Bachelor Of Nursing For Pathology In Relation To Patient: Case Study And Analysis

Admission Summary

Head injury is complex injury with a wide spectrum of disabilities and symptoms. The impact of head injury on person and his or family is devastating (Hou et al., 2012). Mrs Waxman is a 31 year working lady who has recently encountered a traumatic head, neck and leg injury. The following reprt provides a clear insight about the admission summary of Mrs Waxman followed by a detailing analysis of the nursing care needs of Mrs Waxman while her stay in the neurological ward. The report also sheds light on the consequences of gestational diabetes mellitus and its relation with Mrs Waxman gain in weight, who is also a mother of three young children. Finally he report sums up with the long-term outcomes of brain injury in context of Mrs Waxman. 

Mrs Mary Waxman is 31 years old women. She is an orthodox Jew and works as computer system analyst, managing the Australian branch. She has slipped from the top of the escalator. This accidental fall has resulted in major head injury along with damage of the soft tissues around her neck. She has also encountered grazes and lacerations over her arms and legs along with a deep wound in her lower right leg. Following her fatal injuries, she was admitted to Intensive Care Unit. After 48 hours, she was shifted to the neurological ward. She was unconscious and was having intravenous line along with nasogastric tube and urinary catheter in an in situ condition. 

1. Elevated Level of Glucose

Mrs. Waxman is diagnosed with elevated level of glucose with 25mmole/L. [Normal blood glucose level should be less than 6.9 mmole/L in non-fasting condition (Karlsson  et al., 2013)].

1. Deficient Fluid Volume:This is majorly associated with imbalance in body weight, either gain or sudden loss in weight (Bray & Popkin, 2014). In case of Mrs Waxman, it is gain in weight, over 20 kilos in the past 12 months. It is also associated with imbalance in urine output (>30mls/hour)
2. Imbalance in the level of nutrition:Doctors has recommended for the insertion of Naso Gastric Tube for the introduction of equilibrium level of nutrition and this shows that Mrs Waxman is suffering from deficiency in nutritional level which is common is such clinical condition and also a sign of diabetes (Testa, Genovese & Ceriello, 2014).

Proper monitoring of the body weight and nutritional intake and this will aid in the secretion and synthesis of insulin the blood along with glucose metabolism.

Nursing Intervention Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	Rationale
Proper reference to dietician for obtaining an individualised diet instructions	Individualised diet plan depends on the body weight, BMR, body type, activity level and specific clinical outcomes (Evert et al., 2014). In case of Mrs Waxman, her physical activity is zero at the present clinical scenario and thus her diet plan must be regulated accordingly.
Periodic monitoring of the blood glucose level	Periodic monitoring of the blood glucose level (BGL) is important for a patient suffering from high level of blood glucose; it gives an insight of the current scenario and helps in adjusting the insulin intake accordingly (American Diabetes Association, 2014). In case of Mrs Waxman, doctors has instructed for BGL monitoring after every 6 hours for the next 24 hours in the neurological ward.
Administration of Insulin	Subcutaneous administration of insulin helps in the reduction of the insulin level in blood as it promotes insulin absorption into the cells (American Diabetes Association, 2014).

Evaluation method

The evaluation method will be based on the BGL and how the patient is responding to the nutritional intake and insulin.

1. Low GCS (Glasgow Coma Scale) Score

Mrs Waxman, on the admission to the neurological ward from intensive care unitwas unconscious and was not responding to the painful stimuli. The GCS score 10. However, the pupils are intact and reacting upon exposure to light.

GCS scale is based on 15 point scale that is required for estimating and simultaneously categorising the possible outcomes on the brain injury. 

Risk of injury responsible for the decreased level of consciousness: In case of Mrs Waxman, the injury which has attributed to unconsciousness is head injury (Wilkinsonet al., 2016).

Disturbed Sensory Perception in response to severe Neurological Impairment: Neurological impairment is a chance in case of Mrs Waxman as she has encountered severe brain injury followed by injury in the soft tissues of the lying over the neck (Wilkinsonet al., 2016).

Her Glass Glow Coma Scale Reported 10, which means, her GCS score is moderate. This moderated GCS is attributed to lack of consciousness (LOC) for 30 to 24 hours along with Post Traumatic Amnesia for 1 to 7 days. In case of Mrs Waxman PTA is 48 hours (till now). 

Nursing Care Needs

Proper Nursing care will help Mrs Waxman to score 15 in GCS.

