Assessing Level of Consciousness

Virtual Simulation

Case Study: Head Injury

1. What cranial nerves were assessed initially by the nurse and how were they assessed?
Identify the nerve and how to complete the assessment.

CN 11 – Vision
 Use Snellen chart 20 feet away from patient and ask patient to cover one eye and read
letters from the lowest line they can see.
CN III – opening eyelids, pupil constriction
 Use finger or pen light and ask patient to follow using eyes
 Use the pen light to assess pupil response (constriction/dilation)
CN VII- Facial nerve
 Ask to close her eyes and then open.
 Ask patient to follow directions for the following commands:
o Smile and show teeth, puff cheeks, then both simultaneously, frown, raise
eyebrows. Looking for symmetry and strength of facial muscles.
 Can test the sense of taste by using different cotton applicators with salt, sugar and lemon
and ask patient to identify the taste.
CN XI- Spinal Accessory
 Ask patient to shrug shoulders and turn head side to side

In addition to the Motor Function

2. If Mrs. Patterson exhibits the following symptoms: hypoxia, hypotension, and tachycardia.
Please explain why she is having these symptoms.

Hypoxia, hypotension and tachycardia are possible symptoms of a possible hemorrhage.

Hypoxia should be addressed first by an oxygen mask. Decreased BP and increased HR would
require administration of IV fluid. Possible result from blood loss and decreased blood to organs
related to the head injury.

3. How could the injuries/symptoms (hypoxia, hypotension, tachycardia) affect the

neurological condition?

These injuries can cause changes in the level of consciousness. Lack of oxygen and blood leads to
ischemia. The brain is very sensitive to change in oxygen saturation and this can cause
irreversible damage or even death.
4. Priority decision: What are the priority nursing interventions should the nurse implement
at the end of the simulation?

 Protect airway
 Call CCRT (critical care response team).
 Get ready to intubate if needed
 Check vital signs and perform continue neuro-assessment
 Monitor for increased ICP
 Call MD to get orders
 Inform family of change in condition

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Barry M. A., Lok, J,. Tyerman,
J., & Goldsworthy, S., (2019). Medical-surgical nursing in Canada: Assessment and
management of clinical problems  (4th ed). Elsevier 
WTCS. (n.d.). 6.5 assessing cranial nerves – Nursing skills. WI Technical Colleges Open
Press – Publishing open resources for students. Retrieved March 30, 2023,
from https://wtcs.pressbooks.pub/nursingskills/chapter/6-5-assessing-cranial-nerves/