Read about the patient assessment of Mr Robert Brown who was hit by a car and is suffering from mild traumatic brain injury. Learn about the normal and abnormal data of the patient, the consequences if no action is taken, and the priority nursing diagnosis related to the case.
Contribute Materials
Your contribution can guide someone’s learning journey. Share your
documents today.
Student number: CNA253 AT2 Scenario: Mr Robert Brown Consider the patient situation Mr Robert Brown is a 30-year-old male who was hit by a car. The impact caused him to be thrown into a nearby garden bed. Passers-by came to his aid immediately. They helped him up and noticed hewas bleeding from a laceration to the back of the head. He sustained no other obvious injuries. An ambulance was called. He has been at hospital for nearly 24 hours and was transferred to your ward overnight. It is now 0800 and you have just come on shift. You enter his room and he seems to be unsure of where he is (requires orientation) and keeps asking other patients the location of his dog (whom Robert was walking at the time of the accident). Collect CuesReview: Examine existing documentation via the assessment resources folder in MyLO. Gather new information (patient assessment): Upon undertaking an assessment of Mr Brown, you obtain the followingnewinformation: Vital signs BP: 160/95 (high) NORMAL 120/80 Pulse: 111bpm (high) NORMAL 60-100 RR: 18NORMAL 12-20 SaO2: 98%NORMAL 95-100% Temp 36.6OC NORMAL 36.1oC – 37.2OC O2flow rate: ≤ 3 NORMAL 2-6 LPM Other data GCS: 15 (patient seems confused/agitated) and keeps rubbing at his head and mumbling that it hurts. Whilst his movements seem purposeful, he does not obey commands or accurately answer specific questions). The patient in the adjacent bed says to you 'that poor bloke, he's been up half the night. He keeps going on about his dog and gets lost when he goes to the bathroom'. Wound chart: no further documentation evident. However, upon looking at Mr Browns head wound from a distance, dressing appears blood soaked and has partly come off. There are smears of blood on his pillow. Interpret: List of normal and abnormal data of the patient. Normal (Subjective & Objective)Abnormal (Subjective & Objective) Temperature =36.6OC NORMAL 36.1oC – 37.2OC SO2 =98%NORMAL 95-100% Respiratory rate =18NORMAL 12-20 GCS = 13Severe:GCS 8 or lessModerate:GCS 9-12Mild:GCS 13-15 High blood pressure = 165/95 (Hypertension)NORMAL 120/80 Pulse rate high= 111bpm NORMAL 60-100bpm
Secure Best Marks with AI Grader
Need help grading? Try our AI Grader for instant feedback on your assignments.
O2flow rate=≤ 3 NORMAL 2-6 LPM (Scanlon and Sanders 2014). Bleeding from laceration to back of head Poor orientation (Kumar and Gandhi 2014). Relation and Inference according to the data and symptoms: Through, evaluation of Mr Brown case study, it is noted that GCS score of Mr Brown is 13 as compared with the normal range which is near to 15.GCS level is used to record the level of consciousness in a person by assessing the eye response, motor response and verbal response of person due injury in Brain (McNettet al2014). The score below 3 depict there is permanent damage of cells in Brain. Reviewing the pathology of brain injury, it can be understood that GCS score of 13 depict mild traumatic brain injury which show temporary neurological indications (McKee and Robinson 2014). By Considering the study of neurological observation of Mr Brown, sign of confusion, bewilderment and deficient in attention was noticed. (Kehoeet al2016). In Mild traumatic injury the brain cells are affected which might result in loss of consciousness, concentration problem and profound confusion (Kristman etal2014). The reason behind such is changes in white mater of brain which cause disruption of neurological signal transmission. (Johnson, Stewart and Smith 2013). In relation to symptoms of pathophysiology of brain injury it can be inferred that Mr Brown is undergoing mild cognitive impairment. The diagnosis calls for behavioural treatment by monitoring Mr Brown closely at home regarding occurrence of any other symptoms (cooket al2013). Another abnormal result observed in Mr Brown is high blood pressure after the injury because after giving pain killer, the blood pressure was high. On observation at 2100 and 2300, blood pressure was slightly high however, on reviewing at 0800, his pressure was got to 160/95. Looking into the pathology of hypertension after injury, the brain cell gets damaged and diffusion of cerebral edema cause in increase in ICP which result in complex interaction of neuroendocrine response by stimulating autonomic system of brain with disruption of catecholamine pathway (Kinoshita 2016). Hypertension also result from increase in blood flow due to injury, which might also result in high heart rate in Mr Brown (Sheriff and Hinson 2015). Thus, needs clear monitoring, proper treatment and medication. Based on the interpretation of all information, the disorientation in behaviour of Mr Brown is due to his changes in brain functions after injury. Mr Brown was hit by a car, which might have