NRS 460 Topic 1 Assignment Case Study: John Doe – Emergency Department

NRS 460 Topic 1 Assignment Case Study: John Doe – Emergency Department

Use the “Case Study: John Doe – Emergency Department” template to complete the assignment.

This case study has indirect care experience requirements. The “NRS-460 – Case Studies: Indirect Care Experience Hours” form, found in the Topic 1 Resources, will be used to document the indirect care experience hours completed in the case study. As progress is made on the case study, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 5. Read the next task here NRS 460 Topic 2 DQ 1 For patients admitted to the ICU, what are two ethical considerations a nurse will use to help facilitate the patient’s mental and spiritual well-being?

You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the past 5 years and appropriate for the assignment criteria and relevant to nursing practice.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 1.3, 2.3, 2.4, 2.5, and 4.2.

NRS-460 Case Study: John Doe – Emergency Department

Directions: Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit this completed template to the assignment dropbox.

The purpose of this assignment is to evaluate and synthesize patient data to propose interventions for an individualized plan of care prioritizing health problems and health concerns.

PART I: Health History and Medical Information

Evaluate the health history and medical information for John Doe, presented below.

John Doe, a 35-year-old male, was riding his motorcycle under the influence and experienced a motor vehicle accident resulting in multiple fractures and a traumatic brain injury (TBI).

On scene, John Doe was alert but exhibiting restlessness and agitation with hands-on care. En route to the hospital, he displayed changes in level of consciousness (LOC), mood and behavior, nausea and vomiting (N/V), and dilated pupils. Upon arrival to the emergency department, John was unconscious with a Glasgow Coma Scale (GCS) score of 6, indicating a severe TBI. Prior to losing consciousness, he was exhibiting signs of extreme pain on the left side.

Objective Data – completed by ambulance personnel:

1. 84/60 BP, HR 136, RR 28 irregular, SpO2 92%
2. 5′ 11″ height, 180 lbs. weight
3. GCS Score: 6
   1. No response in eyes: 1
   1. No verbal response: 1
   1. Flexion withdrawal from pain: 4
4. Change in LOC
5. Possible fractures to left leg and left ribs
6. Intubated in route to ED

Objective Data and Laboratory/Test Results – on arrival to the emergency department (initial results)

1. Complete blood count (CBC) –
   1. White blood cells: 11.3
   1. Hemoglobin: 15.6

• Hematocrit: 41.5
  • Platelets: 316,000
• Comprehensive Metabolic Panel (CMP) –
  • Alanine Aminotransferase (ALT): 32 U/L
  • Albumin: 4.8 g/dL
  • Alkaline Phosphatase (ALP): 122 U/L
  • Aspartate Aminotransferase (AST): 52 U/L
  • Blood Urea Nitrogen (BUN): 16mg/dL
  • Bilirubin: 1.4mg/dL
  • Calcium: 9.8mg/dL
  • Creatinine: 1.1mg/dL
  • Glucose: 112mg/dL
  • Potassium: 3.9 mEq/L
  • Sodium: 138 mEq/L
• Prothrombin time (PT) – 12 seconds
• Partial Thromboplastin time (PTT) – 37 seconds
• Panscan CT (Polytrauma Whole Body Imaging): Results –
  • Closed left femur fracture
  • Hairline fracture of 3 left ribs
  • TBI consisting of frontal-temporal skull fracture
• Urinalysis (UA) – positive for red blood cells in urine
• Drug panel – positive for cannabinoids
• Consent to treat options

PART II: Critical Thinking Activity

Use the findings from your evaluation to complete the following:

Assessment Findings Evaluate Mr. Doe’s health history and other pertinent medical information presented above to answer the questions that follow.
Based on your evaluation, synthesize normal and abnormal findings. Create a list prioritizing three to five problems and health concerns present for the patient. Your response should be a minimum of 300 words.	The first set of objective data that is abnormal and concerning is John Doe’s vitals, BP 84/60, HR 136, RR 28 irregular, and SpO2 92%. The second concern for John Doe would be the Glascow Coma Scale of 6 along with an altered level of consciousness, indicating severe trauma. Additionally, John Doe has severe trauma including fractures to his femur, ribs in three spots, and a skull fracture that is indicating severe TBI. Patients’ labs are fairly normal at this time, but I would expect them to change rapidly. John Doe’s urinalysis also shows blood, indicating possible internal damage. All of these findings indicate the patient is in critical condition and time is of essence to ensure the best possible outcome for John Doe. He will require a skilled team that can easily communicate and work together to diligently handle his care.
Provide rationale justifying your proposed list. Use at least one evidence-based resource to support your rationale. Your response should be a minimum of 200 words.	As an experienced nurse, I am able to look at the data provided and quickly identify what data is abnormal. I am also able to use my critical thinking to understand and prioritize which vitals need immediate attention as well as which vitals can indicate what may happen to my patient next. “The Modified Early Warning Score (MEWS) uses vital signs to categorize the severity of a patient’s physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions.” (Keen, 2017) Vital signs are some of the very first pieces of information we seen when assessing a patient. This is why normal ranges are drilled into our heads during nursing school. Normal ranges are as follows: BP – 90/60 to 120/80 Pulse – 60 to 100 Respiratory Rate – 12-18 breaths per minute Oxygen level – 95% to 100%

