Assessment, Resuscitation And Early Management – Clinical Reasoning In Nursing

Collect cues and information

Discuss about the Assessment, Resuscitation and Early Management.

Clinical reasoning is the term generally used interchangeably with clinical judgment, problem solving, decision making and critical thinking. Clinical reasoning is the stepwise approach incorporating collection of cues and information, processing of the information, understanding patient’s exact problem, planning and implementing nursing interventions and evaluation of outcomes. Clinical reasoning is not a linear process, however it is complex process comprising of different steps. Tasks in the clinical reasoning should be modified according to the condition of the patient. Clinical reasoning is very important aspect in nursing intervention because it has positive impact of the outcome of the patient. An improper clinical reasoning would result in the wrong diagnosis and consequently wrong treatment. As a result, there is possibility of deterioration of the patient. Adverse patient outcome can be prevented by accurate diagnosis, appropriate treatment and appropriate management of related complications. All these three aspects can be effectively implemented using clinical reasoning (Cooper and Frain, 2016). In case of Katie clinical reasoning is used for her assessment. Nurse described about Katie, collected information about medical condition of Katie, understood her exact problem, planned and implemented nursing interventions for Katie. In this essay all these steps are discussed.  Assessment of Katie should include medical, social and psychological aspects. Hence, nurse should be well versed with all these aspects for implementing clinical reasoning in case of Katie.          

Katie a 23 year old woman is admitted to the hospital due to sustained haematoma 18 hours ago because she was hit by a slow moving car. After assessment, it was observed that she had mild traumatic brain injury. Intracranial hemorrhage and haematoma are very common in persons with traumatic brain injury. Approximately 50 % patients with traumatic brain injury suffer through haematoma. This haematoma can be indentified in first four hours of the brain injury (Qureshi et al., 2015). From the literature, it is evident that persons of Katie’s age, are less susceptible to brain injury as compared to the older people. Because in older people, chances of brain injury are more due to fall. Younger people of Katie’s age can recover fast in terms of neurological symptoms as compared to the older people. This age people can recover from neurological symptoms in approximately 5 years (Plata et al., 2008).

From the provided handover, her heart rate was 89 beats per minute, respiratory rate was 13 breaths per minute and oxygen saturation (Sp02) was 96 %. All these values indicated that her heart rate, respiratory rate and oxygen saturation were normal. Her Glasgow Coma Score was 14. It indicated she had mild coma. Her blood pressure was 142/78 mmHg. Her systolic blood pressure was higher than normal while diastolic blood pressure was normal. She was forgetting recent information and remembering with some prompting. It indicates that she had developed little memory loss. There was information missing about the pupillary size and reaction to light because brain injury can directly affect retina. Her temperature recording was also missing because patients with brain injury are susceptible to pyrexia. Recording of central venous pressure was also missing from her handover because in patients with brain injury there is possibility of increase in intracranial pressure. Her haematology full blood count and coagulation screening should have been performed; however this information was missing from her handover. Her blood sugar level and urinary output using urinary catheter should have been done. Also, in the provided handover there was no information about the medications which were used as an initial therapy. These medications should have been mentioned in handover because it would have been used to plan further management of Katie (Moppett, 2007). Her past medical history revealed that she was suffering through painful ankle mainly due to basketball. However, she used to avoid consumption of painkillers.   

Process information

From the evaluated parameters, it was evident that Katie’s heart rate, respiratory rate and oxygen saturation were in the normal range. Heart rate should be 70- 100 beats per minute, respiratory rate should be 12 – 20 breaths per minute and oxygen saturation should be above 94 % for the person of Katie’s age. From the literature, it is evident that person’s with subdural haematoma generally develops hypertension. In case of Katie also, it was observed that she had developed systolic hypertension. Glasgow Coma Score between 13 – 14 is considered as mild coma. Her coma score was within this range. Persons with brain injury generally develop cardiovascular instability. It includes bradycardia and hypertesion. However, heart rate should be normal. People with brain injury also develop hypoxia, however in case on Katie her oxygen saturation is in the normal range (Adams, 2010).

She developed memory loss. Her computed tomography (CT) scan and magnetic resonance imaging (MRI) should be performed to get more insight of brain injury. Thrombocytopenia should be performed for her because it can be helpful in bleeding diathesis. Her blood group should be taken. It would be helpful in finding matched blood group, if surgical intervention required for subdural haematoma. She should be provided with artificial intubation because patients with brain injury might develop hypoxia. Also she should be provided with central venous catheter. It would be useful in monitoring intracranial pressure because in patients with brain injury there is possibility of increase in the intracranial pressure. This intracranial venous catheter would also be useful in providing fluid and drugs (Blissitt, 2006). Persons of Katie’s age are not generally associated with the hypertension. However, due to brain injury and haematoma, she developed hypertension. Other person’s who are not experiencing this condition, would not have memory loss and they would be conscious. However, Katie is suffering through memory loss and mild coma. There is possibility of hyperpyrexia and hypercarbia in Katie. This condition would not be there in persons without brain injury. Katie may need artificial intubation as she may develop hypoxia and blood loading. However, person’s without brain injury may not require artificial intubation and blood loading (Moppett, 2007). There is possibility of development of paralysis in Katie. There is possibility of vision loss and other complications due to retinal injury. However, in people of Katie’s age, there is less possibility of development of paralysis and retinal complications. There is possibility of proprioceptive dysfunction in Katie. There is possibility of sensory processing disorder in Katie. This sensory processing disorder comprises of speech impairment, memory loss and cognitive impairment. Katie may also develop facial paralysis which is termed as facial palsy. People without brain injury may not develop these conditions (Ponsford et al., 2008).

