Nursing Care For Mrs Marry Waxman With Traumatic Brain Injury And Soft Tissue Injury

First nursing care needs: Controlling High blood glucose level

Mrs Marry Waxman is a 31 year old Jewish woman who has suffered traumatic brain injury along with injury in soft tissues at her neck, lacerations and grazes to her arms and deep wound in lower right leg. She was brought unconscious to neurological ward after spending 48 hours in Intensive Care Department (Subjective Data). Her GCS score is 9, body temperature is 38.5-38.9 degree Celsius, pulse beat is 80 to 92 beats per minute, respiratory rate is 18 to 20 beats and blood pressure is 180/120 mmHg (static) oxygen saturation is 97%SpO2 (objective). At present Mrs Waxman is at 6 hours intravenous antibiotics with urinary output <30 ml/hours and redness is noted at sacrum and heels with high blood glucose level along with purulent discharge from wound in lower right leg (Assessment). Intravension include control of blood pressure, wound management and monitoring of vital signs and blood pressure. Evaluation can be done through constant monitoring and revision must be taken in blood pressure management.

Assessment	Expected outcomes	Interventions	Rationale Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	Evaluation
Mrs. Waxman has high blood level of glucose level 25mmole/L. [Normal blood glucose level < 6.9 mmole/L in non-fasting condition (American Diabetes Association, 2014)].	Reduction in the blood glucose level	Implementation of diabetic diet plan according to the height, weight age and gender under a thorough supervision of trained dietician. The diet will be divided within small meals after every three hours with restricted intake of calorie (American Diabetes Association, 2014)	According to American Diabetes Association (2014) following a diabetic diet which is rich in vegetables and fruits and has restricted consumption of carbohydrate and sugar helps in reducing the blood glucose level	The evaluation of the blood glucose level will be done through blood test both before an d after taking food through glucometer (American Diabetes Association, 2014)
Reduction in the intake of snacks. This intake of snacks will be replaced with fruits salads and green salads (American Diabetes Association, 2014).	Case study indicates that Ms. Waxman feeds on snacks most of the time. Increase intake of snacks increases the amount of simple carbohydrate within the body which increases the blood glucose level. The intake of green salads in between her diet will help to reduce her cravings for food and at the same time will help to enrich her body with nutrition along with reduction in the blood glucose level (American Diabetes Association, 2014)	Measurement of the weekly body weight and blood glucose level (American Diabetes Association, 2014)
Promotion of physical activity. The nature of physical activity in case of Mrs Wilson will be mild to moderate. The reason behind this is, Mrs Waxman has injury in her head, neck and arms and leg. So rigorous physical activity might be harmful for Mrs Wilson. Her main activity session will include walking, gardening, and basic hand leg movements. This will help to reduce her sedentary tenure. The activity will be designed in such a way that Mrs Wilson can conduct or practice the same during her office hours (Sigal et al., 2013)	The analysis of the case study indicates that increase in the overall body mass index increases the severity of developing diabetes mellitus. Hence, increase in the physical activity will help to burn the extra calorie and this will help in the reduction in body weight along with decrease the blood glucose level. This in turn will help to reduce the severity of the diabetes mellitus. Increase in the physical activity will help reduce the marco and microvascuar complications of diabetes (Sigal et al., 2013)	Measurement of decrease in the body weight along with the BMI index (Body mass index) (Sigal et al., 2013)
Decrease in the rate of alcohol consumption and this can be done through proper education about the harmful effects of alcohol and its relation to type 2 diabetes mellitus. This education will help to generate awareness (Gepner et al., 2015)	Increase in the intake of alcohol increases the overall calorie intake of the body and this in turn increases the blood glucose level along with an increase in the deposition of cholesterol in the arteries (Gepner et al., 2015)	Monitoring of the level of blood cholesterol (Gepner et al., 2015)

Assessment	Expected outcomes	Interventions	Rationale	Evaluation
The deep wound present on her lower right leg is inflamed and is oedematous and oozing moderate amount of purulent discharge. Proper assessment of the wound through evaluation of exudates coming out from the wound and detection of infection at the site of wound (Lewis et al., 2016)	Decrease in the purulent discharge of the wound along with reduction in the secretion of oedematous exudates from the wound and thereby promoting fast wound healing (Lewis et al., 2016)	Proper monitoring of the site of the wound for accessing tissue injury	Regular monitoring will help in study the level or the status of wound healing and this fall under documentation process	Proper monitoring of the wound  in order to detect wound healing (wis et al., 2016)Regular dressing along with the use of proper antibiotics and ointments (Lewis et al., 2016)
	Regular changing of dressing will help to prevent the formation of sepsis and use of antiseptic ointments and antibiotics will help to reduce bacterial infection (Lewis et al., 2016)
Maintenance of proper hand hygiene while wound dressing (Preece, 2016)	This will help to prevent the chances of cross-infection at the wound site. This will help to maintain aseptic condition in wound management (Preece, 2016)
Proper cleaning of the wound and avoidance of alkaline soap while cleaning the wound (Holmes et al., 2013)	Cleaning of the wound helps in the maintenance of aseptic condition and use of alkaline free soap will help to maintain the pH balance of the wound (Holmes et al., 2013)