Nursing Intervention	Rationale	Evaluation
Protecting the patient from encountering any further accidental injuries while stay in the hospital	Unconscious patient lies at an increased risk of encountering physical injuries and hence protection must be given in order to avoid the chances of accidents (Kandeel & Attia, 2013)	Installation of padded side rails in both sides of the hospital bed will prevent the chance of unwanted fall (Kandeel & Attia, 2013)
Proper maintenance of the fluid as well as the nutrient balance	Unconscious patient in the majority of time is physically unfit for the oral intake of food. Mrs Waxman has injuries to the soft tissues of the neck and thus she need proper fluid support in order to maintain her fluid balance (Hannon, Finucane, Sherlock, Agha & Thompson, 2012)	Insertion of Nasogastric Tube in order to maintain the nutrient balance along with regular blood test for the detection of the macro and micro nutrient level along with total protein count (Hannon et al., 2012)
Prevention of urinary retention	Lack of urine excretion from the body will lead to the increase in the level of toxic urea inside the body which ultimately increases the concentration of ammonia. Proper clearance of urine is must for the eradication of toxic materials from the body fluid (Weiner, Mitch & Sands, 2015)	Measuring hourly urine output along with regulating proper urine intake (Weiner et al., 2015)

Problem in wound healing in lower right leg

Mrs Waxman is facing difficulty in wound in her lower right leg with purulent discharge.

Nursing Diagnosis	Expected Outcome
Proper access of the site of impaired tissue integrity	Redness and swelling of the area, along with pain and burning indication these are the signs of inflammation and hypersensitivity reaction (Carpenito-Moyet, 2006)
Assess any physiological change in the body like increase in body temperature	Fever is regarded as an systemic manifestation inflammation and also an indication for infection (Carpenito-Moyet, 2006)

Nursing Intervention	Rationale
Proper monitoring of the site of injury for accessing tissue injury	Proper yet systematic intervention aids in early identification of the impending problems (Carpenito-Moyet, 2006)
Maintenance of sterile dressing technique	Sterile dressing technique helps in the reduction of chances of infection (Carpenito-Moyet, 2006)

Pregnancy may results in the development of insulin resistance that predispose women to acquire diabetes mellitus. Gestational Diabetes Mellitus (GDM) is manifested when the pancreatic function of a pregnant woman fails to overcome the diabetogenic environment, common during pregnancy (Coustan, 2013). GDM can also defined as a condition related with glucose intolerance and its susceptibility increases if the excepting mother is previously suffering from Type 2 Diabetes Mellitus. During pregnancy, alteration of growth hormone, lactogen secretion from the human placenta negatively affects the process of glucose metabolism and on the other hand, promotes lipolysis, increases insulin secretion and decreases glucose uptake. All these physiological factors disrupt the normal balance of insulin modulation, giving rise to GDM (Coustan, 2013). During pregnancy, there also occurs a large change in the hormonal activity, mostly estrogen and progesterone and this sudden change in the hormonal secretion disrupts the equilibrium between glucose and insulin secretion, further increasing the chances of developing GDM. The risk factors which are associated with GDM are polycystic ovary, obesity and pregnancy related hypertension (Coustan, 2013).

The chances of GDM increase with the prevalence of Type 2 Diabetes Mellitus (Erem, Kuzu, Deger & Can, 2015). Long working hours of Mrs Waxman accompanied with active corporate socialization may have promoted her susceptibility towards development of Type 2 Diabetes Mellitus. This Type 2 Diabetes has further promoted the susceptibility of GDM. Since, Mrs Waxman is survived by three young children, the rate of susceptibility can be assumed to be more. The chances of development of GDM, may be responsible behind her weight gain (20 kg in the past 12 months) and now increase in the blood glucose level (25 mmole/L) (Erem  et al., 2015). [Normal blood glucose level should be less than 6.9 mmole/L in non-fasting condition (Karlsson  et al., 2013)]. 

Brain function of Mrs Waxman can be temporarily impaired the condition is commonly known as concussion (Hou et al., 2012). In long term outcomes, head injury can lead to headaches, dizziness, depression, fatigue irritability along with memory problems. Complex long term problems include change in personality, change in the dimension of relationship and difficulty in leading an independent life (Ponsford et al., 2014).

Brain injury can change the psychological balance of a person. In case of Mrs Waxman, the long term outcomes include mood swings, difficulty in controlling emotions. In some extreme cases, traumatic brain injury may result in sudden episodes of crying or laughter, without any significant reasons. Emotional expression may at times fail to match with the situation, like crying during a funny situation or vice versa (Washington et al., 2012).

The cognitive outcome after traumatic brain injury may include difficulty in attention or issues with maintaining sound concentration. Problems associated with speech, language, learning and memory (Washington et al., 2012). Mrs Waxman may also face problem on carrying out long conversation with people. This may inversely affect her carrier as active socialization is an important aspect for her corporate life.

