Answer for NRS 460 Case Study: John Doe – Emergency Department

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Directions: Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit this completed template to the assignment dropbox.

The purpose of this assignment is to evaluate and synthesize patient data to propose interventions for an individualized plan of care prioritizing health problems and health concerns.

PART I:Health History and Medical Information

Evaluate the health history and medical information for John Doe, presented below.

John Doe, a 35-year-old male, was riding his motorcycle under the influence and experienced a motor vehicle accident resulting in multiple fractures and a traumatic brain injury (TBI).

On scene, John Doe was alert but exhibiting restlessness and agitation with hands-on care. Enroute to the hospital, he displayed changes in level of consciousness (LOC), mood and behavior, nausea and vomiting (N/V), and dilated pupils. Upon arrival to the emergency department, John was unconscious with a Glasgow Coma Scale (GCS) score of 6, indicating a severe TBI. Prior to losing consciousness, he was exhibiting signs of extreme pain on the left side.

Objective Data -completed by ambulance personnel:

  1. 84/60 BP, HR 136, RR 28 irregular, SpO2 92%
  2. 5’11″height, 180 lbs. weight
  3. GCS Score: 6
    1. No response in eyes: 1
    2. No verbal response: 1
    3. Flexion withdrawal from pain: 4
  4. Change in LOC
  5. Possible fractures to left leg and left ribs
  6. Intubated in route to ED

Objective Data andLaboratory/Test Results -on arrival to the emergency department (initial results)

  1. Complete blood count (CBC) –
    1. White blood cells: 11.3
    2. Hemoglobin: 15.6
    3. Hematocrit: 41.5
    4. Platelets: 316,000
  2. Comprehensive Metabolic Panel (CMP) –
    1. Alanine Aminotransferase (ALT): 32 U/L
    2. Albumin: 4.8 g/dL
    3. Alkaline Phosphatase (ALP): 122 U/L
    4. Aspartate Aminotransferase (AST): 52 U/L
    5. Blood Urea Nitrogen (BUN): 16mg/dL
    6. Bilirubin: 1.4mg/dL
    7. Calcium: 9.8mg/dL
    8. Creatinine: 1.1mg/dL
    9. Glucose: 112mg/dL
    10. Potassium: 3.9 mEq/L
    11. Sodium: 138 mEq/L
  3. Prothrombin time (PT) – 12 seconds
  4. Partial Thromboplastin time (PTT) – 37 seconds
  5. Panscan CT (Polytrauma Whole Body Imaging): Results –
    1. Closed left femur fracture
    2. Hairline fracture of 3 left ribs
    3. TBI consisting of frontal-temporal skull fracture
  6. Urinalysis (UA) – positive for red blood cells in urine
  7. Drug panel – positive for cannabinoids
  8. Consent to treat options

 

PART II:Critical Thinking Activity

Use the findings from your evaluation to complete the following:

Assessment Findings 

Evaluate Mr. Doe’s health history and other pertinent medical information presented above to answer the questions that follow.
Based on your evaluation, synthesize normal and abnormalfindings.Create a list prioritizingthree to five problems and health concerns present forthe patient. Your response should be a minimum of 300 words. Normal findings: 

i)                   Normal hemoglobin and hematocrit levels at 15.6g/dl and 41.5% respectively.

ii)                  Normal platelet at 316000 cells/mm3.

iii)               Normal PT and PTT at 12 and 37 seconds respectively.

iv)               Normal sodium, calcium, and potassium levels.

v)                  Normal alkaline phosphatase and bilirubin levels at 122U/L and 1.4mg/dL respectively.

vi)               Normal blood urea nitrogen and creatinine levels at 16mg/dl and 1.1mg/dL respectively.