 

Assessment	Expected outcomes	Interventions	Rationale	Evaluation
Mrs. Waxman has gained weight due to her sedentary life style and long working hours, where she has to survive mostly on snacks and the strong caffeinated drinks	Reduction of the weight as per the age	Chalking out a proper meal plan for Mrs. Waxman.	A balanced diet is necessary to provide the body with vital nutrients suitable for building and maintaining the vital tissues and the organs, repairing of the damaged tissues and controlling weight (Johns et al., 2013).	The evaluation of the weight control should be done by a weekly check-up of the weight.
Reduction in the intake of snacks and strong caffeinated drinks. This has to be replaced by proteinaceous and calcium rich food, as she had suffered from a bone and a tissue injury (Johns et al., 2013).	High caffeinated drinks especially those with whipped cream and caramel and other fancy coffee packs has several calories that can increase the body weight (Johns et al., 2013). Furthermore, consumption of the snacks causes an imbalance between the calories consumed and the energy expensed. The excess calories and stored as fat and might lead to obesity and overweight (Kirk et al., 2013)	Measurement of the weekly body weight
One of the nursing intervention is to encourage Mrs. Waxman to practice mild exercises after being discharged. Physical activities are one of the important intervention for managing weight. Since, Mrs. Waxman has suffered from a head injury and soft tissue injury, low to moderate incidental activities can be suitable her. Exercises like rhythmic walking, mild yoga can be helpful.	Physical exercise helps in weight management, reduces stress level, and improves memory, attention, endurance, strength, balance, flexibility and blood pressure. It has also been found that regular physical activities positively influences cardiorespiratory fitness and cognition.	Measurement of decrease in the body weight.
Encouraging Mrs. Mary Waxman to abstain from alcohol is another important nursing intervention in the controlling of the body weight.	Consumption of alcohol regularly might lead to weight gain and obesity. A heavy drinker is likely to be consuming extra 1000-3000 calories per day that can lead to the accumulation of fat in the abdominal region (Shelton & Knott, 2014). This is due to the fact that the body starts using up the alcohol for the generation of energy instead of the fat and the carbohydrate reserves of the body, thus storing the excess fat.  Again people who consume alcohol are less likely to be engaged in physical activities (Traversy & Chaput, 2015).	Monitoring the weight and to check the blood reports to find if any alcohol had been consumed.

Assessment	Expected outcomes	Interventions	Rationale	Evaluation
Mrs. Waxman has suffered from a head injury and soft tissue injury to her neck as she slipped from the top of an escalator at the Melbourne airport	Management of the pain	Head injury and soft tissue injury can be painful and can decrease the quality of life of the patient. Hence painkillers like acetaminophen can be given to provide relief to the patient. Anti-inflammatory agents, paracetamol can be used to manage pain. For severe pain opiates and morphinomimetics can be given.	The pain killers stops the secretion of the prostaglandin that helps in the reduction of the pain. Morphine have similar effects on the cerebral opioid receptors and reduces the secretion of prostaglandin thus reducing the pain.	A numeric pain rating scale can be used for measuring the intensity of pain in the patient. Facial grimacing or other non-verbal expressions can also be used in measuring any increase or decrease of the pain.
Ensuring bed rest in proper positions. Mrs. Waxman should be instructed to avoid positioning of the head in an extended or a hyper flexed position (Cohen, 2015, February).	Prolonged bed rest is without any scientific merit, but it helps to support immobilisation with the deleterious effect on the bones and the tissues (Cohen, 2015, February).	The patient will be able to report less pain which can be recorded by a pain rating scale.
Methods of immobilisation had been used for thousands of years for treating injuries to the human body (Sommerfeldt et al., 2015). Hence in acute pain in neck and head injury, bracing can give relief to pain.	A bracing helps to provide support to the neck and the back of a person with injury. It protects the acute soft tissue injury and alleviate pain by providing time for healing (Sommerfeldt et al., 2015).	Feedback can be taken from the patient to understand the severity of the pain that the patient is experiencing. Faces scale can be used, where corresponding faces depicting various levels of pain can be used by the patient to inform her choice.
Ensuring a correct posture might help to relive pain in patients with head injury and soft tissue injury of the neck. A nurse might consult with a physiotherapist and the patient can be encouraged to take the slump position by protruding the head forward, head flexion, rounding of the shoulders and reversed lumber lordosis at the time of sitting. Some of the range of motion exercises that helps to relive pain are flexion, side bending and rotation.	Mild exercises and suitable neck retractions can significantly provide relief to pain. Gait exercises ad stretching would facilitate proper blood flow and relive pain.	Patients will report less pain or fMRI brain scanning might be used to measure pain and helps in correlating with the self-reported pain

