Clinical Reasoning Cycle For Mild Traumatic Brain Injury Essay.

Katie McConnell is a 23 year old woman who has been admitted to your unit. She sustained a subdural haematoma 18 hours ago when she was hit by a slow moving car. She has been diagnosed with a mild traumatic brain injury, and has been transferred to the neurosurgical trauma unit to receive ongoing assessment and rehabilitation. The previous nurse hands over to you: HR 89, BP 142/78, Sp02 96%, RR 13. Glasgow Coma Score 14. Katie was also noted to have some difficulty with remembering recent information but can recall with some prompting. You introduce yourself to Katie and her partner and inquire about her past medical history. Katie says that she also has a painful ankle from years of basketball, but that she doesn’t really like to use painkillers. You will need to complete the admission assessment(s) for Katie.

Utilising elements of Levett-Jones (2013) Clinical Reasoning Cycle below, write an essay, incorporating the following the information.

1. Consider the person’s situation: Identify and discuss the key elements of the demographic data recorded in your chosen scenario: Is this a typical complaint for this age and/or gender?
2. Collect cues and information: Review handover information. Describe any additional information that you think is missing that may be relevant to this clinical presentation.
3. Process information: Interpret what you currently know about their presenting problem – how would you expect this person to present? What are the expected assessment findings for this person’s situation?
4. Identify problems/issues Describe what focused health assessment/s you think you would need to conduct and why Describe how your chosen person’s findings differ from someone NOT experiencing this condition
5. Detail the assessment Detail how you are going to undertake the health assessment – ensuring you describe the technique and person considerations.

Person’s situation

Clinical reasoning is used assess accurate condition of the patient. For effective application of clinical reasoning, nurse should be well versed with clinical judgment, effective problem solving approach, accurate decision making and capable of critical thinking. For the implementation of clinical reasoning nurse should collect cues and information, process the collected information, understand patient’s exact complication, plan, implement and execute nursing interventions and evaluate outcomes. Nurses should follow these steps in a sequential manner. Effective implementation of the clinical reasoning is directly correlated to the outcome of the patient. Hence, clinical reasoning is very important step in the nursing intervention. Inappropriate clinical reasoning leads to the inaccurate diagnosis and accordingly there would be provision of improper treatment to the patient. This can lead to the development of more complications in the patient and further deterioration of the patient. Exact diagnosis and appropriate treatment are important for providing holistic management to the patient. This can be achieved by implementing efficient clinical reasoning (Higgs, 2008). In Katie’s case also clinical reasoning is implemented for her assessment. Nurse illustrated exact condition of Katie, collected information from the performed tests and by asking questions, recognized her exact complication, planned and applied nursing interventions. In this essay, all the steps implemented for the clinical reasoning of Katie are discussed. For the implementation of clinical reasoning in case of Katie, nurse should be aware of the medical, social and psychological aspects of Katie.      

Katie is a 23 year old woman admitted to the hospital due to sustained haematoma. She developed haematoma because 18 hours ago she was hit by slow moving car. After the completion of nursing assessment, it was evident that she had mild traumatic brain injury. From the literature, it is evident that approximately half of the patients with traumatic brain injury develop haematoma. There is possibility of intracranial hemorrhage in persons with traumatic brain injury. Haematoma in patients with traumatic brain injury can be identified in the initial 4 – 5 hours after brain injury (Qureshi et al., 2015). There is less possibility of brain injury in persons of Katie’s age. Older people are more susceptible to the falls, hence, older people are more susceptible to brain injury. There can be speedy improvement in terms of neurological symptoms in case of people of Katie’s age as compared to the older people. Young people can exhibit improvement in neurological symptoms within 5 years or less (Plata et al., 2008).

