Patient Care in Multidisciplinary Setting - Essay Example

? A significant patient care event within a multidisciplinary care setting Head injuries are commonly caused as a resultof trauma in road traffic accidents, sports accidents and any falls. It has been reported that in UK alone around one million people report with some kind of head injury each year (Adam & Osborne 2005). There are also one of the main causes of death in accidents (Kim 2011). Being a critical care nurse in the emergency department, I encountered such a case. I was working at the teaching hospital affiliated with my college a few months back when a 23 year female, Elizabeth reported to the emergency department at 1am at night (the names have been changed to respect the privacy of the patient). The paper will focus on the events that led to her injury and the steps taken by the emergency department staff to stabilize her. After stabilization, the steps taken to manage the patient are discussed. I was on duty when Elizabeth reported to the emergency. She had an attendant, James, with her. Elizabeth was conscious but she had sustained severe injury and so was not in a condition to tell the details of what had happened to her. James was bruised but and had a bleeding tooth but had not sustained any serious injury as Elizabeth. James gave the history. He said that Elizabeth was driving while he was in the back seat when a deer came on the road. They were on a relatively silent country road on their way to the city. On seeing the deer, only a few meters from them, Elizabeth immediately reacted by steering the car towards the side of the road. In doing so, the car hit the side pavement. Since the car was being driven at 80km/h, the collision threw them forward in their seats. James was not badly hurt but Elizabeth sustained serious head injuries. James said that Elizabeth had seizures before she lost consciousness. Panicking, he called for help. When the paramedics arrived, they immediately lay her on a stretcher, and transported Elizabeth and James both to the hospital. They gave James some shot that lessened the pain that he was experiencing. On reaching the hospital, John was examined and found not to have any serious injury. His bruises and bleeding from the teeth were addressed and managed. I was assigned as the critical care nurse for Elizabeth. The paramedics mentioned that Elizabeth had gained consciousness while on the way back; however she was not oriented in time and space. She had mobility of all her limbs but her speech was not clear and coherent. She was speaking broken words that made no sense. On measurement of her pupils, they were of 3mm in size, with intact papillary reflexes. On assessing her consciousness level, she was rated as 9 on the Glasgow Coma Scale. According to Brooker and Nicol (2003), measurement of the GCS is the one of the most significant procedure the nurse carries out when a patient who is not well oriented in time and space comes. It is also the duty of the nurse to properly and accurately write down the results. Moreover, the nurse must be alert and continually observe the neurological condition of the patient. If there is any change, the nurse must report them immediately since quick interventions are required. Clinical decisions are dependent on the credibility and strength of these nursing interventions (Brooker & Nicol 2003). When assessing the consciousness, if the patient has a GCS rating of less than 7, the patient is said to be in a comatose state. Elizabeth, with a GCS rating of 9, was not labeled comatose. On carrying out the assessment and the standard protocol of ABC and stabilization of her vitals, it was seen that she was experiencing a quick decline of her neurological functioning. It is necessary to keep a track on the neurological condition of the patient. As mentioned above, such deterioration in the patient’s neurology is a matter of concern and should be duly addressed. Within a matter of a few seconds, Elizabeth’s speech started to deteriorate and she only made incomprehensible sounds now. Her eye responses had also progressively deteriorated. She did not respond when her name was being called. It was apparent that her conscious level is falling. She also failed to respond to painful external stimuli. This required that I reassess the state of consciousness of the patient on the Glasgow Coma Scale. Matzo and Sherman observe that injury to the brain can lead to coma (2009). It is essential to make a differential diagnosis of the persistence of the unconscious state. Unconsciousness can result from structural lesions (as may happen in the case of head injury or stroke), irritation of the meninges and seizures. In the case of a sudden loss of consciousness, the comatose state is usually attributed to intracranial bleed or infarct. Where some of the reasons which cause