Mrs. Mary Waxman (31) is a computer system analyst and manages the Australian unit of the company. While returning from her business trip, she fell down from the escalator of Melbourne airport. This fall resulted in severe head injury, soft tissue injury in neck, laceration and grazes to her arms and legs and a deep wound in right leg.
This critical analysis of the case study will discuss the severe head injury she is going through. Due to this head injury, she is unconscious from last 48 hours. this case study discussion will discuss the admission history and the progression of the patient, analysis of three nursing care needed including diagnosis, expected outcomes, nursing interventions, rational and evaluation method. Her past medical complication, gestational diabetes mellitus and its relation to her recent accident is also going to be discussed. Finally, the effect of this head injury on Mrs. Waxman’s physical, emotional, cognitive and behavioral potential is going to be discussed.
After facing the dangerous accident on Melbourne airport, Mrs. Waxman has been taken to the intensive care department of the hospital. She spent 48 hours in the intensive care unit and then taken to the neurological department. She is unconscious from last two days and has nasogastric tube intravenous line and indwelling urinary catheter in situ in her body. She has several visible and invisible injuries on her body such as head injury, neck tissue injury, deep wound on leg and grazes and lacerations. However, no evidences of skull crack has been found through CT scan and X-ray reports.
Her breath rates are slightly high than normal (12 to 18 per minute) and her blood pressure is high as well. She is having moderately high body temperature with 38o C. her pupils are equal and are reacting to light, however she is unconscious and not responding to painful stimuli. She is diabetic and her blood glucose level is excessively high, which can hinder the healing process of her wounds. Dressing of her lacerations and grazes has been done. However, her wound on the right leg is still inflamed and oozing purulent discharge. Her catheters are draining properly that indicates proper functioning of her kidneys.
From this above nursing assessment, three nursing care needs has been chosen to address the client problem. These are –
The patient has been unconscious from last 48 hours and it is a matter of concern. There are several levels of unconsciousness such as stupor, delirium, automatism, semi coma and coma and so on that can affect the health of the patient adversely. The interventions that need to be applied here are maintaining patent airway by elevating the head by 30 degree to prevent aspiration (Lindner et al., 2013). Protection of such client is very important as they can fall from the bed. Hence, padded side rails should be present in her bed and the nurse need to talk to the patient in between the procedures to notice any sign of consciousness. Evaluation of the intervention should be done hourly by recording the pulse and breathing rates (Nolan et al., 2015).
Her right leg is still inflamed and purulent discharge has been observed. Nursing interventions for this problem management of its surrounding skin should be done to prevent further deterioration. Nurses should be aware of the dressing procedures for such unconscious patient and should focus on pain, dressing and healing aspects of the treatment. Her increased blood glucose level is a hindrance in the healing procedure (Tzeng et al., 2012). Therefore, first interventions to treat the elevated blood glucose level should be enforced to overcome the wound oozing problems and inflammation. However, proper dressing of the wound should be time at suitable time intervals. Evaluation of healing process of the wound can be done on daily basis (Ignatavicius& Workman, 2015).
Hyperglycemia or elevated blood glucose level can affect the patient adversely as her wounds can take longer time to heal. One of the prime reasons for her elevated result can be stress. As she is working in a multinational company and has a poor food habit, her blood glucose level is always high. Excess glucose in the blood causes increased thirst, hunger and polyuria (Inzucchi et al., 2012). Furthermore, another rationale can be head injury that leads the brain to use more glucose than normal and leading to hyperglycemic condition. Nursing intervention for such patient should include, proper care of her diet, as she is unable to eat food directly. She should also be provided with basal level of insulin to balance the glucose level. Evaluation of these interventions can be done by testing the blood samples after ingestion of insulin (American Diabetes Association, 2015).
Gestational Diabetes Mellitus (GDM) can be described as a condition a woman without diabetes develops. It includes glucose intolerance with high amount of blood sugar. The occurrence of gestational diabetes includes the risk of developing pre-eclampsia, depression and the probability of having a caesarean section (American Diabetes Association, 2014). The babies also have the risk of having low blood sugar, jaundice. These babies born to the mothers with gestational diabetes, has the risk of being large. If the condition is left untreated, the babies born to the mothers with gestational diabetes can be stillborn.
