Comprehensive Nursing Case: TBI, Wound Care, and Diabetes Management

This nursing case study details the care plan for a 31-year-old Jewish woman, Mrs. Waxman, who suffered a traumatic brain injury, soft tissue injuries, lacerations, and a deep wound on her lower right leg. The case study outlines four priority nursing care needs: controlling high blood glucose levels through diet and physical activity, proper wound management with regular monitoring and dressing, weight reduction through diet and exercise, and pain management using analgesics and proper positioning. Interventions include monitoring vital signs, administering medications, promoting wound healing, and educating the patient on lifestyle modifications. The case study also touches upon gestational diabetes mellitus (GDM) and its implications during pregnancy, emphasizing the importance of managing insulin resistance to prevent complications.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Answer: a
Mrs Marry Waxman is a 31 year old Jewish woman who has suffered traumatic brain
injury along with injury in soft tissues at her neck, lacerations and grazes to her arms and
deep wound in lower right leg. She was brought unconscious to neurological ward after
spending 48 hours in Intensive Care Department (Subjective Data). Her GCS score is 9, body
temperature is 38.5-38.9 degree Celsius, pulse beat is 80 to 92 beats per minute, respiratory
rate is 18 to 20 beats and blood pressure is 180/120 mmHg (static) oxygen saturation is
97%SpO2 (objective). At present Mrs Waxman is at 6 hours intravenous antibiotics with
urinary output <30 ml/hours and redness is noted at sacrum and heels with high blood
glucose level along with purulent discharge from wound in lower right leg (Assessment).
Intravension include control of blood pressure, wound management and monitoring of vital
signs and blood pressure. Evaluation can be done through constant monitoring and revision
must be taken in blood pressure management.
Answer: b
First nursing care needs: Controlling High blood glucose level
Assessment Expected
outcomes
Interventions Rationale Evaluation
Mrs. Waxman has
high blood level
of glucose level
25mmole/L.
[Normal blood
glucose level <
6.9 mmole/L in
Reduction in
the blood
glucose level
Implementation of
diabetic diet plan
according to the
height, weight age
and gender under a
thorough supervision
of trained dietician.
According to American
Diabetes Association
(2014) following a
diabetic diet which is rich
in vegetables and fruits
and has restricted
consumption of
The evaluation of
the blood glucose
level will be done
through blood
test both before
an d after taking
food through

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non-fasting
condition
(American
Diabetes
Association,
2014)].
The diet will be
divided within small
meals after every
three hours with
restricted intake of
calorie (American
Diabetes Association,
2014)
carbohydrate and sugar
helps in reducing the
blood glucose level
glucometer
(American
Diabetes
Association,
2014)
Reduction in the
intake of snacks. This
intake of snacks will
be replaced with fruits
salads and green
salads (American
Diabetes Association,
2014).
Case study indicates that
Ms. Waxman feeds on
snacks most of the time.
Increase intake of snacks
increases the amount of
simple carbohydrate
within the body which
increases the blood
glucose level. The intake
of green salads in between
her diet will help to
reduce her cravings for
food and at the same time
will help to enrich her
body with nutrition along
with reduction in the
blood glucose level
(American Diabetes
Association, 2014)
Measurement of
the weekly body
weight and blood
glucose level
(American
Diabetes
Association,
2014)
Promotion of physical The analysis of the case Measurement of

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activity. The nature of
physical activity in
case of Mrs Wilson
will be mild to
moderate. The reason
behind this is, Mrs
Waxman has injury in
her head, neck and
arms and leg. So
rigorous physical
activity might be
harmful for Mrs
Wilson. Her main
activity session will
include walking,
gardening, and basic
hand leg movements.
This will help to
reduce her sedentary
tenure. The activity
will be designed in
such a way that Mrs
Wilson can conduct
or practice the same
during her office
hours (Sigal et al.,
2013)
study indicates that
increase in the overall
body mass index increases
the severity of developing
diabetes mellitus. Hence,
increase in the physical
activity will help to burn
the extra calorie and this
will help in the reduction
in body weight along with
decrease the blood
glucose level. This in turn
will help to reduce the
severity of the diabetes
mellitus. Increase in the
physical activity will help
reduce the marco and
microvascuar
complications of diabetes
(Sigal et al., 2013)
decrease in the
body weight
along with the
BMI index (Body
mass index)
(Sigal et al.,
2013)
Decrease in the rate of Increase in the intake of Monitoring of the