coma can be reversible, others may not. This has implications for nursing practice. As professionals committed to the cause of the patients, nurses are required to make the best of their efforts to provide care to the patients. Moreover when examining patients who have sustained traumatic brain injury, nurses are required to look for signs other than the obvious signs of head injury, assess the neurological condition, repeat the observations to confirm, and manage any changes in ICP (Brooker & Nicol 2003). In the case of patients who have gone into coma, it is necessary for the nurses to carry out a certain protocol regarding the vitals of the patient. Therefore my next step was to recheck the breathing and airway of Elizabeth. I carried out an endotracheal intubation to rule out any possibility of breathing complications resulting from the coma. I had an idea that it is necessary to carry out the intubation with the utmost care since there were chances that Elizabeth had sustained an injury of the cervical region. I also thought it best to insert an orogastric tube, via the mouth rather than through the nose. This was to avoid any complications occurring in case there is fracture of the cribriform plate, giving easy access to the brain and causing leakage of the CSF. It was also necessary to intubate the patient because there were chances of aspiration. Her stomach was washed since vomiting can further exacerbate any raised intracranial pressure that Elizabeth may have after the head injury. Throughout this time, I was working in concert with the medical officer to stabilize Elizabeth. There was no effect on her circulation; however a urinary catheter was inserted just to monitor any changes in her urinary output. Standard management of a patient with head injury necessitates immediate steps to improve oxygenation as well. This is because head injury can cause trauma to the brain and consequently affect it greatly. The accumulation of carbon dioxide or hypoxia can both be serious conditions. This is because both conditions lead to dilation of the cerebral vessels. This in turn causes greater pooling of blood in the vessels, which is responsible for increasing the intracranial pressure. Moreover the cerebral blood vessels respond quickly to changes in carbon dioxide; a decrease in this leads to reduction in the volumes of carbon dioxide as well as vasoconstriction. The consequence of this series of events is a fall in the blood volume being delivered to the brain, and hence raised intracranial pressure. Elizabeth showed signs and symptoms of raised ICP. However we had to order some tests before we could say that for sure. Till then, we had to ensure that her ventilation is proper as well. ICP can decrease after only a few minutes of proper ventilation but there is a catch to it. Too much ventilation can cause the blood vessels to constrict as mentioned earlier. Therefore we aimed to bring the levels of carbon dioxide back to normal, rather than increasing or decreasing them (Brooker & Nicol 2003). The breathing was thereby stabilized by putting Elizabeth on a ventilator. Having stabilized the ABC of initial management, the next step was to determine the cause of her comatosed condition. For this purpose, the medical officer ordered a CT scan. When the results of the CT scan came, they showed a lenticular-shaped hemorrhage- a sign that is typically related to acute epidural hematomas (Mashour & Farag 2011). Such a condition also implied raised intracranial pressure. Thereby our management was now more focused towards the management of the hematoma and the raised ICP. ICP is a serious medical condition, which if untreated, can lead to death. A sudden increase in the ICP affects cerebral perfusion. The raised ICP acts as a force against the normal blood supply of the brain and therefore decreases perfusion. This can cause ischemia of the brain tissues, further complicating the medical condition. On an average, the blood flow to the brain is 50 mL/100 g/min. A reduction in the blood flow to less than 18 mL/100 g/min can lead to ischemia. Therefore if such a situation persists, the brain tissue will be affected significantly, causing edema and resultant necrosis of the cells (Ahrens, Prentice & Kleinpell 2006). Cerebral blood flow is calculated by taking the cerebral perfusion pressure of the patient and dividing it by cerebrovascular resistance (Ahrens, Prentice & Kleinpell 2006). The cerebral perfusion pressure (CPP) is the main way of estimating the blood flow to the brain. It is calculated by finding out the difference between the mean arterial pressure and the mean intracranial pressure. In the case of traumatic brain injury, the CPP should at least be 60 mmHg. If CPP is found to be less than this value, it is a matter of great concern since it indicates a dilation of the cerebral blood