...Nursing Management of a Patient with Raised Intracranial Pressure after Traumatic Brain Injury and Dealing with Family Anxiety. Introduction The aim of this assignment is to explore, analyse and evaluate the nursing management of raised intracranial pressure (ICP) and family anxiety after head injury. In order to obtain a wider knowledge of the care of patients with raised ICP, a literature review was carried out. From this information I hope to improve the standard of care and ultimately patient outcome. The anxiety felt by family members are large and therefore I have decided to discuss this in my assignment. Consent has been sought from the next of kin. Confidentiality will be maintained in accordance with Nursing and Midwifery Council (NMC 2008). Patient’s Presentation Aldi is a 42 year old male who was found by police lying in the street, with loss of consciousness and believed to be assaulted. His eyes, lips and face was swollen. He was brought to the nearest hospital via ambulance as he had a seizure episode. In A&E it was noted that Aldi has sustained a head injury associated with a decrease level of consciousness and seizure activity. His pupils are both 2mm and reacting to light. His Glasgow Coma Scale (GCS) was 9-10. Opening eyes on pain, incomprehensible sound and moving all limbs. GCS is a worldwide recognized scale for documenting neurological assessment (Mavin,2008). After the initial presentation in A&E his neurological condition was rapidly...
Words: 1817 - Pages: 8
...Case Study Three 1. What is the definition of ARDS? Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. More fluid in your lungs means less oxygen can reach your bloodstream. This deprives your organs of the oxygen they need to function. Acute Respiratory Distress Syndrome (ARDS) is also known as shock lung, wet lung, post perfusion lung and a variety of other names related to specific causes. What are the associated clinical indicators? The first signs and symptoms of ARDS are feeling like you can't get enough air into your lungs, rapid breathing, and a low blood oxygen level. Other signs and symptoms depend on the cause of the ARDS. They may occur before ARDS develops. Sometimes, people who have ARDS develop signs and symptoms such as low blood pressure, confusion, and extreme tiredness. This may mean that the body's organs, such as the kidneys and heart, aren't getting enough oxygen-rich blood. 2. What conditions did this patient experience that are common risk factors ssociated with ARDS? Brain present with near drowniess syndrome that lead to his diagnosis of ARDS. 3. Describe the major pathophysiological alterations in ARDS. Increased capillary permeability is the hallmark of ARDS. Damage of the capillary endothelium and alveolar epithelium in correlation to impaired fluid remove from the alveolar space result in accumulation of protein-rich fluid inside the...
Words: 1795 - Pages: 8
...Ackowledgement First of all, I would like to praise ALLAH THE ALL MIGHTHY. His will, I will not be able to complete the assignment. I would like to express my gratitute to all who gave me the possibility to complete this assignment. I want to thank the Dean of Nursing Faculty, I for giving the support, encouragement towards compliting the assignment. I deeply indebted to my tutor who gave an idea and suggestion and encouragement, helped me at the time of writing the assignment. My colleagues from Nursing Faculty who supported me in my assignment work. I thank them for all their support, help, interest and valuable hints. Last but not least, I would like to thank my family especially my husband whose patient love enable me to complete this work. Table of Content | | |Page No. | |1. |Introduction |1 – 2 | |2. |Clinical Assessment |3 – 6 | |3. |Management Related To Head Injury |7 - 8 | |4. |Immediate Care And Management Of Patient ...