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alcohol consumption
and this can be done
through proper
education about the
harmful effects of
alcohol and its
relation to type 2
diabetes mellitus.
This education will
help to generate
awareness (Gepner et
al., 2015)
alcohol increases the
overall calorie intake of
the body and this in turn
increases the blood
glucose level along with
an increase in the
deposition of cholesterol
in the arteries (Gepner et
al., 2015)
level of blood
cholesterol
(Gepner et al.,
2015)
Priority 2: Proper management of the wound in the lower right leg
Assessment Expected
outcomes
Interventions Rationale Evaluation
The deep wound
present on her
lower right leg is
inflamed and is
oedematous and
oozing moderate
amount of
purulent
discharge. Proper
assessment of the
wound through
Decrease in the
purulent discharge
of the wound
along with
reduction in the
secretion of
oedematous
exudates from the
wound and
thereby promoting
fast wound
Proper monitoring
of the site of the
wound for
accessing tissue
injury
Regular
monitoring will
help in study the
level or the status
of wound healing
and this fall under
documentation
process
Proper monitoring
of the wound in
order to detect
wound healing
(Lewis et al.,
2016)
Regular dressing
along with the use
of proper
Regular changing
of dressing will
help to prevent

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evaluation of
exudates coming
out from the
wound and
detection of
infection at the
site of wound
(Lewis et al.,
2016)
healing (Lewis et
al., 2016)
antibiotics and
ointments (Lewis
et al., 2016)
the formation of
sepsis and use of
antiseptic
ointments and
antibiotics will
help to reduce
bacterial infection
(Lewis et al.,
2016)
Maintenance of
proper hand
hygiene while
wound dressing
(Preece, 2016)
This will help to
prevent the
chances of cross-
infection at the
wound site. This
will help to
maintain aseptic
condition in
wound
management
(Preece, 2016)
Proper cleaning of
the wound and
avoidance of
alkaline soap
while cleaning the
wound (Holmes et
al., 2013)
Cleaning of the
wound helps in
the maintenance
of aseptic
condition and use
of alkaline free
soap will help to
maintain the pH

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balance of the
wound (Holmes et
al., 2013)
Priority 3: Reduction of weight
Assessment Expected
outcomes
Interventions Rationale Evaluation
Mrs. Waxman has
gained weight due
to her sedentary
life style and long
working hours,
where she has to
survive mostly on
snacks and the
strong caffeinated
drinks
Reduction of
the weight as
per the age
Chalking out a proper
meal plan for Mrs.
Waxman.
A balanced diet is
necessary to provide the
body with vital nutrients
suitable for building and
maintaining the vital
tissues and the organs,
repairing of the damaged
tissues and controlling
weight (Johns et al.,
2013).
The evaluation of
the weight
control should be
done by a weekly
check-up of the
weight.
Reduction in the
intake of snacks and
strong caffeinated
drinks. This has to be
replaced by
proteinaceous and
calcium rich food, as
she had suffered from
a bone and a tissue
injury (Johns et al.,
High caffeinated drinks
especially those with
whipped cream and
caramel and other fancy
coffee packs has several
calories that can increase
the body weight (Johns et
al., 2013). Furthermore,
consumption of the snacks
causes an imbalance
Measurement of
the weekly body
weight

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2013). between the calories
consumed and the energy
expensed. The excess
calories and stored as fat
and might lead to obesity
and overweight (Kirk et
al., 2013)
One of the nursing
intervention is to
encourage Mrs.
Waxman to practice
mild exercises after
being discharged.
Physical activities are
one of the important
intervention for
managing weight.
Since, Mrs. Waxman
has suffered from a
head injury and soft
tissue injury, low to
moderate incidental
activities can be
suitable her. Exercises
like rhythmic
walking, mild yoga
can be helpful.
Physical exercise helps in
weight management,
reduces stress level, and
improves memory,
attention, endurance,
strength, balance,
flexibility and blood
pressure. It has also been
found that regular
physical activities
positively influences
cardiorespiratory fitness
and cognition.
Measurement of
decrease in the
body weight.
Encouraging Mrs. Consumption of alcohol Monitoring the

