NURS90092 Emergency Nursing

1. Develop a concept map OR written response that explains the pathophysiological processes underpinning Jack’s clinical presentation to the emergency department. (10 marks)

Jack has TBI and it is necessary that pediatric nurses understand the how to manage the injury before it progresses. The injury progression is classified as either primary or secondary injury. Both are contributing factors in the major pathways of dysfunction in TBI (Allen, 2016).

This pathophysiological state comes when there is linear and rotational forces to brain tissue during impact (Allen, 2016). Jack is likely to have had a primary brain injury immediately after head came into contact with the brick surface. Coup or contracoup contusions could have resulted from the linear forces during impact. Epidural and subdural hemorrhage are so common with children and it is likely that Jack suffered from one McKee & Daneshvar, 2015). Jack has a swollen right occiput that confirms possibilities of intracranial epidural hematoma (Finnie, 2016). The former is linked to fractures in the skull and the latter is associated with vein rapture. This can explain why jack’s swelling to right occiput. Rotational forces are also associated with concussions which result into loss of consciousness as it happens with Jack. . Loss of consciousness is associated with epidural or subdural hematoma in that blood accumulates between the skull and the Dura matter and beneath the Dura matter in the exterior part of the brain respectively leading to period of consciousness and lapses into unconsciousness. Cerebral contusions are also associated with trauma and this could also be a condition within Jack considering his laceration and swollen backside of the head (Allen, 2016).

Secondary injury is said to have occurred when there is an altered cerebral blood flow (Allen, 2016). During secondary injury, there is increased intracellular calcium that triggers nitric oxide synthetase (NO) causing cerebral edema (Tameem, & Krovvidi, 2013). Jack is suspected to have cerebral edema and that confirms secondary injury. The altered level of consciousness could be from a possible cerebral edema that could have resulted from injured blood vessel within the brain leaking and blocking the paths for absorption to force fluid into the brain tissues (Elling, et al., 2007; Jha 2003).

According to Mehta, Babu and Venugopal (2014), it is important to understand the mechanism of injury in order to perform the correct diagnostic evaluation for patients like Jack. The method of assessing damage that results from an accident helps in the determination of the severity of an accident. Sudden deceleration is a common term among mechanism of injury terms. MOI is differs from patient to patient.

Jack has a closed head injury. It has been established that sudden deceleration affect the young probably because of the weak tenacity of the bones. Being 8, Jacks bones and flesh are not strong enough to withstand the sudden deceleration on a static hard brick surface. A brick surface is not just a normal earth surface. The damage that result from a stone surface is more severe compared to an earth surface.

It is probable that Jack falls was from losing control probably because of speeding or confusion from his older siblings and friends. This means that he fell when at a considerable speed hence the serious injury to the brain. Jack fell like diving his head to the driveway’s brick surface hence the head injury without boney deformities in his limbs or other injuries. It is probable that Jack has diffuse axonal injury as he does not present normal state upon neurological examination. The disorder is normal in patients with TBI and GCS of less than 8. The insults of diffuse axonal injury are a disconnected and malfunctioned neuron interconnection affecting multiple areas of the brain functions (Mesfin & Dulebohn, 2018).

Increased intracranial pressure (ICP) is common in severe brain injury and it when it is raised above the optimum, it affects the cerebral blood flow (Prabhakar, Sandhu, Bhagat, Durga, & Chawla, 2014). This ultimately result into cerebral ischemia. Jack is hypertensive as his systolic pressure is way above the normal value. Mortality rate from TBI is proportional to the ICP (Moore, et al., 2015).

Consciousness is the state of being awake and awareness to the surrounding of one. An extent of brain dysfunction is indicated by LOC. ALOC condition is a life threatening situation even if itself not being a disease. The state of wakefulness is affected by the ascending reticular activating system (ARAS) (Ebmedicine, 2018). It is a symptom of multiple pathophysiological causes and one of them is head injury (Blyth, & Bazarian, 2010). The condition leads to neurological dysfunction whereby the cells in the nervous system, brain anatomy as well as neurotransmitter are all disrupted. Jack has seizures lasting for 2-3 minutes. Seizures are associated with ALOC and according to Elling, Smith and Pollak, (2007), LOC is diminished when in a seizure or post seizure. Jack’s ALOC is also from trauma. Trauma is an identified etiology for ALOC (Nelson, 2011). From GCS, Jack has a level 2 eye opening (to pain), level 2 verbal response (incomprehensible words) and level 4 motor response (withdraws/ pain). The total GCS is 8/15 meaning that Jack has a severe-moderate traumatic brain injury and hence the ALOC (Elling, et al., 2007). Jack is allocated ATS 2 because he can only wait for 10 minutes before intervention (his conscious state is fairly severe).

