Rhys’ Clinical Scenario: Pathophysiological Basis, Priorities of Care, and Principles of Age Appropriate Development and Care

This article discusses Rhys’ clinical scenario, including the pathophysiological basis for the abnormal findings reported in his primary survey, the six immediate priorities of care for Rhys, and the incorporation of principles of age-appropriate development and care into Rhys’ ongoing management on the ward. It also covers the family-centered care principles incorporation in Rhys’ health care service provision.

Running Head: RHYS’ CLINICAL SCENARIO 1
Rhys’ Clinical Scenario
Author’s Name
Institution
Date

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The Pathophysiological Basis For The Abnormal Findings That Are Reported In Rhys’
Primary Survey
The main pathophysiological stages of cerebral damage after traumatic brain injury
manifests as damage sustained by tissues directly, impairment of the mechanisms that regulate
cranial blood flow and metabolism. Ischemia causes lactic acid increase which causes edema
which alters cerebral blood flow hence leading to hypoperfusion, decreased blood pressure,
reduced cognitive levels measured via GCS, tachycardia, hyperventilation, increased intracranial
pressure and alteration of cerebral perfusion pressure all of which contributes to the signs and
symptoms experienced (Tanriverdi et al. 2015).
Rhy has a traumatic head injury as a result of the accident which resulted in a blow to the
head. The traumatic head injury is the basis of symptoms experienced by Rhy such as a Glasgow
Coma Scale of 10, Eyes with a sluggish reaction to the light with a size 4, heart rate of 68bpm,
respiratory rate of 18bpm and blood pressure of 138/49. These symptoms are due to the
increased intracranial pressure (ICP) that results from traumatic head injury (McGinn &
Povlishock, 2016). The pathophysiology of brain injury is important since its understanding
helps the health practitioner the ability to offer adequate and patient-oriented treatment. Just like
in the case of Rhy, these injuries based on their level of severity results in varying degrees of
morbidity that are usually accessed by the use of the Glasgow Coma Scale Score (Teasdale et al.
2014). Traumatic brain injury causes increased intracranial pressure that alters the cerebral blood
flow in terms of hypoperfusion, alteration of the cerebrovascular autoregulation, affects the
cerebral metabolic process and also causes inadequate cerebral oxygenation. Inflammation and
excitotoxic cell damage cause brain cell apoptosis and necrosis (Dixon, 2017).

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Traumatic brain injuries causes reduced regulation of CSF and metabolism (Tanriverdi et
al. 2015). This is followed by the accumulation of lactic acid as a result of anaerobic glycolysis,
increase in the permeability of the membrane which is followed by oedema which leads to low
blood pressure due to reduced blood pressure as seen in the case of Rhy who has a blood
pressure of 138/49 and a MAP of 77. Due to the reduced circulation in the brain due to the
oedema formation, signals are sent to cause hyperventilation which results in the number of
breaths per minute as seen in the case of Rhy who has 18bpm while the normal is around 15
bpm. In traumatic brain injury, there is an increase in the heart rate as the heart works hard to
compensate poor cerebral oxygenation (Tanriverdi et al. 2015). This is evident in the case of Rhy
who has a heart rate of 68bpm. Glasgow Coma Scale (GCS) records the conscious state of an
individual. A patient is assessed against the standards of the scale. Rhys’ GCS of 10 shows that
he has a moderate brain injury. Rhys’ GCS results show that he is conscious and has only mild
confusion state (Pearn et al. 2017). The eye level 4 and their sluggish reaction to light indicate
that his eyes open spontaneously. Rhy’s sluggish eyesight is caused by sedatives and analgesics
that he was given to reduce pain. Therefore, the pupillary response is low. The GCS of 10
indicates that Rhy has a moderate brain injury (Pearn et al. 2017). The GCS is used to asses the
level of consciousness and since that of Rhy is 10, it means that he is conscious but with some
elements of confusion.
Six Immediate Priorities Of Care For Rhys
Airway Control and Ventilation
Airway control and ventilation are important and should be prioritized since hypoxemia
leads to poor outcomes (Chowdhuri & Badr, 2017). Although airway control and ventilation is
the primary concern for patients with traumatic brain injury studies show poor outcomes for the