According to Alfadhli (2015) pregnancy results in the development of insulin resistance and increases the predisposition of diabetes mellitus in women which is characterised by gestational diabetes mellitus (GDM). GDM is manifested when the function of the pancreas of pregnant women fails to overcome the diabetogenic environment which is a common scenario during pregnancy (Alfadhli, 2015). GDM can also define a condition of glucose intolerance during gestational period of women who have previous reported cases of Type 2 Diabetes Mellitus (T2DM) (Spaight et al., 2014). The alteration of the growth hormone along with increase in the secretion of lactogen by human placenta hampers the breakdown of blood glucose, increase in lipolysis, and disruption in the equilibrium of insulin secretion from the pancreatic beta cells along with decrease in the glucose uptake. These pathological changes during pregnancy increase the vulnerability of developing GDM. Other risk factors which increases the risk of developing GDM include obesity, polycystic ovary and pregnancy related hypertension (Spaight et al., 2014). The sedentary lifestyle of Mrs Waxman and active corporate socialization has increased her vulnerability of developing T2DM and this has further increased the severity of developing GDM. Development of diabetes mellitus might have increased her tendency of rapid weight gain (20 kg in the past 12 months) along with increase in the blood glucose level [Normal blood glucose level should be less than 6.9 mmole/L in non-fasting condition] (Spaight et al., 2014).

Priority 2: Proper management of the wound in the lower right leg

Normal blood pressure of an adult human body is 120/80 mmHg. This is also known as optimal blood pressure. 120 mmHg is systolic blood pressure and 80 mmHg is diastolic blood pressure (Tzeng & Ainslie, 2014). Blood pressure amounting to 180/120 is known as malignant blood pressure. It is defined as extremely high blood pressure and develops rapidly and cause organ damage. Malignant blood pressure thus must be treated with medical emergency.  Having previous reported cases of hypertension increases the chance of developing malignant blood pressure moreover; missing medication dosage of hypertension also increases the chance of developing malignant blood pressure (Tzeng & Ainslie, 2014).

Following her accident in the business trip, where she slipped from an escalator in Melbourne airport, Mrs. Waxman encountered major head injury along with damage in the soft tissue around neck including lacerations and grazes in her arms. While she was transferred to the neurological ward after 48 wards of intensive care department, she was unconscious and was not responding to the painful stimuli. Her GCS score was 10 and her pupils was reacting to light (Andrews et al., 2015). According to Roozenbeek, Maas and Menon (2013), the long term outcomes of head injury followed by operations and unconsciousness after the completion of the operation can be serious. Roozenbeek, Maas and Menon (2013) highlighted it may cause headaches, dizziness under the impact of minimal stress or anxiety. Andrews et al. (2015) stated that head injury can also increase the sense of fatigue along with severe memory problems. This can hamper the professional life of Mrs. Waxman going forward as she has an active corporate life along with heavy-end responsibilities which demands mental strain. Moreover, serious brain injury will also result in the development of the neurological problems which might hampers the daily living activities by causing difficulty in hand-eye co-ordination or other complex mental health problems (Roozenbeek, Maas & Menon, 2013).

Massive or severe brain injury can change the psychological balance of a person’s life. In case of Mrs Waxman, the long-term outcome of brain injury includes mood swings along with problem in controlling emotions (Bower & Cohen, 2014). Bower and Cohen (2014) highlighted a person who has recovered from a fatal brain injury might have sudden or frequent episodes of crying or laughter without any significant reasons underlying it. Bower and Cohen (2014) argued that person who have experienced traumatic brain injury in the past might develop emotional instability leading to imbalance in overall mental equilibrium. This lack of emotional equilibrium results in inappropriate surfacing of emotions or opposite emotions like crying in funny situations, stating serious under extremely funny moment or remaining expressionless under certain emotional conflict or in some situation of stress or tension. This problem in emotional expression further hampers quality of life and also creates difficulty in leading a normal social life. Since, Mrs Waxman is an active corporate tycoon and her job responsibilities demand high end of socialization, her emotional imbalance can hamper her overall quality of life. This might damage both her professional and personal life (Bower & Cohen, 2014).

Priority 3: Reduction of weight

The main cognitive outcome after a traumatic brain injury might include difficulty in maintaining attention or concentration over any particular topic or subject or conversation. Traumatic brain injury also leads to the development of language and speech problems while causing significant effect on the learning and memory. Thus Mrs Waxman might face significant problem while entering into conversation with people and this might hamper her career life (Coco, Lopez & Corrao, 2016).

The behavioural problems will be associated with the cognitive impairments like sudden change in mood. Moreover, her physical injury in legs, might demand bed rest for couple of months. This sedentary life will affect hamper the mental health state of Mrs Waxman leading to depression, irritability and helplessness (Sampson et al., 2015).

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