Seizure (convulsion) is a confirmation of TBI (Englander, Cifu & Diaz-Arrastia, 2014). Seizure is an abnormal electrical disturbance in the brain from a collision of one’s head with a surface and has some signs like peculiar movement of the body, eyes, arms, head, legs, unresponsiveness, drowsiness, and incomprehensible words which are manifested in Jack. During a seizure occurrence, the membrane potential of neurons is affected in a way that neurons become oversensitive and overactive from some stimuli or activated events (Bromfield, Cavazos, & Sirven, 2006). Seizures are either focal or generalized. Focal seizures are further categorized into simple and complex partial seizures. The former does not lead to LOC but the latter does. This confirms that Jack has a complex partial seizure (Study.com, 2018). Because of the seizure, jack is dizzy, confused and cannot understanding things easily (from GCS). Jacks convulsion falls under the category of early post-traumatic seizures Jack’s looks more serious as it is described as an epileptic seizure that lasts for 2-3 minutes. Epileptic seizures are more than one and happen for up to 30 minutes or more to mean they are more serious (Bersten & Soni, 2013; Englander, et al., 2014).

When the airways are obstructed, that becomes an emergency as Jack may be at a risk of brain damage and even death (Krishnamoorthy, Dagal & Austin, 2014). The first intervention is assessment for airway stability (Thim, Krarup, Grove, Rohde, & Løfgren, 2012). The accessory muscles as well as paradoxical chest movements should be checked for signs of obstruction. There is also the need to listen for the upper- airway noises as their manifestation indicate partial airway obstruction. Jack has vomitus in the mouth which conforms a soiled airway. This may lead into a tracheal blockage when the vomitus enter the trachea. The primary intervention against vomitus obstruction is by opening the airway using a chin lift and jaw thrust and suctioning taking caution not to overdo it to avoid ICP. It is also confirmed that depressed consciousness leads to airway blockage and therefore Jack should be monitored closely considering he has ALOC (Resuscitation Council, 2018). To prevent hypoxemia, Jack should be attended to immediately to avoid injury to the brain, kidneys, heart attack that could culminate into death. Jack has an oral-pharyngeal airway inserted to remove obstruction from vomitus. The cervical collar (neck brace) used is meant to support Jack’s cervical spine following TBI for airways (Kreinest et al., 2015) Special care is required to prevent damage to the cervical spine when the above mentioned airway maneuvers are performed. To manage the cervical spine, it is also advisable to have head blocks and in –line immobilization (Trauma Victoria., 2018)

Breathing

Jack’s respiration rate is at 28 bretahs per minute with an oxygen concentration of 96 % in room air. The normal respiration rate is 12-20 breaths per minute. Any value above 25 is considered to be high and that is a mark of morbidity that notifies the medical team that the condition of Jack may deteriorate further (Resuscitation Council, 2018). It is recommended that the nurse should check the depth of each breath and the pattern of respiration including the chance of chest expansion on both sides. Jack’s breath sounds should be assessed to detect noisy breathing that would imply obstruction of the airways. In case the nurses conclude that breathing is inadequate, the immediate intervention should be improving ventilation using bag masks or pocket masks. However, as at the moment, Jack’s SpO₂ of 96 % is at an optimum level and does not require high flow 100% oxygen administration. Other management practices include, assessing the chest for breath sounds, wheeze, stridor and reduced air entry (Trauma Victoria., 2018).

The presence of breathing problems like vomitus airways obstruction in the case of Jack, compromise his circulatory state. Jack’s heart rate is 125 beats per minute and regular. It is estimated that the normal heart beat for children between ages 7-9 have a heart rate of 70-110 beats per minute, that means the Jack’s heart rate is abnormal. He has a blood pressure of 138/62. The normal systolic pressure is 97-115 while normal diastolic pressure is 57-76. This means that Jack’s systolic pressure is abnormal. Jack also has a relatively warm and dry skin. Having a dry skin is an abnormality since a normal skin should be relatively warm and moist. Jack’s ALOC could be a contributing factor towards his poor cardiac output. Circulation for Jack maybe restored by chest precordial compression and impulsive gasping or alternative mechanical methods (Resuscitation Council, 2018). These practices help in restoring the alveolus ventilation during the initial 6 minutes of CPR. Oxygen is given when the SpO₂ is less than 94% but for Jack that cannot be an option as his SpO₂ is at 96%. It is advisable that an SBP of over 90mmHg is maintained to contain cerebral perfusion and avoid further injury to the brain. Jack’s external wounds should be contained via direct pressure application. Checking capillary refill time (ensure it is not more than 3 seconds) and pulse rate is important to prevent ICP (World Health Organization, 2013). Fluid therapy is recommended for restoration of normal blood pressure and volume.

