NSB236 Integrated Nursing Practice 3 – On Campus
Question:
The assessment tasks requires you to:
Following on from your presented discussion associated with point one (1), develop a clinical plan of care which identifies: x One (1) priority of clinical care and; Discuss three (3) nursing interventions that directly address the identified clinical priority. The discussion should refer to relevant clinical assessments. Measurable outcome parameters for each intervention will be discussed to justify the intervention and evaluate its efficacy. Discussion is to be supported with contemporary research.
Consolidate knowledge of key NMBA Registered Nurse Standards for Practice, National Safety and Quality Health Services Standards, and National Health Priorities to enable effective decision planning and action in a range of complex clinical situations across the lifespan.
Apply knowledge of anatomy, physiology and pathophysiology to support evidence based decision making associated with planning and action.
Demonstrate structured decision making and clinical reasoning to review a range of health situations, synthesise evidence and data, determine priorities and formulate plans of care and interventions in line with timeframes and agreed goals
Assignment Hints
This assignment requires you to critically consider the signs and symptoms associated with clinical deterioration in relation to the patient’s primary clinical diagnosis, with consideration to:
How the patients clinical history may impact on assessment data and core interventions;
The identified clinical priority which should clearly emerge from your discussion of the primary health alteration.
The application of clinical data and research to identify three (3) core interventions and assessments that address the stated clinical priority.
Evaluation data supported by research to effectively determine success of the intervention. The SMART goals format may be of assistance in guiding you in structuring this.
Demonstration of your clinical reasoning for your selected case study.
Answer:
Introduction
Traumatic Brain Injury (TBI), the permanent or temporary damage to brain tissue that impairs brain functions, is a common occurrence in medical practice. The causes of TBI are varied ranging from impact falls, motor vehicle crashes, traumatic assaults to sports-related concussions among other causes (Vos, 2015).
This leads to reduced blood flow to the brain which will eventually activate the cytotoxic processes which will damage the brain tissue. There will be insufficient oxygen and glucose supply to the brain (Thiagarajan, Ciuffreda & Ludlam, 2011). This will lead to inadequate energy supply which causes influx of water, sodium ions and chloride ions hence cytotoxic edema with influx of Ca2+ leading to cellular injury of the brain tissue (Brorsson et al., 2011).
Functional changes in the body associated with TBI are numerous and varied depending on the severity as well as other factors such as age and sex (Crandall, 2011). Young children may experience completely different symptoms from adults. The most common changes within the pathological state include; cerebral edema, herniation, hyperemia, loss of consciousness, tachycardia, apnea, dilated pupils, raccoon eyes, unequal pupils and slurred speech. (Jarvis, 2018)
This paper aims to analyze the common symptoms associated with Traumatic Brain Injury, the priority of clinical care and the nursing interventions in reference to a medical case study. The medical case study is of one Mr. James Parsons. Mr. Parsons, as he was leaving a club at night, engaged in an altercation with a group of males at the front of the bar. He was punched in the face and lost consciousness immediately. This caused him to fall, hitting the back of his head on a pavement. He was rushed to hospital where an immediate surgery was carried out to remove a hematoma.
This paper will employ the knowledge gathered from this case study to recommend the appropriate care needed for the full recovery of Mr. Parsons as well as provide a basis for treatment of future patients with a similar condition.
Symptoms of TBI Related To the Deteriorating Condition
Symptoms of Traumatic Brain Injury are varied and numerous depending on the severity of the case. The Glasgow Coma Scale, (GCS), is a counting system used to measure the level of consciousness in Traumatic Brain Injury (Koh, 2011). It works with on eye opening, oral response and finest mechanical response. A score of fourteen or fifteen shows slight TBI, a score of 9 to 13 shows modest TBI while a notch of 3 to 8 shows serious TBI (Castor & El Massioui, 2018).CT findings coupled up with other factors may also be an indicator of the extent of severity of the case ( Frey & Arciniegas, 2011).
In some cases, patients with initial low and moderate TBI show deteriorating symptoms. Mr.Parsons, in the given case study, shows a range of signs and symptoms related to TBI and the deteriorating condition. Parsons registers an abnormally high rapid heart rate of 118 beats per minute, a clear indication of sinus tachycardia. He also registers frequent shortness in breath especially during sleep (Apnea) at a rate of 11 breaths per minute.