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TBI (traumatic brain injury) patients who have intubation at the site of trauma. This is because
intubation by healthcare workers who are inexperienced have four times likelihood increase in
cases of deaths as well as a very high risk of loss of function when compared to the patients who
have their airways secured in the emergency area (Tanriverdi et al. 2015). Basic airway care that
has been performed well in a prehospital environment can sometimes be better than the
prehospital intubation done poorly (Chowdhuri & Badr, 2017). Therefore it is of paramount
importance to ensure that if intubation is done on Rhy, it is done correctly by a care provider
who has experience on the same. The care provider should ensure that Rhy intubation includes
an in-line neck stabilization so as to reduce the chances of worsening a neurological injury until
when a proper radiological clearance is obtained. The health practitioner should ensure careful
preparation and preoxygenation and provide an anaesthetic drug to allow rapid control of airway
while avoiding elevation of ICP (Chowdhuri & Badr, 2017). The airway management and
control medication such as ketamine, propofol and etomidate should be provided to Rhy. To
ensure rapid intubation, rocuronium or succinylcholine should be used. (Chowdhuri & Badr,
2017).
Management of Blood Pressure and Cerebral Perfusion Pressure (CPP)
Rhys CPP (cerebral perfusion pressure) should be kept above 70mmHg with
Vasopressors to reduce the incidence of the acute respiratory distress syndrome (Qureshi et al.
2016). Vasopressors should be used to supplement CPP in case of traumatic brain injury. The
care provider can give Rhy norepinephrine or dopamine to maintain the desired CPP levels. The
care given to Rhy to maintain the desired blood pressure and CPP should follow the guidelines
which recommend maintaining systolic blood pressure above 110 mmHg to improve his
outcome, target CPP to be maintained between 60 and 70 mmHg. Efforts should be made to

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avoid aggressive attempts to maintain the cerebral perfusion pressure above 70 mmHg with
pressors and fluids (Qureshi et al. 2016).
Fluid Management
Rhy should be placed on Crystalloids which are poor volume expanders. These drugs
should be used to maintain his pressure as they reach the interstitial space within twenty minutes
of injection (Carney et al. 2017). The management of fluid is an important priority since due to
the traumatic brain injury, Rhy has a disrupted blood-brain barrier and hence a passive
distribution into his brain interstitium may occur leading to high blood oedema as well as
increased intracranial pressure if hypotonic solutions are used. Saline should be the most
appropriate crystalloid for Rhy but also Ringer’s lactate can be used instead (Carney et al. 2017).
Balanced crystalloid solutions are preferred since the infusion of large amounts can lead to
hyperchloremic metabolic acidosis.
Sedation And Analgesia
Since Rhy complains of pain, one of the main care priority is to reduce pain and stress.
The adrenocortical response is a significant component in the management of traumatic brain
injury. Sedatives should be given to Rhy to reduce his metabolic stress on the injured brain tissue
by causing a decrease in cerebral metabolism as well as consumption of oxygen in a very dose-
dependent way (Oddo et al. 2017).This will help reduce CBF (Cerebral Blood Flow) hence
leading to the reduction of ICP. The practitioner should take care to maintain a satisfactory mean
arterial pressure (MAP) throughout his sedation duration. If the care provider is able to maintain
an adequate level of sedation, this will reduce the length of hospital stay for Rhy, reduces
ventilatory days and helps in early mobilization. BTF(Brain Trauma Foundation) recommends

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high doses of barbiturates to control ICP and use of Propofol as a sedative for traumatic brain
injury patients (Oddo et al. 2017).
ICP Monitoring and Management
Since Rhy has an elevated ICP, he has a risk of worse outcomes and even a higher risk of
mortality. Therefore, ICP monitoring and management is a priority for care hence should be
managed and monitored to ensure a quick recovery. BTF(Brain Trauma Foundation) guidelines
for ICP monitoring include management of traumatic brain injury on the basis of ICP monitoring
to reduce hospital stay and mortality (Cnossen, Lingsma, Maas, Menon & Steyerberg, 2017).
These guidelines state that the clinical judgement is supposed to be used to initiate the process of
intracranial monitoring in patients who have a high risk of clinical deterioration. Therefore
nurses are required to include a cerebrospinal fluid drainage and give ventilation therapies.
Osmotherapy
This is the use of osmotically reactive elements to reduce intracranial volume. Rhy
should be put on mannitol to treat his raised ICP. Mannitol is a constituent of traumatic brain
injury management guidelines. Mannitol will elevate CBF by expanding plasma, reducing the
viscosity of blood via deformed erythrocytes as well as increases osmotic diuresis (Young et al.
2017). Hypertonic saline should be given to Rhy to increase the influx of water across the blood-
brain barrier as well as increase the flow of blood by expanding the plasma volume (Young et al.
2017).
Incorporation Of Principles Of Age Appropriate Development And Care Into Rhys’
Ongoing Management On The Ward

