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....

• 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.

Intervention:

• 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.

question 1. If Zac deteriorates further, frusemide may be administered. Explain the rationale if this therapy were to be used in Zac's care, and the changes in parameters (or lack thereof) that would be evidence that the intervention is having the desired effect. You should also explain why administration of this drug to Zac should proceed with caution.