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James “Jimmy” Parsons is a 26 year old flight engineer who was admitted postoperatively to the High Dependency Unit approximately 46 hours ago. He was out with friends on Saturday night when he was involved in an altercation out the front of
a bar with another group of males who had been making lude remarks about female acquaintances of Mr Parsons. During this altercation, it is alleged that one of the individuals punched Mr Parsons in the face, and as a result he lost consciousness,
fell, and hit the back of his head on the pavement.


On arrival to the Emergency Department he underwent an urgent CT brain scan which revealed a sub-dural hemorrhage with 1cm mid-line shift and petechial hemorrhages, which was drained intra-operatively. A Codman’s intracranial pressure monitoring device was placed in order to monitor ICP levels post operatively. Mr Parson’s blood alcohol levels were noted to be elevated on
assessment at the ED and his blood toxicology screen was negative for illicit substances. Over the immediate post-operative period he has been deemed to be stable and he has been extubated approximately 6 hours ago and is currently on Hiflow Nasal Prongs (HFNP).

                                                               

Signs and Symptoms of TBI

Traumatic Brain Injury (TBI) results from a rapid, violent jolt on an individual’s head leading to the damage of brain cells (Thurman, 2016). The brain suffers bruises due to the collusion between the inner and outer layers of the skull. The causes of the injury include physical aggression, road accidents, sports injuries, and falls. In the case study, Mr. James Parsons is involved in a fight where the opponent punches him on the face. The physical aggression makes Parsons lose consciousness, fall thereby hitting the back of his head on the pavements. This essay will discuss two signs and symptoms of TBI. Additionally, the paper will identify one priority area and discuss three nursing interventions towards the condition. The write-up will then review the assessment results and evaluate the suitability of the responses. Proper interventional strategies assist in managing TBI.

Unconsciousness is a significant symptom of severe TBI in patients.  The medical imaging results paint a picture of a patient that is unaware of the activities within his surroundings. Unconsciousness occurs due to the damage of brain cells which leads to the disruption in the synthesis of ATP (Marshall et al., 2015). The destruction of brain tissues impairs the regulation of metabolism and CBF. The interruption in energy production leads to the onset of anaerobic respiration which produces insufficient energy to serve the cells of the body. Parsons has a history of diabetes which leads to excessive levels of blood sugar which reduces the amount of glucose available for energy production.

The dilation of pupils of an individual's eyes is another symptom of TBI. The assessment data indicates that the patient's pupils are equal and reactive to light and accommodating. The imaging also shows the evidence of raccoon eyes. The pupil dilation suggests that the patient suffered severe cranium injury (Epstein, Mitra, Cameron, Fitzgerald, & Rosenfeld, 2015). Additionally, the intracranial pressure due to hitting his head on the pavement is responsible for the reactive and accommodating pupils. A significant number of TBI patients experience dilation of both or either of the eye's pupils. Therefore, the symptom is useful in gauging the severity of the condition.

The data indicates that the patient’s respiration (RR) and heart rates (HR) have both increased after the accident. TBI causes an imbalance in the brain’s oxygen consumption and delivery. The mismatch in the cerebral oxygen intake and usage is due to hemodynamic and vascular mechanisms leading to hypoxia. Therefore, the body responds by increasing the RR and HR to correct the deficiency in the levels of brain oxygen.  The blood glucose is 12.4 mmol/Lit which is higher than the normal range of 4 to 5.3 mmol/Lit (Siu, 2015). Brain injury interferes with the hypothalamus which instructs the pancreas to produce insulin for glucose metabolism. Therefore, the inability of the brain to trigger the conversion of blood sugar into energy leads to high glucose levels. The patient’s data also indicate an increase in the amounts of Ca2+ in the arterial blood. The increase is due to oxidative stress and excitotoxicity due to TBI (Hall, Singh, & Cebak, 2018).

Assessment Data

The priority area that requires urgent and relevant nursing intervention is the brain hemorrhage. Appropriate medications, surgical operations, and rehabilitation can assist in correcting the TBI and induce healing.

Proper medications are the primary remedy for reducing the bleeding that Mr. James experienced due to the TBI. The intense pressure on the brain after falling on the pavement caused bleeding in his brain. The nurse attending to Parsons should administer diuretics to decrease the pressure in the patient's brain (Eli, Joyce, & Hawryluk, 2018). Diuretics also lower the level of tissue fluids and enhance the increase in the amounts of urine output.