Abnormal results:

i)                   Altered level of consciousness, mood and behavior

ii)                 Nausea and vomiting.

iii)               Dilated pupils

iv)               GCS 6/15

v)                  Pain on the left side

vi)               Low blood pressures of 80/40

vii)             Slightly elevated white blood cell count at 11.3 cells/mm3.

viii)           Increased pulse rate at 136 beats per minute.

ix)               Increased and irregular respiratory rate of 28 breathes per minute.

x)                  Decreased SpO2 levels at 92%.

xi)               Elevated aspartate and alanine aminotransferase levels at 52U/L and 32U/L respectively.

xii)             Elevated blood glucose at 112mg/dL

xiii)           Hematuria demonstrated by positive red blood cells in blood.

xiv)           Positive cannabinoids in the drug panel.

xv)              Closed left femur fracture on the PanScan CT.

xvi)           Hairline fracture of three left ribs on the PanScan CT

xvii)         Frontal-temporal skull fracture PanScan CT

Associated health problems:

i)                   Increased intracranial pressure

ii)                 Acute respiratory distress

iii)               Hypotension

iv)               Hyperglycemia

v)                  Cannabinoid use
Provide rationale justifying your proposed list. Use at least one evidence-based resource to support your rationale. Your response should be a minimum of 200 words. A traumatic brain injury is often associated with rupture of cranial blood vessels resulting in extradural and subdural hemorrhages. Both hemorrhages cause an increase the intracranial volume resulting in increased ICP (Singhal et al., 2021). Additionally, there is neuronal injury resulting in inflammation and edema which may worsen the increased ICP. Increased ICP is associated with the depression of the medullary respiratory control center which results in alterations of respiratory system mechanics through airway resistance and hypoxemia. In addition, respiratory distress may occur as a result of neurogenic pulmonary edemadue to the increased catecholamine levels that cause increased pulmonary vascular pressures (Jang et al., 2020). As a result, hypoxia ensues which worsens the cerebral perfusion worsening the preexisting edema and ICPs. 

The inflammatory state is characterized by elevated cortisol and inflammatory markers such as interferons. The two causemarked tissue insulin resistance resulting in hyperglycemia (Matovu et al., 2021). Extravasated blood in the epidural, subdural, or at the femoral fracture may cause a decrease in the circulating blood volume which causes a reduction in cardiac output and blood pressures. However, the fall in the blood pressure causes a compensatory mechanism characterized by tachycardia. Cannabinoid use is associated with mild liver and renal injuries resulting in hematuria and elevated liver enzymes
Discuss how each team member can contribute to the formation and improvement of diagnosis for this patient. Your response should be a minimum of 200 words. The ambulance personnel play a crucial role in the initial assessment and evaluation of the patient’s history, physical examination, and vital signs. The team is crucial as they give preliminary results that are very valuable in establishing an initial differential diagnosis and narrowing down the tests for laboratory and radiological investigation (Austin et al., 2020). The emergency physician can coordinate with the ambulance personnel in obtaining a detailed history, vital signs, and intervention done for the patient prior to arrival to the hospital. In addition, the EP is responsible for conducting an initial assessment and physical examination of the patient while in the ED, collect and formulate an update medical history, and order for the any laboratory of radiological tests. On the other hand, emergency nurses also play a crucial role in the ED where they help EP in assessment and evaluation of the patient while monitoring the patient’s vitals to ensure that any change contributes to the diagnosis. 

An additional group that are crucial in diagnosis are the laboratory technicians who are responsible for performing and analyzing laboratory test. The group can highlight the abnormal test results to help the EP easily make a diagnosis based on the abnormal findings (Austin et al., 2020). Radiologists and radiology technicians play an important role in performing imaging procedures such as X-rays and CTs that are crucial in helping formulate a radiological diagnosis based on abnormal findings.
Interventions 

Mr. Doe requires numerous interventions upon arrival to the hospital.
Based on your assessment, describe the interventions that are required upon Mr. Doe’s arrival to the hospital to mitigate the risk of further complications. Your response should be a minimum of 300 words. Upon admission, it is crucial to reevaluate the patient’s airway, breathing, and circulation. The intubation placed on the patient should be reevaluated to ensure it is in the right position.The patient started on oxygen on a ventilator attached to monitor the respiratory rate. Invasive blood pressure monitoring using the radial artery should be started and pulse oximeter attached to monitor oxygen saturation, arterial blood gases, and blood pressure (Yang et al., 2022). Two intravenous lines should be set up and normal saline administered to correct hypotension. In addition, an internal jugular vein catheter should be inserted to monitor jugular vein oxygen saturation and give an estimate between the cerebral oxygen delivery and uptake. A thermistor can be placed in the esophagus to help monitor the patient’s core temperature. The patient should be placed in intensive care unit in a room with favorable temperatures to reduce any incidence of hypo- or hyperthermia which may worsen the prognosis. 

