The patient is a 68-year-old man who sustained a head injury after falling in the bathroom. He arrives in the emergency department (ED) cheerful, alert, and oriented to person. On physical examination, he has a large hematoma on his left forehead. He reports a headache in the left temporal area, which he rates as an 8/10. His wife was present during the incident. Admission vital signs are: blood pressure, 170/92 mm Hg; pulse, 92 beats/min; respirations, 14 breaths/min; and temperature, 98.7° F. The physician orders a one-time dose of acetaminophen 650 mg orally for the patient’s headache, which the nurse promptly administers. The patient reports a pain level of 5/10 at 1 hour after the intervention.
1. Why is it important to determine the circumstances of the fall for this patient?
2. Discuss the importance of obtaining baseline behavior and information from the wife.
3. The ED physician orders computed tomography (CT) of the brain for the patient. What is the purpose of this test, and what are the nursing responsibilities in preparing the patient for this procedure?
4. Because the patient is at risk for increased intracranial pressure, explain how the patient should be positioned and moved in bed.
5. The CT and other diagnostic results are negative and the patient is diagnosed with a minor head injury and contusion to the right extremity. He is discharged to home. Review the patient teaching instructions that should be given to the patient and his wife.
6. The wife appears unwilling to take her husband home and she states that she doesn’t understand the discharge instructions. What can the nurse do in this situation?
7. Use the focus charting method (also known as the DAR method—data, action, response) to document the administration of acetaminophen, including appropriate follow-up.