CRITICAL INCIDENT ANALYSIS

Reflection is an important aspect of nursing education therefore for this assignment an acute event that occurred during a practical placement will be selected, reflected upon and critically analysed. To do this effectively a reflective model will be used. The model selected was Marks-Maran and Rose (1997). Reflection and analysis of a critical incident is recognised as a valuable learning tool for nurses (Rich and Parker 2001). In doing so it allows the opportunity of adapting our way of practicing, thinking and developing self-awareness (Alphonse 2007). It also helps to gain a better understanding of an incident, therefore exploring whether the correct decisions were made or whether alterations should be made to future practice.
The scenario that will be used is one that was encountered while on practice placement. To protect the patient’s confidentiality in line with the Nursing and Midwifery Council’s (NMC) code of conduct a pseudonym of Mrs Smith will be used (NMC 2008).
Mrs Smith was admitted to hospital following a collapse at home. An emergency craniotomy and evacuation of a blood clot following a large Posterior Fossa Haemorrhage was performed. After the surgical procedure an external ventricular drain (EVD) was inserted. An EVD is a drain that is inserted through the skull into the area of the brain that encountered the haemorrhage, this allows any extra fluid and blood to be drained, and it also assists with maintaining the intracranial pressure (ICP) within the brain at a therapeutic level. An alternative that can be used is an intracranial skull bolt, although this does not enable drainage of fluid it does provide accurate ICP readings, however the EVD drain is considered the gold standard for measuring ICP (Rickert and Sinson 2003). It is important to identify at this time that the patient had no significant previous medical history including no previous history of hypertension.
Mrs Smith was admitted to the ward following surgery. Nursing staff were advised by the neurological surgeon of key points in the management of the patient. The patient’s mean arterial pressure (MAP) was to be maintained at between 80-90mmHg as this is important to maintain adequate cerebral perfusion pressure (Cree 2003). The patient had an arterial cannula in place to allow accurate continuous monitoring of the patients arterial blood pressure and MAP. Also regular arterial blood gases were to be obtained to ensure efficient oxygenation (check details and ref). The patient’s neurological status should also be assessed on a regular basis using the Glasgow coma scale (GSC). During the initial twenty four hours the patient was monitored closely and regular observations were taken and no immediate causes for concern were noted.
While checking the patient’s observation on day two it was identified that the blood pressure (BP) had increased dramatically to a systolic pressure of 202mmHg with a MAP of 139mmHg. After recording this on the patients chart it was noted that the patient’s BP had begun to rise over the previous two hours. Neurological status was reassessed at this stage and a reduction in the Glasgow Coma Scale (GCS) was documented. I informed the nurse who was looking after the patient of the increase of bp and reduction of gcs. The nurse immediately reviewed the patient and at this time a doctor was requested. No anti-hypertensive medications were currently prescribed; therefore the main objective of me and the staff nurse was to closely observe the patient until medical staff arrived.
This incident was one that I had not encountered previously and although chronic hypertension is a familiar condition, I had not cared for a patient who had an acute episode of hypertension while suffering from a brain injury. I was also not fully aware of the potential serious complications of hypertension in these patients. Therefore this incident encourages exploration of acute hypertension on a patient with a brain injury and the steps that can be taken to prevent or treat this. The definition of hypertension varies and the level of what the systolic pressure must be before it is classed as hypertension. Prabhu et al (2000) defines acute hypertension in brain injuries as a blood pressure greater than 160/90 mmHg lasting longer than five minutes (Prabhu et al 2000).
The aim of treating and caring for a patient with a head injury is to prevent further damage to the brain. To fully understand the management of a patient with a brain injury an understanding of the physiology of the brain and cerebral perfusion is required. Cerebral perfusion pressure (CPP) is the pressure at which the brain tissue is perfused. CPP is an important indicator on the adequacy of cerebral blood flow, it is calculated by measuring the difference between mean arterial pressure (MAP) and the intracranial pressure (ICP). Cerebral blood flow supplies the brain with adequate oxygen and substrates (Singhi and Tiwari 2009). Systemic hypertension can have a negative effect on tissue on tissue perfusion. If a MAP increases beyond normal physiologic parameters it can overstretch cerebral vasculature and disrupt the blood brain barrier and increase CBF which could result in cerebral oedema (Fryman and Murray 2007). It is also recorded that acute systemic hypertension is a risk factor for post craniotomy intracranial hematomas (Lukitto et al 2005). This claim is also supported by Singhi and Tiwari (2009) who also state that systemic hypertension may increase CBF and therefore risks post-operative intracranial haemorrhage.
When assessing a patient with a brain injury and evaluating the patient’s BP it is important to identify that the decision to treat a raised BP with a patient who has a brain injury needs to be considered on an individual basis. It is recognised that when deciding to treat acute hypertension after a brain injury an ideal BP and MAP must be considered and recorded. If the BP is lowered too significantly it can result in decreased tissue perfusion resulting in ischemia and hypoxia. It is recognised that a slightly elevated BP can assist in maintaining cerebral perfusion. Therefore it is important that an optimum systemic BP is documented and subsequently maintained (Shiozaki 2005).