altered his brain signalling pathway and cause high blood pressure and high pulse rate. (Stocchetti and Maas 2014). However, matter of concern in case of Mr Brown is his condition has not been better as he is constantly looking for his dog and is in state of confusion. There is a great need to control his blood pressure otherwise this may lead to severe consequences of blood vessel damage and wound healing. There is also need to manage his wound as because his wound was found soaked in blood. Result and consequences to the patient if no action is taken: The patient who have mild brain traumatic injury, face severe consequence if no action is taken in time of if left untreated. The brain injury can cause severe problem both physical and emotional which might cause depression. Brain traumatic injury cause damages of brain cell and signalling pathway, there can be extreme neurological failure. If the injury has cause hypertension then, this may cause blockage or heart failure if no immediate action has taken. As the poor result of this, the patient may face loss of vison, hearing capability as well as problem in speech as because there is disruption in signalling pathway of sense organs (Hutchinson,et al2013). Patient may also undergo mental retardation. Where he may face problem in remembering thing or may struggle in reading and writing (Li and Liu 2013).
Priority nursing diagnosis related to case: The three prioritise nursing diagnosis given toMr Brown are as follows: 1.There is need to diagnose the reason behind high blood pressure even after given paracetamol, as this may cause late recovery. 2.To determine the behaviour changes and cognitive problem like profound confusion and loss of consciousness. 3.Need to deal with wound soaked in blood as this may cause loss of blood from body. Goals, Actions and Evaluation: Diagnosis 1GoalsRelated actionsRationaleEvaluate outcomes Raise of blood pressure in patient after injury in head. To decrease the level of blood pressure to normal range for faster recovery and to control the loss of blood due to injury (Bodenheimer and Smith 2013). 1.Nurse need to carefully monitor the blood pressure at regular interval. 2.Anti-hypertensive medicine should be administered to the patient (Maet al 2014). 3.Nurse need to keep regular observation on the rate and rhythm of apical and peripheral pulse (Peeterset al2014). 1.This will keep a regular record of blood pressure and be useful to observe the changes when given medicine. 2.This will allow to bring the blood pressure down to normal range and recover fast from mild traumatic injury. 3.To notice the consequence of hypertension on heart and blood vessel. (Mersal and Mersal 2015). 1.After proper diagnosis and setting plan and action accordingly, Mr Brown will be able to manage the consequences that he might have face if he was left untreated with the issue connected with hypertension. 2.Medication will help to control blood pressure. By checking the blood pressure at regular interval will help to know the effectiveness of medicine provided to him. 3.His wound infection will be treated fast, which can be evaluated by continuous dressing of his wound.
4.Bleeding will be controlled soon. 5.Brain traumatic injury will not cause damage to his brain after controlling his hypertension. Diagnosis 2Goal/sRelated actionsRationaleEvaluate outcomes 1.To determine the behaviour changes and cognitive problem like profound confusion and loss of consciousness. To improve the neurological disorder of patient and to recover from the consciousness and confusion. The related action taken to contradict the issue are 1.Keen observation on the patient’s behaviour and level of consciousness need to be assess. 2.Mr. Brown was seen to be confused and anxious about his dog, so nurse need to give him mental support and keep him calm (Giacinoet al 2014). 3.The patient must be indulged in regular conversation with nurse and keep him reminding about the date, time and family. 1.This will evaluate the improvement of neurological condition of patient on giving proper medicine. 2.This will help him to manage his emotion and level of depression. 3.As patient with traumatic brain injury may cause memory loss, so this will make him keep all his memories. 1.By keeping check on his behaviour and maintaining daily record his outcome can be better evaluated. 2.His recovery symptoms will be monitored and related action shall be taken. 3.Neurological disorder will be treated and managed well. 4.The consequence related to neurological disorder will be diminished. 5.He will be in hydrated state. 6.Early recovery. Reference list: Bodenheimer, T.S. and Smith, M.D., 2013. Primary care: proposed solutions to the physician shortage without training more physicians.Health Affairs,32(11), pp.1881-1886. Cook, R.S., Gillespie, G.L., Kronk, R., Daugherty, M.C., Moody, S.M., Allen, L.J., Shebesta, K.B. and Falcone Jr, R.A., 2013. Effect of an educational intervention on nursing staff knowledge, confidence, and practice in the care of children with mild traumatic brain injury.Journal of Neuroscience Nursing,45(2), pp.108-118.