Parsons past medical history of type one diabetes, smoking and social drinking could have also triggered the above symptoms. Visual evidence of raccoon eyes and a battle sign behind the ear indicate possible presence of a fracture in the skull. Loss of consciousness and sensitivity to light are also observed. The initial CT scan shows hematoma which was treated intra-operatively on arrival at the hospital.
The two major symptoms in Mr. Parson’s case, indicating a deteriorating condition that should receive immediate attention include the basal skull fracture and sinus tachycardia. Other causes for medical concern that should be looked into are shortness of breath and type one diabetes. These, if not monitored, could contribute to further deterioration of the patient.
Priority of Clinical Care
Sinus tachycardia, raccoon eyes and battle sign should be monitored. The abnormally high blood pressure should receive immediate care, to reduce it to normal levels so as to avoid any complications post operatively. Since Mr. Parsons recently left surgery, where the hematoma was removed, monitoring of the blood pressure is very essential to avoid further brain injury. The battle sign and raccoon eyes are evidence of a possible fracture in the skull. This should also be monitored to ensure quick healing of the fracture.
Nursing interventions
Mr. Parsons should receive adequate care so as to fully recover from the Injury. The major symptoms that are to be monitored are sinus tachycardia, basal skull fracture and apnea. Since Mr. Parsons is from an operation, he should be given coma inducing drugs to prevent him from suddenly waking up causing further brain damage. He can also be given diuretics so as to reduce the amount of fluid in soft tissue. The altered breathing patterns should be taken care of by placing the patient on a ventilator machine to support breathing. Adequate intravenous fluid should also be given to the patient to maintain the blood pressure. However, the three main nursing interventions that should be considered in line with the priority of clinical care include;
Hemodynamic parameters to monitor oxygen, saturation, blood pressure and temperature.
Monitoring of intra-cranial pressure to eliminate any possible relapse post- surgery
Neurophysiological and psychosocial interventions (Protheroe & Gwinnutt, 2011). .
Hemodynamic monitoring and control
Hemodynamic intensive care deals with the measurement of BP in the veins, heart and arteries (Kim, 2011).Moreover, it measures the rate of flow of blood and oxygen levels in it. It is a standard gauge on the state of the heart. The goal of hemodynamic monitoring is to maintain adequate tissue perfusion (Protheroe & Gwinnutt, 2011). It also helps in gauging cardiovascular response to tissue oxygen demands.
The techniques used in hemodynamic monitoring include; invasive, minimally invasive and non-invasive methods (Adal & Kirkevold, 2011). Intrusive methods include Pulmonary artery or Swan-Ganz catheter, measurement of blood movement, measurement of intrathoracic intravascular pressures, diverse venous overload to include additional oximetric variables. Invasive methods are more preferable to the other methods as they give more accurate and reliable results.
Considering the sinus tachycardia and apnea present in the patient, this is a necessary intervention. The patient should be given adequate intravenous fluids to maintain the blood pressure and completely eliminate the tachycardia while providing mechanical ventilator support for apnea. This intervention is expected to reduce blood pressure to normal levels from 118 beats per minute to a range of 60-100 beats per minute. Shortness of breath will also be eliminated.
Monitoring of intra-cranial pressure
Monitoring of intra-cranial pressure has been used over the years on patients suffering from Traumatic Brain Injury or recovering from it (Tume, Baines & Lisboa, 2011). The two main techniques used in monitoring include invasive and non-invasive methods (Witternberg, 2018).
The invasive techniques include ventriculostomy and microtransducers while the non-invasive practices include transcranial Doppler, , optic nerve sheath diameter, tympanic membrane dislocation, CT examination to include fundoscopy (Peebles & Cruz, 2018). Invasive methods are preferable as they are considered to be more accurate.
Following Mr. Parsons surgery for removal of hematoma and the basal skull fracture which is evidenced by raccoon eyes and battle sign, monitoring of intra-cranial pressure is very necessary. This is to avoid any further swelling after the operation preventing further brain damage. If any swelling is detected, cerebrospinal fluid can be drained accordingly so as to prevent brain deprivation of oxygen.