Unconsciousness is one characteristics considered in this approach (Resuscitation Council, 2018). Nursing should therefore be in a lateral position for Jack who is unresponsive with an unchanged GCS of 8/15.  The pupil functioning for Jack is normal as the size of the pupil are the same with response to light (Hoffmann et al., 2011). The resuscitation priority against unconsciousness however is ensuring that ABCs are well monitored. Assessing and maintaining the blood sugar level is important to ensure that Jack’s LOC, if influenced metabolically, is controlled instantly.  Low blood sugar level is associated with unconsciousness but Jack’s glucose level in the blood is 5.6 mmol/L that means he does not need a glucose injection since he has an optimum glucose level.  It is recommended that the factors that would lead to an immediate death for an unconscious patient like airways obstruction, and breathing be dealt with without delay. A CT scan of the brain, facial bones and cervical spine is recommended for all patients of severe brain injury especially when the GCS is below nine like Jack’s.

This entails looking at the patient’s body full exposure for identification of further injuries (Resuscitation Council, 2018). A Focussed Assessment with Sonography for Trauma (FAST) scan is to done by appropriately trained personnel on the bedside to detect presence of intraperitoneal free fluid. A full body assessment for signs of internal hemorrhage is advisable as the fall could have resulted into these complications. There is no clinical history to look at however with Jack. In case the oral-pharyngeal fails, it is good to consider tracheal intubation. Intubation helps protect Jack’s airways to ensure that there is optimum ventilation and oxygenation as the medical team examine the patient for presence of further injuries. This is of particular importance considering that lack of efficient running of these process lead to sudden unexpected death. Following a TBI, raised body temperature is so common and that necessitates its assessment and moderation (Sacho & Childs, 2008).

Having a leader in the healthcare profession entails a conduct of effective and innocuous running of any medical practice and directing activities in the goal of ensuring better care (Al-Sawai, 2013). In the case of Jack, the lead nurse should direct the administration of all the ADCBE interventions and facilitating efficient communication between colleagues to ensure that Jack’s care is prioritized. The lead nurse also facilitates an efficient allocation of roles in the resuscitation and also in communicating missed events to the scribe nurse. Communication failure results to a lot of errors and it is the role of leader to set an example by introducing a discussion prior to the administration of any care. With good communication, there is team building and therefore better health outcomes.

3. Drawing on best available evidence, explain a mechanical ventilation strategy, and the associated specific nursing care considerations, in the management of Jack’s ventilation and oxygenation needs while he is undergoing resuscitation and treatment in the emergency department. (12 marks)

The manifestation of respiratory failure from difficulties in breathing require that mechanical ventilation be considered. Mechanical ventilation creates airflow by creating a pressure gradient (Chang, 2013). The causes for mechanical ventilation could be either ventilator or inefficient gas exchange (hepercapnic and hypoxic). The aims of mechanical ventilation are to relieve patients off the respiratory distress, decrease the work of breathing (high respiratory rate), improve the exchange of gases, reverse any condition of muscle fatigue, and avoiding complications among other reasons. (Alex, 2018) Mechanical ventilation is indicated for certain physiologic conditions including head trauma (Chang, 2013). Jack has a respiratory distress with an abnormal respiration rate of 28 breaths per minute. The condition is worse considering that Jack is unconscious witsuh a poor LOC of 8/15. He further experiences seizures and has drowsy symptoms. Lack of proper ventilation for Jack could lead to his death. That necessitate the application of the best mechanical ventilation strategies above the oral-pharyngeal sanctioning and tracheal intubation already done. It has been identified that airways resistance is increased by these clinical conditions of using intubations, thus a necessity for ventilation for Jack. Breathing is with difficulties and Jack has an increased breathing work because of airway resistance (Chang, 2013).

