Case Study Head Injury

Question: Write about theCase Studyfor Head Injury. Answer: Introduction Mr. Tan is a 29 years old male, who has been rushed to the emergency department at 12 noon yesterday, upon experiencing a serious injury to his head, as he made an accident with a bus, while driving his car. He was unconscious, when he was brought to the emergency department of the nearby hospital. He was brought to the hospital by the road side passengers and his wife, Mrs. Tan. He was in serious condition, while brought to the emergency department, thus, immediate diagnosis was done. The bed number of the patient was not discussed. He was driving back to home from a party and was drunk, which was the predicted cause behind his accident. Diagnosis The patient had a history of hypertension and his father had also high blood pressure and diabetes. However, Mr. Tan is not diabetic, but his is overweight, having a high chance of developing obesity. He has undergone Laparoscopic gallbladder surgery with the extraction 5 gallstones from common bile duct. He has a fall history at the age of 21 with the experience of fracture of left wrist distal radius, which led to an open-reduction internal fixation surgery. However, Mr. Tan does not have any drug allergy. Thus, no specific restriction on drug or diet was required for him. His chief compliant upon this accident is a severe head injury. Head injury refers to the type of injury to brain, skull or scalp. The head injury can range from a mild bump or bruise on head to a traumatic brain injury (McCrory et al. 2012). The common head injuries involve scalp wound, skull fracture and concussions. However, the consequences of the health issue can vary greatly based on the severity of the disease as well as physical condition of the patient. The treatments also vary according to the above mentioned aspects as well as on the basis the cause of head injury. In case of Mr. Tan the key cause of his head injury is accident of his car with a bus. There are two types of head injury on the basis of cause; one is head injury due to shake or head injury due to blow. Mr. Tan caused head injury as a result of blow to head as a result of motor vehicle accident. However, his injury was severe and he undergone bleeding. Thus, the key compliant in Mr. Tans case is brain haemorrh age due to head injury. However, for assessing the presence of blood clot in brain, advance diagnosis is needed because, in many cases, severe injuries does not bleed at all, enhancing the possibility of internal clot formation, whereas in many cases, minor injuries causes rapid bleeding, reducing the chance of internal clot formation. Thus, X-ray and imaging is required as the diagnosis tools for assessing, whether there is internal or bleeding in Mr. Tans case (Hilario et al. 2012). When he was brought to the hospital, he was bleeding and unconscious. Social History/ Background Mr. Tan works in a IT software development company from last 3 years. He has married Mrs. Tan in last year and lives with his parents and wife in a 3 room flat, at 4th floor of an apartment. The socioeconomic condition of Mr. Tan is stable. He is good in sports, i.e. basket ball and swimming. However, Mr. Tan used to live a harsh life; he smokes 20 cigarettes per day and drinks 25 unit alcohols per week. He is not involved in regular physical activity. He is also not involved in any social activities. Overall Examination After bringing him at the emergency department of the hospital, the person unconscious and A-E assessment was done for assessing his vital signs and a holistic assessment. Airway- Tans airways were clear upon admission and no airway obstruction was noted in his case. Breathing- His respiratory rate was 32 per minute, which his more than the normal rate of respiratory rate. The oxygen saturation was 89 %, which is also less than the normal range. At this time, oxygen is not needed, but in case of further deterioration, oxygen supply would be needed (intermark et al. 2015) Circulation- Tan was looking pale, when he was brought to the hospital. The capillary filling time or CRT was 4 second, which is suggesting poor peripheral perfusion. The pulse rate was also low, i.e. 26 bpm, showing the sign of hypothermia. His blood pressure was low, i.e. 100/60 mmHg, indicating the tendency towards shock. Disability- When the patient was brought to the hospital, he was unconscious, he revived after 2 hours; he was feeling pain throughout his body, but no significant disability was shown. He was unable to walk initially, due to pain. Blood glucose level was checked, which was 130 mg/dl on random testing, which is in normal range (Barkhoudarian