Nursing Diagnosis

The behavioural problems will be somewhat related with the cognitive problems like mood swings (Washington et al., 2012). Moreover, due to her physical injury in leg, Mrs Waxman may need to spend a couple of months in a complete bed rest condition. This sedentary life will affect Mrs Waxman negatively giving rise to depression and this depression will lead to irritability, or helplessness.

Change in family dynamic may occur as due to brain injury, Mrs Waxman may fail to connect emotionally with her children and husband (Washington et al., 2012).. 

Conclusion

Thus from the above discussion, it can be concluded that, the aftermath and the sufferings of head injury are wide stretch. Proper nursing intervention along with effective medical treatment is the only way out to treat this problem.

References

American Diabetes Association. (2014). Diagnosis and classification of diabetes mellitus. Diabetes care, 37(Supplement 1), S81-S90. https://doi.org/10.2337/dc14-S081

American Diabetes Association. (2014). Standards of medical care in diabetes—2014. Diabetes care, 37(Supplement 1), S14-S80. https://doi.org/10.2337/dc14-S014

Bray, G. A., & Popkin, B. M. (2014). Dietary sugar and body weight: Have we reached a crisis in the epidemic of obesity and diabetes?. Diabetes care, 37(4), 950-956. https://doi.org/10.2337/dc13-2085

Carpenito-Moyet, L. J. (Ed.). (2006). Nursing diagnosis: Application to clinical practice. Lippincott Williams & Wilkins.

Coustan, D. R. (2013). Gestational diabetes mellitus. Clinical chemistry, 59(9), 1310-1321. doi: 10.1373/clinchem.2013.203331

Erem, C., Kuzu, U. B., Deger, O., & Can, G. (2015). Prevalence of gestational diabetes mellitus and associated risk factors in Turkish women: the Trabzon GDM Study. Archives of medical science: AMS, 11(4), 724. doi:  10.5114/aoms.2015.53291

Evert, A. B., Boucher, J. L., Cypress, M., Dunbar, S. A., Franz, M. J., Mayer-Davis, E. J., … & Yancy, W. S. (2014). Nutrition therapy recommendations for the management of adults with diabetes. Diabetes care, 37(Supplement 1), S120-S143. https://doi.org/10.2337/dc14-S120

Hannon, M. J., Finucane, F. M., Sherlock, M., Agha, A., & Thompson, C. J. (2012). Disorders of water homeostasis in neurosurgical patients. The Journal of Clinical Endocrinology & Metabolism, 97(5), 1423-1433. https://doi.org/10.1210/jc.2011-3201

Hou, R., Moss-Morris, R., Peveler, R., Mogg, K., Bradley, B. P., & Belli, A. (2012). When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury. J Neurol Neurosurg Psychiatry, 83(2), 217-223.

Kandeel, N. A., & Attia, A. K. (2013). Physical restraints practice in adult intensive care units in Egypt. Nursing & health sciences, 15(1), 79-85. DOI: 10.1111/nhs.12000

Karlsson, F. H., Tremaroli, V., Nookaew, I., Bergström, G., Behre, C. J., Fagerberg, B., … & Bäckhed, F. (2013). Gut metagenome in European women with normal, impaired and diabetic glucose control. Nature, 498(7452), 99.

Ponsford, J. L., Downing, M. G., Olver, J., Ponsford, M., Acher, R., Carty, M., & Spitz, G. (2014). Longitudinal follow-up of patients with traumatic brain injury: outcome at two, five, and ten years post-injury. Journal of Neurotrauma, 31(1), 64-77. https://doi.org/10.1089/neu.2013.2997

Ramirez, S. H., Rom, S., & Persidsky, Y. (2013). U.S. Patent Application No. 14/406,400.

Testa, R., Genovese, S., & Ceriello, A. (2014). Nutritional imbalances linking cellular senescence and type 2 diabetes mellitus. Current Opinion in Clinical Nutrition & Metabolic Care, 17(4), 338-342. doi: 10.1097/MCO.0000000000000066

Washington, P. M., Forcelli, P. A., Wilkins, T., Zapple, D. N., Parsadanian, M., & Burns, M. P. (2012). The effect of injury severity on behavior: a phenotypic study of cognitive and emotional deficits after mild, moderate, and severe controlled cortical impact injury in mice. Journal of neurotrauma, 29(13), 2283-2296. https://doi.org/10.1089/neu.2012.2456

Weiner, I. D., Mitch, W. E., & Sands, J. M. (2015). Urea and ammonia metabolism and the control of renal nitrogen excretion. Clinical Journal of the American Society of Nephrology, 10(8), 1444-1458. doi: 10.2215/?CJN.10311013

Wilkinson, J. M., Treas, L. S., Barnet, K. L., & Smith, M. H. (2016). Procedure Checklists for Fundamentals of Nursing. FA Davis.