Nursing Assessment And Diagnosis For Tania’s Traumatic Injuries

Raised Intracranial Pressure and Nursing Actions for Treatment

Discuss about the Perioperative Glucose Control in Neurosurgical Patients.

From the nursing assessment provided in the case study, we are informed that Tania had suffered a high-speed car accident that resulted in a head injury. This head injury due to the impact of the accident could lead to a possible rise in the intracranial pressure. This is a condition characterized by increased pressure around the brain as a result of the amount of fluid that surrounds the brain (Freeman, 2015). It may also result from the swelling of the brain tissues due to an injury to the head. If this condition is not addressed promptly, it can lead to brain injury which may escalate into a life-threatening situation. Initially, Tania was alert and oriented on admission but she now feels drowsy. Further assessment reveals that her Glasgow coma scale is 12 with eye-opening assigned a score of 3. This is an indication that she opens her eyes in response to a speech. It is important to note that loss of consciousness and difficulty to rouse ate some of the characteristics of intracranial pressure (Chesnut et al., 2012). These signs are exhibited by the patient.

Additionally, from her medical history, it is revealed that Tania has a history of type 2 diabetes. The trauma she has from her accident can lead to an elevation of blood glucose levels in the blood due to her diabetic condition (Haddad & Arabi, 2012). An elevation of the blood glucose level can lead to drowsiness as exhibited by Tania. Additionally, she uses intravenous (IV) morphine to help in managing her acute pain. One of the side effects of this medication is drowsiness that is experienced some hours after administration of the drug. She is also prescribed ondansetron to manage effects of nausea and this medication too can cause drowsiness and a difficulty to rouse. Tania displays these symptoms prior to going to the theatre and it is important if the registered nurse develops action plans to address these signs.

The initial nursing actions for raised intracranial pressure may include hyperventilation, an artificial increase of blood pressure, and analgesia and sedation among other plans. Adequate breathing, airway, and oxygenation are important for patients who have experienced head injury like Tania (Raboel, Bartek, Andresen, Bellander & Romner, 2012). Poor oxygenation implies that there will be an inadequate amount of blood oxygen which may cause cerebral vessels to dilate thus increasing the blood flow to the brain that thus leads to ICP. Blood pressure can also be artificially increased to oxygenate tissues and thus remove wastes, therefore, reducing the swelling of the brain. This helps in lowering the intracranial pressure (Raboel et al., 2012). Analgesia and sedation are used to reduce the metabolic demands of the brain which may increase due to head injuries.

Nursing Care Plan for Acute Pain and Risk of Infection Prior to Surgery

For the case of an increase in the level of blood sugar, it could be important for the nurse to administer an insulin medication to help in lowering the blood glucose level. Insulin administration could also be helpful in maintaining the blood glucose level at a normal range (Godoy, Di Napoli, Biestro & Lenhardt, 2012). The nurse could additionally perform a symptomatic assessment of the side effects of morphine and ondansetron with the aim of treating these side effects with a medication that would directly address her condition of drowsiness and the difficulty to rouse.

Prior to her surgery, Tania needs to be taken care of in the orthopedic ward by special nursing diagnoses and interventions. The nursing care plan necessary for Tania’s condition prior to her surgery might include the following two nursing diagnoses, that is to say, acute pain and the risk of infection.

Acute pain may be described as an unpleasant emotional or sensory experience that may arise from a potential damage to the tissues. Acute pain may be related to muscle spasms and an injury to the soft tissues (Abou-Setta et al., 2011). It is normally characterized by protective behavior and reports of pain. The desired outcome of this diagnosis may be to verbalize the relief of pain and to enhance the ability to participate in activities, which will help in avoiding the depression that Tania, had previously been diagnosed with. The following four nursing interventions can be used in this diagnosis.

Maintaining the elevation of the fractured limb by means of a bed rest

This intervention helps in relieving the pain and prevents the displacement of the fractured bone and an extension of the tissue injury (Hung, Egol, Zuckerman, & Siu, 2012).

Explain the procedure of the surgery to the patient before beginning them

This intervention helps the patient to be mentally prepared for the procedure (Abou-Setta et al., 2011). It also encourages the patient to participate in controlling the discomfort levels.

Provision of emotional support and encouraging the patient to apply stress management techniques

The intervention helps in refocusing the patient’s attention thus promoting a sense of control. It also helps in managing stress related to traumatic injuries like in Tania’s case (Abou-Setta et al., 2011). Stress management will be particularly important given her history with depression and type2 diabetes. Stress may lead to a rise in the levels of blood sugar thus stress management could be important in managing her diabetic condition.

Compartment Syndrome and Diagnostic Tests for Diagnosis

Elevation and support of the injured extremity

This intervention is aimed at enhancing venous return, reduce edema and reduce the pain associated with the fracture (Hung et al., 2012).