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There are eight core themes that can be derived from incorporating the principles of
appropriate care into the management of Rhys’ health issues. The impact of the condition,
provision of information, the role played by the health professionals, place of care, psychological
support, knowing what is culturally important, coping and life after getting well (Craig, Glick,
Phillips, Hall, Smith & Browne, 2015).
Knowing the Impact Of Traumatic Brain Injury on Rhy – Understand the extent of
damage and conditions that arise from the accident and suffering of TBI such as the surgery, the
insertion of a peripheral ventricular drain with ICP monitoring and medication will help in giving
better healthcare services (Craig et al. 2015).
Provision of Information – The family members should be given information on every
aspect of Rhys’ treatment and the outcome so that to ensure effective decision-making
mechanisms (Ho, Shaul, Chapman & Ford-Jones, 2016).
The Role Of The Healthcare Professional – The healthcare personnel that has been
assigned to Rhy should ensure that he receives the best medical care by making informed
decisions, asking for an opinion from other health care providers, having knowledge on all the
aspects of Rhys treatment and involving his family through giving them information and expert
advice (Craig et al. 2015).
Incorporation Of Culture – It is of paramount importance that the healthcare provider to
know what is culturally important to Rhy and his family. Therefore, an effort should always be
made to ensure that one is aware of the culture of Rhys’ Family in terms of their cultural values,
their expectations and the various factors that shape their family and communal lives (Craig et al.

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2015). This background information and knowledge help in the provision of relevant, mindful
and respectful interventions.
The Place Of Care – This principle ensures that the patient receiving treatment is placed
in safe and convenient environments. Place of care can be a hospital, a recovery facility or at
home (Craig et al. 2015). This reduces accidents and enhances service delivery. Rhy should be
hospitalized she he has just come out of a surgery, he has a peripheral ventricular drain with ICP
(intracranial pressure) monitoring, he has a low GCS and he is on medication (Craig et al. 2015).
This will ensure quick recovery at the hospital the services that he needs are readily available.
Psychological Support – Counseling should be incorporated into Rhys’ management plan
since he might be having trauma and difficult emotions due to shock, anxiety and fear (Ho et al.
2016). Therapy help deals with these issues and leads to having a normal cognitive approach to
issues and other aspects of life.
Coping And Life After Getting Well – The care provided to Rhy should help in the
development of coping mechanisms to deal with stress, pain and the changes that have occurred
to his life such as surgery, being admitted at the hospital and not going to school due to the
accident. The care provider should encourage Rhy to keep active, express emotions and have a
positive perspective of the future and determine his life after getting well (Dennis, Baxter, Ploeg
& Blatz, 2017).
Family-centred Care Principles Incorporation In Rhys’ Health Care Service Provision
Family-centred care is a collaboration between patients, the health professionals and
families in evaluation, planning and delivery of healthcare services (Dennis et al. 2017). Family-
centred care is founded on four basic principles which include;

RHYS’ CLINICAL SCENARIO 9
People To Be Treated With Respect And Dignity
Patients and family members are vulnerable hence nurses assigned to Rhy in the wards
should ensure that they preserve their dignity and are respected at all times (Dennis et al. 2017).
For instance, nurses should always to knock before entering his room and especially when the
family members are present since they might be discussing private matters. The nurses should
also respect the family or patient final decision (Ho et al. 2016).
Health Care Professionals To Communicate While Giving Unbiased And Complete
Information To The Family Members And Patients In Useful And Affirming Ways
Nurses, Rhy and his family should always share all the information. For example, they
should be allowed to see Rhys’ medical charts. The nurse should accept information and also
give information that will be used in the decision-making process (Craig et al. 2015).
Family Members And Patients To Build Their Strengths By Their Participation In
Experiences That Promote Independence And Control
If the family members and Rhy are given resources, information and their decisions are
respected, the delivery of healthcare will be successful as they are given the opportunity to
participate in their own care through the process of decision making (Mortensen et al. 2015).
This principle is an important one in this scenario as Rhy has been in critical condition hence
when his family members are included, they are able to give consent and make important
decisions (Mortensen et al. 2015).
Collaboration Among The Family Members, Patients And Care Providers In Program And
Policy Development And Professional Education And Care Delivery