Hemorrhage also leads to seizers after a week from the injury. The caregivers should prescribe anti-seizers drugs to avoid further brain damage (Sundararajan, Milne, Edwards, Chapman, & Shakib, 2015). The blood transports oxygen to the brain cells to aid in the synthesis of energy. Therefore, brain bleeding interferes with the oxygen supply to the brain. The caregivers should administer coma-inducing drugs to the patients; since a comatose brain requires little amounts of oxygen to operate. Apart from the diuretics, anti-seizer, and coma-inducing drugs, painkiller are also useful in managing brain injury. The pain relievers lower the pain due to intracranial pressure and bleeding. Therefore, appropriate drugs help to manage hemorrhage due to TBI.

Surgical operations are also useful in the management of the effects of the brain hemorrhage. Operative procedures are helpful in the removal of clotted blood after bleeding (Mendelow et al., 2015). External or internal brain bleeding leads to the development of hematoma that increases pressure on the brain cells. The clotted blood causes damage to brain tissues if the caregivers do not get rid of it. Therefore, the surgical procedures remove the clotted blood. TBI damages the skull leading to bleeding in the brain. An operation can remove the damaged section of the head and also repair the fractures.

Operative procedures can also stop the bleeding after brain injury. Mr. James suffered a head injury that caused bleeding of the skull. Efficient surgical procedures repair the cranium and end the hemorrhage (Kolias et al., 2016). Surgeons can also construct an opening in the head to reduce the pressure in the brain. The caregivers can use the opening to drain the accumulated fluid after bleeding. Furthermore, the opening creates room for the inflammation of the injured section. Healthcare professionals should operate after the accident to minimize the effects of bleeding and pressure in the brain. Therefore, surgery is an alternative for medication in managing brain hemorrhage.

The effects of TBI limit the ability of the patient to talk or to move from one place to the other. The hemorrhage dehydrates the brain; thus interfering with the production of ATP. Therefore, the patient finds difficulties in conducting daily activities. Therefore, rehabilitation specialists have a role to play in the recovery of Mr. James. The first rehabilitation officer is the physiatrist who monitors the entire process of rehabilitation. The specialist prescribes related drugs such as diuretics to manage brain bleeding (Tate et al., 2014). Occupational therapist assists patients to resume daily chores. Therefore, the specialist has the task of helping Parsons to continue his duties.

Priority Area

Hemorrhage also interferes with the segment of the brain that coordinates speech in healthy individuals. Therefore, a language and speech pathologist should assist the patient to regain his communication skills (Braaf et al., 2018). A nurse specializing in TBI should educate the patient’s family about the complication and the process of recovery. The patient also needs the services of a neuropsychologist to assess the cognitive functions. The specialist assists the patient to control the behavioral changes. The rehabilitation nurse plans the discharging process after adequate medical attention to the patient. Therefore, rehabilitation is a back-up for medication and surgery.

The first intervention is the administration of medications such as diuretics, anti-seizer, and coma-inducing drugs. The intake of the diuretic according to the doctor's prescription reduces the pressure due to TBI thereby reducing the extent of hemorrhage (Udy et al., 2017). Anti-seizer drugs minimize brain damage; thus decreasing bleeding. The coma-inducing medicines place the brain at rest and reduce the oxygen requirements.

The second line of intervention is through surgical operations. Surgery removes blood that clots after hemorrhage (Carney et al., 2017). The hematomas exert further pressure on the brain cells; hence the surgeons should remove it to reduce pain. Operative procedures also prevent hemorrhage directly thereby reducing hypoxia. Surgery also helps to repair cranium fractures; therefore decreasing external bleeding.

The third intervention is through rehabilitation sessions which help in the recovery of the affected individuals. The physiatrist ensures that the patient intakes the correct drugs such as diuretics to manage to bleed (Pretz et al., 2016). Rehabilitation processes are efficient as they help the patient to resume daily chores.

