NURS90092 Emergency Nursing 2


Case Study: Jack

Jack is an 8-year-old boy, who was riding his bike in the driveway with his older siblings and friends, when he reportedly fell striking his head on the brick paved driveway, followed by a period of unresponsiveness. He was not wearing a helmet at the time.

When Jack’s mother arrived, she found him drowsy with an obvious laceration to right side and front his head- so she put him in the back of the car and drove him to the local Emergency Department where you are working. During the journey to hospital Jacks mother noted he had what she described as a seizure lasting 2-3 minutes

On arrival Jack is assessed by the Triage Nurse and allocated ATS 2 based on his conscious state. He is rapidly transferred into the resuscitation room.

Triage Nurse Handover

This is Jack, an 8-year-old boy with no previous medical history, who has presented to triage with his mother. She reports he has fallen from a skateboard with a head strike with associated LOC – estimated as approximately 4-5 minutes. He appears to have swelling to right occiput. She found him drowsy and irritable at the scene but in transit he began to convulse which had ceased on arrival at the ED some 4 minutes later. She described his convulsions as “like an epileptic seizure”. His GCS is 8/15 (E2V2M4). No obvious boney deformity of limbs or other injuries seen at this stage. Nil relevant medical history and nil known allergies.


Signs of vomitus in mouth

Oropharyngeal suctioning performed

C-collar applied immediately with inline immobilisation


Respiratory rate 28 breaths per minute

SpO2 96% on room air


Heart rate 125 beats per minute and regular

Blood Pressure 138/62

Skin – centrally warm and dry

Capillary refill > 3 sec


GCS 8/15 no change from as described by Triage nurse above

Pupils equal and reacting to light

Blood Glucose 5.6 mmol/L


Clothing removed- nil obvious injury to limbs, chest abdomen or lower body

Temperature 36.8 C tympanic

Shortly after arrival a decision is made to intubate Jack to protect his airway, ensure optimal ventilation and oxygenation and further investigate the nature of his injuries.

Assessment task

  1. Develop a concept map or written response that explains the pathophysiological processes underpinning Jack’s clinical presentation to the emergency department.

In your concept map or explanation consider:

  • Mechanism of injury
  • Altered conscious state
  • Convulsions
2. Using an ABCDE approach, discuss the resuscitation priorities in the initial management of Jack.
  • Provide a rationale for each priority identified
  • Consider role of the lead nurse in ensuring effective communication and teamwork
3. Drawing on best available evidence, explain a mechanical ventilation strategy, and the associated specificnursing care considerations, in the management of Jack’s ventilation and oxygenation needs while he is undergoing resuscitation and treatment in the emergency department.
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