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  • Subject Name : Nursing

A-G Clinical Assessment

Peter, with o negative blood, admitted to hospital by paramedical staff, due to brain injury.

Peter is a 32-year-old who is working by profession. He suffered because of an accident. While going to the office. He was driving a motor vehicle when he collided with the truck. He received many injuries and deformation as he is not wearing a seat belt. After 15-0 minutes ambulance paramedics arrived the to location spot and found Peter unconscious. The paramedical staff reported that at that time, it’s obvious a head injury, with multiple lacerations, profuse maxillofacial bleeding and a substantial amount of blood in his oropharyngeal cavity. Other than this, it was also reported that his respirations were irregular and tedious, chest rise, expansion and equal air entry.

Intubations, in this case, is not possible because of traumatic airway obstruction and trismus. So with taking care of this situation, paramedics immobilised Peter’s cervical spine with a hard cervical collar and able to maintain his airway through Guedel’s airway and continuous oropharyngeal suctioning. He patient was also given assisted ventilation using a bag and mask. He also gave haemodynamically, hypotensive, intravenous access and 900 ml of compound sodium lactate. Peter able to opined his eyes to painful stimuli, his pupils were equal and are able to react to the eye, but he is not able to do a verbal communication. This confirms that he has a head injury. Paramedic staff transferred Peter to hospital and informed the emergency department about his whole condition. At 9:20 hour, Peter bypassed to triage and was shifted to the resuscitation area where the members of the trauma team conduct primary and secondary surveys. The primary survey ensures rapid prioritised assessment of vital function and needs using A, B, C, D, E approach. The secondary survey does a comprehensive, systematic, head to head, front-to-back examination of the patient.

His primary survey provides a vital sign including a heart rate of 140beats/min; respirations 8 breathesminutte and stridulous; blood pressure 110/70 mmHg; Saturated oxygen level 88-90% with a temperature of 35.1%. Peter found the profuse visible head and facial breathing, plus suspected intra-abdominal haemorrhage. His secondary survey findings included that he has an extensive haemorrhage, with multiple facial lacerations. He has open fracture and deformity of the right arm with lacerations and bursting, and pulses present . in the lower limb, no obvious deformity present with lacerations and extensive bursting. the risk of intracranial haemorrhage was increased due to his emerging coagulopathy and delayed neurosurgical intervention because the circulatory issue is the clinical priority for the doctors. At 10:00 hour, Peter was transferred to the operating theatre for an exploratory laparotomy; grade one liver laceration repair and examination of an internal organ. He was also treated for control of facio-maxillary bleeding through the insertion of Foley balloon catheters in both nostrils and packing of the nasopharynx with adrenaline-soaked gauze to provide localise vasoconstriction. Following this surgery, Peer was transferred to radiology for an urgent CT scan which will release extensive head injuries including intraventricular haemorrhage. Currently, He is admitted to ICU for further management of his condition.

In ICU, Peter was ventilated using synchronised intermittent mandatory ventilation with pressure and pressure support for the potential spontaneous breaths. Hyperventilation is avoided in the first twenty-four-hour of supervision as cerebral vasoconstriction would compromise cerebral perfusion when CBF is already limited. Hyperventilation is recommended only when clinical signs of acute neurological deterioration like acute rises in ICP. Peter was also admitted sodium bicarbonate (8.4%) for treatment of his continuing metabolic acidosis on second (380mmol) and third day (480mmol) . in the second day of incubation, PEEP increased to 12 cm H2O to maintain alveolar inflation because of Peter’s acute long injury. Regular assessment of transducer position and line patency need to be ensured as it helps in hemodynamic measurements accurately.

Hour measurement and recording of fluid balance provide a piece of information which directed therapeutics fluid resuscitation. Mannitol was administered was indicated to treat episodes, of spiking ICP and cerebral oedema. Intravenous fluids were infused to correct hypovolemia if detected. To manage Peter’s coagulopathy, packed cells, cryoprecipitate, fresh frozen plasma, and synthetic clotting factors. Peter’s does not show any significant changes with pneumatic leg compression in terms of MAP, CVP, ICP, and CPP. Many components of Peter's cerebral perfusion were made including IP control, managing external ventricular drain, pathophysiological conditions management such as cerebral haemorrhage, vasospasm, seizures, temperature, pain, and cervical spine clearance.

The nursing care unit of the hospital has strategically planned and implemented ways to minimise the noxious stimuli which are responsible for elevated ICP. Neuromuscular blocking agents were used to post-intubation to stabilise uncontrollable ICP by reducing metabolic demand and peripheral nerve stimulator. The patient’s temperature was measured using an indwelling urethral catheter and active cooling were communed using a cooling blanket if the temperature becomes progressively unstable. Paracetamol was used throughout the admission in conjugation with exogenous cooling strategies to reduce hyperthermia. The initial blood glucose level was elevated due to sympathetic stimulation. Other than this insulin infusion was commenced which is directed to maintain the hyperglycaemia and hypoglycaemia. He was also given a lower dose erythromycin to facilitate gastric emptying.

The optimal physiological parameters became extremely difficult which outlines the median value for haemodynamic and intracranial parameters. On the eighth and ninth day of his admission, his temperature was labile and uncontrollable.

Next shift requires a deep intervention of Peter’s condition and a close eye on his ill-health condition. The close interaction of family members and their awareness about the condition and beliefs.

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