NSB236 Integrated Nursing Practice 3 – On Campus

Identify and discuss two (2) signs or symptoms of clinical deterioration associated with the presenting problem, from chosen case study. This discussion should consider the potential impact of case study data (e.g. pathology results, past medical history) on the health status of the patient in the chosen case.

Following on from your presented discussion associated with point one (1), develop a clinical plan of care which identifies: x One (1) priority of clinical care and; Discuss three (3) nursing interventions that directly address the identified clinical priority. The discussion should refer to relevant clinical assessments. Measurable outcome parameters for each intervention will be discussed to justify the intervention and evaluate its efficacy. Discussion is to be supported with contemporary research.

Consolidate knowledge of key NMBA Registered Nurse Standards for Practice, National Safety and Quality Health Services Standards, and National Health Priorities to enable effective decision planning and action in a range of complex clinical situations across the lifespan.

Apply knowledge of anatomy, physiology and pathophysiology to support evidence based decision making associated with planning and action.

Demonstrate structured decision making and clinical reasoning to review a range of health situations, synthesise evidence and data, determine priorities and formulate plans of care and interventions in line with timeframes and agreed goals

The change in health status associated with the primary clinical diagnosis;

How the patients clinical history may impact on assessment data and core interventions;

The identified clinical priority which should clearly emerge from your discussion of the primary health alteration.

The application of clinical data and research to identify three (3) core interventions and assessments that address the stated clinical priority.

Evaluation data supported by research to effectively determine success of the intervention. The SMART goals format may be of assistance in guiding you in structuring this.

Demonstration of your clinical reasoning for your selected case study.

Introduction

Traumatic Brain Injury (TBI), the permanent or temporary damage to brain tissue that impairs brain functions, is a common occurrence in medical practice. The causes of TBI are varied ranging from impact falls, motor vehicle crashes, traumatic assaults to sports-related concussions among other causes (Vos, 2015).

This leads to reduced blood flow to the brain which will eventually activate the cytotoxic processes which will damage the brain tissue. There will be insufficient oxygen and glucose supply to the brain (Thiagarajan, Ciuffreda & Ludlam, 2011). This will lead to inadequate energy supply which causes influx of water, sodium ions and chloride ions hence cytotoxic edema with influx of Ca²⁺  leading to cellular injury of the brain tissue (Brorsson et al., 2011).

Functional changes in the body associated with TBI are numerous and varied depending on the severity as well as other factors such as age and sex (Crandall, 2011). Young children may experience completely different symptoms from adults. The most common changes within the pathological state include; cerebral edema, herniation, hyperemia, loss of consciousness, tachycardia, apnea, dilated pupils, raccoon eyes, unequal pupils and slurred speech. (Jarvis, 2018)

This paper aims to analyze the common symptoms associated with Traumatic Brain Injury, the priority of clinical care and the nursing interventions in reference to a medical case study. The medical case study is of one Mr. James Parsons. Mr. Parsons, as he was leaving a club at night, engaged in an altercation with a group of males at the front of the bar. He was punched in the face and lost consciousness immediately. This caused him to fall, hitting the back of his head on a pavement. He was rushed to hospital where an immediate surgery was carried out to remove a hematoma.

This paper will employ the knowledge gathered from this case study to recommend the appropriate care needed for the full recovery of Mr. Parsons as well as provide a basis for treatment of future patients with a similar condition.

Symptoms Of TBI Related To The Deteriorating Condition

Symptoms of Traumatic Brain Injury are varied and numerous depending on the severity of the case. The Glasgow Coma Scale, (GCS), is a counting system used to measure the level of consciousness in Traumatic Brain Injury (Koh, 2011). It works with on eye opening, oral response and finest mechanical response. A score of fourteen or fifteen shows slight TBI, a score of 9 to 13 shows modest TBI while a notch of 3 to 8 shows serious TBI (Castor & El Massioui, 2018).CT findings coupled up with other factors may also be an indicator of the extent of severity of the case ( Frey & Arciniegas, 2011).

In some cases, patients with initial low and moderate TBI show deteriorating symptoms. Mr.Parsons, in the given case study, shows a range of signs and symptoms related to TBI and the deteriorating condition.  Parsons registers an abnormally high rapid heart rate of 118 beats per minute, a clear indication of sinus tachycardia. He also registers frequent shortness in breath especially during sleep (Apnea) at a rate of 11 breaths per minute.

Parsons past medical history of   type one diabetes, smoking and social drinking could have also triggered the above symptoms. Visual evidence of raccoon eyes and a battle sign behind the ear indicate possible presence of a fracture in the skull. Loss of consciousness and sensitivity to light are also observed. The initial CT scan shows hematoma which was treated intra-operatively on arrival at the hospital.

The two major symptoms in Mr. Parson’s case, indicating a deteriorating condition that should receive immediate attention include the basal skull fracture and sinus tachycardia. Other causes for medical concern that should be looked into are shortness of breath and type one diabetes. These, if not monitored, could contribute to further deterioration of the patient.

Priority Of Clinical Care

Sinus tachycardia, raccoon eyes and battle sign should be monitored.  The abnormally high blood pressure should receive immediate care, to reduce it to normal levels so as to avoid any complications post operatively. Since Mr. Parsons recently left surgery, where the hematoma was removed, monitoring of the blood pressure is very essential to avoid further brain injury.  The battle sign and raccoon eyes are evidence of a possible fracture in the skull. This should also be monitored to ensure quick healing of the fracture.

Nursing Interventions

Mr. Parsons should receive adequate care so as to fully recover from the Injury. The major symptoms that are to be monitored are sinus tachycardia, basal skull fracture and apnea. Since Mr. Parsons is from an operation, he should be given coma inducing drugs to prevent him from suddenly waking up causing further brain damage. He can also be given diuretics so as to reduce the amount of fluid in soft tissue.