et al. 2011). Exposure- As a result of accident, he got scratches and deep scars over his arms. Moreover, he had a significant head injury with bleeding. Based on the assessment, some immediate lab tests were performed; these included neurological examination, CBC, a CT scan, MRI and X-ray. The neurological examination involved Glasgow coma scale, which was 8 in case of Mr. Tan. Management of Patient To manage the patient with proper care plan, a systematic approach would be undertaken. The systematic planning would begin with the in-depth assessment of the patient, based on which the care plan will be planned and implemented for the patient. Finally, the success of the care plan would be evaluated through the patients health outcomes. Assessment Signs and Symptoms Upon admission, Mr. Tan was unconscious and revived after 2 hours. Initially, he was experiencing a severe headache and nausea. He has been vomited 5 times since yesterday midnight. In addition, he was having abnormal eye movement and coordination problem. Moreover, his headache was worsening continuously (Silver et al. 2011). When assessed for neurological functionality, he was unable to recall 3 out of 5 objects. Pathophysiology He was diagnosed with a head injury, which can be of two types, one is hematoma and the other one is haemorrhage. In case of hematoma, blood clot is found outside of the blood vessels, which can create pressure on the skull, causing unconsciousness. In contrast, haemorrhage is referred to the uncontrolled bleeding. Subarachnoid bleeding causes headaches and vomiting often. The severity of intracerebral haemorrhage is dependent upon the level of bleeding and length of bleeding. However, in case of Tan blood came out due to skull fracture (Blennow et al. 2012). Thus, Tans brain injury can be classified as the primary injury or traumatic brain injury (TBI). The traumatic brain injurys physical mechanisms are classified in different categories, one is impact loading, which refers to the collision of head with a solid object at a tangible speed, whereas the impulsive loading refers to sudden motion without significant physical contact; on the other hand, static leading is referred to the loading, where the effect of speed of occurrence might not be significant. Tan has cerebral edema, as a result of tissue perfusion and intracranial haemorrhages, i.e. subarachnoid haemorrhage (Carlson et al. 2011). The primary injury caused by accident or fall, through a biochemical cascade leads to the secondary injury, thereby worsening the brain damage caused by primary injury. Due to the inflammation of brain tissue or swelling, the rise of intracranial pressure occurs. The worsening of primary injury and other factors may lead to change in the flow of blood to brain and hypoxia, i.e. insufficient oxygen to brain. Ischemia is the result of enhanced intracranial pressure. Too much pressure within the skull can lead to brain death. Course of Treatment The course of treatment is referred to the systematic integration of medical activities for patients recovery in a step-by-step manner. Initial step after his transfer to emergency room in hospital would be oxygen pump, vital sign assessment, pain medication, pressure and pulse rate control, bleeding control and initial wound management. Based on diagnostic results, brain surgery, wound management, coma recovery program, extended care program and inpatient rehabilitation program would be suggested (Carlson et al.2011). After noticing significant improvement, community support services and occupational therapy would also be involved. Nursing Care Needs The key nursing care needs for Mr. Tan is as follows: Wound management Monitoring patients vital sign Pain management Reducing of intracerebral pressure Patients consciousness and disability monitoring Elevate head of bed to 30 degrees Diagnosis Results Based on the initial assessment of the patient some key diagnostic tests were done for Mr. Tan, the result of which is as follows: CGS- 8 X-ray- skull fracture, CT scan- Brain swelling, Blood clots at 3 internal sites of brain, subarachnoid haemorrhage MRI- More detailed results confirming the results of CT scan, worsening of primary injury CBC- Abnormal RBC count and less haemoglobin Factors Affecting Patients Ability to Meet Needs There are several factors, which can affect the ability of the patient to meet his needs. These are: Patients adherence to therapeutics Wound infection and swelling Inappropriate monitoring Miscommunication Misinterpretation of diagnosis Negligence Lack of therapeutic alliance and support Multiple TBIs Inappropriate quality of care Lack of family support Patients