Identify problems/issues

Nursing and medical goals should be set for Katie. Her blood pressure, respiratory rate and  hypoxia should remain normal. For this purpose appropriate medications should be administered to Katie. Her physical assessment and vital signs should be monitored on regular basis. Blood pressure should be measured using blood pressure apparatus and hypoxia should be evaluated by incorporating arterial blood gas (ABG) test. If nurse found abnormality in these values, nurse should consult with doctor to modify treatment accordingly. Nurse should evaluate oxygen saturation before and after artificial intubation. Nurse should consult with the psychologist to take care of her speech problem and cognitive impairment. Nurse should assess her cognitive impairment by giving different tasks (Schultheis and Whipple, 2014; Guy et al., 2014). This would be helpful for nurse to make conclusion on type of memory loss. Nurse should evaluate paralysis in her by assessing reaction time to particular task. Nurse should evaluate her urine output on regular basis because cardiovascular complications can affect urine output. Nurse should use catheter to measure amount of urine collected in prior 24 hours. Nurse should evaluate intracranial pressure of Katie using central venous catheter. In case, if there is raised intracranial pressure observed in Katie, nurse should consult doctor for surgical intervention (Carone and Bush, 2012).                         

Conclusion:

Nurse should be well versed with biomedical and clinical sciences for implementing clinical reasoning for Katie. Nurse should be skillful in gathering clinical and medical data. Based on the collected information, nurse should interpret clinical data. This interpretation would be helpful for the nurse to take further action. Next step should be based on the known information and hypothesis based on the clinical data. Nurse should have knowledge of different aspects like history collection, physical examination, differential diagnosis, signs, symptoms and tests. In case Katie, information about her was collected. Persons of Katie’s age generally doesn’t face problem of traumatic brain injury. Heart rate, respiratory rate and oxygen saturation of Katie are normal. Her Glasgow Coma Score indicates mild coma. It is evident that she is experiencing memory loss. There should be requirement of tests to be performed for papillary size, pyrexia, central venous pressure, blood count and coagulation. These all parameters can be significantly changed in cases of traumatic brain injury. Nurse should use different tests and techniques like ABG and central venous catheter for further evaluation of Katie. Thus with the application of clinical reasoning complete assessment of Katie can be performed and holistic management can be provided.

References:

Adams, J.P. (2010). Non-neurological complications of brain injury”. In John P. Adams; Dominic Bell; Justin McKinlay. Neurocritical care : a guide to practical management. London: Springer. pp. 77–88.

Blissitt, P.A. (2006). Care of the critically ill patient with penetrating head injury. Critical Care Nursing Clinics of North America, 18(3), 321–32.

Carone, D., and Bush, S.S. (2012). Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering. Springer Publishing Company.

Cooper, N., and Frain, J. (2016). ABC of Clinical Reasoning. John Wiley & Sons.

Guy, R., Furmanov, A., Itshayek, E., Shoshan, Y., and Singh, V. (2014). Assessment of a noninvasive cerebral oxygenation monitor in patients with severe traumatic brain injury. Journal of Neurosurgery, 120(4), 901–907.

Moppett, I.K. (2007). Traumatic brain injury: Assessment, resuscitation and early management.  British Journal of Anaesthesiology, 99(1), 18–31.

Plata, C.M.,  Hart, T.,  Hammond, F.M.,  Frol, A., et al., (2008). Impact of Age on Long-term Recovery From Traumatic Brain Injury.  Archives of Physical Medicine and Rehabilitation, 89(5), 896–903.

Ponsford, J., Draper, K., and Schonberger, M. (2008). Functional outcome 10 years after traumatic brain injury: its relationship with demographic, injury severity, and cognitive and emotional status. Journal of the International Neuropsychological Society, 14(2), 233–242.

Qureshi, A.I., Malik, A. A., Adil, M.M., Defillo, A., Sherr, G., and Suri, K. (2015). Hematoma Enlargement Among Patients with Traumatic Brain Injury: Analysis of a Prospective Multicenter Clinical Trial. Journal of vascular and interventional neurology, 8(3), 42–49.

Schultheis, M. T., and Whipple, E. (2014).  Driving after traumatic brain injury: evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Reports, 2(3), 176–183.