TV 800); Eyes open to painful stimuli, pupils equal but sluggishÂ
to respond to light, 3 mm; No attempt to track with eyes; Does notÂ
appear to recognize his mother; Withdraws arms away from pain.Â
No spontaneous movement of lower extremities. IntracranialÂ
pressure monitor zeroed. Intracranial pressure (ICP) = 16 mmHgÂ
per subdural screw (bolt) monitor.
Calculate the Glasgow Coma ScaleÂ
Â
What assumptions can the nurse make, based on the GCS?
The nurse recognizes the signs of increased intracranial pressure from the baseline assessment. WhichÂ
assessment finding(s) support(s) this assumption?
Identify the Top 3 Priority actions the nurse should take.
1.
2.
3.
SCIENCE
HEALTH SCIENCE
NURSING