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Rhy and his family should be included in coming up with his care plan so that they can give their
preferences that are taken into considerations and incorporated in the care delivery plan if they
are reliable. Professional education by the nurse will ensure that Rhy and his family have
information in all aspect of his health care delivery program (Ho et al. 2016).
References
Carney, N., Totten, A. M., O'reilly, C., Ullman, J. S., Hawryluk, G. W., Bell, M. J., ... &
Rubiano, A. M. (2017). Guidelines for the management of severe traumatic brain
injury. Neurosurgery, 80(1), 6-15.
Chowdhuri, S., & Badr, M. S. (2017). Control of ventilation in health and disease. Chest, 151(4),
917-929.
Cnossen, M. C., Lingsma, H. F., Maas, A. I., Menon, D., & Steyerberg, E. W. (2017). Estimating
treatment effectiveness of intracranial pressure monitoring in traumatic brain
injury. Outcome and Comparative Effectiveness Research in Traumatic Brain Injury: A
methodological perspective, 331.
Craig, J. W., Glick, C., Phillips, R., Hall, S. L., Smith, J., & Browne, J. (2015).
Recommendations for involving the family in developmental care of the NICU
baby. Journal of Perinatology, 35(S1), S5.

RHYS’ CLINICAL SCENARIO 11
Dennis, C., Baxter, P., Ploeg, J., & Blatz, S. (2017). Models of partnership within family‐centred
care in the acute paediatric setting: a discussion paper. Journal of advanced
nursing, 73(2), 361-374.
Dixon, K. J. (2017). Pathophysiology of traumatic brain injury. Physical Medicine and
Rehabilitation Clinics, 28(2), 215-225.
Ho, K., Shaul, R. Z., Chapman, L. A., & Ford-Jones, E. L. (2016). Standard of Care in
Pediatrics: Integrating Family-Centred Care and Social Determinants of
Health. Healthcare quarterly (Toronto, Ont.), 19(1), 55-60.
McGinn, M. J., & Povlishock, J. T. (2016). Pathophysiology of traumatic brain
injury. Neurosurgery Clinics, 27(4), 397-407.
Mortensen, J., Simonsen, B. O., Eriksen, S. B., Skovby, P., Dall, R., & Elklit, A. (2015). Family‐
centred care and traumatic symptoms in parents of children admitted to
PICU. Scandinavian journal of caring sciences, 29(3), 495-500.
Oddo, M., Crippa, I. A., Mehta, S., Menon, D., Payen, J. F., Taccone, F. S., & Citerio, G. (2016).
Optimizing sedation in patients with acute brain injury. Critical Care, 20(1), 128.
Pearn, M. L., Niesman, I. R., Egawa, J., Sawada, A., Almenar-Queralt, A., Shah, S. B., ... &
Head, B. P. (2017). Pathophysiology associated with traumatic brain injury: current
treatments and potential novel therapeutics. Cellular and molecular neurobiology, 37(4),
571-585.

RHYS’ CLINICAL SCENARIO 12
Qureshi, A. I., Palesch, Y. Y., Barsan, W. G., Hanley, D. F., Hsu, C. Y., Martin, R. L., ... &
Toyoda, K. (2016). Intensive blood-pressure lowering in patients with acute cerebral
hemorrhage. New England Journal of Medicine, 375(11), 1033-1043.
Swaiman, K. F., Ashwal, S., Ferriero, D. M., Schor, N. F., Finkel, R. S., Gropman, A. L., ... &
Shevell, M. I. (2018). Preface to the Sixth Edition. In Swaiman's Pediatric Neurology
(Sixth Edition) (p. xii).
Tanriverdi, F., Schneider, H. J., Aimaretti, G., Masel, B. E., Casanueva, F. F., & Kelestimur, F.
(2015). Pituitary dysfunction after traumatic brain injury: a clinical and
pathophysiological approach. Endocrine reviews, 36(3), 305-342.
Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N., & Murray, G. (2014). The
Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology, 13(8),
844-854.
The Royal Children’s Hospital Melbourne, (n.d). Patients and Families. Family Centered Health
Care. Available Online At: https://www.rch.org.au/search/?addsearch=family
%20centered%20care/ Retrieved On 18 August 2018
Young, A. M., Guilfoyle, M. R., Donnelly, J., Scoffings, D., Fernandes, H., Garnett, M., ... &
Hutchinson, P. J. (2017). Correlating optic nerve sheath diameter with opening
intracranial pressure in pediatric traumatic brain injury. Pediatric research, 81(3), 443.