A urinary catheter can also be placed to monitor the patient’s urine output and help rule out any acute kidney injury. In addition, anintra-parenchymal fiber optic catheter can be placed in the lateral ventricle to allow for continuous monitoring of intracranial pressures (Yang et al., 2020). The patient’s head should be elevated and mannitol administered to help relieve the elevated intracranial pressures. Additionally, an electroencephalogram should be attached to the patient and anticonvulsants given to prevent any seizure. The patient should also be given analgesics for the pain and a sedative to help relieve elevated ICPs. A chest radiograph and whole body CT can be done to show the injuries the patient has after the traumatic incident. The patient’s left limb also needs to be immobilized to help reduce pain and incidences of fracture displacement which may complicate the injury. In addition, there should be continuous monitoring of the left limb for any paralysis, paraesthesia, pain, or pulselessness that may indicate compartment syndrome (Gupte et al., 2021). Lastly, John’s chest movements should be closely monitored to prevent any incidence of a flail chest or hemo-pneumothorax.
Diagnostic Tests 

Reviewthe diagnostic tests that were ordered.
Choose two diagnostic tests and explain how these tests relate to the patient’s condition. Your response should be a minimum of 200 words. PanScan CT scan and a comprehensive metabolic panel (CMP) are crucial in the evaluation of the patient. traumatic injuries following road traffic accidents often cause multi-organ injuries including the central nervous, cardiorespiratory, gastrointestinal, genitourinary, and musculoskeletal. Thus, whole body imaging is very crucial in identifying any internal organ injuries and bone fractures (Thippeswamy et al., 2020). In John Doe’s case, the scan was able to identify and localize injuries such as the TBI, hairline rib fractures, and femoral fractures for further evaluation for severity and management. In addition, in case of any other injury such as hemo-pneumothorax and abdominopelvic hemorrhage, the scan would have identified any other additional injury. 

On the other hand, a CMP is crucial in evaluating organ function post-trauma. As mentioned earlier, RTA can injure multiple organs including the liver and kidney causing an imbalance in the enzymes and electrolytes (Bertschi, 2020). In addition, TBIs often cause alterations in metabolic rates, hence the CMP is crucial in identifying and monitoring for any predicted complications. Metabolic and electrolyte levels alterations also guide the kind of interventions that may be needed that aim to prevent further organ damage. Lastly, an initial CMP done after trauma can be used as a baseline for comparison for subsequent tests done while the patient is still admitted and after any medical or surgical interventions.
Surgical Intervention 

Review your assessment of Mr. Doe’s physical injuries to answer the questions below.
Discuss the possible surgical interventions necessary to address Mr. Doe’s multiple fractures. Your response should be a minimum of 200 words. Frontal-temporal skull fractures are associated with deteriorating brain injuries. For example, head injuries may cause depressed skull fractures and open wounds. As a result, the injury necessitates surgical wound debridement, elevation of depressed bone, and lost bone craniotomy to relieve underlying pressure (Singhal et al., 2021). In case an epidural hemorrhage occursepidural hemorrhage evacuation is necessary to avoid complications such as herniation of brain tissues. In addition, duraplasty and dura tenting are crucial following epidural evacuation. Lastly, in case of a suspected acute subdural hemorrhage, surgical decompression is necessary to avoid complications of increased intracranial pressure. 