Paraphrase This Document
Need a fresh take? Get an instant paraphrase of this document with our AI Paraphraser
Giacino, J.T., Fins, J.J., Laureys, S. and Schiff, N.D., 2014. Disorders of consciousness after acquired brain injury: the state of the science.Nature Reviews Neurology,10(2), p.99. Hutchinson, P.J., Kolias, A.G., Czosnyka, M., Kirkpatrick, P.J., Pickard, J.D. and Menon, D.K., 2013. Intracranial pressure monitoring in severe traumatic brain injury. Johnson, V.E., Stewart, W. and Smith, D.H., 2013. Axonal pathology in traumatic brain injury.Experimental neurology,246, pp.35-43. Kehoe, A., Smith, J.E., Bouamra, O., Edwards, A., Yates, D. and Lecky, F., 2016. Older patients with traumatic brain injury present with a higher GCS score than younger patients for a given severity of injury.Emerg Med J,33(6), pp.381-385. Kinoshita, K., 2016. Traumatic brain injury: pathophysiology for neurocritical care.Journal of intensive care,4(1), p.29. Kristman, V.L., Borg, J., Godbolt, A.K., Salmi, L.R., Cancelliere, C., Carroll, L.J., Holm, L.W., Nygren-de Boussard, C., Hartvigsen, J., Abara, U. and Donovan, J., 2014. Methodological issues and research recommendations for prognosis after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.Archives of physical medicine and rehabilitation,95(3), pp. S265-S277. Kumar, P.M. and Gandhi, U.D., 2018. A novel three-tier Internet of Things architecture with machine learning algorithm for early detection of heart diseases.Computers & Electrical Engineering,65, pp.222-235. Li, L. and Liu, J., 2013. The effect of pediatric traumatic brain injury on behavioral outcomes: a systematic review.Developmental Medicine & Child Neurology,55(1), pp.37-45. Ma, C., Zhou, Y., Zhou, W. and Huang, C., 2014. Evaluation of the effect of motivational interviewing counselling on hypertension care.Patient education and counseling,95(2), pp.231-237. McKee, A.C. and Robinson, M.E., 2014. Military-related traumatic brain injury and neurodegeneration.Alzheimer's & Dementia,10(3), pp. S242-S253. McNett, M., Amato, S., Gianakis, A., Grimm, D., Philippbar, S.A., Belle, J. and Moran, C., 2014. The FOUR score and GCS as predictors of outcome after traumatic brain injury.Neurocritical care,21(1), pp.52-57. Mersal, F.A. and Mersal, N.A., 2015. Effect of evidence based lifestyle guidelines on self efficacy of patients with hypertension.Int. J. Curr. Microbiol. App. Sci,4(3), pp.244-263. Peeters, M.J., van Zuilen, A.D., van den Brand, J.A., Bots, M.L., van Buren, M., ten Dam, M.A., Kaasjager, K.A., Ligtenberg, G., Sijpkens, Y.W., Sluiter, H.E. and van de Ven, P.J., 2014. Nurse practitioner care improves renal outcome in patients with CKD.Journal of the American Society of Nephrology,25(2), pp.390-398. Scanlon, V.C. and Sanders, T., 2018.Essentials of anatomy and physiology. FA Davis. Sheriff, F.G. and Hinson, H.E., 2015, February. Pathophysiology and clinical management of moderate and severe traumatic brain injury in the ICU. InSeminars in neurology(Vol. 35, No. 01, pp. 042-049). Thieme Medical Publishers. Stocchetti, N. and Maas, A.I., 2014. Traumatic intracranial hypertension.New England Journal of Medicine,370(22), pp.2121-2130.