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Mary Waxman to
abstain from alcohol
is another important
nursing intervention
in the controlling of
the body weight.
regularly might lead to
weight gain and obesity.
A heavy drinker is likely
to be consuming extra
1000-3000 calories per
day that can lead to the
accumulation of fat in the
abdominal region (Shelton
& Knott, 2014). This is
due to the fact that the
body starts using up the
alcohol for the generation
of energy instead of the
fat and the carbohydrate
reserves of the body, thus
storing the excess fat.
Again people who
consume alcohol are less
likely to be engaged in
physical activities
(Traversy & Chaput,
2015).
weight and to
check the blood
reports to find if
any alcohol had
been consumed.
Priority 4: Pain management
Assessment Expected
outcomes
Interventions Rationale Evaluation
Mrs. Waxman has Management Head injury and soft The pain killers stops the A numeric pain

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suffered from a
head injury and
soft tissue injury
to her neck as she
slipped from the
top of an escalator
at the Melbourne
airport
of the pain tissue injury can be
painful and can
decrease the quality
of life of the patient.
Hence painkillers like
acetaminophen can be
given to provide relief
to the patient. Anti-
inflammatory agents,
paracetamol can be
used to manage pain.
For severe pain
opiates and
morphinomimetics
can be given.
secretion of the
prostaglandin that helps in
the reduction of the pain.
Morphine have similar
effects on the cerebral
opioid receptors and
reduces the secretion of
prostaglandin thus
reducing the pain.
rating scale can
be used for
measuring the
intensity of pain
in the patient.
Facial grimacing
or other non-
verbal
expressions can
also be used in
measuring any
increase or
decrease of the
pain.
Ensuring bed rest in
proper positions. Mrs.
Waxman should be
instructed to avoid
positioning of the
head in an extended
or a hyper flexed
position (Cohen,
2015, February).
Prolonged bed rest is
without any scientific
merit, but it helps to
support immobilisation
with the deleterious effect
on the bones and the
tissues (Cohen, 2015,
February).
The patient will
be able to report
less pain which
can be recorded
by a pain rating
scale.
Methods of
immobilisation had
been used for
thousands of years for
A bracing helps to provide
support to the neck and
the back of a person with
injury. It protects the
Feedback can be
taken from the
patient to
understand the

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treating injuries to the
human body
(Sommerfeldt et al.,
2015). Hence in acute
pain in neck and head
injury, bracing can
give relief to pain.
acute soft tissue injury
and alleviate pain by
providing time for healing
(Sommerfeldt et al.,
2015).
severity of the
pain that the
patient is
experiencing.
Faces scale can
be used, where
corresponding
faces depicting
various levels of
pain can be used
by the patient to
inform her
choice.
Ensuring a correct
posture might help to
relive pain in patients
with head injury and
soft tissue injury of
the neck. A nurse
might consult with a
physiotherapist and
the patient can be
encouraged to take
the slump position by
protruding the head
forward, head flexion,
rounding of the
shoulders and
Mild exercises and
suitable neck retractions
can significantly provide
relief to pain. Gait
exercises ad stretching
would facilitate proper
blood flow and relive
pain.
Patients will
report less pain or
fMRI brain
scanning might
be used to
measure pain and
helps in
correlating with
the self-reported
pain

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reversed lumber
lordosis at the time of
sitting. Some of the
range of motion
exercises that helps to
relive pain are
flexion, side bending
and rotation.
Answer: c (i)
Gestational Diabetes Mellitus
According to Alfadhli (2015) pregnancy results in the development of insulin
resistance and increases the predisposition of diabetes mellitus in women which is
characterised by gestational diabetes mellitus (GDM). GDM is manifested when the function
of the pancreas of pregnant women fails to overcome the diabetogenic environment which is
a common scenario during pregnancy (Alfadhli, 2015). GDM can also define a condition of
glucose intolerance during gestational period of women who have previous reported cases of
Type 2 Diabetes Mellitus (T2DM) (Spaight et al., 2014). The alteration of the growth
hormone along with increase in the secretion of lactogen by human placenta hampers the
breakdown of blood glucose, increase in lipolysis, and disruption in the equilibrium of insulin
secretion from the pancreatic beta cells along with decrease in the glucose uptake. These
pathological changes during pregnancy increase the vulnerability of developing GDM. Other

