Nursing Professional Practice

Primary Assessment

D-Danger- In the given case scenario the patient was riding her bicycle on a considerably high speed when she accidently got stuck by sudden opening of a car’s gate. She was not wearing helmet as well. Riding without wearing a helmet, can be quite fatal for the person, even when commuting at a slower pace. The patient in the give case scenario was at a high speed of 40km/hour, when she hit the gate of the car. The danger in such given scenario magnifies by multiple folds. Without the protective gear, the damage can be more than anticipated and can also lead to traumatic brain injury to the person, leading to severe impairments and even death in worst case scenario (Wu, 2018). If the person doesn’t suffer from grave consequences, there are still long-term medical implications from the injury caused to the brain in such scenarios.

R-Response- The patient in the give case scenario was having a GCS of 14 at the site of injury. However, on arrival to the emergency department she was unconscious. A GCS reflecting a score of 14 can be considered under the category of the patient having minor brain injury (Ogami, 2017). However, upon arrival the patient was opening her eye to verbal command and was in a drowsy state as well. The GCS for the patient, by the time she arrived at the hospital must have dropped considerably low, falling in the category of severe brain injury or severe traumatic brain injury. Although a painful stimulus was not applied to her limbs but they were observed to be having a normal response, presuming no motor loss.

A-Airway- The patient was not found to have anything stuck in her air passage. However, her respiratory rate was found to be considerably shallow. The patient was maintained on 5 liters of oxygen supply with the help of Hudson mask. As the patient had normal saturation rate, she was managed with the help of oxygenation through the means of Hudson mask (Yan, 2018). There were no open wounds to be found in the patient. Apart from this the patient is not having hypoxia or any abnormal breath sounds on auscultation. The patient’s neck is also supported with a spinal collar in situ, to avoid any further damage (Ballester, 2019).

B- Breathing- The patient had a shallow respiratory rate, but she had normal oxygen saturation reading. The shallow respiration can also be due to her drowsy status (Liang, 2020). The patient was however maintained on 5 liters of supplement oxygen, she should be ventilated as the respiratory rate and other vital parameters might alter drastically with her deteriorating state of clinical presentation. In the given scenario the vitals can be monitored after ventilating the patient, as a precautionary measure.

C- Circulation- The patient is having a high heart rate reading of 110 bpm. The body temperature of the patient is found to be normal. The blood pressure reading of the patient is however, found to be considerably low, noted as 89/60mmHg. The patient is in hypotension. Traumatic brain injury patients are shown to reflect on the signs of hypotension (Spaite, 2017). Post-traumatic injury the blood circulation is hampered due to injury at multiple sites. This can be directly reflected in low blood pressure readings, due to inadequate blood circulation to the vessels of the body (Spaite, 2017).

D- Disability- The patient is in a drowsy state but she is opening her eye in response to the command given to her. The arms and legs are also reflecting a normal pattern of movement. The patient can be presumed to have a GCS score of 9-10. The patient however, had a GCS reading of 14 at the injury site. Due to progressive impact of the injury and medications given to her she must have attained a reduced level of consciousness. The pupil size also appears to be in normal range. The blood glucose level in the given case scenario stands at a reading of 5.2mmol, which can be indicated to be in a normal range (Burns, 2018). So, there are no potential disabilities observed in the patient at present.

E- Exposure- The patient was safely evacuated from the injury site. She was placed in a spinal immobilizer. Her coagulation parameters were all within normal range and these were no additional injuries observed in the patient on examination.

Secondary Assessment

History

The patient is a 27-year-old professional athlete, who met with an accident while cycling. She was not wearing a helmet at the time of incidence and was driving her bike at a speed of 40km/hour when suddenly a person sitting in a car parked on her way, opened his gate. The patient smashed into the car and was thrown about 15meters away. Volunteer ambulance was called. The patient had a GCS score of 14 at the time of the incidence and was rushed to the emergency department for further management. The patient was given supplement oxygen at 5lts and was placed in a spinal support for further management. Lab tests and scanning examinations were carried out for the patient. The patient arrived at the hospital in a drowsy state, with eye opening response to verbal command. There are no details available on the patient’s past medical or surgical history. The incidence landed the patient in a drowsy state, but with no physical harm visible to the naked eye. The incident happened in late evening hours.

Examination

The patient is having high heart rate and low respiratory rate as well as blood pressure. There are no external wounds noted in the patient. The pupils are of normal size. There is asymmetry in the breathing pattern observed in the chest area. The limbs are responding normally in terms of movement. The patient is in a drowsy state and is not in a state to provide her details (Wurster, 2017).

