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  3. complete the statement the cerebo ischaemic response crushings reflex states that...

Question: complete the statement the cerebo ischaemic response crushings reflex states that...

Question details

Complete the statement

  • The cerebo ischaemic response (Crushing's reflex) states that upon raised intracranial pressure, the ..........................increase to overcome the ............................and ensure that the ...................................is above 60mmHg.
  • If Zac deteriorates, the may require a pain stimulus as part of his GCS assessment. In response to a pain stimulus, Zac may exhibit................................if he has significant damage to the motor cortex in the cerebrum.

Case study

Last evening Zac went out to the local pub with a few friends from university. There was a new band playing at the pub and Zac was especially excited to be going. To save money Zac and his friends met up at a friend’s house for ‘pre-drinks’. During this time Zac drank around four full strength beers. Zac Smyth is 18 year old university student who lives on-campus as his parents reside in another state. Zac is studying engineering and enjoys university life. Zac has a part-time job working at the local supermarket for 15 hours each week. Zac has no immediate family in the state but he has a friend of his parents that he sees from time to time. Zac usually goes home to his family during his breaks but due to his work commitments, Zac has not seen his mum, dad and younger brother for the past 4 months.

When Zac and his friends arrived at the pub, they headed straight for the bar to get another beer. Zac and his friends were having a great night, the music was good and the pub was busy.

Later in the evening Zac started talking to a friendly young woman. Shortly after Zac was approached by a man who aggressively accused Zac of talking to his girlfriend. Zac apologised and returned to his group of friends. Approximately an hour later Zac said goodbye to his friends as he decided to head home.

As Zac was leaving the pub he was followed out by the man who had earlier confronted him. The man was still verbally aggressive and ended up pushing Zac to the ground, resulting in Zac hitting his head on the cement curb of the road. The security guard saw this incident and intervened. Whilst Zac was not punched, he did sustain a laceration to the back of his head. The security guard noticed quite a bit of bleeding and rang an ambulance.

 

 Collect cues

Paramedics

When the ambulance arrived, Zac had a GCS of 15 and could recall the whole incident. Zac appeared to have no other injuries. The paramedics undertook vital signs which they stated were ‘normal’ and applied a bandage to Zac’s head wound. The security guard stated that he ‘didn’t think Zac lost consciousness’.

Triage

  • 18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs.
  • Patient is denies loss of consciousness but unable to recall all events. Patient appears alert but teary and takes a couple of moments to answer questions.
  • On examination, 4cm laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries.
  • Patient denies drug use, states has had approximately ‘five beers since 7pm’. Breath alcohol taken at 2330 hours 0.06%.
  • Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation.
  • Patient states is usually fit and well.

Past medical history

Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago).
Not on any medications and no known allergies.

Assessment and investigation data

Vital signs


 

  • Blood Pressure: 141/88 mmHg
  • Heart Rate 90 beats/minute
  • Respiratory Rate 17 breaths/minute
  • SpO2 99% on room air
  • Temperature 36.0 c (tympanic)

 


Neurological observations


 GCS

Eyes 4

Verbal 4

Motor 6

Pupillary response - bilateral 4+

Limb strength - bilateral, upper and lower limbs: normal power

 

 

CT report


 Exam Information
Modality: CT
Body Part: NEURO
Description: CT Brain and C-Spine
Performed Date: 25/3/Year Time: 0015
Final Report
CT BRAIN AND C-SPINE
CLINICAL NOTES:
Witnessed awkward fall after physical altercation, head knock with no reported loss of consciousness
Findings:
A non- contrast CT has been acquired.
No acute intracranial abnormality is seen.
There is no intra or extra-axial haemorrhage noted.
There is no cerebral oedema, midline shift or hydrocephalus.
Unremarkable posterior fossa structures.
No skull fractures are seen.
No obvious fractures from C1 to T2.
IMPRESSION:
No acute abnormality on the examination.

 

Other

 Zac complains that his hand is hurting.

Medical Review - soft tissue injury from extending his hand to break his fall.

Interventions

The decision is made to keep Zac in hospital overnight, for observation.

Paracetamol is charted for pain. No other medications are charted.

Vital signs and neurological observations to be undertaken hourly.

You are the nurse who is allocated to care for Zac. You review all Zac's documentation and go to attend his observations at 0700.

You gather the following data:

Vital signs:

  • BP: 146/98 mmHg
  • Pulse: 106 bpm
  • RR: 18
  • Sp02: 98%
  • Temp: 37.3C
  • Pain: he mumbles that his "head is hurting", but cannot rate the pain; he is holding his head with his hands

Neurological Assessment:

  • Best Eye Response: Eye opening to verbal stimuli
  • Best Verbal Response: Confused
  • Best Motor Response: Obeys commands - slow to respond
  • Pupils: Right - size 3 mm, sluggish reaction; Left - size 3 mm, sluggish reaction
  • Limb Movements: Left arm only - normal power; Bilateral legs - normal power
  •  
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