A study revealed that 8-10% of women in Australia are affected by GDM during their pregnancies. Most of the women who suffer from gestational diabetes have previously unrecognized diabetes mellitus. There are many risk factors, which causes GDM. These include a family history of diabetes mellitus, polycystic ovary, previous incidence of macrosomia and obesity (Koivusalo et al, 2016). GDM increases the risk of the mother to acquire diabetes mellitus in future. The HAPO study (Hyperglycemia and Adverse Pregnancy Outcome) investigated the fetal and maternal effect of gastrointestinal hyperglycemia and found a strong relation between GDM and birth weight. In means thjat maternal obesity increases the risk of worse fetal outcomes.
The women with DM and GDM should maintain a standard 75gm OGTT during the pregnancy period.
ADIPS and IADPSG criteria for the diagnosis of GDM:
Fasting: (≥5.1 mmol/L)
1 hour pre gestation: (≥10.0 mmol/L)
2 hour Pre Gestation: (≥8.5 mmol/L)
The doctors make the diagnosis of GDM based on these criteria. There is confusion about the pathology of GDM in Australia. Some pathology providers are using these criteria, which are the modified version of the previous criteria, and some of the general practitioners are using the old criteria (Ozougwu et al, 2013). About the management of GDM, a study of Australian Carbohydrate Intolerance in Pregnant Women found a result, which states that, the severe outcomes like death, bone fracture, shoulder dystocia and nerve palsy is reduced in women who receives treatment for GDM, than those with the untreated women. The blood glucose targets of fasting and after the commencement of meal of 1 and 2 hours should be –
Mrs. Waxman had also suffered from GDM during her last pregnancy, which was resolved after the birth of her baby. Mrs. Waxman works as a computer system analyst at a firm and manages the branch of the company. She is subjected to obesity as she works for long hours at the office and her food habits are bad as her consumption of food is mainly junk food. Because of this food habit and lack of exercise, she has gained 20 kgs in a span of 12 months. The relationship between diabetes mellitus, obesity and gestational diabetes mellitus has been proved. It is not stated in the case study that if Mrs. Waxman has the family history of diabetes mellitus or not. However, it can be stated that the occurrence of gestational diabetes increased the risk of her having diabetes mellitus in later life. With this, risk her food habit and lack of exercise also increased the risk of her suffering from DM in later life. After this accident, it was seen that her BGL is actually 25mmol/L, which is way much higher than the normal level of BGL which is 4-5m mmol/L.
There is some existing evidence, which states that the patients who suffer from major to moderate head injury may declines cognitively many years after the injury.
It is proved that, even a minor head injury can propel the occurrence of concussion and the normal brain function can be impaired temporarily (Romner, & Grände, 2013). The difficulties can lead to make the patient suffer from headache, fatigue, dizziness, irritability and memory problem. Mrs. Waxman has suffered from a major head injury and has spent the first 48 hours in intensive care unit. Her possibility of developing these symptoms is higher than normal (Carroll et al, 2014). ‘
The people who suffer from head injury can develop some emotional changes for later in life. If the injury affects their basic cognitive works such as the ability to speak, they become more difficult to handle. The people deal with a patient with head injury who is showing emotional changes must show patience and sensitivity to the patient as the emotional change might lead to the patient having severe mental illness. Sometimes brain injury can lead a person to change their natural personality.
Brain injury can affect the natural cognitive function of a person. It can change the whole process of the way of thinking, learning and remembering. Head injury can also give rise to memory loss in some person (Spitz et al., 2012). Mrs. Waxman is an intelligent person as she manages the Australian branch of her company. If the brain injury affects her cognitive function, it might become traumatic for her.
A brain injury can lead to a change of behavior in a person. If the head injury impairs the natural cognitive function of the patient, it might bring change in her behavior. The patient is currently working for a computer farm as a head. If she becomes impaired in some aspects, it might affect her natural behavior (Hou et al, 2012).