Factors that also need to be considered when deciding to treat acute hypertension include the type of neurologic emergency, the level of hypertension, the patient’s BP history and the condition of the patient’s autoregulatory system. Also identified is that before a decision is made as whether to treat acute hypertension a pain assessment should be undertaken. Poorly controlled pain is recognised to significantly increase a patients’ BP (Pancioll 2008). Therefore treatment may not be required if appropriate analgesia is administered to the patient. In a patient who is unable to verbalise their pain, other factors need to be considered. Body language and physiological status need to be considered, such as an increased heart rate (Stanik-Hutt 2003).
When the decision is made to reduce BP there is a number of pharmalogical agents that can be prescribed to treat acute hypertension specifically in brain injury patients. On researching the recommended agents there are variations depending on author. Pancioll (2008) recommends labetalol, nicardipine and esmolol. Nimodipine is also recommended as it delays ischemic neurological deficits whilst also having a hypotensive effect (Pancioll 2008). Schubert (2007) supports the use of esmolol and labetalol whilst suggesting the use of sedatives such as propofol. This would work in not only sedating the patient but has been identified to reduce bp as a contra indication (Schubert 2007). Goma and Ali (2009) however, compare the hypotensive effect of esmolol and remifentanil and conclude that remifentanil should be recommended as a prophylaxis against acute hypertension (Goma and Ali 2009). Whilst the particular drug that is recommended varies among authors they do agree that ideally where possible the drug of choice should be prescribed in such a way that enables the nurse the ability to titrate the dose. This allows the nurse to use their own clinical judgement to meet the patients’ fluctuating demands and to meet the BP and MAP parameters set by medical staff. However Cree (2003) recognises that for this to be done effectively the nurse must clearly understand the aims of managing a brain injury patient and effectively communicate with medical staff. Also nurses need to identify changes in a patient’s condition and promptly take action (Cree 2003)
Within literature it is recognised that there are alternative nursing care interventions that nurses should be aware of when caring for a patient with a brain injury in an attempt to keep bp as low as possible. Patients should be kept hydrated and administered laxatives to prevent constipation. Straining at a stool increases intra-abdominal pressure which in turn can increase ICP and BP (Mcleod 2004). Also it is important that the head and neck remain in a straight alignment, the head of the bed should be lower than ninety degrees, ideally flat to thirty 30 degrees. Also it is recommended that tracheostomy and endotracheal tube holders should not be overly tight. By ensuring these interventions are implemented it can ensure that venous return is optimised (Lejeune and Howard-Fain 2002). When nursing a patient with a brain injury there is some disagreement within literature as to whether nursing interventions should be clustered together or spread out over a period of time (Osborne 2008). However, it is recognised that nursing interventions increase bp and it is agreed that a patient should be observed closely during these nursing interventions and what effect it is having on their BP and ICP assessed (Hickey 2002)
When observing a patient with a brain injury, methods are implemented to allow constant BP monitoring. Invasive arterial BP monitoring is regularly used when caring for a critical patient as it provides constant BP readings. However it must be recognised the potential weaknesses in using these monitors. McCann et al (2001) recognises that to obtain accurate readings patients should be in a supine position. Also depending on where the catheter is situated, radial or brachial, movement of the patients’ limbs can also affect readings (McCann et al 2001). Therefore this could present a significant risk to patients; most pointedly to patients who have a brain injury as if accurate readings are not made then this can result in delayed treatment and increased risk of complications. This introduces consideration as to whether manual or non-invasive BP readings should be taken to ensure that accurate readings are being recorded and hypertension is identified as soon as it develops
In conclusion this incident emphasised a number of important factors when nursing a patient with a brain injury. The importance of strict control of BP has been highlighted and the potential complications of not doing so discussed. The importance of communication between medical and nursing staff was highlighted. Nursing staff should be made fully aware of the aims of treatment, they should also be advised of an optimum BP and this should also be documented within the patient’s notes. This ensures that any significant change to the patient’s condition is recognised promptly. Evidence identifies that anti-hypertensive medication should be prescribed at first sign of a raise in BP and in a way that allows the nurse to use clinical judgement to adjust the dose to meet patient requirements. Doing this ensures that there is no delay in treating the acute hypertensive episode and therefore reduces the risk of a secondary brain injury. Also identified was the importance of nurses keeping themselves up to date with current research and the use of evidence as a means of caring for their patients. This would provide nurses caring for a patient with a brain injury with the knowledge of nursing interventions to assist in the patient’s care and when to implement them. Finally also identified was that despite the use of devices to continuously monitor BP nurses should be aware of the potential faults and be skilled in taking manual BP when necessary.

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