Case study - Head injury: Nursing

Nurse Laquanna works on an oncology unit but was floated to the neurology unit earlier today. She's caring for Molly, a 74-year-old female with a history of atrial fibrillation, or a-fib, who was recently admitted for a head injury. After settling Molly in her room, Nurse Laquanna goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Molly’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. 

First, Nurse Laquanna recognizes important cues including a Glasgow Coma Scale, or GCS, score of 14, and vital signs which are temperature 98.2 F, or 36.8 C, heart rate 98 beats per minute, respirations 16 breaths per minute and regular, blood pressure 134/62 mmHg, and oxygen saturation 95 percent on room air. Nurse Laquanna also notices Molly seems slightly agitated.  

Next, Nurse Laquanna analyzes important cues. She reviews the electronic health record, or EHR, and sees Molly was involved in a head-on motor vehicle collision with airbag deployment, and she takes an anticoagulant daily to treat her a-fib. Nurse Laquanna recognizes that a head injury coupled with Molly’s history of anticoagulation places her at risk for intracranial bleeding. She also knows that subtle neurologic changes can be early indicators of complications. Nurse Laquanna knows Molly will require frequent neurological assessments, or neuro checks, to monitor for changes in her mental status.  

During Molly’s neuro check an hour later Nurse Laquanna notes Molly opens her eyes when her name is called; she’s disoriented; and does not respond when asked to move her fingers. Nurse Laquanna realizes her GCS is now 12, and that Molly needs intervention quickly. She's unsure what to do next, so she enlists the help of a fellow staff nurse. 

Nurse Laquanna: Hi, Nurse Elijah. My patient has had a change in her neurologic status. I don’t have much experience in neurology, so I’m wondering what I should do next.  
 
Nurse Elijah: I’m glad you asked. Let’s call the health care provider to report the changes in your patient. 

Now, using the information she’s gathered, Nurse Laquanna chooses a priority hypothesis of altered mental status.  

Then, she generates solutions to address Molly’s altered mental status that'll include pharmacologic and nonpharmacologic interventions, and she establishes the outcome that after intervening, Molly will maintain adequate cerebral oxygenation and perfusion.