Words: 4409 - Pages: 18
...After reviewing the information that was gathered, I have come up with these two Nursing Diagnosis: 1. Impaired Gas Exchange r/t ventilation- perfusion imbalance AEB ( havent met pt. yet) Assess: assess oxygen saturation Outcome: the patient will demonstrate improved ventilation and adequate oxygenation with oxygen saturation monitoring during PCS. Intervention: the nurse will keep the patients head of bed elevated to forty five degrees at all times. Intervention: the nurse will administer oxygen via nasal cannula at four liters per minute to maintain oxygen saturation at ninty percent or higher. 2. Ineffective Peripheral Tissue Perfusion r/t hypertension AEB edema and left foot cool to touch Assess: assess the patient skin temperature to left foot Outcome: the patient will demonstrate adequate tissue perfusion by having skin temperature warm to to bilaterral feet during PCS. Intervention: the nurse will apply antiembolism stockings, as ordered, to patient when out of bed. Intervention: the nurse will keep the patient warm by applying a blanket. Narrative Notes after Implementation Phase Intake: 320ml, compliant with fluid restrictionbeyond what was allowed. Output: 360ml bright yellow urine. Alerted nurse on patient apical pulse, respirations, and weight, Mobility: Patient sitting in semi fowlers position in bed, head of bed to remain elevated at all times with patient. Student explained that she was to...
Words: 786 - Pages: 4
...Discussion This experiment was based on data that oxygenated perfusion of NHBD livers will promote cellular recovery from warm ischaemic injury. (Schon, 1994: S159-62) Without perfusion, cold storage exacerbates the injury by subjecting the organ to additional (cold) ischaemia; then, during surgical anastomosis in the recipient, another period of warm ischaemia. These consecutive ischaemic periods facilitate the progression of cellular injury to a state that is not compatible with recovery upon reperfusion. (Endoh, 1996: 110-15) It is therefore essential to restore cellular energy levels between retrieval and reimplantation for NHBD livers. Previous studies have shown that perfusion prior to harvesting of the NHBD liver can restore cellular energy levels before cold storage. Total body reperfusion with cardiopulmonary bypass (CPB) using autologous blood after 30 min without ventilation was shown to revive total adenosine 5' -triphosphate (ATP) content in porcine livers and kidneys", Conditioning the liver with 30 min of normothermic isolated perfusion in vivo, using whole blood, has been shown to increase mitochondrial ATP content after 10 min of circulatory arrest in the porcine model7. CPB for only 10 min after 30 min of arrest, at 37°C, provided functional recovery of the heart, liver and kidney in the canine models. In the porcine transplant model, CPB for systemic perfusion with cold, oxygenated Eurocollins solution restored tissue energy charge after 10 min ofarrest9....
Words: 3584 - Pages: 15
...(5marks) 4 Nursing Interventions and Rationale for Managing a patient with Acute Chest pain(6marks) 4 and Ineffective Tissue perfusion (6marks) 5 Acute chest Pain 오류! 책갈피가 정의되어 있지 않습니다. 1. PQRST questions to evaluate MI- intensity, location, radiation, duration, precipitation & alleviating factors, in order to accurately evaluate, treat and prevent further ischaemia. 오류! 책갈피가 정의되어 있지 않습니다. 2. Semi-Fowler’s position & O2 therapy 2L via Hudson Mask in order to increase oxygenation of myocardial tissue & prevent further ischaemia. 오류! 책갈피가 정의되어 있지 않습니다. 3. Administer medications- Morphin (normally 2.5-5mg) & anginine 600mcg (given every five minutes; maximum 3 tablets in order to relieve/prevent pain & ischemia to decrease anxiety & cardiac workload. 오류! 책갈피가 정의되어 있지 않습니다. 4. 12-lead ECG & monitor in order to check hypotension & bradycardia, which may lead to hypoperfusion. 오류! 책갈피가 정의되어 있지 않습니다. Ineffective tissue perfusion 오류! 책갈피가 정의되어 있지 않습니다. 1. Monitor vital signs (Hourly) and saturation oxygen to determine baseline and ongoing change. 오류! 책갈피가 정의되어 있지 않습니다. 2. Administer oxygen by Hudson’s mask (6-10L/min) and monitor the effectiveness to increase oxygenation of myocardial tissue and prevent further ischaemia. 오류! 책갈피가 정의되어 있지 않습니다. 3. Monitor respiratory status for sysptoms of heart failure to maintain appropriate levels of oxygenation & Observe for signs of pulmonary oedema. 오류! 책갈피가 정의되어 있지 않습니다. CORONARY ANGIOGRAM 5 Nursing responsibilities and rationale pre...