Conclusion:

The caregivers diagnose Parsons with TBI which resulted from the fight that made him hit the back of his head on the pavement. The signs and symptoms of the complication include unconsciousness and dilation of the eyes' pupils. Unconsciousness makes an individual unaware of the activities in the surrounding environment. The dilation of the pupils indicates that the patient suffered a severe brain injury. The assessment data indicates an elevation in the patient's blood glucose levels and the RR. The brain controls the levels of blood sugar level and the respiratory rates; hence an injury distorts its functions. The priority area for nursing interventions is the brain hemorrhage due to the TBI. The nursing interventions include medications, surgery, and rehabilitation. An efficient application of the remedies minimizes the bleeding and ensures recovery from the complication.

Reference:

Braaf, S., Ameratunga, S., Nunn, A., Christie, N., Teague, W., Judson, R., & Gabbe, B. J. (2018). Patient-identified information and communication needs in the context of significant trauma. BMC health services research, 18(1), 163.

Carney, N., Totten, A. M., O'reilly, C., Ullman, J. S., Hawryluk, G. W., Bell, M. J., ... & Rubiano, A. M. (2017). Guidelines for the management of severe traumatic brain injury. Neurosurgery, 80(1), 6-15.

Eli, I., Joyce, E., & Hawryluk, G. W. (2018). Use of Guidelines in the Management of Traumatic Brain Injury. In Controversies in Severe Traumatic Brain Injury Management (pp. 207-230). Springer, Cham.

Epstein, D. S., Mitra, B., Cameron, P. A., Fitzgerald, M., & Rosenfeld, J. V. (2015). Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: definition, incidence, and outcomes. British journal of neurosurgery, 29(1), 118-122.

Hall, E. D., Singh, I. N., & Cebak, J. E. (2018). Oxidative Damage Mechanisms in Traumatic Brain Injury and Antioxidant Neuroprotective Approaches. In Acute Neuronal Injury (pp. 39-61). Springer, Cham.

Kolias, A. G., Adams, H., Timofeev, I., Czosnyka, M., Corteen, E. A., Pickard, J. D., ... & Menon, D. K. (2016). Decompressive craniectomy following traumatic brain injury: developing the evidence base. British journal of neurosurgery, 30(2), 246-250.

Marshall, S., Bayley, M., McCullagh, S., Velikonja, D., Berrigan, L., Ouchterlony, D., & Weegar, K. (2015). Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Injury, 29(6), 688-700.

Mendelow, A. D., Gregson, B. A., Rowan, E. N., Francis, R., McColl, E., McNamee, P., ... & STITCH (Trauma) Investigators. (2015). Early surgery versus initial conservative treatment in patients with traumatic intracerebral hemorrhage (STITCH [Trauma]): the first randomized trial. Journal of Neurotrauma, 32(17), 1312-1323.

Pretz, C. R., Kean, J., Heinemann, A. W., Kozlowski, A. J., Bode, R. K., & Gebhardt, E. (2016). A multidimensional Rasch analysis of the Functional Independence Measure based on the national institute on disability, independent living, and rehabilitation research traumatic brain injury model systems national database. Journal of Neurotrauma, 33(14), 1358-1362.

Siu, A. L. (2015). Screening for abnormal blood glucose and type 2 diabetes mellitus: US Preventive Services Task Force recommendation statement. Annals of internal medicine, 163(11), 861-868.

Sundararajan, K., Milne, D., Edwards, S., Chapman, M. J., & Shakib, S. (2015). Anti-seizure prophylaxis in critically ill patients with traumatic brain injury in an intensive care unit. Anesthesia and intensive care, 43(5), 646.

Tate, R., Kennedy, M., Ponsford, J., Douglas, J., Velikonja, D., Bayley, M., & Stergiou-Kita, M. (2014). INCOG recommendations for management of cognition following traumatic brain injury, part III: executive function and self-awareness. The Journal of head trauma rehabilitation, 29(4), 338-352.

Thurman, D. J. (2016). The epidemiology of traumatic brain injury in children and youths: a review of research since 1990. Journal of child neurology, 31(1), 20-27.

Udy, A. A., Jarrett, P., Lassig-Smith, M., Stuart, J., Starr, T., Dunlop, R., ... & Bisht, K. (2017). Augmented renal clearance in traumatic brain injury: a single-center observational study of the atrial natriuretic peptide, cardiac output, and creatinine clearance. Journal of Neurotrauma, 34(1), 137-144.

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