Femoral fractures often when unstable and causing soft and neurovascular injury require surgical management. One common surgical intervention used is open reduction and internal fixation where the fracture is initially reduced to facilitate alignment (Gupte et al., 2021). The procedure also includes fixation of nails and screws to hold the bone segments together. bones are held together using metal implants. In addition, an intramedullary nail can be inserted into the medullary cavity of a bone and across the fracture in order to provide a solid support for the fractured bone and favor healing. The nails are either be inserted anterograde or retrograde depending on severity of the fracture. Lastly, use of K-wires in external fixation of the fracture is very useful in stabilizing the fracture.
If surgery is not necessary, what steps are needed to ensure proper healing of the bones? Your response should be a minimum of 200 words. Non-severe frontal-temporal fracture often require medical management often requiring analgesics, cold compress, and head elevation.On the other hand, hairline rib fractures management involves use of non-steroidal anti-inflammatory drugs or acetaminophen to manage pain and reduce excessive fracture site inflammation which may delay healing (Hoepelman et al., 2023). In addition, the patient may require rest and ice-packing to help reduce the pain and also promote healing. The patient can also be initiated into chest exercises that help patient breath in deeply thus reduce the incidence of pneumonia which may delay healing. Lastly, the patient may require a chest wrap to help stabilize the fractured ribs. 

Some femoral fractures especially when minimally displaced do not require surgery. The patient may be initiated on analgesic to help relieve the pain. The left lower limb also needs to be immobilized (Gupte et al., 2021). One method used to immobilize the limb includes use of a hinged knee brace and skeletal traction. Both procedures help relieve pain and reduce displacement of the bone segments. In some cases, a functional Thomas Splint can be used to stabilize the femoral fracture. In addition, closed reduction is very crucial in bringing the two segments close to each other to facilitate healing. Lastly, the patient can be initiated on physiotherapy to promote wound healing.
Panscan Results 

The panscan results indicate a positive TBI.
Based on these results, what interventions do you foresee as necessary when treating the patient? Your response should be a minimum of 300 words. The patient requires an admission into intensive care unit for close monitoring. It is crucial to intubate him using an endotracheal tube and oxygen administered to reduce any worsening hyperventillation and incidence of hypoxemia. In addition, phenylephrine can be used to maintain and improve cerebral perfusion pressure (Jha et al., 2022). On initial assessment the patient was hypotensive with his blood pressure at 80/40, as a result, it is crucial to initiate the patient on either normal saline or Ringer’s Lactate to help boost blood volume and reduce incidence of acute kidney injury. Sedative agents are crucial in lowering cerebral blood flow and perfusion. High dose phenobarbital can be used as an analgesic and sedative as it also confers hemodynamic stability to the patient. Alternatively, propofol and ketamine can be used to sedate the patient. 

While in ICU, ICP pressures should be closely monitored to prevent them from worsening. Mannitol can be used to relieve cerebral edema and acetazolamide to reduce cerebrospinal fluid leak which may help lower ICP (Yang et al., 2022). In addition, prophylactic anticonvulsants such as phenytoin and close electroencephalogram can be used to monitor brain activity and reduce incidence of seizures. Blood glucose levels should be monitored and maintained at 4-8mmol/l and glucose containing fluids avoided. TBI is associated with high cortisol levels which may induce hyperglycemia and anaerobic metabolism resulting in worsened cerebral edema (Matovu et al., 2021). Transgastric-jejunal feeding should be initiated to facilitate early nutritional support and metoclopramides used to facilitate feeding tolerance.

Broad-spectrum antibiotics can be used as prophylactics to any infection that may arise from the wound or intubation. Craniotomy, extradural hematoma evacuation, and decompression can be initiated to relieve any subdural or extradural hematoma (Singhal et al., 2021). After the surgery, the patient will need thrombo-prophylaxis therapy using compression stockings and heparin to reduce any incidence of thrombi and its complications.
Psychosocial and Spiritual Considerations 