Nurse should collect information about Katie form handover. In handover, it is mentioned that Katie’s heart rate is 89 beats per minute, respiratory rate is 13 breaths per minute and oxygen saturation (Sp02) is 96 %. Values for the heart rate, respiratory rate and oxygen saturation are in normal range. It is observed that her Glasgow Coma Score is 14. Form the Glasgow Coma Score, it is evident that she is suffering through mild coma. Her recorded blood pressure is 142/78 mmHg. Her systolic blood pressure is in the hypertensive range and diastolic blood pressure is in the normal range. Katie developed slight memory loss because she is forgetting current information and regaining it after some prompting. In her handover, some of the information about her condition is missing. There is no information about papillary size and reaction to light. This information is important because retina gets affected due to brain injury. There is no record of temperature of Katie because patients with brain injury are susceptible to pyrexia. In patients with traumatic brain injury, there are chances of increase in the intracranial pressure. However, there is no mention of her central venous pressure in her handover. There is no mention about haematology full blood count and coagulation screening in her handover. In patients with traumatic brain injury, there should be record of blood sugar level and urinary output using catheter. This information is missing from her handover. There is no information about the medications prescribed for initial therapy in case of Katie. Information about the medications in the initial therapy would have been useful in planning further intervention in Katie (Moppett, 2007). From her past history, it is evident that she was associated with ankle pain, however she refused to take painkillers. 

Collect cues and information

Katie’s heart rate, respiratory rate and oxygen saturation are in the normal range. Normal range of heart rate should be 70- 100 beats per minute, respiratory rate should be 12 – 20 breaths per minute and oxygen saturation level should be above 94 % for the person of Katie’s age. There is possibility that subdural haematoma can leads to hypertension. Katie also developed systolic hypertension. According to Glasgow Coma Score, values between 13 – 14 indicate mild coma. Katie’s coma score is in the range of mild coma. Literature indicates that, patients with brain injury can develop cardiovascular complications like bradycardia and hypertension. In case of Katie heart rate is normal, however she developed systolic hypertension. Patients with brain injury are prone to develop hypoxia. However, there is no development of hypoxia in case of Katie (Zink, 2001).

It is evident that, Katie developed memory loss. Hence, to get more insight of brain injury, computed tomography (CT) scan and magnetic resonance imaging (MRI) should be performed in Katie. Katie’s blood group should be identified because there may be requirement of surgical intervention for subdural haematoma. For surgical intervention, matched blood group should be identified from the other person. For bleeding diagnosis, thrombocytopenia should be performed in case of Katie. As there is possibility of hypoxia development in patients with traumatic brain injury, Katie should be supplied with supplemental oxygen. In patients with traumatic brain injury, there is possibility of increase in the intracranial pressure. Hence, central venous catheter should be provided to Katie. Fluids and drugs can also be supplied using this intracranial venous catheter. There are very less chances of hypertension development in persons of Katie’s age. Nevertheless, as a result of brain injury and haematoma, systolic hypertension developed in Katie (Blissitt, 2006)  

Persons without traumatic brain injury would not have symptoms exhibited by person with traumatic brain injury. There would not be memory loss and coma, in persons without traumatic brain injury. However, these symptoms are evident in Katie. Due to traumatic brain injury, Katie may have pyrexia and hypercarbia. Person without traumatic brain injury may not have pyrexia and hypercarbia. There would be requirement of blood loading and artificial oxygen supplementation for Katie. There would not be requirement of blood loading and artificial oxygen supplementation in a person without traumatic brain injury. Katie may develop paralysis and vision loss. There may be occurrence of proprioceptive dysfunction, facial paralysis and sensory processing disorder in case of Katie. Sensory processing disorder comprises of speech impairement, memory loss and cognitive impairment. There are less chances of development of proprioceptive dysfunction, facial paralysis, speech impairement, memory loss and cognitive impairment in as person without traumatic brain injury (Moppett, 2007; Ponsford et al., 2008).

