The Slippery Slope: Using Pathophysiological Concepts to Explain the Clinical Deterioration of a Patient with Traumatic Brain Injury

Introduction
Between the flags (BTF) is a tool designed to provide early identification and
recognition of deteriorating patient to enable the best possible clinical outcomes.
The slippery slope shows how the BTF system is designed to intervene in the
process of patient deterioration (Mathew, 2015). Patient safety must be
promoted on all levels, and successfully implemented each time at all levels of
intervention. This essay will discuss the four phases of the slippery slope using
pathophysiological concepts to explain the clinical deterioration of Sally a 15-
year-old girl who sustained a closed left temporal skull fracture. In some health
services 15 year olds may be considered as adults, due to body size, social
status and bed availability, for the purposes of this essay Sally will be considered
as a child.
Prevention Phase
Prevention phase is when the nurse provides prompt, timely and appropriate
intervention to prevent patients from deteriorating. (Mathew, 2015).
Traumatic brain injury (TBI) is defined as an impact, penetration or rapid
movement of the brain within the skull that results in altered mental state
(Andrews et al., 2015). The Monro–Kellie hypothesis states that the volume in the
cranium which consists of blood, cerebrospinal fluid (CSF), and brain tissue is
fixed. These constituents create a state of volume equilibrium therefore any
increase in volume of one of the cranial constituents must be compensated by a
decrease in volume of another. TBI occurs at the moment of impact as a result of
mechanical forces to the head. (Andrews et al., 2015). On arrival in Emergency
Department (ED), the nurse assessed Sally using a paediatric ED observation
chart. This chart is used to record baseline vital observations of patients that are
aimed at assisting clinicians in developing a systematic approach to ensure
appropriate assessment and timely intervention and escalation, protecting
patients from deteriorating undetected and to ensure they receive appropriate
care (Souter et al, 2015).
Sally’s clinical presentation in the prevention phase indicates Sally needs closer
observations. The Glasgow Comma Scale (GCS) is 13. GCS scale is a neurological
scale used to measure patient’s consciousness.it gives a score between 3 which
indicates deep unconsciousness and 15 which indicates full consciousness (Levett-
Jones & Bourgeois, 2015). Sally‘s GCS is of concern, she is bordering between mild
and moderate neurological deteriorating as she is disorientated to time. Sally’s
blood pressure is 135/86mmHg, this reading is slightly elevated which could be
related to pain and anxiety (Marshall et al., 2015). Pain and anxiety can elevate the
blood pressure by causing the discharge of stress hormones into the blood
influencing the heart to beat faster and vasoconstriction directing more blood to
the affected areas of the body (Marshall et al., 2015). Sally’s pulse and respirations
rates were within normal ranges, 82bpm and 18rpm respectively. Sally’s
vomiting without any nausea can be an indication of pressure changes in the
cranium due to the brain trying to compensate (Wäljas et al., 2015)
To maintain a normal intracranial pressure (ICP) there are three ways in which
the body adapts to volume changes within the skull (Wäljas et al., 2015). These

