PROGRESSING CASE STUDY #1/MUST BE HAND-WRITTEN with a pencil

TO BE TURNED IT AT TIME OF EXAM 1 DUE: 10/31/2020

A young male client was ejected from a moving vehicle, which was
traveling 70 mph. His injuries included a severe closed head
injury with an occipital hematoma, bilateral wrist fractures, and
a right pneumothorax. During his neurologic intensive care unit
(NICU). He was intubated and placed on mechanical ventilation,
had a feeding tube inserted and was placed on tube feedings, had
a Foley catheter placed, and a central venous catheter (CVC)
inserted. He developed pneumonia 1 week after admission.

1. Define the term primary head injury.

Primary head injury is also known as a “coup injury. ” It is an injury caused by direct impact and
the injury is sustained under the impact site. It can be caused by a direct hit to the head such as
hitting someone in the head with a hammer. A bullet to the head would also be considered a
primary injury as it would result in a direct penetration of the skull.

2. Define the term secondary head injury.

Secondary head injury is an injury as a result of the primary head injury complications. also
known as contrecoup injury. These injuries tend to be more severe. Initial symptoms are few
and then progress to more severe days to weeks later. They can occur hours, days and even
weeks later.

3. What is normal ICP, and why is increased ICP so clinically

important?

The normal range for ICP is 5-15 mm Hg. ICP is kept in balance by the Monro-Kellie doctrine;
which includes a critical balance of brain weight, blood, and CSF. If any one of these 3
components increase, the others must compensate by decreasing. This can result in an increase
of ICP. Elevated intracranial pressure is clinically significant because “it diminishes CPP,
increases risks of brain ischemia and infarction, and is associated with a poor prognosis” (Lewis,
et al, p. 1425-1427) and can leave an individual vulnerable to permanent brain injury, coma or
death if compensation and autoregulation fail.

4. Identify at least five signs and symptoms of increased ICP.

1. Change in level of consciousness (most sensitive and reliable)
a. may be dramatic (coma) or subtle (flat affect)
2. Change in vital signs
a. Change in body temperature may occur. As ICP increases, a normal response is a
rise in body temperature.
b. Depending on the location most affected respiratory and cardiovascular system.
Also decrease in LOC can affect patient’s respirations. When ICP becomes critical
Cushing’s triad occurs:
i. systolic HTN with widening pulse pressure
ii. Bradycardia with bounding pulse
iii. irregular respirations (Cheyne-Stokes)
3. Vision/Ocular/Pupil Changes
a. ipsilateral dilation from the pressure
b. Bilateral dilation ( ICP is dangerously high)
c. Double vision
d. sluggish to no response at all to light
e. Ocular motor paralysis
i. inability to move eye upward and adduct
f. ptosis of eyelid
4. Decrease in motor function
a. contralateral hemiparesis or hemiplegia
i. Maybe mild to moderate
ii. Temporary to permanent
b. decorticate (flexor) or decerebrate (extensor) posturing
i. ICP pressure is now lethal
5. Headache
a. either at night or in the morning

6. List four medication classifications that the NICU nurses

could use to decrease or control increased ICP and describe
the primary action of each.

a. Mannitol
i. MOA: decreases ICP by plasma expansion and has an osmotic effect;
plasma expansion reduces hematocrit and blood viscosity, which
increases CBF and cerebral O2 delivery. Fluid moves from the tissues into
the blood vessels
b. Lasix
 i. MOA: a potent loop diuretic that works to increase the excretion of Na+
and water by the kidneys by inhibiting their reabsorption from the
proximal and distal tubules, as well as the loop of Henle. It works directly
acts on the cells of the nephron and indirectly modifies the content of the
renal filtrate.
ii. It lowers ICP by decreasing production of CSF. Inhibition of CA results in a
drop in sodium ion transport across the choroidal epithelium. Reduction
of CSF production occurs within hours.
c. Vecuronium (Norcuron), cisatracurium besylate (Nimbex):
i. Nondepolarizing neuromuscular blocking agents: achieve complete
ventilatory control in the treatment of refractory intracranial
hypertension. (These agents paralyze muscles without blocking pain or
noxious stimuli, therefore they are used in combination with sedatives,
analgesics, or benzodiazepines (Lewis, p. 1436). 
d. Corticosteroids (As long as ICP increase is not a result of a TBI)
i. treats vasogenic edema surrounding tumors and abscesses. Stabilize the
cell membrane and inhibit the synthesis of prostaglandins. They also
improve neuronal function by improving CBF and restoring
autoregulation

6. List eight independent nursing measures and the rationale for the use of each that the
NICU nurses could use to decrease or control increased ICP.

