Posted: September 18th, 2017
You are a nurse in the ICU department of your hospital. You are preparing a care plan for a recently admitted patient. Data is as follows.
Age and Gender: 38 Year Old Male Patient
Admission Diagnosis: Traumatic Brain Injury secondary to MVA as an unrestrained driver.
Assessment Findings of Interest:
T: 99.5 ; Pulse: 135 ; BP: 85/60 ; Pulse Ox. 95% ; Resp. 25; PCWP of >25mmHg; End Tidal CO2 = 29
Unresponsive. With no reflexes or responses to stimuli noted. Does have Pupil reaction to light.
Sinus Tachycardia between 110 to 140.
Mechanical Ventilation Via Endotracheal Tube
GU / GI
Foley Cath. With clear, yellow urine at 50ml/hr; 2 Incontinent BM’s. Positive Bowel Sounds all 4 Quadrants. NG tube intact to low-intermittent suction. Major bleeding noted from major laceration in upper abdominal area.
D5W at 125ml/hr; Levophed at 20mcg/min; Diprivan at 2mg/kg; 4 Units of Blood ordered.
Hgb and Hct = 6.9 and 25%. Blood Ph 7.51. paC02 = 15, HCO3 = 24.
Fracture to C5 and Right Humorous and Right Tibia
CT reveals enlarged liver.
Place an order in 3 easy steps. Takes less than 5 mins.