Kent Clark, age 29, was admitted 24 hours ago for observation related to a suspected closed head injury following a motor vehicle accident (MVA). Mr. Clark's baseline vital signs are stable. He has a cervical collar and is scheduled to undergo an MRI to determine if he has a cervical spine injury. The health care provider has asked you to reduce his activity until cervical spinal injuries are ruled out.Currently, Mr. Clark is awake, alert, and oriented (to person, place, and time); his pupils are equally round and reactive to light and accommodation (PERRLA). He moves all four extremities bilaterally. His head is elevated 30 degrees to minimize increased intracranial pressure (ICP) and edema. A peripheral IV in his right arm is infusing D5 ½ NSS at 40 mL/hr.Just before you are scheduled to take him to Special Procedures for the MRI, Mr. Clark becomes restless and anxious. During the neuro check, you notice that his right pupil is sluggish. Although he denies pain, he says, “I don't care what the doctors say. I am not going to stay in this bed any longer!” When you call the health care provider, they prescribe lorazepam 0.5 mg IV push. However, as you give the IV push medication to Mr. Clark, you notice a cloudy substance forming in the IV line and the patient reports a slight burning at his IV insertion site.
Prescribed Interventions
- Bed rest
- Intravenous fluids: D5 ½ NSS at 40 mL/hr
- HOB elevated 30 degrees
- Neurologic checks q2h
- Lorazepam 0.5 mg IV push now × one dose
- Cervical collar
Developing Clinical Reasoning and Clinical Judgment
- What clinical symptoms alert you that Mr. Clark's condition is changing? What additional assessments will you do?
- Identify the source of the pain at the IV insertion site and the cloudy substance in the IV tubing.
- Describe special positioning and transfer techniques to be followed for Mr. Clark.
- What could you have done to prevent these complications, and how will you intervene now?
- How will you handle Mr. Clark's anger and maintain reduced activity?
Suggested Responses for Integrated Nursing Care
- In a patient with a closed head injury, bleeding or swelling may occur within the confines of the skull, leading to increased ICP. This increased ICP could cause extensive brain damage. Mr. Clark became increasingly restless and anxious, which could be a subtle sign of increased ICP. Even slow bleeding inside the cranium can cause changes. When you observe a change, immediately perform a neurologic assessment to determine if there are further neurologic alterations (refer to Chapters 3 and 17). When Mr. Clark became restless, you noticed that his right pupil was more sluggish to light than the left, which is another sign of increased ICP. Complete neurologic checks as often as his condition warrants, and immediately report subtle changes in neurologic checks to the health care team. Meticulous documentation of baseline neurologic checks and subsequent assessments is important to detect subtle neurologic changes (Chapters 3 and 17).
- Cervical spinal injuries can vary in severity, and even hairline fractures can become unstable if the patient is not positioned and transferred correctly. Mr. Clark has a cervical collar and the health care provider has asked you to minimize his movement (refer to Chapter 17). If you need to turn Mr. Clark, keep his head lowered and then turn him as a unit without flexing or turning his neck. Obtain help from additional staff so that you can stabilize his head, neck, and torso in straight alignment while he is being turned. When Mr. Clark is transferred from the bed to a stretcher, use a friction-reducing sheet or lateral transfer device to move him gently and carefully as a unit (refer to Chapter 9). Even though he has a cervical collar, do not assume that it is safe for him to sit up further in the bed or get up and move around.
- Mr. Clark is angry and wants to get out of bed. For Mr. Clark, careful pharmacologic sedation may be a good option. The health care provider has prescribed lorazepam to reduce his agitation and anxiety. Another possible intervention is to help Mr. Clark feel more in control of his environment. This could be as simple as having a family member stay with him, and frequently checking his needs. Restraints would be the least desirable option for him. At this time, placing restraints on him could increase his agitation and make him feel more trapped, and this could increase his ICP; alternatives to restraints should be implemented (refer to Chapter 4).
- Pain at the IV site could mean that the IV is not patent. Carefully observe the IV site for any signs of phlebitis or infiltration before and while giving the IV push (refer to Chapers 5 and 16). If you determine that Mr. Clark's IV has a good blood return and is not infiltrated, the burning sensation at his IV site may be related to the administration of the lorazepam IV. Medications given by intravenous (IV) bolus can be irritating. Give the medication and the flush that follows at a slower rate. If not contraindicated, some medications can also be diluted, based on facility policy and/or as prescribed.
- The most probable cause for the cloudy appearance in Mr. Clark's IV line is precipitation of the drug due to chemical incompatibility of the lorazepam and the IV fluid of D5 ½ NSS. When giving any medication through an IV line, you must know whether the drug and IV solution are chemically compatible (refer to Chapter 5). When IV drugs are not compatible, a reaction immediately occurs that may or may not be visible to the eye, but nevertheless can be dangerous. To prevent this, flush the IV line before and after medication administration per facility policy. Since a precipitate has already formed, clamp the tubing off using the clamp closest to Mr. Clark and make sure that the cloudy substance does not reach him (see Chapter 5). Some facilities require discontinuing the IV and restarting another IV with new IV tubing; other hospitals require changing only the IV tubing. If signs of incompatibility occur, notify the health care team and continue to assess Mr. Clark's need for further medication.