1) Glasgow coma scale followed by neuro checks q hourly- q2hr until stable
a. GCS is a widely used scoring system for quantifying the level of consciousness
following traumatic brain injury. Also, can help determine if a patient needs to
be ventilated or intubated. Initial assessment should always be completely for a
baseline so frequent follow up assessment can be compared and measured and
provide crucial indications for interventions needed
2. Assess Vital sign
a. Frequent assessment of VS to compare to baseline and show potential clues for
worsening ICP such as Cushing’s Triad as it can lead to brain herniation.
3. Proper Head positioning and avoidance of neck flexion
 a. Keep HOB @ 30* to enhance respiratory exchange, facilitate drainage of
ICP/edema/CSF and improve cerebral perfusion
4. Suctioning
a. Suctioning can increase ICP and decrease CPP. If patient requires suctioning,
preoxygenate them before suctioning and again after with at least 100% O2.
Limit suctioning to no more than 10 seconds with max 2 passes.
5. Strict I&O:
a. Need to make sure the pt is regulating fluid appropriately especially if using an
osmotic diuretic. Decrease in U/O can cause fluid overload and increase/worsen
ICP.
6. Reduce/ Maintain metabolic demands:
a. Maintain pt’s temperature between 96.8-98.6. Shivering requires the brain to
use more energy and 02. Same for pain. This can increase ICP. Thereby maintain
body temp, o2 sat and adequate coverings and appropriate interventions for
pain can decrease metabolic demands and help decrease in ICP.
7. Turn patient q2 hrs slowly, and position them to avoid hip flexion
a. Turn the pt with slow, gentle movements. Rapid changes in position may
increase ICP.
b. Avoid extreme hip flexion which can raise intra-abdominal pressure which
increases ICP.
8. Frequent monitoring of ABG’s:
a. If patient is ventilated, respiratory ventilator support depends on Pa02 and
PaC02

7. What outcome criteria would you use to determine whether the

independent nursing measures you chose for Y.W. were
effective?

Initial assessment is key to planning proper interventions needed to minimize complications

from increased ICP. This will tell me if my patient needs mechanical ventilation, intubation,
or additional o2 as well as a baseline for further evals. Frequent assessments there after is
an appropriate and effective intervention in managing and preventing any additional
increase of ICP. Strict I/O’s was an important intervention especially if patient is on an
osmotic diuretic and can indicate if there are any issues with kidney perfusion. While the
patient did develop pneumonia one week after, the interventions I took were mainly aimed
 at preventing further ICP during a critical timeline as it could cause brain herniation if not
managed resulting in coma and death.

8. The client’s medication list includes clindamycin (Cleocin)

150 mg IV q6h, ranitidine (Zantac elixir) 150 mg per PEG
tube bid, and phenytoin (Dilantin) 100 mg per PEG tube tid.
Indicate the reason Y.W. is receiving each medication.

Phenytoin is an anti-seizure medication. Anti-seizure medications are usually given

prophylactically after a head injury or when ICP is suspected due to the increase risk of seizure.

Clindamycin is an antibiotic prescribed to treat respiratory infections.

Ranitidine is an antihistamine and antacid. Zantac is used to treat or prevent gastric ulcers.
Patients fed into the stomach via gastrostomy tube are at risk for GERD, especially those
confined to a bed.

9. The pharmacy supplies phenytoin (Dilantin) 125 mg per 5 mL.

How many milliliters will you administer to correctly
fulfill the order of 100 mg per dose?

4mL

10. You are preparing to administer the client the medications

through his PEG tube. To safely administer the medications, you
will perform which actions? (Select all that apply.)

a. Position the client in a side-lying position with the HOB

flat.

b. Temporarily stop the feeding while administering the

medications.

c. Flush the PEG tube with water after medication administration.

d. Hold the tube feeding for 2 hours after administering the

medication.

e. Place the medications into the feeding bag with his tube feed
formula.
f. Aspirate for gastric residual before administering the
medications.

11.A STAT portable chest x-ray (CXR) was ordered after the
client’s CVC was inserted. According to hospital protocol,
no one is permitted to infuse anything through the catheter
until the CXR has been read by the physician or
radiologist. What is the purpose of the CXR, and why isn't
fluid infused through the CVC until after the CXR is read?

After the insertion of a CVC, a CXR is needed to verify correct placement by a physician or
radiologist. Therefore, fluid is not infused until after CXR confirmed placement.

