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Case 4 Paul Jackson: traumatic brain injury - Coggle Diagram
Case 4 Paul Jackson: traumatic brain injury
Read Mr Jackson’s triage information and decide if he was triaged appropriately. Rationalise your answer.
Triage 2 to be seen within 10 minutes are for conditions that could be life threatening and require prompt attention such as chest pain.
O2 saturation is 88%
What was the process of physical assessment in the ED?
(C) ABCDE
(Catastrophic haemorrhage control)
Airway and cervical spine
Breathing and adequate ventilation
Circulation and haemorrhage control
Disability (neurology and pupils)
Expose and temperature (warm)
Describe the primary assessment findings on arrival to the ED
Airway: patent and talking. Epistaxis - at risk
Breathing: RR32, decreased symmetry R. Laboured breathing. Sats 88-90% RA. S/c emphysema R chest. (Emphysema: A disorder affecting the alveoli (tiny air sacs) of the lungs)
C: BP 95/56mmHg. HR 92 SR. Centrally well perfused. Peripherally cool. Epistaxis.
D:GCS 13/15 (3/4/6). R pupil 4+. L pupil unable to assess.Swelling, possible rhinorrhea. Intoxicated +++(intoxicated: drunk or under the influence of drugs.)
E:Temp 35.8. Bruising R eye.
Based on the primary assessment, what are the priorities in care? Provide a rationale for your answer.
Intubate patient (ETT) > 95% → rationale as your cells need oxygen to make energy. Your lungs absorb oxygen from the air you breathe. The oxygen enters your blood from your lungs and travels to your organs and body tissues.
Identify cause of epistaxis → determine cause, restore volume, stop bleeding → rationale is to identify potential factures and reduce volume depletion.
Identify cause of high respiratory rate → to correct the underlying cause of laboured breathing
Keep him warm → avoid hypothermia and keep patient comfortable
Fluid → increase BP
Based on the pre-hospital information provided, what are the potential injuries the patient may have sustained?
Internal bleeding in the brain
Fractures
Haemorrhage
(tension?)Pneumothorax
Head injury
Nose fracture
Discuss the red flags and provide a rationale for each.
Contusion → indication of ruptured blood vessels
Swelling to his left eye → potential raccoon eye
Epistaxis → want to control loss of blood volume and may have nose fracture
Combative and cooperative → brain injury? deteriorating?
Discuss the interventions required for this patient. Provide a rationale for each.
A: check position ETT, tapes secure. Soft collar insitu. → to avoid causing trauma to organs and tissue, and to ensure efficient oxygen supply and maintain patent airway
B: apply O2 15L via NRM. Urgent CXR. Respiratory ax 30/60. Suction as required. → your cells need oxygen to make energy. Your lungs absorb oxygen from the air you breathe. The oxygen enters your blood from your lungs and travels to your organs and body tissues. Suction to clear airway and provide oral hygiene.
C: vital signs 15/60. Cardiac monitoring. Insert x2 IVC. Full bloods/G&H and X-match. Warm IVF. eFAST. → Increase blood pressure
D: GCS and pupils 30/60. CT brain within 30 minutes. Observe for ongoing D/C from ears/nose. → monitor neurological obs and determine and diagnose any potential clinical problems
E: keep normothermic and warm everything → to avoid hypothermia
What factors lead to his intubation? You will need to consider the patient’s presenting signs and symptoms and the results of any investigations in your discussion.
Low oxygen levels
decrease of LOC → become combative and agitated
c/o abdominal pain
Discuss the trend in his vital signs. You should compare his Glasgow Coma Scale (GCS) at the scene, upon on arrival to the ED and throughout his ED stay. What is the significance of the drop in his GCS?
Unstable
GCS is declining → it is now 8 he can’t maintain airway management on his own well,
at risk of aspiration and the loss of airway reflexes.
The patient is thought to have a traumatic brain injury and a chest injury. What are the nursing considerations for this patient in ED.
Aims:
Early diagonosis (GCS/pupils, CT scan within 30 minutes)
Early Nsx review (neurosurgeon)
Early OT
Avoid secondary brain injury
Good supportive mx including:
Good oxygen
Avoid hypoxaemia
Early intubation
Good ventilation and oxygenation
SpO2>95%
Good BP
Avoid hypotension and hypovolaemia
Regular monitoring vitals
SBP>90mmHg
Use vasopressors as required
Arterial line to ensure accurate BP (invasive)
positioning
Not too much CO2
ETCO2 35-40mmHg (ETCO2 is the amount of carbon dioxide (CO2) in exhaled air, which assesses ventilation)
Signs and symptoms of elevated ICP
Commonest
Changes in LOC
Restlessness
Agitation
confusion
Headache
Nausea and vomiting
Pupil changes and BP
Focal
Motor weakness
Sensory deficit
Visual field deficit
seizure
Discuss the nursing care of a chest drain.
Never lift drain above chest level
Ensure the unit is securely positioned on its stand or hanging on the bed
Water seal is maintained at 2 cm (prevents backflow of air or fluid)
Drain insertion site
Signs of infection and inflammation (document findings)
Dressing is clean and intact
Sutures remain intact and secure
Pain
Pain relief
Allow PT and mobilise
Pain ax should be conducted frequently and documented
suction
Not always required, may lead to tissue trauma and air leak
Orders should be written by medical staff
Drainage
Document hrly/total amount of fluid in FBC/notes
Review sudden increase
Blocked drains are major concern for cardiac surgical pt due to the risk of cardiac tamponade (extra fluid builds up in the space around the heart)
Notify medical staff if a drain with ongoing loss / stops draining
Monitor colour/type of drainage
Dressings
Change after 3 or 7 days
When no longer dry and intact, or signs of infection (redness, swelling, exudate)
Discuss the nursing care of EVD (external ventricular drains)
The normal range of ICP is 0-15mmHg with the upper limit being 20mmHg.
At the beginning of each shift it is the responsibility of the nurse RN caring for a patient with an EVD to complete the following
mandatory safety checks
:
Patient has a
valid EVD treatment order
EVD drainage point is set at the
prescribed level
(as per Neurosurgeon documentation in postoperative orders)
EVD column is oscillating and patent
ICP waveform
is pulsatile on monitor
Head dressing is dry and intact
Observe and record volume level of CSF in burette
Report any signs of changes inpatient’s neurological condition to medical staff.