at Risk for Complication Key risk factors of Mr. Tan are listed below: Brain infection Coma Fatal consequences Paralysis Loss of memory Planning Objectives Patients recovery Wound management Pain management Control patients vital signs Successful elimination of haemorrhage in brain Improving his lifestyle Expected Outcomes Reduced pain Reduced inflammation or swelling of brain tissue Elimination of blood clot and successful rehabilitation of patient Improved blood pressure, pulse rate and heart rate Improved coordination and social involvement Absence of disability Improved lifestyle Early Discharge Planning Patient will be released upon meeting expected treatment goals and recovery Follow up sessions would be discussed Key vital signs will be measured before release Social support and ambulatory support will be arranged if required Implementation Care Plan Initial step towards Tans care plan is management of airway and circulation. He was provided with oxygen accordingly. Following stabilization, the next concern is towards prevention of secondary injury, by keeping mean arterial pressure above 90 mmHg and CT scan In the next step, with sterilized process, wound is cleaned and protected from infection by bandage In next part, urgent attention would be towards the reduction of intracranial pressure, for this intravenous mannitol, hyperventilation and CSF drainage would be used In the next step, ICP control is suggested for diminishing the chance of mortality High dose barbiturate therapy would be implemented, if intracranial pressure does not respond. Appropriate ICP monitoring is suggested (Silver et al. 2011) Hypothermic therapy is the next step for reducing intracranial pressure; however, it has a risk of developing deep venous thrombosis Phenytoin is administered for controlling posttraumatic seizures To reduce pain, acetaminophen (Tylenol) is suggested rather than anti-inflammatpry drugs like aspirin (Carlson et al.2011) Surgery is not recommended for Mr. Tan to reduce intracranial pressure, as it is more applicable for patients undergoing hematoma Finally, Rehabilitation is very important for improving his daily functioning and back to normal life. Rehabilitation would also help him to motivate for improving his lifestyle by reducing smoking and alcohol consumption (Barkhoudarian et al. 2011) Strategies for Assisting Patient Empathy Moral support Strong therapeutic alliance Involvement of family and holistic care Evaluation The nursing interventions would be evaluated on the basis of patients outcomes The assessment and care plan would be documented on regular basis, from where the adherence of nursing staffs with the therapeutic procedures, would be evaluated (Barkhoudarian et al. 2011) Lack of strong therapeutic alliance and lack of family and social support would hinder the success of the care plan and recovery Conclusion Mr. Tan was assessed for a traumatic head injury after he underwent an accident of his car with a bus. The report provided his assessment and care plan along with the expected outcomes and evaluation process. From this case study, management of a critical patient and required skills has been learned. References Barkhoudarian, G., Hovda, D.A. and Giza, C.C., 2011. The molecular pathophysiology of concussive brain injury. Clinics in sports medicine, 30(1), pp.33-48. Blennow, K., Hardy, J. and Zetterberg, H., 2012. The neuropathology and neurobiology of traumatic brain injury. Neuron, 76(5), pp.886-899. Carlson, K.F., Kehle, S.M., Meis, L.A., Greer, N., MacDonald, R., Rutks, I., Sayer, N.A., Dobscha, S.K. and Wilt, T.J., 2011. Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: a systematic review of the evidence. The Journal of head trauma rehabilitation, 26(2), pp.103-115. Hilario, A., Ramos, A., Millan, J.M., Salvador, E., Gmez, P.A., Cicuendez, M., Diez-Lobato, R. and Lagares, A., 2012. Severe traumatic head injury: prognostic value of brain stem injuries detected at MRI. American Journal of Neuroradiology, 33(10), pp.1925-1931. McCrory, P., Davis, G. and Makdissi, M., 2012. Second impact syndrome or cerebral swelling after sporting head injury. Current sports medicine reports, 11(1), pp.21-23. Richardson, J., 2013. Clinical and neuropsychological aspects of closed head injury. Psychology Press. Silver, J.M., McAllister, T.W. and Yudofsky, S.C., 2011. Textbook of traumatic brain injury. American Psychiatric Pub. Wintermark, M., Sanelli, P.C., Anzai, Y., Tsiouris, A.J., Whitlow, C.T. and Institute, A.H.I., 2015. Imaging evidence and recommendations for traumatic brain injury: conventional neuroimaging techniques. Journal of the American College of Radiology, 12(2), pp.e1-e14.