Nursing – Eva Mendoza Case Study – Report Writing Assessment Answer

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Eva Mendoza Case Study Assessment Answer

Assignment Task:

Eva Mendoza Case Study –

Eva Mendoza is a 35-year-old female involved in a bicycle accident. She was thrown over the bicycle handles and despite wearing a helmet she was found to be unconscious after hitting her head on the pavement by nearby bystanders that witnessed the event and called an ambulance. On initial assessment it was evident that she sustained multiple cuts and grazes to her arms, legs and face and two front teeth were dislodged.

On arrival in the ED Eva was classified as ATS 1. Assessments were made, and findings include; temperature 37 C, 98 pulse, 20 respirations, 100% Oxygen saturation. Incomprehensible words, pupils 5 mm and sluggish, bilateral upper and lower spastic flexion, eyes open to pain only.

Eva was intubated, an IDC inserted and shenwas ventilated in preparation for transport to CT. This showed a right subdural haematoma, cerebral oedema and an intact C spine.

She was scheduled for an urgent craniotomy; her GCS had dropped to 6. There was no longer any response from Eva, her right pupil was sluggish to light.

Following drainage of the haematoma and insertion of a EVD, Eva was transferred to the ICU for ongoing care. In ICU, Eva continued to be ventilated and was hyperventilated to keep the PaCo2 below 30 mmHg. Ongoing assessment and management of ICP continued.

Eva stabilised over the next few days and was extubated and her EVD was removed; she was transferred to the ward 72 hours later. Her GCS was 12, she was confused, localised to pain and opened her eyes to speech.

Six days later, her GCS was 14, however she was very sleepy and at times continued to be confused. On mobilisation, she was unsteady on her feet. She had a weakness in her left leg.

Three weeks later, Eva was transferred to the rehabilitation unit. While she was no longer confused, her memory was poor, and she lacked concentration, tired easily, tended to be impulsive and easily become distracted. When she became tired her speech slurred and she complained of blurred vision. She also complained of diminished sense of smell.

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