Words: 5365 - Pages: 22
...Fundamentals II Exam 3 Study Guide Chapter 41 – Fluid, Electrolyte, and Acid-Base Balance 1. Extracellular Fluid (ECF): Located OUTSIDE cells. Makes up about 1/3 total body H2O in adults. Two major divisions: Intravascular Fluid (plasma) and Interstitial Fluid (btw. cells and outside blood vessels. Minor division: Transcellular fluid – cerebrospinal, pleural, peritoneal and synovial fluids (all excreted by epithelial cells). Intracellular Fluid (ICF): Located INSIDE cells. Makes up about 2/3 total body H2O in adults. 2. ECV Deficit: BUN >25 mg/dl Insufficient isotonic fluid in the extracellular compartments. Output of isotonic fluid exceeds intake of sodium-containing fluid. Signs and Symptoms – sudden weight loss, postural hypotension, tachycardia, thready pulse, neck veins flat or collapsing with inhalation when supine, dry mucous membranes, poor skin turgor, restlessness, clammy skin, hypovolemic shock. ECV Excess: BUN <10 mg/dl Too much isotonic fluid in the extracellular compartments. Intake of sodium-containing isotonic fluid has exceeded fluid output. (When you eat too much salt and don’t drink enough H2O and you get bloated.) Signs and Symptoms – Sudden weight gain, edema, neck veins full when upright or semi upright, crackles in dependent portions of lung, pulmonary edema. 3. Isotonic: A fluid with the same concentration of nonpermeant particles as blood. Ex. - 0.9% sodium chloride, commonly called normal saline (NS)...
Words: 1878 - Pages: 8
...Definitions of systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and multiple organ dysfunction syndrome Systemic inflammatory response syndrome Two or more of the following clinical signs of systemic response to endothelial inflammation: • Temperature > 38°C or < 36°C x Heart rate > 90 beats/min • Tachypnoea (respiratory rate > 20 breaths/min or hyperventilation (Paco2 < 4.25 kPa)) • White blood cell count > 12 ⋅ 109/l or < 4 ⋅ 109/l or the presence of more than 10% immature neutrophils In the setting (or strong suspicion) of a known cause of endothelial inflammation such as: • Infection (bacteria, viruses, fungi, parasites, yeasts, or other organisms) • Pancreatitis x Ischaemia x Multiple trauma and tissue injury x Haemorrhagic shock x Immune mediated organ injury x Absence of any other known cause for such clinical abnormalities Sepsis Systemic response to infection manifested by two or more of the following: • Temperature > 38°C or < 36°C x Raised heart rate > 90/min • Tachypnoea (respiratory rate > 20 breaths/min or hyperventilation (Paco2 < 4.25 kPa)) • White blood cell count > 12 × 109/l or < 4 × 109/l or the presence of more than 10% immature neutrophils Septic shock Sepsis induced hypotension (systolic blood pressure < 90 mm Hg or a reduction of >40 mm Hg from baseline) despite adequate fluid resuscitation Multiple organ dysfunction syndrome Presence of altered organ...
