Discuss about the Focussed Assessment For Katie Mcconnell.
The patient Katie McConnell is 23-year-old woman who was admitted to the neurosurgical trauma unit after a road traffic accident that involved a slow-moving car. She sustained a subdural haematoma due to the accident which occurred 18 hours ago. During the change of shift, the patient was received with the following vital signs: Blood Pressure of 142/78, a heart rate of 89 beats per minute, and respiration rate of 13 breaths per minute. She also had a 96% oxygen saturation and a Glasgow Coma scale of 14. Moreover, she had some problems in remembering recent information. However, she could recall some when prompted.
On verbal assessment, she reports having had a painful ankle which had lasted for a long time and was sustained when she was playing basketball. She also does not like to use painkillers due to an unexplained reason. At the time of handing over, she was with her partner. She has been diagnosed with a mild traumatic injury. This condition has a characteristic effect on memory especially if it affects any part of the brain. Therefore, the symptoms that Katie McConnell is experiencing are typical of the condition. However, the ankle pain has lasted for long, and in most cases, these conditions heal after a short while (Parry, 2015). It indicates that the problem could be more intense.
Additionally, her inability to recall recent information has not been established whether it is related to the accident or another cause that she has not explained. Therefore, I will have to enquire more about the historical perspective of her mental state through a mental status examination.
Furthermore, any mild joint injury such as a contusion heals within a week or two (Fischbach, 2012). However, Katie’s ankle pain has lasted for so long (Parry, 2015). This phenomenon indicates that it could be a sprain that was never corrected due to overstretching or tension on either the deltoid ligament, the anterior talofibular ligament, the posterior talofibular ligament or the calcaneofibular ligament when she was playing basketball. Additionally, it could be a strain on the peroneus longus or Brevis muscles, the posterior and anterior tibialis muscles, the lower portion of the gastrocnemius or the soleus muscles. Either one or more of the ligaments could be damaged or one or more muscles.
Katie’s systolic blood pressure is very high at 142 mmHg indicating that she is in stage 1 hypertensive state. Because some blood has been lost due to the subdural haematoma, the body’s compensatory mechanism has been initiated to pump enough blood to reach the vital body organs such as the brain and the liver. Moreover, the blood pressure is also increased due to the fright, fight and flight mechanism of the sympathetic nervous system due to the patient’s panic and anxiety caused by the reality and shock of getting involved in an accident. The blood pressure is elevated to supply more nutrients to the vital organs which are necessary to create more energy and activity for escape. When involved in an accident, the blood pressure is expected to be elevated but not exceeding the pre-hypertensive state where the systole is supposed to range between 120-139mmHg and diastole between 80-89mmHg (“I.1. Workshop: Health Technology Assessment and Health Impact Assessment – Two key examples of health assessment”, 2014).
As such, Katie’s systolic pressure has exceeded the expected, and this has to be handled with immense care and administration of the necessary medications because a hypertensive crisis is dangerous for the blood capillaries and the major organs such as the kidneys, lungs and the liver.
Katie’s heart rate is within the normal range of between 60-100 beats per minute. This indicates that her myocytes contractility and their rhythm is normal. I am not too worried about her pulse, but the blood pressure draws my optimal concern. Therefore, it’s imperative to check her urinary output and also perform the Liver Function Tests (LFTs) to ascertain the effects of the increased systolic pressure on the two organs, the liver, and the kidneys.
The respiration rate of Katie is within the normal ranges of 12-20 breaths per minute. It, therefore, indicates that the lungs are yet to be affected by the elevated systolic pressure. It is expected that in the long run, she could develop pulmonary oedema and subsequent tachypnoea, dyspnoea, lethargy and other respiratory symptoms if the blood pressure is not corrected (Ducker, & Simmons, 2015). Therefore, one organ is safe but only for a while.
Katie’s oxygen saturation is at 96% within the expected ranges of between 95%-100%. This means that the organs are receiving the required amounts of oxygen for normal metabolic activities. The brain is also part of the vital organs that is receiving enough oxygen despite the subdural haematoma. As such, prompt measures to remove the haematoma will maintain the functioning of her nervous system and restoration of normal health. Moreover, the level of injury to Katie’s brain is not severe because her Glasgow Coma Score was 14 out of the highest possible 15.
The loss of short-term memory could be due to the pressure on the limbic system caused by the haematoma and the rise in blood pressure (Payne, 2015). Additionally, it could be pressure to any of the constituent organs of the limbic system that control memory; they include the hippocampus, the amygdala, hypothalamus, thalamus, epithalamiums, cingulate gyrus among others (Payne, 2015). Therefore, I will have to ascertain her Intracranial Pressure (ICP) and maintain it at the normal levels using hypertonic saline or mannitol (“Cerebral Perfusion Pressure or Intracranial Pressure?”, 2013). However, I will have to perform a brain imaging to ascertain the extent of the haematoma to determine the management mode. If it is mild, I will just monitor and maintain bed rest so that the macrophages clear it. However, if it is severe, I will prepare her for Burr hole trephination, a craniotomy or a craniectomy depending on the surgeon’s recommendations (Emich, Dollenz, & Winkler, 2015). When the haematoma clears, the increased ICP will normalise and most likely resolve her problems with recent memory loss.