CASE STUDY PROGRESS

The client spent 2 months in acute care and is now on your

rehabilitation unit. He follows commands but tends to get
agitated with too much stimulation. His tracheostomy site is well
healed, and the pneumonia is finally resolving. He is receiving a
supplemental tube feeding and has some continued incontinence of
both bowel and bladder. The client has a supportive group of
friends who are students at the university; several of them are
also from Thailand. The client’s latest lab results are as
follows: Laboratory Test Results

Sodium 149 mmol/L Creatinine 1.2 mg/dL

Potassium 4.2 mmol/L Glucose 133 mg/dL

Chloride 119 mmol/L WBC 15,400/mm 3

Total CO 2 21 mmol/L Hgb 14.9 g/dL

BUN 12 mg/dL Hct 36.4%

Platelets 140,000/mm 3

12. What are your concern about the labs value and what actions
would you suggest correcting?

The increase NA, Cl, and decrease HCT is most likely a result of dehydration. Medications given
to prevent ICP such as mannitol can cause dehydration from the increase u/o. Giving fluids can
help correct this.

Hyperglycemia is a frequent complication of enteral and parenteral nutrition in hospitalized

patients. It can also occur from stress and infections. Monitoring for s/s as well monitoring
blood sugar after pneumonia resides can help us determine cause. We can also consult the
nutritionist about a different formula.

Increase WBC and low CO2 is most likely due to the pneumonia which could be causing him to
hyperventilate. Patient is receiving antibiotics to treat the pneumonia. I will montor 02 stat
since CO2 is low and determine if additional O2 is needed. If O2 stat is in normal range, once
the pneumonia fully resolves CO2 should increase. Will continue to monitor.

13. Are you surprised by The client’s agitated behavior? Explain

why.

Brain injuries can affect a person’s personality and increase emotional labile. Also given the
patients age and length of hospitalization, this loss of control may leave him with feelings of
anxiety, powerlessness, overdependence, helplessness and loss of independence. During
hospitalization, teens and young adults may lose the ability to decide even the most basic
aspects of their day such as when they eat, sleep or use the bathroom. They lose control over
their privacy and depending on the extent of reason for being in the hospital can even lose
control of bodily functions (i.e. incontinence) during a time in their lives when self-
consciousness is peaking.

14. Outline a general rehabilitation plan for the client, based

on the previous data.

First, I will need to be cognizant of the impact of any cultural differences.

Then I will need to identify which services Y.W. will need to help determine which care setting
will be most appropriate.
Rehab should be started as soon as patient is cleared with follow up and close monitoring of
teaching and adherence from professionals such as physical therapist, occupational therapist
and speech therapist.
Goals need to be realistic with patient input and maintained at consistent approach.
This can include more extensive teaching on PROM, AROM as well as having physical therapy
plan an exercise program to regain balance and muscle strength lost as either a complication to
the injury or impaired mobility from the extensive hospital stay.
Maximize cognitive function and make sure a tutor has been reserved to help Y.W. not fall
behind in school.
An inter-collaboration with O.T. to help Y.W. relearn activities of daily living;
Initiating or continuing toilet training q2h and increase teaching on ADL and independence.

15. His mother has just arrived in the United States and speaks
no English. What measures can be taken to facilitate
communication between medical personnel and the mother?

A confirmation in what language the mother speaks, and then I would put an urgent request for
an interpreter. No one other than the interpreter should not attempt to communicate patients
diagnosis and prognosis until the interpreter is present, this includes the patient himself.

16. The client’s mother will need a place to stay while in the
United States. What can you do to facilitate the initial contact
with the Thai community?

I would request a case manager come speak with the mother and interpreter to help determine
possible community resources and establish a safe environment while the mother is here.

17. What special instructions that should be included in the

discharge planning?

Patient needs constant teaching and there needs to be constant confirmation that patient
understands his injuries, risk, complications and how to monitor for any s/s/. as well as the
terms of rehabilitation.

Patient needs to be evaluated on what modifications he has made to his lifestyle post injury so
far.
If the patient needs any special devices to assist in rehabilitation and ADL’s (i. e. wheelchair,
cane, etc.,) a case manager should be contacted to help ensure patient receives these and
other needs needing to be met.

Importance of establishing a regular pattern of elimination at the same time every day or every
other day. Thirty minutes after meals, and when he has time to relax, help him to an upright
sitting position.

A diet with increased fluids, high fiber, increased roughage, and warm fluids might stimulate
the gastrocolic reflex. Stool softeners, fluids, exercise, or bulk agents are also used to keep the
bowels moving.

Emphasize importance of medication regimen such as the development of antibiotic resistant

bacteria if antibiotics are not followed through course dose.