Words: 1653 - Pages: 7
...Reflection 1: Plan of Care This reflection paper is compiled on the care of a patient that was admitted to Providence Holy Cross Medical Center with a diagnosis of a severe traumatic brain injury, pulmonary contusion, respiratory failure, and multiple fractures of the extremities. Due to the severity of the trauma, the patient was closely monitored in the ICU on 3/2/15. In this reflection paper, I will focus on the pathophysiology, signs and symptoms, treatments, interventions, and evaluations of care regarding the diagnosis of severe traumatic brain injury for the patient, JL, and compare and contrast the care to the textbook reading for similarities or differences. A traumatic brain injury can occur due to either a blow or jolt to the head, which causes the normal functioning of the brain to be disrupted causing a wide array of physical and cognitive problems. The patient, JL, arrived at the Emergency Department after a motorcycle accident where his motorcycle crashed with a truck, suffering extensive injuries and brain damage from a closed head injury. A closed head injury is the result of blunt trauma; the integrity of the skull is not violated and is more serious of the two types of injury, and the damage to brain tissue depends on the degree and mechanisms of injury, (Ignatavicius, 2013). This type of injury differs from an open head injury because the skull would have been compromised, exposing the brain to outside, environmental contaminants. On the medical record...
Words: 2403 - Pages: 10
...during labour revealed that normal values were approximately 58 ± 10%. Traditionally, oxygenation levels of newly born infants have been assessed clinically. However, O’Donnell et al3 showed that there is substantial inter-observer and intra-observer variability in assessments of colour. Assessing of colour is difficult and is a poor proxy for tissue oxygenation therefore experts have recommended the use of pulse oximeter to measure oxygenation in this...
Words: 755 - Pages: 4
...Intracranial Pressure (ICP): Overview: ❑ Intracranial pressure (ICP) is the hydrostatic force measured in the brain cerebrospinal fluid (CSF) compartment. Intracranial Pressure (ICP) is the combination of the pressure exerted by the brain tissue, blood, and cerebral spinal fluid (CSF). The modified Monro- kellie doctrine states that these three components must remain at a relatively constant volume within the closed skull structure. ❑ If the volume of any one of the three components increases within the cranial vault and the volume from another component is displaced, the total intracranial volume, and therefore, pressure, will not change. Factors that influence ICP under normal circumstances are changes in arterial pressure, venous pressure, intraabdominal and intrathoracic pressure, posture, temperatue and blood gases, particularly CO2. ❑ Normal ICP ranges from 0 to 15 mm Hg; a sustained pressure above the upper limit is considered abnormal. ICP can measured in the ventricles, subarachoid space, subdural space, epidural space or brain tissue using a pressure transducer. ❑ The purpose of Intracranial Pressure (ICP) monitoring is to trend the pressure inside the cranial vault. The pressure readings determine the interventions necessary to prevent secondary brain injury, which can lead to permanent brain damage and even death. ❑ If the intracranial pressure is in the range of 20 – 25 mmHg, therapeutic interventions, medical and/or surgical...
Words: 3951 - Pages: 16
...opening. To get a baseline of David's GCS score, LOC and understand his level of orientation to time, place and person, focusing on the strength of upper body limbs. It is also important to monitor the patient if at risk of deterioration, assessing pupil size and reactivity to assess high cranial nerve function. Impaired comfort - to manage pain and provide comfort, using a pain scale or completing a pain assessment post intervention, to be completed within the next hour. Impaired gas exchange - to maintain an optimal level of gas exchange, measuring and reassessing SpO2 saturations and completing a respiratory assessment, to be completed within 2-4 hours, depending on the patient. Risk of ineffective tissue perfusion - prevent and reduce risk of impaired tissue perfusion, monitor blood pressure and oxygen saturation, assess quality of pulse sites, measure Hgb levels. To be completed throughout patient stay. Risk of nutritional deficit - to prevent and reduce risk of malnutrition, measuring oral intake using a food chart, complete throughout patient stay. Provide pharmacological pain relief as prescribed - These medications work by inhibiting pain pathways, some of which block or reduce the synthesis of prostaglandins which stimulate nociceptors. By alleviating the patient's pain and reducing pain levels to a more manageable level, David can improve David's overall comfort, reducing David's pain perception and improving his ability to engage in ADLs. Eliminating stressors and...