Treatment

The patient has been provided with supplement oxygenation through the means of Hudson mask. Various blood tests have been carried out for the patient, reflecting all parameters within the normal range. The arterial blood gas analysis of the patient was also done. It revealed the patient is having respiratory acidosis. Patient also underwent CT-scan for brain (Goyal, 2020), which showed results as a depressed focal right temporal skull fracture and the whole clinical presentation reflecting towards a moderate head injury.

Nursing Priorities

Following nursing priorities can be catered to in this case scenario:

  • It is vital to assess the patient for underlying allergies. Before beginning with any intervention, the next of kin and family of the patient should be informed (Curran, 2019). As the patient is not in a conscious state of mind, she cannot give consent for any of the procedural intervention to be carried out for her (Nandra, 2020). The family can also provide details on the patient’s past medical history as well any hidden allergies, so that medication management can be commenced in accordance with the same (Lamore, 2017).
  • The patient can be assessed for arterial blood gas analysis. This can be useful for setting a diagnosis for the patient and defining a line of treatment as well. The patient can be intubated and manged accordingly. Additional supplement of oxygen provision in this case scenario can cause oxygen toxicity in the patient (Ciarlone, 2019). By intubating the patient, the effort of the patient can be reduced and overall stress on the body to manage the bodily functions can be lowered comparatively. Ventilating patients with head injury, has shown to cause improved healthcare outcomes in them (McCredie, 2017). This is also vital from the point of stabilizing the vitals of the patient and keeping her hemodynamically stable (Russell, 2020).
  • The patient should be also be assessed for starting a medication course of treatment, best suitable for the patient’s condition. Usually in cases of head injury the patient is started on mannitol to reduce the swelling caused in the brain in response to the injury (Schreibman, 2018). This will also be helpful in enabling adequate blood circulation throughout the brain and thus, helping in stabilizing the vitals of the patient. The patient should also be started on a course of antibiotics to fight against the underlying infections such as respiratory, renal infections and others that may arise from the situation (Carrie, 2018).
  • The vitals monitoring as well neurological assessment of the patient should be carried out on every hourly basis (Vedantam, 2017). As the medication will start to reflects its effect the condition might progress or regress for the patient. For early identification and prevention of abnormal signs the patient should be monitored and examined thoroughly. This can include neurological assessment, heart rate monitoring, blood pressure, arterial blood gas analysis and so on. Also checking the extremities for pulse and temperature variation.
  • Fluid output for the patient should be managed with the help of diuretics. As the blood pressure of the patient is quite low, it is important that a close watch is kept on urine output of the patient. In case of reduced or hampered urine output patient is liable to develop acute kidney injury, have a poor cardiac output and get haemodynamically unstable within fractions of seconds. Bladder scan can also be performed for retention or obstruction (Rossi, 2018).
  • Sepsis assessment in such cases should also be one of the major priorities. This can be carried out by the help of blood culture and levels of serial lactate in the patient (Pandya, 2018). Sepsis can develop easily in such patients and can be life-threatening in worst case scenarios. It can also be caused due to the underlying condition of respiratory acidosis patient is suffering from.

References for Nursing Professional Practice

Ballester, O. C., Llari, M., Afquir, S., Martin, J. L., Bourdet, N., Honoré, V., ... & Arnoux, P. J. (2019). Analysis of trunk impact conditions in motorcycle road accidents based on epidemiological, accidentological data and multibody simulations. Accident Analysis & Prevention127, 223-230. https://doi.org/10.1016/j.aap.2019.03.006

Burns, R. J., Deschênes, S. S., & Schmitz, N. (2018). Associations between depressive symptoms and indices of obesity in adults with prediabetes and normal blood glucose levels: results from the emotional health and wellbeing study. Canadian Journal of Diabetes42(6), 626-631. https://doi.org/10.1016/j.jcjd.2018.05.005

Carrie, C., Bentejac, M., Cottenceau, V., Masson, F., Petit, L., Cochard, J. F., & Sztark, F. (2018). Association between augmented renal clearance and clinical failure of antibiotic treatment in brain-injured patients with ventilator-acquired pneumonia: A preliminary study. Anaesthesia Critical Care & Pain Medicine37(1), 35-41. https://doi.org/10.1016/j.accpm.2017.06.006

Ciarlone, G. E., Hinojo, C. M., Stavitzski, N. M., & Dean, J. B. (2019). CNS function and dysfunction during exposure to hyperbaric oxygen in operational and clinical settings. Redox Biology27, 101-159. https://doi.org/10.1016/j.redox.2019.101159

Curran, C., Lydon, S., Kelly, M. E., Murphy, A. W., & O’Connor, P. (2019). An analysis of general practitioners’ perspectives on patient safety incidents using critical incident technique interviews. Family Practice36(6), 736-742. https://doi.org/10.1093/fampra/cmz012

