Traumatic brain injury or TBI occurs when a bump, jolt, blow, or other head injuries that damage the brain. It can cause neck pain or a headache, ringing in the ears, nausea, tiredness, and dizziness. The symptoms associated with TBI include seizures or convulsions, slurred speech, deleted eye pupil, repeated nausea and weakness (Risdall & Menon, 2011). In the given case study the patient has been diagnosed with two different brain injuries: a subdural hematoma (SDH) and a petechial hemorrhage. A subdural hematoma is generally determined because of its size and the location (Hedlund, 2012). A petechial hemorrhage is described as the tiny pinpoint red mark that can be characterized as the sign of asphyxia that is caused by some type of external obstructing the airways. It occurs when the blood leaks from some type of tiny capillaries in the eyes (Kim & Gean, 2011). In this particular report, the sign & symptoms reflect that changes, the priority of clinical care, nursing interventions, nursing assessment, current recommendations, and impacts of nursing interventions on the patient will be discussed.
From the time of hospitals admission, the patient assessment shows that Mr. Parson’s has been laying supine GCS 10/15, pupils are equal and reactive to the light and accommodating. He has been diagnosed with sub-Dural hemorrhage, which is of 1-centimetre mid-line shift and had the petechial hemorrhage. His blood alcohol level has been reported to be increased on the assessment in an emergency department and toxic substance was negative. The assessments also reveal the raccoon eyes and some battle sign on the right side. The physical condition of the patient has been changed such as the change in respiration rate, heart rate, temperature. BGL label, SpO2 level of At 8.00 hours patient’s physical examination findings shows that she has temperature of 36.9, respirations (breaths/min), BP and MAP (Mean Arterial pressure) was 128/92, heart rate was 87, SpO2 was 97 %, blood glucose level was 6 (actrapid infusion at 2 unit/hr). At 10.00 hours the ICP has been raised to 12, the temperature raised to 37.2, the respiration increased to 23, BP & MAP reduced to 122/68, heart rate has been increased 96, SpO2 decreased to 96 and the BGL glucose level increased by 0.4. At the time of 13.00 hours, the patient suffered from a heart rate of 118. At 13.10 the BP has been being recorded to 108/54 mmHg, heart rate 118-123 beats/ min, the temperature has been raised to 37.8. The 12 lead electrocardiograms also identified the sinus tachycardia. The one priority of clinical care, in this case, should be his respiratory Rate, which has been, noticed 11 breaths per minute. The air entry has also been decreased in both right and left bases. The patient carer should maintain the respiration rate by providing proper air to Mr. Parson (Kelly et al., 2014). The patient’s history has indicated that he has type-1 diabetes and used to smoke seven to ten cigarettes per day. He also drinks six to ten beers on weekends and has wisdom teeth removal.
Nursing interventions can play a crucial and vital role in this case. Nursing interventions provide an additional care to the deteriorating patient. The patient can be deteriorating suddenly or after some time. Sometimes the nurses miss when something like this happens (Liaw, Zhou, Lau, Siau, & Chan, 2014). To provide better nursing care in this case scenario he or she should use the ABCDE method to assess the patient. In ABCDE, A stands for Airway, B is for Breathing, C means Circulation, D indicated any disability, and E is Exposure. The airway should be patent for O2 to pass in and out of the patient’s lower respiratory tract. The nurse should recognize the airway obstruction by asking the patient how they are feeling, if the patient does not respond to the question, it indicates that he or she might face compromised airway or unconsciousness. A nurse can also look for abdominal movement and symmetrical chest. The patient can also be assessed by listening and feeling the airway at the nose or mouth. The partial airway obstructions are generally noisy and the complete airway obstructions are silent. If a nurse assessed that the person’s airways are compromised, he or she can commence the basic life support measure for the patient. Assessing the breathing is the second most important assessment for the patient with deterioration. Severe distress in the respiratory system can result in cardiac and respiratory and cardiac risk. This has also been reported in the patient’s case as he has developed tachycardia issue. Lung disease, CNS depression or any inadequate respiratory efforts can lead to respiratory distress. The breathing difficulties can be recognized by looking at the patient, listen to the difficulty in speaking, and feeling the chest wall for any surgical emphysema (Liaw, Chan, Scherpbier, Rethinks, & Pua, 2012). A nurse provides an appropriate position for the patient. The patient should be asked to sit upright position; if the patient is unconscious, he or she should be advised to recovery position. Oxygen mask should be provided to the patient, high flow O2 should be given in only for the short-term period (Lindsey, & Jenkins, 2013). The flow rate should be checked with the rapid response as soon as the patient arrives at the emergency ward. The six necessary nursing actions should be taken for the patient with deterioration in hospitals: get help from others, collecting more information about the patient’s condition, poisoning of the patient properly, considering the O2 therapy, preparing the equipment for any medical emergency, and handover using ISBAR. The patient should be looked after most of the time or a nurse should be with him all the time to assess any negative health issues. The blood pressure has been raised at irregular intervals in this case; the elevated BP may lead to hematoma expansion, a risk of re-bleeding and peri-hematoma edema. Therefore, the nurse should check and monitor the increase in blood pressure. Further interventions can include Seizers and antiepileptic drugs, which reduce the risk of epilepsy in the patient (Liaw, Rethans, Scherpbier, & Piyanee, 2011). The ICH should be monitor by the nurses and the BP should be well controlled as it is still fluctuating. The patient should also be assessed for the vital sign at regular intervals. The Patient in the given case scenario has issues in breathing so this intervention may play a vital role to achieve the health goals already set for the person.