Neurophysiological and psychological interventions.
Neurophysiology involves measuring of electrical activities of the nerves .brain and spinal cord (Vacca, 2018).It is helpful in the monitoring of recovery as well as identification of any abnormalities that may be present post- surgery and immediate corrective measure is taken (Lump, 2014).
Psychological interventions are also necessary so as to reduce levels of fatigue in patients suffering from Traumatic Brain Injury to ensure quick recovery. (Frey & Arciniegas, 2011). These interventions prevent and control any abnormalities present while also ensuring the patient is relaxed and stress free (Aadal & Kirkevold, 2011). Mr. Parsons ought to undergo the mentioned interventions for a quick recovery.
Other nursing interventions that can be considered aside the above mentioned include; injury prevention, behavioral management, communication management, emotional support, environmental management, family support, health education, memory training and speech therapy among others (Jarvis, 2018).
Conclusion
Traumatic Brain Injury being a common occurrence needs adequate monitoring, control and immediate treatment as outlined in the paper. The major symptoms associated with Traumatic Brain Injury, if not carefully identified and treated could lead to worsening of the condition and eventual complications. The earlier the named symptoms are identified and controlled, the quicker the patient is able to recover to their normal state of being.
Mr. Parsons’s case as outlined, was a mild case of Traumatic Brain Injury especially after removal of the hemostasis intra-operatively. With the recommended clinical care outlined in the paper, Parsons will be able to recover fully. The nursing interventions should also be closely followed to rule out possibilities of abnormalities and further complications. Traumatic Brain Injury is mere brain injury when well managed and treated and is eventually eliminated.
References
Aadal, L. and Kirkevold, M. (2011). Integrating situated learning theory and neuropsychological research to facilitate patient participation and learning in traumatic brain injury rehabilitation patients. Brain Injury, 25(7-8), pp.717-728.
Brorsson, C., Rodling-Wahlström, M., Olivecrona, M., Koskinen, L. and Naredi, S. (2011). Severe traumatic brain injury: consequences of early adverse events. Acta Anaesthesiologica Scandinavica,
Castor, N. and El Massioui, F. (2018). Traumatic brain injury and stroke: does recovery differ? Brain Injury, pp.1-8.
Crandall, M. (2011). Sex Differences for Traumatic Brain Injury Outcomes.Archives of Surgery, 146(4), p.442.
Frey, K. and Arciniegas, D. (2011). Revisiting the neuroanatomical correlates of the clock drawing test among persons with traumatic brain injury. Brain Injury, 25(5), pp.539-542.
Jarvis, C. (2018). Physical Examination and Health Assessment. [S.L.]: Saunders.
Kim, Y. (2011). A systematic review of factors contributing to outcomes in patients with traumatic brain injury. Journal of Clinical Nursing, 20(11-12), pp.1518-1532.
Koh, S. (2011). Animal Models of Traumatic Brain Injury. Brain & Neurorehabilitatio , 4(1), p.12.
Lump, D. (2014). Managing patients with severe traumatic brain injury. Nursing, 44(3), pp.30-37.
Peebles, P. and Cruz, S. (2018). A primer on traumatic brain injury for nursing faculty. Journal of Professional Nursing.
Protheroe, R. and Gwinnutt, C. (2011). Early hospital care of severe traumatic brain injury. Anaesthesia, 66(11), pp.1035-1047.
Thiagarajan, P., Ciuffreda, K. and Ludlam, D. (2011). Vergence dysfunction in mild traumatic brain injury (mTBI): a review. Ophthalmic and Physiological Optics, 31(5), pp.456-468.
Tume, L., Baines, P. and Lisboa, P. (2011). The effect of nursing interventions on the intracranial pressure in pediatric traumatic brain injury. Nursing in Critical Care, 16(2), pp.77-84.
Vacca, V. (2018). Managing mild TBI in adults. Nursing, 48(8), pp.30-37.
Vos, P. (2015). Traumatic brain injury. Chichester: Wiley-Blackwell.
Wittenberg, C. (2018). Recognizing and managing traumatic brain injury. Nursing Critical Care, 13(1), pp.20-27
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