The patient Mrs. Waxman has three children and her husband is a writer who stays at home and usually watches the children, while Mrs. Waxman works for long hours. After she is discharged from the hospital, the children would feel happy; as she would spend, more time at home (Ponsford et al, 2014). However, in a long run, if she is subjected to any cognitive, physical and behavioral change, it might affect her relationship with her husband and children.
The report is about Mrs. Waxman, who is suffering from major head injury and other injuries like neck injury and edema. The report discussed some major details about her injuries and the nursing care needs. The patient has also suffered from GDM. The report discusses its relation with the current condition of high BGL level of the patient. The report also analyses the possible outcomes that can result from the head injury of the patient.
American Diabetes Association. (2014). Diagnosis and classification of diabetes mellitus. Diabetes care, 37(Supplement 1), S81-S90.
American Diabetes Association. (2015). 2. Classification and diagnosis of diabetes. Diabetes care, 38(Supplement 1), S8-S16.
Carroll, L. J., Cassidy, J. D., Cancelliere, C., Côté, P., Hincapié, C. A., Kristman, V. L., ... & Hartvigsen, J. (2014). Systematic review of the prognosis after mild traumatic brain injury in adults: cognitive, psychiatric, and mortality outcomes: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of physical medicine and rehabilitation, 95(3), S152-S173.
Hou, R., Moss-Morris, R., Peveler, R., Mogg, K., Bradley, B. P., & Belli, A. (2012). When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury. J Neurol Neurosurg Psychiatry, 83(2), 217-223.
Ignatavicius, D. D., & Workman, M. L. (2015). Medical-Surgical Nursing-E-Book: Patient-Centered Collaborative Care. Elsevier Health Sciences.
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., ...& Matthews, D. R. (2012). Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 55(6), 1577-1596.
Koivusalo, S. B., Rönö, K., Klemetti, M. M., Roine, R. P., Lindström, J., Erkkola, M., ... & Andersson, S. (2016). Gestational diabetes mellitus can be prevented by lifestyle intervention: The Finnish Gestational Diabetes Prevention Study (RADIEL). Diabetes Care, 39(1), 24-30.
Lindner, T. W., Langørgen, J., Sunde, K., Larsen, A. I., Kvaløy, J. T., Heltne, J. K., ... &Søreide, E. (2013). Factors predicting the use of therapeutic hypothermia and survival in unconscious out-of-hospital cardiac arrest patients admitted to the ICU. Critical care, 17(4), R147.
Nolan, J. P., Soar, J., Cariou, A., Cronberg, T., Moulaert, V. R., Deakin, C. D., ...&Sandroni, C. (2015). European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care. Intensive care medicine, 41(12), 2039-2056.
Ozougwu, J. C., Obimba, K. C., Belonwu, C. D., & Unakalamba, C. B. (2013). The pathogenesis and pathophysiology of type 1 and type 2 diabetes mellitus. Journal of Physiology and Pathophysiology, 4(4), 46-57.
Ponsford, J. L., Downing, M. G., Olver, J., Ponsford, M., Acher, R., Carty, M., & Spitz, G. (2014). Longitudinal follow-up of patients with traumatic brain injury: outcome at two, five, and ten years post-injury. Journal of Neurotrauma, 31(1), 64-77.
Romner, B., & Grände, P. O. (2013). Traumatic brain injury: Intracranial pressure monitoring in traumatic brain injury. Nature Reviews Neurology, 9(4), 185-186.
Spitz, G., Ponsford, J. L., Rudzki, D., & Maller, J. J. (2012). Association between cognitive performance and functional outcome following traumatic brain injury: A longitudinal multilevel examination. Neuropsychology, 26(5), 604.
Tzeng, H. M., Yin, C. Y., Anderson, A., & Prakash, A. (2012). Nursing staff’s awareness of keeping beds in the lowest position to prevent falls and fall injuries in an adult acute surgical inpatient care setting. Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses, 21(5), 271.
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