The ankle pain that Katie has is due to a most probable sprain or strain on the ankle ligaments, muscles or tendons and it is not mild because it should have healed a long time ago (Jones, 2013). Therefore, I will recommend an X-ray to confirm either of the conditions above and most probably, there will be a need for a surgical intervention to correct the problem. Moreover, Katie does not like analgesics perhaps due to the side effects that they cause. Therefore, I will have to ascertain the exact drugs that she uses and the kind of effects that they cause her. This will help rule out possible adverse reactions and establish an alternative and safer drug for her.
Katie has an epidural haematoma and a mild traumatic brain injury secondary to a road traffic accident that has subsequently caused an increased intracranial pressure (“Cerebral Perfusion Pressure or Intracranial Pressure?”, 2013). The increased ICP led to pressure on the hippocampus which processes memory. The hippocampal pressure has affected her recent memory that can only be achieved after provocation. Moreover, the blood loss due to the haematoma and the activation of the sympathetic nervous system after involvement in the accident has led to elevated systolic blood pressure as a compensatory mechanism. Additionally, she has ankle pains due to a significant injury to either the muscles, the tendons or ligaments that were not managed earlier (Parry, 2015). I will focus on the above health concerns because they will lead to a major health crisis for Katie if ignored (Robinson, 2014).
A person who is not experiencing Katie’s situation has a normal ICP with no problem remembering recent activities with or without provocation. Additionally, the blood pressure of a normal person would not be this high with disparities in the systole and diastole. Moreover, a normal ankle should not be painful during any activity as opposed to Katie’s problem (Robinson, 2014).
After administration of antihypertensive drugs such as mannitol, which is an osmotic diuretic, I will perform an hourly confirmation of blood pressure by using an adult size cuff, a stethoscope and a manual sphygmomanometer (Bilo et al., 2016). I will place the cuff on Katie’s either arm and inflate it up to 30mmmHg as I auscultate the brachial artery until the radial pulse is impalpable.
Afterward, I will slowly release the pressure until I hear the first sound, and record the pressure on the sphygmomanometer scale and at the level where the sounds disappear (Lant, 2014). The two levels indicate the systolic and diastolic pressures.
By using Cushing’s triad, I will assess the levels of declining diastolic and a rise in systolic pressures which are characteristic of an increased ICP after every hour. These findings shall be recorded at the same time the blood pressure is taken because the values are the same. If this method gets unreliable, I will use a strain gauge manometer at the bedside to continuously record the ICP through the ventriculostomy that shall be introduced by a neurosurgeon (“Ventriculostomy,” 2013).
I will also perform a mental status examination with specific emphasis on Katie through content, mood, touch with reality and memory. I shall do this by asking her specific questions of recent and long-term memory. For instance, if she recalls the name of her partner, the year she was born and if she was involved in an accident. I will also examine her moods by being provocative and inquisitive. These findings are vital to ascertain the extent of the injury to the brain and the implications for the involvement of a psychiatrist.
I will assess her use of analgesics for the ankle pain through a past medical history. I shall ask her partner to provide the records of the previous prescriptions of the medications, and then identify the specific reactions to each drug (Jones, 2013). Afterward, I will explain whether it is a normal side effect of the drug or it is an allergic reactions.
References
Bilo, G., Giglio, A., Styczkiewicz, K., Caldara, G., Kawecka-Jaszcz, K., Mancia, G., & Parati, G. (2016). How to improve the assessment of 24-h blood pressure variability. Blood Pressure Monitoring, 10(6), 321-323.
Cerebral Perfusion Pressure or Intracranial Pressure?. (2013). Journal Of Neurosurgery, 92(1).
Ducker, T., & Simmons, R. (2015). Increased Intracranial Pressure and Pulmonary Edema. Journal Of Neurosurgery, 28(2), 118-123.
Emich, S., Dollenz, M., & Winkler, P. (2015). Burr hole is not burr hole: technical considerations to the evacuation of chronic subdural hematomas. Acta Neurochirurgica, 157(3), 497-499.
Fischbach, F. (2012). Brunner and suddarth’s textbook of medical-surgical nursing (1st ed.). [Place of publication not identified]: Wolters Kluwer Health.
I.1. Workshop: Health Technology Assessment and Health Impact Assessment – Two key examples of health assessment. (2014). European Journal Of Public Health, 24(suppl_2).
Jones, M. (2013). Clinical reasoning and pain. Manual Therapy, 1(1), 17-24.Lant, A. (2014). Diuretic Drugs. Drugs, 31(Supplement 4), 40-55.
Parry, W. (2015). Foot and Ankle Pain. Pain, 19(1), 102-103.
Payne, E. (2015). An atlas of the pathology of the brain (1st ed.). [Cardiff] (c/o E.E. Payne, Dept. of Pathology, Welsh National School of Medicine, Royal Infirmary, Newport Rd, Cardiff CF2 1SZ): Sandoz.
Robinson, R. (2014). The Treatment of Subacute and Chronic Subdural Haematomas. BMJ, 1(4904), 21-22.
Ventriculostomy. (2013). Journal Of Neurosurgery, 93(6).
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