Goyal, K., Tomar, G. S., Sengar, K., Singh, G. P., Aggarwal, R., Soni, K. D., ... & Prabhakar, H. (2020). Prognostic value of serially estimated serum procalcitonin levels in traumatic brain injury patients with or without extra cranial injury on early in-hospital mortality: A longitudinal observational study. Neurocritical Care, 1-11. https://doi.org/10.1007/s12028-020-01009-y

Lamore, K., Montalescot, L., & Untas, A. (2017). Treatment decision-making in chronic diseases: what are the family members’ roles, needs and attitudes? A systematic review. Patient Education and Counseling100(12), 2172-2181. https://doi.org/10.1016/j.pec.2017.08.003

Liang, G. P., Zeng, Y. H., Chen, B. X., & Kang, Y. (2020). Prophylactic noninvasive positive pressure ventilation in the weaning of difficult-weaning tracheotomy patients. Annals of Translational Medicine8(6). https://dx.doi.org/10.21037%2Fatm.2020.02.150

McCredie, V. A., Alali, A. S., Scales, D. C., Adhikari, N. K., Rubenfeld, G. D., Cuthbertson, B. H., & Nathens, A. B. (2017). Effect of early versus late tracheostomy or prolonged intubation in critically ill patients with acute brain injury: A systematic review and meta-analysis. Neurocritical Care26(1), 14-25. 10.1007/s12028-016-0297-z

Nandra, R., Brockie, A. F., & Hussain, F. (2020). A review of informed consent and how it has evolved to protect vulnerable participants in emergency care research. EFORT Open Reviews5(2), 73-79. https://doi.org/10.1302/2058-5241.5.180051

Ogami, K., Dofredo, M., Moheet, A. M., & Lahiri, S. (2017). Early and severe symptomatic cerebral vasospasm after mild traumatic brain injury. World Neurosurgery101, 811-813. https://doi.org/10.1016/j.wneu.2017.03.039

Pandya, A., Chaput, K. H., Schertzer, A., Moser, D., Guilfoyle, J., MacGillivray, S., ... & Thompson, G. C. (2018). Risk of infection and sepsis in pediatric patients with traumatic brain injury admitted to hospital following major trauma. Scientific Reports8(1), 1-6. https://doi.org/10.1038/s41598-018-28189-0

Rossi, S., Picetti, E., Zoerle, T., Carbonara, M., Zanier, E. R., & Stocchetti, N. (2018). Fluid management in acute brain injury. Current Neurology and Neuroscience Reports18(11), 74. https://doi.org/10.1007/s11910-018-0885-8

Russell, A., Rivers, E. P., Giri, P. C., Jaehne, A. K., & Nguyen, H. B. (2020). A Physiologic Approach to Hemodynamic Monitoring and Optimizing Oxygen Delivery in Shock Resuscitation. Journal of Clinical Medicine9(7), 2052. https://doi.org/10.3390/jcm9072052

Spaite, D. W., Hu, C., Bobrow, B. J., Chikani, V., Barnhart, B., Gaither, J. B., ... & Mullins, T. (2017). The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury. Annals of Emergency Medicine69(1), 62-72. https://doi.org/10.1016/j.annemergmed.2016.08.007

Spaite, D. W., Hu, C., Bobrow, B. J., Chikani, V., Sherrill, D., Barnhart, B., ... & Adelson, P. D. (2017). Mortality and prehospital blood pressure in patients with major traumatic brain injury: Implications for the hypotension threshold. JAMA surgery152(4), 360-368. 10.1001/jamasurg.2016.4686

Vedantam, A., Robertson, C. S., & Gopinath, S. P. (2017). Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury. Journal of Neurosurgery129(1), 234-240. https://doi.org/10.3171/2017.3.JNS162720

Wu, D., Hours, M., Ndiaye, A., Coquillat, A., & Martin, J. L. (2019). Effectiveness of protective clothing for motorized 2-wheeler riders. Traffic Injury Prevention20(2), 196-203. https://doi.org/10.1080/15389588.2018.1545090

Wurster, L. A., Thakkar, R. K., Haley, K. J., Wheeler, K. K., Larson, J., Stoner, M., ... & Groner, J. I. (2017). Standardizing the initial resuscitation of the trauma patient with the Primary Assessment Completion Tool using video review. Journal of Trauma and Acute Care Surgery82(6), 1002-1006. 10.1097/TA.0000000000001417

Yan, S. H. I., Yixuan, W. A. N. G., Maolin, C. A. I., Zhang, B., & Jian, Z. H. U. (2018). An aviation oxygen supply system based on a mechanical ventilation model. Chinese Journal of Aeronautics31(1), 197-204. https://doi.org/10.1016/j.cja.2017.10.008

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