Recommendations for the painter can include taking care of this breathing issues, proper rest, peaceful environment, and lying position. Ha has a history of diabetes type 1, therefore, it should be kept in mind while prescribing the medication to the patient. Diabetes-related issues could be raised again after a period, more often in the patient with serious injury, as they are not able to manage proper diet and nutrition intake (Liaw, Rethans, Scherpbier, & Piyanee, 2011). Accurate interpretation of medical findings should be used, calling for help if identified any early signs, and making sure that it arrives on a time. The other recommendations for the patient mentioned in the case study include early identification of any serious issues to the patent. Education and training, data collection related to the patient physical examinations and health issues related information, executive and medical buy-in, evaluation, escalations protocols and instant response system that was the part of a safer system to save lives (Diringer et al., 2011).
A SMART tool can be used to evaluate the success of interventions for the patient in the given case study. This approach has been used to design and develop a work plan, mentoring the progress to achieve the goals, measuring performance, identifying the opportunities for more improvements and determining how the goals can be met (Liaw, Scherpbier, Klainin?Yobas, & Rethans, 2011). In SMART S stands for Specific (what exactly a nurse going to do for the patient), M means measurable (is the interventions are measurable and quantifiable), A means Attainable/ Achievable (can we complete the task in the given period and the available support). R means relevant (what effects the interventions had on the patient and how it achieves the goal that is set for the patient. T indicated Time bond (when the objective will be accomplished. The patient oxygen saturation has been maintained to 95 %, respiration rate has been determined to maintained, blood pressure has been recorded in the patient’s data sheet at regular time intervals (Lavoie, Pepin, & Cossette, 2015).
The traumatic brain injury can occur when the bump, blow or other injury takes please in a head that damages a part of the brain. The patient in this case study has been identified with different brain injuries subdural hematoma (SDH) and a petechial hemorrhage. His vital signs such as breathing problems show that he has been facing issues in breathing and disturbed BGL level, tachycardia and disturbed SpO2 levels. The nursing interventions can be provided in this case includes assessing Airway, breathing, circulation, disability, and exposure, providing enough oxygen resources and managing the patients’ position at the bed. Key Recommendations, in this case, are taking care of breathing issues and patent’s position, proper rest should assist. The SMART tool can be used to evaluate the success of the interventions provided to the patient. It can evaluate the nursing interventions has been identified successfully by maintained oxygen saturation, regulated breathing, and maintenance if the data of the patient.
References
Diringer, M. N., Bleck, T. P., Hemphill, J. C., Menon, D., Shutter, L., Vespa, P., & Hänggi, D. (2011). Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocritical care, 15(2), 211.
Hedlund, G. L. (2012). Subdural hemorrhage in abusive head trauma: imaging challenges and controversies. J Am Osteopath Coll Radiol, 1(1), 23-30.
Kelly, P., Hayman, R., Shekerdemian, L. S., Reed, P., Hope, A., Gunn, J., & Beca, J. (2014). Subdural hemorrhage and hypoxia in infants with congenital heart disease. Pediatrics, peds-2013.
Kim, J. J., & Gean, A. D. (2011). Imaging for the diagnosis and management of traumatic brain injury. Neurotherapeutics, 8(1), 39-53.
Lavoie, P., Pepin, J., & Cossette, S. (2015). Development of a post-simulation debriefing intervention to prepare nurses and nursing students to care for deteriorating patients. Nurse education in practice, 15(3), 181-191.
Liaw, S. Y., Chan, S. W. C., Scherpbier, A., Rethans, J. J., & Pua, G. G. (2012). Recognizing, responding to and reporting patient deterioration: transferring simulation learning to patient care settings. Resuscitation, 83(3), 395-398.
Liaw, S. Y., Rethans, J. J., Scherpbier, A., & Piyanee, K. Y. (2011). Rescuing A Patient In Deteriorating Situations (RAPIDS): a simulation-based educational program on recognizing, responding and reporting of physiological signs of deterioration. Resuscitation, 82(9), 1224-1230.
Liaw, S. Y., Rethans, J. J., Scherpbier, A., & Piyanee, K. Y. (2011). Rescuing A Patient In Deteriorating Situations (RAPIDS): a simulation-based educational program on recognizing, responding and reporting of physiological signs of deterioration. Resuscitation, 82(9), 1224-1230.
Liaw, S. Y., Scherpbier, A., Klainin?Yobas, P., & Rethans, J. J. (2011). A review of educational strategies to improve nurses’ roles in recognizing and responding to deteriorating patients. International Nursing Review, 58(3), 296-303.
Liaw, S. Y., Zhou, W. T., Lau, T. C., Siau, C., & Chan, S. W. C. (2014). An interprofessional communication training using simulation to enhance safe care for a deteriorating patient. Nurse Education Today, 34(2), 259-264.
Lindsey, P. L., & Jenkins, S. (2013). Nursing students’ clinical judgment regarding rapid response: the influence of a clinical simulation education intervention. In Nursing forum, 48(1), 61-70.
Risdall, J. E., & Menon, D. K. (2011). Traumatic brain injury. Philosophical Transactions of the Royal Society of London B: Biological Sciences, 366(1562), 241-250.
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