Words: 999 - Pages: 4
...Questions Differentiate the following terms: Systemic Inflammatory Response Syndrome (SIRS): Is aggressive widespread inflammatory response to infection (sepsis) or perceived invader. Also, ischemia, infarction and injury. Sepsis: Is a systemic inflammatory response in the presence of a documented infection. Severe sepsis: Is sepsis complicated by organ dysfunction, is diagnosed in more than 750,000 patients per year and has mortality rates as high as 28%-50%. Septic shock: Is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. Multiple organ dysfunction syndrome (MODS): Is the failure of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention. Identify the nursing priorities in the care of the patient with sepsis and septic shock: Oxygenation -Provide supplemental O2 Intubation/mechanical ventilation, if necessary Monitor SvO2 or ScvO2 Circulation- Aggressive fluid resuscitation End points of fluid resuscitation: CVP 15 mm Hg Pawp 10-12 mm Hg Drug Therapies- Antibiotics as ordered Vasopressors (dopamine) Inotropes (dobutamine) Anticoagulants (low molecular –weight heparin) Drotrecogin alfa (xigris) for patients with high risk death Supportive Therapies- Obtain cultures (blood, wound ) before beginning antibiotics Monitor temperature Control blood glucose Stress ulcer prophylaxis What class of bacteria...
Words: 602 - Pages: 3
...admitted one of the nurses asked my nurse if my nurse would be alright with having her as a patient instead. She told my nurse that she had already assigned her to my nurse room, but she just wanted to make sure my nurse didn’t have to much work already. o Health assessment: I saw an FHR assessment test done today routinely. I also received my patient’s vital signs as well. o Elimination: My nurse gave my patients Colace to help with eliminations and she did an in and out cath with one patient. She also assisted another patient to the bathroom. o Safety: I saw all the beds low and locked and all patients were assisted with getting out of bed. o Perfusion: The nurse had me to get my patients blood pressure and HR. The nurse also monitored the FHR and the mother’s contractions determine the infant perfusion. o Oxygenation: The nurse often checked the O2 sat of her patients. Especially the patient that was having tingling and numbness in her right arm. o Growth and development: On the ultrasound the ultrasound tech was assessing the twin infants to determine if the fetuses were growing and developing the way that they should. Such as two eyes, two kidneys, the spine, femur, etc. o Infection control: Hand sanitizers were everywhere in the hallway. My nurse washed her hands after certain exams. However, she was also sure to use hand sanitizer upon entering and leaving all patients rooms. a. My expectations for today was to learn something new. Yes, this expectation was...
Words: 673 - Pages: 3
...Critical Care Case Study Crystal Meyer Mohave Community College Nursing 222 Mrs. Michelle Christensen April 1, 2014 Critical Care Case Study ADMISSION TC is a 61-year-old English speaking Caucasian female born on April 29, 1952. She weighs 99.7 Kg and is 5 feet, 5 inches in height with a BMI of 35.84. On March 5, 2014, TC was brought into the emergency department after her daughter-in-law called 911 when she found TC unresponsive at home in her bathroom. When paramedics arrived, she was found to be cool, pale, and diaphoretic with oxygen saturations in the high 70’s. Emergency responders placed a non-rebreather high flow oxygen mask and her oxygenation began to improve with saturations in the low 90’s. Upon arrival to the emergency department, TC’s vital signs were as follows: T 97.4; P 97; BP 120/95 mm Hg; RR 15 per minute; and O2 sats of 98% via NRB oxygen mask on 8L. A chest x-ray (CXR) revealed no abnormality and lungs were determined to be grossly clear. However, TC was checked for a pulmonary embolism via a pulmonary artery angiogram with IV contrast and found to have a large clot burden with a small saddle embolism. TC also complained of right ankle pain. An X-ray of her right ankle revealed a distal tib/fib fracture, which was presumed to be related to her fall during her hypoxic episode. With these findings, TC was admitted to the Intensive Care Unit of Kingman Regional Medical Center and placed on an NPO diet in preparation for placement of an inferior vena...
Words: 4071 - Pages: 17
