Nursing Care Plan


NursingCare Plan

NursingCare Plan

Nineteenyears old Melvin Strong was brought into the emergency department inan unconscious state.


Thepatient was in an unconscious state with breath smelling likealcohol. The pupils were unequal because the right pupil was biggerin size than the left pupil. Despite not moving, the pupils respondedto the movement of light. When the patient was transferred from thebackboard, the patient body relaxed. The release from cervical collarresulted in a little movement of the neck. Temperature 100 degrees F,heart rate 50, bpm, blood pressure 180/50 mm Hg. Respiratory rate 14breaths per minute that is normal. The patient movements wereuncoordinated on all extremities accompanied by a rapid reaction tolight change. There was no open injury in the entire body. However, atest needs to be done to establish internal ones.

Nospinal or neck injury at a glance either no fluids coming out fromthe mouth or ears. There was no bleeding in the scalp. Furthermore,there was no clear skull fracture on the patient whether linear ordepressed. Reported headache by the emergency paramedics coupled withseizures when release from the backboard and cervical collar led tofurther investigation of intracranial pressure. Sudden loss ofconsciousness also is a symptom of intracranial pressure includingvision loss. A bedside Magnetic Resonance Imaging (MRI) confirmsintracranial pressure.





180/50mm Hg established with breathing difficulties. There will beincreased cerebrospinal fluid.


  • Cerebral Angiography is recommended when the patient becomes more stable.

  • Single Photon Emission Computed Tomography (SPECT) is equally set to be done or Position Emission Tomography (PET) in place of SPECT.

  • Spinal tap.

ActualNursing Diagnosis

Thepatient looked to be in deep pain when brought into the emergencyroom. However to relieve this pain, he/she should be moved from thebackboard to the bed. In addition, a sedative should be administeredto relieve the pain. A further step should include the draining ofthe cerebrospinal fluid (CRF) using a catheter to ease pain anddiscomfort. The patient is placed on a ventilator to increase hisoxygen circulation and enhance breathing.

AtRisk Nursing Diagnosis

Thepatient is at risk of bleeding, brain tissue damage, brain bleeding.There is also a risk of infection if the nurse places the catheterincorrectly.

Healthpromotion Nursing Diagnosis

Thecare provided immediately the patient is brought into the emergencyroom until the doctor comes is meant to ensure he/she does notsuccumb to injuries attained. This is in the respect that braininjury without proper and immediate health care provision may resultin a permanent damage. In the state the patient is brought into theroom, communication is impossible from him. However, as the nurse,the overriding concern is to bring him back to normal status as soonas possible. This is to be achieved without permanent damage to thepatient as much as possible. This procedure requires strict adherenceto the common first aid steps of handling a person with spinalinjuries or neurological complications.

Everynursing diagnosis is to be implemented on a priority basis like inthe first instance. Therefore, to stabilize the patient should be theprimary concern. This is followed by the administration ofintravenous drugs to mitigate further and erase internal medicalconcerns. Soon after, further tests should be conducted to ascertainif there are further concerns to be looked at by the doctor. In thefirst step, the intervention involved physical examination toestablish the injury and the extent of the same. This is developed inthe assessment report to be given to the examining doctor. However,the MRI was done because of the immediate result of the physicalexamination. The placing of the patient on the ventilator, using thecatheter to drain the CRF and applying intravenous injection isstandard practice. This is followed by monitoring the patient everyhour to evaluate the patient progress whether negative or positive.


Anderson,M. (2005). Management of Patients with Neurologic Trauma.

Becker,D. P., Miller, J. D., Ward, J. D., Greenberg, R. P., Young, H. F., &ampSakalas, R. (1977). The outcome from severe head injury with earlydiagnosis and intensive management. Journalof Neurosurgery,47(4),491-502.

Zwimpfer,T. J., &amp Moulton, R. J. (1993). Neurologic trauma concerns.Criticalcare clinics, 9(4),727-739.