This diagnosis helps in assessing the increased risks of the patient’s injured area being invaded by pathogens. The risk factors associated with this diagnosis may include insufficient primary defenses such as environmental exposure, broken skin, and traumatized tissues among others (Gulanick & Myers, 2011). The aim of this diagnosis is to achieve a timely healing of the wounds. The following are some of the nursing interventions associated with this diagnosis.

An institution of isolation procedures as prescribed

This is aimed at preventing cross-contamination by wound and linen contaminations in the event that there is purulent drainage (Gulanick & Myers, 2011).

Inspection of the skin for breaks in continuity or preexistent irritations

This is done to ensure that pins are note inserted through the skin infection to prevent the possibilities of a bone infection (Cierny III, 2011).

Instructing the patient to avoid touching the insertion region

This intervention helps in minimizing contamination of the wound that might result from the fracture (Gulanick & Myers, 2011).

Preparing the patient for surgery as indicted

The fracture may sometimes limit the flow of blood to the bone leading to the formation of a necrotic bone that is developed as a result of the death of the bone tissues (LeMone et al., 2015). This bone should, therefore, be removed to facilitate the process of healing.

Some of the complications that may arise due to the fracture of the closed mid-shaft fracture include compartment syndrome, a damage of the nerves and blood vessels, bone infection, and blood clots. Compartment syndrome may be described as the swelling and pain that is experienced in the muscles that surround the fractured bone (van Rensburg, 2012). Additionally, a fracture exposes sharp ends of the broken bones that can cut and tear the surrounding blood vessels and nerves. Furthermore, the broken bones may be exposed to the environment where there are a lot of fungi and bacteria thus causing bone infection. A blood clot can occur deep into the bones causing a condition known as deep bone thrombosis. Below, we discuss the diagnostic tests for the acute compartment syndrome.

The doctor can make a diagnosis of this complication based on the type of injury suffered by the patient. From the presented case, we are told that Tania suffered a closed mid-shaft fractured femur. The doctor after identifying the type of injury proceeds to make his/her diagnosis based on the physical examination and Tania’s description of the symptoms (Taylor, Sullivan & Mehta, 2012). Another diagnostic test that the doctor could perform may be described as the direct measurement of the compartment pressure. This test is normally definite and it involves the doctor inserting a needle that is attached to a pressure monitor into the compartment region suspected to be bearing the syndrome. The pressure monitor records the pressure for reference. Additionally, the doctor can choose to insert a plastic catheter to continuously monitor the compartment pressure.

The acute compartment syndrome is a condition which results from the increased pressure within the space in the fractured bone region. This increase in pressure compromises the flow of blood thus affecting the functions of the surrounding tissues. This results in necrosis and damage to the nerves (Von Keudell et al., 2015). A widely accepted theory to this condition is known as the arterio-venous pressure theory gradient theory. This theory explains that a fracture like the one suffered by Tania may lead to an increase in the intra-compartment pressure which in turn causes a rise in the venous pressure that is accompanied by a decrease in the arterio-venous pressure gradient (Taylor et al., 2012). The reduction in the arterio-venous pressure gradient leads to a decrease in local tissue perfusion.

This complication is characterized by a persistent deep ache in the leg that has suffered a fracture, numbness, excruciating pain, and swelling. From the assessment, we are informed that Tania’s left upper leg is deformed and swollen which could be an indication of the compartment syndrome. A crushing injury to the extremity and involvement in high-impact sports are some of the risk factors for this complication (Taylor et al., 2012). A fracture of the femur causes significant bleeding in the compartment thus leading to the compartment syndrome. As presented in the scenario, Tania was involved in a high-speed car accident that led to her breaking her femur. This injury due to the car crash could be one of the risk factors of compartment syndrome as initially stated.

	Tramadol
Therapeutic class	It belongs to a group of drugs known as opioid analgesics (Giorgi, 2012). These analgesics are used to treat pain from moderate level to a more severe level.
Appropriate dosage for Tania	Tania’s condition can be classified as severe pain and thus she needs an immediate release tablet. The total daily dosage must not exceed 400 mg (Giorgi, 2012). This dosage can be continually increased by 50 mg after every three days until the patient reaches 200 mg every day. Additionally, a maintenance dosage of 50 mg to 100 mg is necessary every 4-6 hours. Alternatively, she could be given an extended-release tablet. The maximum dosage per day for an extended-release tablet is 300 mg per day whereas the starting dosage could be 100 mg once in a day if she currently is not on the immediate release tablet (Giorgi, 2012). The doctor can opt to increase the dosage by 100 mg every five days.
Pharmacological action at cellular level	This medication works by alternating the way the brain identifies pain. Tramadol shares similarities with endorphins which are a special substance found in the brain. This medication binds to the pain receptors thus decreasing the pain messages sent to the brain by the body (“Drug Study Tramadol | Opioid | Analgesic”, 2018). As a result, the amount of pain that the brain might think an individual is having is reduced.
Nursing responsibilities	It is important that the nurse assess the location and intensity of the pain before administration of the drug and around 2-3 hours after the patient has used the drug (“Drug Study Tramadol | Opioid | Analgesic”, 2018). The nurse should additionally assess the blood pressure and the respiratory rate prior to and during the administration (“Drug Study Tramadol | Opioid | Analgesic”, 2018). Finally, the nurse is also tasked with assessing Tania’s previous history with analgesics because tramadol may not be appropriate for patients using other opioids to avoid cases of opioid withdrawal (“Drug Study Tramadol | Opioid | Analgesic”, 2018).