Doctor and nurse should set goals for the outcome in case of Katie. Nurse should perform her physical assessment and measure vital signs on regular basis. Nurse should look for the normal level of blood pressure, respiratory rate and hypoxia in Katie. To achieve these levels nurse should provide holistic care to Katie. This care should comprise of administration of medication, diet plan, physical exercise and emotional support. Nurse should apply validated methods for the measurement of parameters in Katie. Blood pressure apparatus should be used for the measurement of blood pressure and arterial blood gas (ABG) test should be used for measurement of O2 and CO2 level in Katie. Nurse should assess oxygen saturation level prior to and after supplementation of artificial oxygen. Nurse should take help of psychologist to address speech impairment and cognitive impairment problems in Katie. Memory loss could be of different types. These different types of memory loss can be evaluated by utilizing different tasks. Nurse should give different tasks to Katie for assessing her memory loss (Schultheis and Whipple, 2014; Guy et al., 2014). Susceptibility to paralysis should be evaluated in Katie by recording the reaction time to external stimuli. Nurse should monitor urine output in Katie using catheter because cardiovascular complications can affect urine output. Central venous catheter should be used in Katie to measure intracranial pressure (Carone and Bush, 2012).                         

Conclusion:

Nurse should be well versed with biomedical and clinical sciences for implementing clinical reasoning for Katie. Nurse should be skillful in gathering clinical and medical data. Based on the collected information, nurse should interpret clinical data. This interpretation would be helpful for the nurse to take further action. Next step should be based on the known information and hypothesis based on the clinical data. Nurse should have knowledge of different aspects like history collection, physical examination, differential diagnosis, signs, symptoms and tests. In case Katie, information about her was collected. Persons of Katie’s age generally doesn’t face problem of traumatic brain injury. Heart rate, respiratory rate and oxygen saturation of Katie are normal. Her Glasgow Coma Score indicates mild coma. It is evident that she is experiencing memory loss. There should be requirement of tests to be performed for papillary size, pyrexia, central venous pressure, blood count and coagulation. These all parameters can be significantly changed in cases of traumatic brain injury. Nurse should use different tests and techniques like ABG and central venous catheter for further evaluation of Katie. Thus with the application of clinical reasoning complete assessment of Katie can be performed and holistic management can be provided.         

References:

Blissitt, P.A. (2006). Care of the critically ill patient with penetrating head injury. Critical Care Nursing Clinics of North America, 18(3), 321–32.

Carone, D., and Bush, S.S. (2012). Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering. Springer Publishing Company.

Guy, R., Furmanov, A., Itshayek, E., Shoshan, Y., and Singh, V. (2014). Assessment of a noninvasive cerebral oxygenation monitor in patients with severe traumatic brain injury. Journal of Neurosurgery, 120(4), 901–907.

Higgs, J. (2008). Clinical Reasoning in the Health Professions. Elsevier Health Sciences.

Moppett, I.K. (2007). Traumatic brain injury: Assessment, resuscitation and early management.  British Journal of Anaesthesiology, 99(1), 18–31.

Plata, C.M.,  Hart, T.,  Hammond, F.M.,  Frol, A., et al., (2008). Impact of Age on Long-term Recovery From Traumatic Brain Injury.  Archives of Physical Medicine and Rehabilitation, 89(5), 896–903.

Ponsford, J., Draper, K., and Schonberger, M. (2008). Functional outcome 10 years after traumatic brain injury: its relationship with demographic, injury severity, and cognitive and emotional status. Journal of the International Neuropsychological Society, 14(2), 233–242.

Qureshi, A.I., Malik, A. A., Adil, M.M., Defillo, A., Sherr, G., and Suri, K. (2015). Hematoma Enlargement Among Patients with Traumatic Brain Injury: Analysis of a Prospective Multicenter Clinical Trial. Journal of vascular and interventional neurology, 8(3), 42–49.

Schultheis, M. T., and Whipple, E. (2014).  Driving after traumatic brain injury: evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Reports, 2(3), 176–183.

Zink, B.J. (2001). Traumatic brain injury outcome: Concepts for emergency care. Annals of Emergency Medicine, 37(3), 318–32.