Posted: September 18th, 2017

Nursing

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:

Vitals

T: 99.5 ; Pulse: 135 ; BP: 85/60 ; Pulse Ox. 95% ; Resp. 25; PCWP of >25mmHg; End Tidal CO2 = 29

Neurological

Unresponsive. With no reflexes or responses to stimuli noted. Does have Pupil reaction to light.

Cardiovascular

Sinus Tachycardia between 110 to 140.

Respiratory

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.

Vascular Access

PICC Line

Medications

D5W at 125ml/hr; Levophed at 20mcg/min; Diprivan at 2mg/kg; 4 Units of Blood ordered.

Labs

Hgb and Hct = 6.9 and 25%. Blood Ph 7.51. paC02 = 15, HCO3 = 24.

Musculoskeletal

Fracture to C5 and Right Humorous and Right Tibia

Radiology

CT reveals enlarged liver.