Case Study #1 – Jordan Johnson Temp

Case Study #1 – Jordan Johnson Temp 97.2°F (36.2°C), HR 60, BP 122/75 (91), RR 16, Oxygen Saturation 97% on (these are ventilator settings 50% FIO2; SIMV 12; TV 800); Eyes open to painful stimuli, pupils equal but sluggish to respond to light, 3 mm; No attempt to track with eyes; Does not appear to recognize his mother; Withdraws arms away from pain. No spontaneous movement of lower extremities. Intracranial pressure monitor zeroed. Intracranial pressure (ICP) = 16 mmHg per subdural screw (bolt) monitor. Calculate the Glasgow Coma Scale What assumptions can the nurse make, based on the GCS? The nurse recognizes the signs of increased intracranial pressure from the baseline assessment. Which assessment finding(s) support(s) this assumption? Identify the Top 3 Priority actions the nurse should take. 1.

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