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	Temperature – 36.1c to 37.2c Vitals should be continuously monitored for John Doe to ensure stability as well as be able to trend these vitals to let the medical staff know if there is a declination in John Doe’s status.
Discuss how each team member can contribute to the formation and improvement of diagnosis for this patient. Your response should be a minimum of 200 words.	Each team member is vital in the care of John Doe and ensuring the best outcome. “The optimal approach to the multiply injured patient involves the involvement of anesthesiologists, trauma-trained surgeons, intensivists, orthopedic specialists, diagnostic and interventional radiologists, urologists, neurosurgeons, rehabilitation specialists, otolaryngologists, among many others.” (Bach, 2017) Additionally, CNA’s, nurses, respiratory nurses, cardiac team, lab personnel, and imaging technicians are all critical in John Doe’s care. Each individual is responsible in performing their specialty to ensure the stability and best outcome for him. Lab technicians are there to ensure IV lines and labs a drawn immediately to understand more in depth on interventions the patient may need such as blood transfusions. RN’s and nursing staff are there to assess the patient, sometimes are in charge of insertion of IV lines to administer medications and perform interventions the provider orders. Respiratory is there to ensure airway patency and possible intubation of patient. Providers are there to assess and provide their extensive knowledge and provide complex care and complex procedures that is above the nursing staffs level of care. Neurology is a great specialty to have on staff for John Doe due to the extent of trauma and brain injury. Early interventions of severe TBI may help in long term complications and permanent damage.
Interventions Mr. Doe requires numerous interventions upon arrival to the hospital.
Based on your assessment, describe the interventions that are required upon Mr. Doe’s arrival to the hospital to mitigate the risk of further complications. Your response	John doe will require close examinations and careful monitoring to ensure safety and further complications associated with his rib fractures, skull fracture, and femur fracture. Initially, we are going to be concerned with John Doe’s airway, breathing, and circulation (ABC’s). Upon arrival we will performed a quick

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should be a minimum of 300 words.	Glascow Coma Scale to compare to his enroute GCS score. Additionally for the skull facture and neurological status, we should monitor the patients level of consciousness, orientation, behaviors, speech, reflexes, and sensations. John Doe’s responses may reveal the extent of his TBI. We will control any visual bleeding while continuing to monitor his vitals to trend on patients stability. Monitoring and controlling the patients intracranial pressure is extremely important to prevent complications This can be monitored using a probe. Medications such as anticonvulsants, mannitol and coma-inducing medications may be prescribed to help control ICP. We must reorientate these patients as often as needed as well as make sure we keep our instructions and information short and sweet to ensure understanding. Noise and lights should be kept to a minimum to keep ICP decreased. We should be monitoring for Acute Respiratory Distress Syndrome with symptoms such as dyspnea, cyanosis, altered mental status, and rales. With John Doe’s injuries, his should be positioned carefully to ensure air patency and decrease ICP, and prevent further injury from the fractured ribs and femur. The leg should remain in line with the body and braced until ortho can come evaluate. The lower leg and feet should be checked for circulation by checking pulses and capillary refill. Rib fractures should be monitored incase of a lung puncture. Patient would show signs of severe SOB with this.
Diagnostic Tests Review the diagnostic tests that were ordered.
Choose two diagnostic tests and explain how these tests relate to the patient’s condition. Your response should be a minimum of 200 words.	The first diagnostic test that should be performed on the patient would be an MRI or at minimum a CT. MRI’s and CT’s scans both show soft tissue as well as bones. “Inpatient brain MRI utilization in TBI patients is associated with lower inpatient mortality, as well as with increased hospital resource utilization and likelihood of non-home discharge.” (Lee, 2021) The MRI can shows us the extent of each of his injuries including specifics into his brain injury and fractures to give providers information on which injuries should be prioritized to ensure the best outcome. Additionally, labs are the next major diagnostic tool I would use to help in understanding what is going on in my patients