	Ciprofloxacin
Therapeutic class	This medication is a member of the fluoroquinolone class of antibiotics. It is used as a treatment for bacterial infections.
Appropriate dosage for Tania	The appropriate dosage for Tania would be 400 mg every 8-12 hours. This dosage is administered intravenously. Alternatively, she could still take the same drug orally but at around 500 mg to 750 mg after every 12 hours (“Drug Study: Ciprofloxacin (quinosyn) | Drugs | Diseases And Disorders”, 2018). The therapy should last for approximately 4 to 8 weeks during the medication.
Pharmacological action at cellular level	It inhibits enzyme topoisomerase IV and enzyme DNA gyrase. As a result, the replication of the enzyme DNA during the reproduction and growth of bacteria is prevented.
Nursing responsibilities	It is the responsibility of the nurse to ensure that infections have been prevented or treated in addition to reducing the signs and symptoms of infections such as pain (“Drug Study: Ciprofloxacin (quinosyn) | Drugs | Diseases And Disorders”, 2018). The nurse should also advise Tania to report any adverse reactions to the medication to the doctor in charge or the nurse (“Drug Study: Ciprofloxacin (quinosyn) | Drugs | Diseases And Disorders”, 2018). The nurse must also ensure that Tania does not take the medication in large quantities or for longer durations than prescribed by the doctor (“Drug Study: Ciprofloxacin (quinosyn) | Drugs | Diseases And Disorders”, 2018).

References

Abou-Setta, A. M., Beaupre, L. A., Rashiq, S., Dryden, D. M., Hamm, M. P., Sadowski, C. A., … & Mousavi, S. S. (2011). Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Annals of internal medicine, 155(4), 234-245.

Chesnut, R. M., Temkin, N., Carney, N., Dikmen, S., Rondina, C., Videtta, W., … & Machamer, J. (2012). A trial of intracranial-pressure monitoring in traumatic brain injury. New England Journal of Medicine, 367(26), 2471-2481.

Cierny III, G. (2011). Surgical treatment of osteomyelitis. Plastic and reconstructive surgery, 127, 190S-204S.

Drug Study Tramadol | Opioid | Analgesic. (2018). Retrieved from https://www.scribd.com/doc/126654029/Drug-Study-Tramadol

Drug Study: Ciprofloxacin (quinosyn) | Drugs | Diseases And Disorders. (2018). Retrieved from https://www.scribd.com/doc/27446733/Drug-Study-Ciprofloxacin-quinosyn

Freeman, W. D. (2015). Raised intracranial pressure. Demaerschalk/Evidence-Based Neurology: Management of Neurological Disorders, eds BM Demaerschalk and DM Wingerchuk (Chichester: John Wiley & Sons, Ltd.), 87-92.

Giorgi, M. (2012). Tramadol vs tapentadol: a new horizon in pain treatment. Am J Anim Vet Sci, 7, 7-11.

Godoy, D. A., Di Napoli, M., Biestro, A., & Lenhardt, R. (2012). Perioperative glucose control in neurosurgical patients. Anesthesiology research and practice, 2012.

Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences.

Haddad, S. H., & Arabi, Y. M. (2012). Critical care management of severe traumatic brain injury in adults. Scandinavian journal of trauma, resuscitation and emergency medicine, 20(1), 12.

Hung, W. W., Egol, K. A., Zuckerman, J. D., & Siu, A. L. (2012). Hip fracture management: tailoring care for the older patient. Jama, 307(20), 2185-2194.

LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU.

Raboel, P. H., Bartek, J., Andresen, M., Bellander, B. M., & Romner, B. (2012). Intracranial pressure monitoring: invasive versus non-invasive methods—a review. Critical care research and practice, 2012.

Taylor, R. M., Sullivan, M. P., & Mehta, S. (2012). Acute compartment syndrome: obtaining diagnosis, providing treatment, and minimizing medicolegal risk. Current reviews in musculoskeletal medicine, 5(3), 206-213.

van Rensburg, L. (2012). Acute Compartment Syndrome. In Bedside Procedures in the ICU (pp. 137-141). Springer, London.

Von Keudell, A. G., Weaver, M. J., Appleton, P. T., Bae, D. S., Dyer, G. S., Heng, M., … & Vrahas, M. S. (2015). Diagnosis and treatment of acute extremity compartment syndrome. The Lancet, 386(10000), 1299-1310.