Providing holistic nursing care for patients with complex conditions requires that the nurse takes into account the patient’s psychosocial and spiritual needs.
Given the patient’s current situation, discuss ways in which the nurse can take into account and address the patient’s psychosocial and spiritual needs. Your response should be a minimum of 150 words. Nurses can create an empathetic relationship with the patient that allows him to have a safe environment where he can raise any concern that may arise. Meanwhile, the nurse can engage in active listening of the patients psychological and spiritual concerns, understand his perspective, and address any issues in a clear and comfortable way to the patient (Dos Santos et al., 2021). While actively listening to the patient, the nurses can gather and inquire for information regarding the patients social, cultural, and spiritual background and coping skills. The information is very helpful as the nurses can offer psychological counseling to the patient and request for a psychologist or psychiatrist to help with the patient. The nurse can also link the patient to support groups either with the family or community who can help foster psychological support. Lastly, the nurse can provide spiritual care to the patient while respecting his cultural and religious background and liaise with spiritual leaders to provide spiritual support to the patient.
References (Please include working hyperlinks.) 

Austin, E. E., Blakely, B., Tufanaru, C., Selwood, A., Braithwaite, J., & Clay-Williams, R. (2020). Strategies to measure and improve emergency department performance: a scoping review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 28, 1-14. https://sjtrem.biomedcentral.com/articles/10.1186/s13049-020-00749-2

Bertschi, L. A. (2020). Abnormal basic metabolic panel findings: implications for nursing. AJN The American Journal of Nursing, 120(6), 58-66. https://doi.org/10.1097/01.NAJ.0000668764.99872.89

Dos Santos, F. C., Macieira, T. G., Yao, Y., Hunter, S., Madandola, O. O., Cho, H., … & Keenan, G. M. (2022). Spiritual interventions delivered by nurses to address patients’ needs in hospitals or long-term care facilities: a systematic review. Journal of Palliative Medicine, 25(4), 662-677.https://doi.org/10.1089/jpm.2021.0578

Gupte, D., Axelrod, D., Worthy, T., Woolnough, T., Selznick, A., & Johal, H. (2023). Management of Femoral Shaft Fractures: The Significance of Traction or Operative Position. Cureus, 15(1), e33776. https://doi.org/10.7759/cureus.33776

Hoepelman, R. J., Beeres, F. J., Beks, R. B., Sweet, A. A., Ijpma, F. F., Lansink, K. W., … & Houwert, R. M. (2023). Non-operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: a multicenter prospective cohort study. European Journal of Trauma and Emergency Surgery, 49(1), 461-471.https://doi.org/10.1007/s00068-022-02093-9

Jang, S. H., Kwon, Y. H., & Lee, S. J. (2020). Tachycardia in a patient with mild traumatic brain injury. Clinical Autonomic Research, 30, 87-89. https://doi.org/10.1007/s10286-019-00646-4

Jha, S., & Ghewade, P. (2022). Management and treatment of traumatic brain injuries. Cureus, 14(10).https://doi.org/10.7759/cureus.30617

Matovu, P., Kirya, M., Galukande, M., Kiryabwire, J., Mukisa, J., Ocen, W., … & Lule, H. (2021). Hyperglycemia in severe traumatic brain injury patients and its association with thirty-day mortality: a prospective observational cohort study in Uganda. PeerJ, 9, e10589.https://doi.org/10.7717/peerj.10589

Singhal, G., Atri, S., Suggala, S., Jaluka, D., Singhal, S., & Shrivastava, A. (2021). Growing skull fractures; pathogenesis and surgical outcome. Asian Journal of Neurosurgery, 16(03), 539-548.https://doi.org/10.4103/ajns.AJNS_183_18

Thippeswamy, P. B., & Rajasekaran, R. B. (2021). Imaging in polytrauma–Principles and current concepts. Journal of Clinical Orthopaedics and Trauma, 16, 106-113.https://doi.org/10.1016/j.jcot.2020.12.006

Yang, C., Ma, Y., Xie, L., Wu, X., Hui, J., Jiang, J., … & Feng, J. (2022). Intracranial pressure monitoring in the intensive care unit for patients with severe traumatic brain injury: analysis of the CENTER-TBI China Registry. Neurocritical Care, 37(1), 160-171. https://doi.org/10.1007/s12028-022-01463-w

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