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risk factors which increases the risk of developing GDM include obesity, polycystic ovary
and pregnancy related hypertension (Spaight et al., 2014). The sedentary lifestyle of Mrs
Waxman and active corporate socialization has increased her vulnerability of developing
T2DM and this has further increased the severity of developing GDM. Development of
diabetes mellitus might have increased her tendency of rapid weight gain (20 kg in the past
12 months) along with increase in the blood glucose level [Normal blood glucose level
should be less than 6.9 mmole/L in non-fasting condition] (Spaight et al., 2014).
Answer: c (ii)
Blood Pressure
Normal blood pressure of an adult human body is 120/80 mmHg. This is also known
as optimal blood pressure. 120 mmHg is systolic blood pressure and 80 mmHg is diastolic
blood pressure (Tzeng & Ainslie, 2014). Blood pressure amounting to 180/120 is known as
malignant blood pressure. It is defined as extremely high blood pressure and develops rapidly
and cause organ damage. Malignant blood pressure thus must be treated with medical
emergency. Having previous reported cases of hypertension increases the chance of
developing malignant blood pressure moreover; missing medication dosage of hypertension
also increases the chance of developing malignant blood pressure (Tzeng & Ainslie, 2014).
Answer c (iii)
Physical
Following her accident in the business trip, where she slipped from an escalator in
Melbourne airport, Mrs. Waxman encountered major head injury along with damage in the
soft tissue around neck including lacerations and grazes in her arms. While she was
transferred to the neurological ward after 48 wards of intensive care department, she was

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unconscious and was not responding to the painful stimuli. Her GCS score was 10 and her
pupils was reacting to light (Andrews et al., 2015). According to Roozenbeek, Maas and
Menon (2013), the long term outcomes of head injury followed by operations and
unconsciousness after the completion of the operation can be serious. Roozenbeek, Maas and
Menon (2013) highlighted it may cause headaches, dizziness under the impact of minimal
stress or anxiety. Andrews et al. (2015) stated that head injury can also increase the sense of
fatigue along with severe memory problems. This can hamper the professional life of Mrs.
Waxman going forward as she has an active corporate life along with heavy-end
responsibilities which demands mental strain. Moreover, serious brain injury will also result
in the development of the neurological problems which might hampers the daily living
activities by causing difficulty in hand-eye co-ordination or other complex mental health
problems (Roozenbeek, Maas & Menon, 2013).
Emotional
Massive or severe brain injury can change the psychological balance of a person’s
life. In case of Mrs Waxman, the long-term outcome of brain injury includes mood swings
along with problem in controlling emotions (Bower & Cohen, 2014). Bower and Cohen
(2014) highlighted a person who has recovered from a fatal brain injury might have sudden or
frequent episodes of crying or laughter without any significant reasons underlying it. Bower
and Cohen (2014) argued that person who have experienced traumatic brain injury in the past
might develop emotional instability leading to imbalance in overall mental equilibrium. This
lack of emotional equilibrium results in inappropriate surfacing of emotions or opposite
emotions like crying in funny situations, stating serious under extremely funny moment or
remaining expressionless under certain emotional conflict or in some situation of stress or
tension. This problem in emotional expression further hampers quality of life and also creates
difficulty in leading a normal social life. Since, Mrs Waxman is an active corporate tycoon

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and her job responsibilities demand high end of socialization, her emotional imbalance can
hamper her overall quality of life. This might damage both her professional and personal life
(Bower & Cohen, 2014).
Cognitive
The main cognitive outcome after a traumatic brain injury might include difficulty in
maintaining attention or concentration over any particular topic or subject or conversation.
Traumatic brain injury also leads to the development of language and speech problems while
causing significant effect on the learning and memory. Thus Mrs Waxman might face
significant problem while entering into conversation with people and this might hamper her
career life (Coco, Lopez & Corrao, 2016).
Behavioural
The behavioural problems will be associated with the cognitive impairments like
sudden change in mood. Moreover, her physical injury in legs, might demand bed rest for
couple of months. This sedentary life will affect hamper the mental health state of Mrs
Waxman leading to depression, irritability and helplessness (Sampson et al., 2015).

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