changes include first changing the CSF volume by reducing CSF production or
altering CSF absorption, secondly, altering the intracranial blood volume through
vasoconstriction in the regional cerebral, collapse of the cerebral veins and
reduction in venous flow, and thirdly, compensation of the tissue brain volume
through the compression of brain tissue. However this compensatory mechanism
ability to changes in volume is limited. This leads to decompensating due to the
continuing increase in volume resulting in compression and ischemia (Rangel-
Castilla, Spetzler & Nakaji, 2015).
Sally’s expression of a pain score of 6/10 within her head is directly related to
the injury of the skull and connective tissues of the head. Brain tissue does not
have pain receptors so will not feel pain (Rangel-Castilla, Spetzler & Nakaji, 2015). Pain
sensation in Sally’s case is likely to arise from the fractured skull and
compression of other intracranial structures, such as the cranial nerves, veins
and the walls of arteries (Rangel-Castilla, Spetzler & Nakaji, 2015).
During the prevention phase the Registered Nurse (RN) can prevent a critical
event. There are many actions the nurse could undertake to protect Sally from
deteriorating further or to recognise early deterioration. Increasing the frequency
of neurological observations to 15 minutely would lead to reduction of the
chances of suffering from a critical event. (Andrews et al., 2015).
It is important to ensure that Sally’s cervical spine was protected as she had a
blunt impact onto her head that can cause stress to the neck structures.
Encouraging Sally to lie in the semi-fowler's position maintains and enhances
respiratory exchange and aids in decreasing cerebral oedema (Andrews et al., 2015).
Because Sally has had a few episodes of vomiting inserting an indwelling urinary
catheter would assist to monitor Sally’s input and output to avoid dehydration
(Andrews et al., 2015). Sally has been placed in a single room for peace and quiet,
this action is quite dangerous. Sally’s condition requires close monitoring for
deterioration; she needs to be closest to the Nurse’s station so the RN’s can
always watch her. Ideally, she should be in a 4-bed bay with the other patients,
who are having frequent observations, this would assist in the nurse’s workload.
The overall goals in the preventative phase are to maintain Sally’s ICP within
normal limits, provide early detection of deterioration, and maintain a patent
airway, as to prevent Sally from moving on to the next phase, clinical review
(Williams, 2018).
Clinical Review Phase
Clinical review is a patient review undertaken within 30 minutes by the attending
medical officer (Hinson, Rowell & Schreiber, 2015).
During the clinical review phase most of the information provided in this case
was subjective such as Sally holding her head and crying out for her mum, these
are subjective expressions of distress (Tanriverdi & Kelestimur, 2015). And vomitus
down the front of her shirt indicates a sudden uncontrolled vomiting event. In
nursing, subjective data refers to information from a patient's point of view, such
as pain score and objective data refers to measurable aspects of a patient's

condition for example temperature (Hinson, Rowell & Schreiber, 2015). Clinical
presentation of distress, vomiting and disorientation to person, place and time
indicates that the brain is compensating (Tanriverdi & Kelestimur, 2015). The
compensation stage in a head injury starts with changes in Cerebrospinal fluid
absorption, decrease in intracranial blood volume through regional cerebral
vasoconstriction and tissue brain volume through compression of brain tissue
(Tanriverdi & Kelestimur, 2015).
During the clinical review phase, the nurse should request a medical officer using
the ISBAR communication tool to review Sally (Prasanna, Mittal & Gandhi, 2015). At this
stage Sally continues to deteriorate this is evidenced by her inability to identify
her name where she was or what time it may have been and this indicates a
further drop in Sally’s GCS. Therefore pain, sudden uncontrolled vomiting event
and worsening confusion are indicators that necessitate Sally to be attended to
and reviewed within 30 minutes by her attending medical officer. (Prasanna, Mittal
& Gandhi, 2015).
While waiting for a clinical review the nurse should conduct a set of clinical
observations including neurological assessment using GCS. When the medical
officer (MO) arrives, there would be a current set of observations available. It is
important in this phase that documentation is kept up to date and readily
available because it informs the MO of Sally’s history of injury and nature of
deterioration. Sally’s past and current clinical status will indicate how quickly she
is deteriorating and also the interventions the nurse provided and the patient’s
response to the treatment (Tulsky et al., 2016). In addition, the RN needs to keep
Sally and Sally’s mum informed using short, simple explanations about what is
happening and why a clinical review is needed. Keeping Sally’s mum informed of
Sally’s condition and treatment is an important nursing practice (family-centred
care) and it is important because she is Sally’s direct carer and by keeping her
informed reassures her alleviating anxiety, fear or panic (Tanriverdi et al., 2015).
The overall goals in the clinical review phase is to provide support to Sally’s
mum, improve Sally’s GCS, relief her from pain and avoiding her from moving to
rapid response phase
Rapid Response Phase
Rapid response is an urgent review within 10 minutes of patients whose
observations are in the red zone on the BTF chart (Rossaint et al., 2016). Sally’s
brain is no longer compensating she is undergoing de-compensation. This
means compensatory mechanism response to changes in volume has reached its
full limit therefore this leads to de-compensation due to the continuing increase
in volume resulting in compression and ischemia (Rossaint et al., 2016).. The clinical
signs that indicate Sally is entering decompensation include the GCS 9, BP
98/42mmHg, respirations shallow and 8rpm, pulse rate thready and 56 bpm,
alteration in pupillary response to light and the inability to open the eyes. This is
a result of the continuing increase in cerebral volume and increased ICP
(Zehendner etr al., 2015).