vessels, causing greater flow of blood and a further rise in ICP. Other than the CPP, cerebral blood flow is also influenced by a number of other factors. These include the pH of the blood, levels of carbon dioxide and oxygen and autoregulation. Autoregulation plays a crucial role in the maintenance of a relatively constant cerebral blood flow despite changes in the mean arterial pressure in other parts of the body. Autoregulation serves to dilate or constrict blood vessels in the brain for a mean arterial pressure range of 50 to 150 mmHg. The effect of carbon dioxide is discussed later. Changes in pH can also affect blood flow. A fall in the pH causes vasodilatation whereas an increase leads to vasoconstriction. When ICp is low, cerebral blood flow is normal and adequate. However with a raised ICP, cerebral blood flow decreases to decrease the blood volume (Ahrens, Prentice & Kleinpell 2006). A sudden temporary rise of an already-raised ICP can occur due to some nursing practices and can further reduce the cerebral perfusion. Coughing, suctioning and bad positioning of the patient can all lead to a rise in ICP. Studies show that rise in ICP can be avoided by moving the patient very slowly and putting him or her in the proper position. Therefore I ensured that whatever steps I took, they are based on evidence-based practice so that my activities do not complicate the condition of the patient. Evidence-based practice dictates that for patients with raised ICP, they should be positioned in a supine position with their head elevated at an angle of 30°. So I placed Elizabeth supine in her bed, making sure that I turn her slowly and raised her head to 30°. This ensured that there is adequate drainage of the venous blood and prevented any pooling of blood. It is argued that where venous return is favored by gravity, blood flowing in the arteries faces difficulty to move against it. If the head is raised to very high angles, there are chances that the arterial blood flow is blocked considerably, starting a chain of events from reduced blood supply to the brain and subsequent ischemia. Therefore elevating the head at an angle of 30° has been seen to provide a favorable force to facilitate venous flow with little effect on the arterial flow. Also, I made sure that Elizabeth’s head is not bent to any side. This practice prevented any bending or torsion of the veins of the neck and the upper part of the body, allowing better drainage (Brooker & Nicol 2003). Elizabeth also had a wound on her head. The injured area was exposed and increased the likelihood of getting infection. Therefore I cleaned the wound and sutured it (Walsh & Crumbie 2007). For the medical and surgical management of Elizabeth’s raised ICP, the medical officer opted for an osmotic diuretic therapy. In this case, he used a mannitol to bring the ICP down to normal level. Mannitol is an effective agent for bringing down ICP levels in the short-term. The medical officer told me to inject mannitol intravenously, in the form of a bolus dose. Mannitol serves to decrease ICP by creating differences in osmolarity between the plasma and the tissues of the brain. The osmotic gradient causes fluid to be drained out of the cisterns and other fluid chambers in the cranium into the blood. It also has an effect on the viscosity of the blood and brings about a reflex vasoconstriction. This helps to reduce the ICP levels (Brooker & Nicol 2003). After injection of mannitol, ICP was measured using ICP devices. The ICP devices can be placed in several of the lateral ventricles of the brain. Also, there are a number of ways of measuring ICP such as through a screw or a bolt, sensor, intraparenchymal fiberoptic catheter or a simple intraventicular catheter (Ahrens, Prentice & Kleinpell 2006). For Elizabeth we used a screw, placed in the subarachnoid space, to monitor the ICP. Along with the bolt, a transducer and a recording instrument were also used. Frequent neurologic assessment should be carried out for a patient who has sustained head injury. This is necessary to be able to pick up any deteriorating changes early, averting the damage resulting from late detection. I checked on Elizabeth after every 15 minutes. After a couple of hours had elapsed since the injection of mannitol, the medical officer opted for a craniotomy in order to take out the subdural hematoma. For this I prepared Elizabeth for the operation and shifted her to the operation theatre. The operation was successful and was able to reduce the raised ICP levels back to normal as well as remove the hematoma. Post operative care of Elizabeth was also under by supervision for a few hours after the operation. Drain (2003) asserts that there are four main things that need to be monitored in a patient who have had cranial surgery. These are vital signs, LOC, motor and sensory functioning, and