The first strategy involves positive pressure ventilation. This method is necessary in ensuring life support measure in the intensive care unit and even environments outside healthcare facilities. The strategy has physiologic effects that lead to the complex interaction with the lungs and associated organ systems. These physiologic effects could have positive and negative effects on Jack all together (Chang, 2013). Another strategy mode of mechanical ventilation for Jack is Synchronized Intermittent-Mandatory Ventilation (SIMV). In this method, Jack should be made to make a certain number of breaths. This method is advised as it has a minimum risk to hyperinflation and alkalosis (Carpio & Mora, 2017). Jack should be made to take synchronized mandatory breaths that coincide with spontaneous respirations. Assist-Control Ventilation (ACV) also called continuous mandatory ventilation (CMV) is also an option and it involves same volume of assist and control breaths (Claure, Bancalari, (2007). The greater the volume the more expiratory time is needed. Under this ventilator mode, the clinician sets tidal volume, back up rate, sensitivity as well as flow rate. The tidal volume should be monitored to prevent alveolar injury. Other considerations for monitoring are physical examination, respiratory rate, the static or dynamic compliance, auto PEEP, airway pressure waveform, work of breathing, rib-cage abdominal motion, peek inspiratory pressure, and gas exchange (Tobias, 2012).

In mechanical ventilation, artificial airways provide a significant link between the ventilator and the patient. There are two common artificial airways that can be used for Jack respiratory distressed condition. They include endotracheal tubes (to the trachea through the mouth) and tracheostomy tubes (Chang, 2013). Tracheotomy involves surgical procedures cutting through the trachea to create airways opening. This one should be avoided for Jake as it is complex procedure that comes with many complications including pain and discomfort. However, the tracheostomy tubes should be considered as the last resort in that they ventilate the patient more adequately and enhance better ventilation when secretions are involved (Chang, 2013).

Jack is a child. His management, therefore, should consider his susceptibility of the young and developing lung tissues to injury, congenital incongruities, disease procedures that are specific to the pediatric population, possible difficulties associated with small patients, among other risks (Gupta & Rosen, 2016). The airway security is a risky situation that allows for strict consideration of the tracheal tubes being used (Pierce, 2007). There tracheal tube (TT) used for Jack should be well assessed based on Jacks body size.

Most intubations for pediatric patients like Jack are meant to allow for proper oxygen circulation, clearing carbon dioxide, reducing the breathing work or all these clinical issues combined (Astna, 2017). Hypoxemia, should it occur, could be countered by raising the portion of the inspired oxygen, increasing the partial pressure of oxygen in the alveoli, optimization of the alveolar patency through employment manoeuvres including availing adequate PEEP in the maintenance of functional residual capacity (FRC). Taking ABGs for Jack is important in determining the acidity, pH and oxygen and carbon dioxide saturation from an artery. This test would be of great help in the determination of the functioning of Jack’s lungs as well as the efficiency of oxygen and carbon dioxide flow. Chest auscultation is also an important consideration in the detection of airway obstruction. The response of Jack’s pupil to light is also an important consideration in the determination of LOC. This should be coupled with a strict fluid measurement by using ICU charts to control secondary brain injury (van der Jagt, 2016). Suctioning should be considered against the vomitus obstruction.  Since sedation therapy has an impact on the effectiveness and duration of mechanical ventilation, it is good that it is optimized (Oddo et al., 2016). Another consideration is using cardiac output together with ICP to maintain adequate ICP and CPP and reducing complications that come along fluid therapy (Dash & Chavali, 2018; So & Yun, 2017). Monitoring of airway pressure (PIP and P _plat ) is another recommend practice in facilitation of ventilation (Kneyber et al., 2017)

When inspired oxygen is adjusted, Jack’s hemoglobin oxygen saturation maintains its safe position. However, the FIo₂ should be monitored to ensure that it does not go above the optimum level to cause atelectasis plus toxicity of oxygen. Ventilation for Jack can be optimized by perfusion matching and FRC which are accomplished through the adjustment of the mean airway pressure further enhanced by making changes to the PEEP and the manoeuvres of recruitment (Gupta & Rosen, 2016). High-frequency oscillatory ventilation has better working power by its ability to recruit and still maintain gas exchange units by use of higher mean airway pressure as compared to conventional ventilation. However, this can only be used as the last resort for Jack as there is no much literature to support its application in pediatric ventilation (Gupta & Rosen, 2016).

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