	body as well as trend on improvements and deteriorations. The first major job I would monitor is his hemoglobin and hematocrit. Hemoglobin should be between 14 to 18. Hematocrit for men should be between 40-54%. If these become abnormally low, this lets us know that there may be internal bleeding that may need intervention. PT/INR will identify if the patient is susceptible to any clotting or bleeding disorders. After trauma, electrolytes are also a major lab we should monitor for. Potassium and sodium are major labs in which should remain stable to prevent further complications such as healing, muscle weakness, and/or arrythmias. Kidney and liver functions may be off due to trauma but significantly altered labs should be monitored to ensure proper healing and proper function of vital organs.
Surgical Intervention Review your assessment of Mr. Doe’s physical injuries to answer the questions below.
Discuss the possible surgical interventions necessary to address Mr. Doe’s multiple fractures. Your response should be a minimum of 200 words.	Mr Doe’s skull and femur fracture will more than likely require surgical intervention. His rib fracture will more than likely require time to heal. Information does not let us know which type of skull fracture Mr. Doe obtained. We do know location so we can monitor for specific symptoms related such as headache, dizziness, pain in facial bones. With severe temporal fractures, surgical intervention to realign bones may be required to prevent further complications such as hearing loss, nerve damage, or cerebrospinal fluid leaking. Surgical repair may require the use of pins, screws, and/or plates and even removal of smaller fragments of bones that cannot be repaired. More than likely the fracture to the femur will require surgical interventions. This also may include pins, screws, or plates to fix. Worst case scenario, Mr. Doe may require a full hip replacement depending on the severity and location of the fracture.
If surgery is not necessary, what steps are needed to ensure proper healing of the bones? Your response should be a minimum of 200 words.	If surgery is not required, maintaining proper alignment and further injury would be required for proper healing of the bones. Ribs are a more difficult fracture to ensure proper healing although we can use proper positioning to bracing to decrease displacement. Skull fractures that do not require surgical intervention must just be continued to be monitored and have

	restrictions to certain movements and lifting precautions in order to prevent pressure. Femur fractures typically require surgical intervention but if it does not, then proper alignment and weight bearing restrictions are typically protocol for proper healing.
Panscan Results The panscan results indicate a positive TBI.
Based on these results, what interventions do you foresee as necessary when treating the patient? Your response should be a minimum of 300 words.	John Doe will require frequent Glascow Coma Scale tests to trend his GCS score. Additionally for the skull facture and neurological status, we should monitor the patients level of consciousness, orientation, behaviors, speech, reflexes, and sensations. John Doe’s responses may reveal the extent of his TBI. We will control any visual bleeding while continuing to monitor his vitals to trend on patients stability. Monitoring and controlling the patients intracranial pressure is extremely important to prevent complications This can be monitored using a probe. Medications such as anticonvulsants, mannitol and coma-inducing medications may be prescribed to help control ICP. We must reorientate these patients as often as needed as well as make sure we keep our instructions and information short and sweet to ensure understanding. Noise and lights should be kept to a minimum to keep ICP decreased. We should be monitoring for Acute Respiratory Distress Syndrome with symptoms such as dyspnea, cyanosis, altered mental status, and rales. With John Doe’s injuries, his should be positioned carefully to ensure air patency and decrease ICP. After initial injuries are stabilized, John Doe should receive a collaboration of care including speech therapy, physical therapy, and occupational therapy. Additionally, severe TBI’s are known to cause behavioral and mood changes, so mental therapy my also be a good resource for him to utilize.
Psychosocial and Spiritual Considerations Providing holistic nursing care for patients with complex conditions requires that the nurse takes into account the patient’s psychosocial and spiritual needs.
Given the patient’s current situation, discuss ways in which the nurse can take into account and address the patient’s	Being a nurse, we should know how to provide holistic care to our patients. This includes physical, mental, and emotional health. First, we should be able to show the patient compassion regardless of what their spiritual or

psychosocial and spiritual needs. Your response should be a minimum of 150 words.

religious beliefs are. By this point, hopefully we would have some close family and/ or friends who could help identify patient preferences. As a nurse, we should be encouraging and educational to the patient and families. “Psychosocial diagnoses are invaluable in creating patient-centered clinical plans, which can lead to better care outcomes.” (Whitehurst, 2023)

References Bach, J. A., Leskovan, J. J., Scharschmidt, T., Boulger, C., Papadimos, T. J., Russell, S., Bahner, D. P., & Stawicki, S. P. (2017). The right team at the right time – Multidisciplinary approach to multi-trauma patient with orthopedic injuries. International journal of critical illness and injury science, 7(1), 32–37. https://doi.org/10.4103/IJCIIS.IJCIIS_5_17     Keene, C. M., Kong, V. Y., Clarke, D. L., & Brysiewicz, P. (2017). The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward. Chinese journal of traumatology = Zhonghua chuang shang za zhi, 20(5), 283–287. https://pubmed.ncbi.nlm.nih.gov/28789825/ Lee, H., Yang, Y., Xu, J., Ware, J. B., & Liu, B. (2021). Use of Magnetic Resonance Imaging in Acute Traumatic Brain Injury Patients is Associated with Lower Inpatient Mortality. Journal of clinical imaging science, 11, 53. https://doi.org/10.25259/JCIS_148_2021     Cleveland Clinic Medical. (2023, March 19). Vital signs: How to check my vitals at home. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/10881- vital-signs     Wagner, M. (2025, January 12). Traumatic brain injury (TBI): Nursing Diagnoses, care plans, Assessment & Interventions. NurseTogether. https://www.nursetogether.com/traumatic-brain-injury-nursing-diagnosis-care-plan/     Whitehurst, L. (2023, July 22). Nursing diagnosis – psychosocial. allnurses. https://allnurses.com/nursing-diagnosis-psychosocial-t188810/