papillary signs. It is recommended that these four parameters are to be checked after every 15 minutes in the first couple of hours after the operation. If there is no derangement seen, these signs can then be checked after every half an hour. Since the medical officer did not specify that assessments should be carried out any more frequently, and Elizabeth also did not show any deteriorating signs after the operation, I carried out her assessment after every 15 minutes in the first two hours post-operatively. Even after the operation, Elizabeth had an ICP device in place to measure her ICP and to provide for any evidence of its increase. I recorded the ICP levels in every check-up and accurately documented the details regarding the waveform. Also I checked the arterial pressure and recorded it. I made it a standard protocol to check her for the four major areas mentioned above in a particular order so that I did not miss out anything. I checked the vitals first. These included measurement of the blood pressure, pulse, breathing and ICP. A derangement of the vital signs is indicative of a disturbance. Measurement of the temperature of the patient is also required. Hyperthermia may be indicative of an infection. Since Elizabeth had sustained a wound, it was necessary to pay attention to any changes in the vitals. An increase in temperature also causes an elevation in the metabolic rate of the neural tissues, causing an increase in ICP. A critical care nurse should also check if the breathing rate and rhythm are normal and the passages intact and open. The nurse should also rule out any possibility of a Cushing’s triad. In the case of Elizabeth there were no serious derangements in the pulse pressure, blood pressure and the heart rate to indicate any significant signs of a Cushing’s triad (Drain 2003). The next parameter for assessment is the level of consciousness or the LOC. The LOC is regarded as the primary means of determining brain function. A fall in the level of consciousness can be due to the effects of anesthesia or agents that have been used to block neuromuscular transmissions. LOC is also affected by a decrease in the levels of oxygen, vitamins or electrolytes imbalances. In order to determine the LOC, the reaction of the patient should be documented rather than the observer’s perception of what the LOC of the patient is. For this purpose, it is recommended to use the GCS. An increase in the LOC signifies improvement in the condition of the patient (Drain 2003). When Elizabeth was taken back to the ICU after operation, she was not conscious. However in the next hour, her GCS improved and she regained consciousness of had a GCS of more than 13. The next step was to check Elizabeth’s motor and sensory functioning. It provides information regarding edema and hemorrhage. I inspected if Elizabeth was able to move her limbs properly and checked her motor strength by asking her to work against gravity as well as against resistance. She performed satisfactorily in both cases. I checked for her papillary reactions in every check-up as well. Throughout the course of her management, I also ensured that she receives proper nutrition and glucose to provide for the increased metabolic demands secondary to injury. After five hours under my care, Elizabeth seemed much stable. The medical officer came for a check-up and asked me to shift her to the medical wards. From that point on, she was relieved from our care. This experience has taught me the importance of acute management of a patient who has sustained a head injury. It was particularly resourceful in making me implement the knowledge I had regarding management of raised ICP. Reference List Adam, SK & Osborne, S 2005, Critical care nursing: science and practice, 2nd edn, Oxford University Press, Oxford. Ahrens, T, Prentice, D & Kleinpell, RM 2006, Critical care nursing certification: preparation, review, & practice exams, McGraw-Hill Professional. Brooker, C & Nicol, M 2003, Nursing adults: the practice of caring, Elsevier Health Sciences, London. Drain, CB 2003, Perianesthesia nursing: a critical care approach, Elsevier Health Sciences. Kim, Y 2011, ‘A systematic review of factors contributing to outcomes in patients with traumatic brain injury’, Journal of Clinical Nursing, vol. 20, no. 11-12, pp. 1518-1532. Mashour. GA & Farag, E 2011, Case Studies in Neuroanesthesia and Neurocritical Care, Cambridge University Press, Cambridge. Matzo, M & Sherman, DW 2010, Palliative Care Nursing: Quality Care to the End of Life, Springer Publishing Company, Massachusetts. Turner, K 1999, Nursing a patient with a severe head injury: a case study, CIAP, viewed 1 June 2011 ,< http://www.ciap.health.nsw.gov.au/hospolic/stvincents/stvin99/Kturner.htm> Walsh, M & Crumbie, A 2007, Watson's Clinical Nursing and Related Sciences, Elsevier Health Sciences. Read More