Ryrey Abraham Pacamana BSN 4C

Based on the case of Atty. Isko. What is the GCS score? (5 pts each parameter a total of 15
points).

Upon admission (15 pts) In the Intensive Care Unit (15 pts)
Eye opening: 3 Eye opening: 3
Verbal response: 2 Verbal response: 2
Motor response: 5 Motor response: 3

What is your interpretation of the above GCS score result you obtained? And what is the
implication to the patient? (10 pts for the GCS interpretation of result and another 10 pts for the
implication)

Upon admission (20 pts) In the Intensive Care Unit (20 pts)

8/15 EO: 3 VR: 2 MR: 5 = Severe 8/15 – (EO-3, VR-2, MR-3 ) = Severe
Brain Injury Brain Injury
A GCS score of 8 or less defines a A GCS score of 8 or less defines a severe
severe head injury. In the situation of Atty. head injury. In the situation of Atty. Isko Upon
Isko Upon admission he has the GCS scoring admission and going to ICU his condition didn't
of Eye response with a score of 3 (being change in terms of GCS scoring of Eye response
responsive to speech) and Verbal Response with a score of 3 (being responsive to speech) and
with a score of 2 (being inaudible when Verbal Response with a score of 2 (being inaudible
speaking) and a score of 3 in motor means when speaking) the only thing that changed in the
there is an abnormal response to the situation of Atty. Isko from admission to ICU is
movement of Atty. Isko, with this condition that his motor response, from 5 to 3, a score of 3
he needs medical attention badly because he means there is an abnormal response to the motor
is at a high risk of getting a stroke. of Atty. Isko, it is said that weakness is noted but
when stimulus is applied for example at the left side
the opposite side will trigger the response. In
general, Atty. Isko having a GCS score of 8 means
that he needs intensive monitoring and more
diagnostics to identify more about the disease
process and to be able to apply proper care to Atty.
Isko.
Assessment Nursing Dx Planning Intervention Rationale Evaluation

SUJECTIVE DATA: Impaired verbal Plan:

"While enjoying his communication After the provision of  Establish rapport.  To build trusting
favorite steak meal, I related to impaired nursing care, the relationship. Short Term:
noticed a blank stare cerebral circulation significant others will
on him followed by possibly evidence verbalize understanding  Monitor and record  To have baseline data. After 3 hrs. of N.I the client
inaudible words from by impaired about the disease. V/S. improved communication
him," as verbalized articulation. Short Term: abilities and improved family
by the wife. After 3 hrs. of N.I the copping.
client will establish
OBJECTIVE DATA: methods of
GCS: 8/15 (E-3, V-2, communication in
M-3 ) which needs can be  Establish good  To maintain good
expressed. relationship, listening communication skills Long Term:
- VS: carefully and with the patient. After 3 days of N.I the pt.
BP: 150/70 mmHg Maintain eye contact attending to client’s abled to indicate an
RR: 21 cpm communication. verbal and non-verbal understanding of the
T: 36.5°C expressions. communication difficulty and
HR: 96 bpm plans for ways of handling.
 Keep communication  Assist the pt.’s need to
simple, using all establish means of GOAL MET.
modes of accessing communicating.
information, visual
Long Term: auditory and
After 3 days of N.I the kinesthetic.
client will be able to  Validate the meaning  Making assumption to the
participate in of non-verbal word maybe wrong.
therapeutic communication. Be
communication. honest if you don’t
Maintain good understand, seek
environment. assistance from
others.
 Plan for alternative  Using aids in
method of communicating promote
Enhance participation communication learning and recovery.
and communication incorporated
plan. information about
type of disability
present.

 Reinforce that loss of  To limit self-pity and

Maintain adequate rest. speech does not depression.
imply that loss of
Medication compliance intelligence.
on time.  Provide sufficient  To give right manner
time for client to when communicating.
respond.
 Use confrontation  To clarify discrepancies
skills, when between verbal and non-
appropriate, within an verbal cues.
establish nurse-client
relationship.

 Provide  To maintain contact with

environmental stimuli reality and to lessen the
as needed or educe anxiety that may worsen
stimuli. the problem.

 Involve SO/ family in  To help the pt. recover

plan of care as much from his condition and
as possible. limit deterioration.

 Recommend a tape  To help the pt. in

recorder with pre- immediate emergency
recorded emergency assistance.
massage near the
telephone.
Information may
include name,
address, telephone
number and type of
airway.
 Refer to appropriate  Speech therapies can help
resources (speech the patient to cope from
therapies). his condition.
 Promote rest can  To stimulate the muscle
improve muscular to function well.
strength.
 Sometimes, medications
 Administer are given to stimulate the
medications on time. brain to function well.
Neurological examination : - Display no further can occur because of the GOAL MET
E3V1(ET)M5 deterioration or recurrence brain damage. After 1 week of nursing
Motor power : Right side (U of deficits. Dysrhythmias and murmurs interventions, the patient
and L E) grade 5; Left side may reflect cardiac disease, was able to:
(U and L which may have precipitated Maintain optimal LOC,
E) grade 4 CVA, for example, stroke cognition and motor, and
NIHSS : 3 (Motor Left arm after MI or from valve sensory function as
drift =1, Motor Left leg drift - Respirations, noting dysfunction evidenced by GCS of 13/15
=1, Moderate Dysarthria=1) patterns and rhythm (E:3, V:5, M:5)
Irregularities can suggest Display no further
location of cerebral insult or deterioration or recurrence
increased ICP and need for of deficits.
further intervention,
including possible
respiratory support.
Monitor neurological status
then compare with the
baseline To assess the level of
consciousness
Submit patient to diagnostic
testing as indicated. A variety of tests are
available depending on the
cause of the impaired tissue
Note urine output. perfusion.

Reduce renal perfusion may

Elevate head of the bed take place due to vascular
occlusion.

Reduces arterial pressure by

promoting venous drainage
and may improve cerebral
Maintain bedrest, provide circulation and perfusion.
quiet environment, and
restrict visitors or activities, To promote relaxation.
as indicated. Provide rest
periods between care
activities, limiting duration
of procedures.

Maintain optimal cardiac

output.
This ensures adequate
Assist with position changes. perfusion of vital organs.

Gently repositioning patient

from a supine to
sitting/standing position can
reduce the risk for
orthostatic BP changes.
Older patients are more
Position patient properly in a susceptible to such drops of
semi- Fowler’s to high- pressure with position
Fowler as tolerated. changes.

Promote active/passive Upright positioning

ROM exercises. promotes improved alveolar
gas exchange.

Dependent: Exercise prevents venous

Check for optimal fluid stasis and further circulatory
balance. Administer IV compromise.
fluids as ordered.
 Sufficient fluid intake
maintains adequate filling
Maintain oxygen therapy as pressures and optimizes
necessary. cardiac output needed for
tissue perfusion.
Administer medications
prescribed: Reduces hypoxemia
- Antihypertensive

These reduce systemic

vascular resistance and
optimize cardiac output and
perfusion.