Case Study 9 EAs - Online Case Study Nursing Assessment

Case Study 9 - EAs

Introduction

The following case scenario will introduce a patient referred to as Henry (pseudonym), who was admitted to a neurosurgical department following a fall.  This case scenario will focus on the use of the Glasgow Coma Scale (GCS) as an assessment tool used in the identification and management of deterioration.  The assessment skills used in this scenario led to timely, effective treatment and a positive outcome for the patient.  Through the exploration of this scenario, relevance will be drawn to clinical reasoning and the role it plays in implementing a thorough health assessment. 

Case Presentation

Henry is a 91-year-old male who was admitted to the neurosurgical ward after experiencing a fall at home.  A computed tomography (CT) scan of his brain demonstrated Henry had a left-sided Subdural Haematoma (SDH).  Upon admission, Henry’s GCS was recorded as 15/15, with a mild right sided weakness.  Nursing documentation noted that Henry was alert and orientated with some mild dysphasia.

The following day, I assumed care of Henry at 0800 hours and began to assist him with the set-up of his breakfast meal.  Upon initial observation, I became aware that Henry was neglecting his right arm.  Upon noticing these changes, I conducted a full GCS assessment.  My findings showed that Henry’s GCS was 14/15; his eyes were open spontaneously, he was confused and obeying commands.  Henry’s pupils were equal and reactive to light. However, the power in his right arm and leg had deteriorated from mild weakness to no movement at all.  I immediately identified that these changes were significant for Henry and proceeded to contact the neurosurgical registrar.  Henry was sent for an urgent CT brain which demonstrated an extension of the SDH.  Henry was sent for urgent theatre to have borehole drainage of the SDH.  Post-operatively, Henry had full power in all limbs, no speech difficulties and had a GCS of 15/15. 

Discussion

Traumatic Brain Injury (TBI) is a leading cause of death and disability worldwide for elderly individuals (Nguyen at all. 2016; Pruitt et al. 2017; Scheetz, Horst &Arbour 2016).  SDH is considered to be the most common form of intracranial hemorrhage caused by TBI (Pruitt et al. 2017; Wang et al. 2015).  SDH is caused by an accumulation of blood within the space between the arachnoid and dura mater; most commonly caused by injuries to the head which cause impairment to bridge veins (Pruitt et al. 2017).  Whilst many cases of SDH can be managed conservatively; approximately 30% of patients will require surgical intervention to prevent long-term morbidity or mortality (Pruitt et al. 2017; Wang et al. 2015). 

Accurate GCS assessment is a vital aspect of the care of patients who present with TBI (Maher 2016; Scheetz, Horst &Arbour 2016).  The integral aim of GCS assessment is to appraise the condition of an individual’s central nervous system; evaluating cognitive function and accurately identifying deterioration (Edwards 2001).  The key aspects of my GCS assessment of Henry included ‘eye-opening response,’ ‘best verbal response’ and ‘best motor response.’  On assessment, Henry’s GCS only showed a reduction by one point, due to confusion, making his GCS 14/15.  Nevertheless, it was evident through my assessment of ‘best motor response’ that Henry’s right-sided weakness had dramatically worsened.  When physically evaluating motor response, Henry was able to follow commands. However, the assessment revealed that he was unable to move his right arm or leg spontaneously.  Due to the extension of Henry’s SDH, his intracranial pressure had acutely increased, causing compression of the brain tissue and subsequent cognitive and motor deficits (Benedettoa et al. 2017).  When performed accurately, GCS assessment identifies neurological deterioration, allowing health professionals to intervene early and alleviate harm (Scheetz, Horst &Arbour 2016).  Had I not identified Henry’s deterioration in a timely manner, he could have had a permanent disability or even death (Wang et al. 2015). 

Identifying potential or actual deterioration in a patient’s condition requires efficient and thorough clinical reasoning skills (Carvalho, Oliveira-Kumakura&Morais 2017; Levett-Jones et al. 2010).  As evidenced by the literature, positive patient outcomes through clinical reasoning rely heavily on well-developed health assessment skills (Lee et al. 2016; Liaw et al. 2018).  In Henry’s case, a pivotal aspect of identifying his deterioration was through effective clinical reasoning; including a proficient collection of cues (Lee et al. 2016).  This involved the detailed GCS assessment which revealed acute neurological changes.  Consequently, through the processing of information I had gathered, I was able to identify a new problem which required immediate action (Levett-Jones et al. 2010).  As a result of my health assessment and associated clinical reasoning, actions were taken which led to a positive outcome for Henry.   

Another important aspect of the clinical reasoning cycle involves evaluation and reflection of outcomes (Liaw at al. 2018).  This case scenario has allowed me to critically reflect upon the assessment skills required for detection of neurological deterioration.  As a nurse working in an acute neurosurgical department, it is pivotal that I have well-developed and evidence-based neurological assessment skills, to effectively mitigate deterioration of the high-risk patients in my care (Herou, Romner&Tomasevic 2015; Maher 2016). 

This case scenario has demonstrated the importance of applying thorough assessment skills and effective clinical reasoning to enable timely, safe and positive patient outcomes.

References:

 Benedetto, N, Gambacciania, C, Montemurro, N, Morganti B, R &Perrenia, P 2017, ‘Surgical management of acute subdural hematomas in elderly: report of a single center experience,’ British Journal of Neurosurgery, vol. 31, no. 2, pp. 244-248, viewed 26 July 2018, CINAHL Complete, EBSCOhost.

 Carvalho, E, Oliveira-Kumakura, A &Morais, S 2017, ‘Clinical reasoning in nursing: Teaching strategies and assessment tools,’ Rev Bras Enferm, vol. 70, no. 3, pp. 662-668, viewed 26 July 2018, CINAHL Complete, EBSCOhost.

Edwards, S 2001, ‘Using the Glasgow coma scale: Analysis and limitations,’ British Journal of Nursing, vol. 10, no. 2, pp. 92-101, viewed 26 July 2018, CINAHL Complete, EBSCOhost.

 Herou, E, Romner, B &Tomasevic 2015, ‘Acute traumatic brain injury: Mortality in the elderly,’ World Neurosurgery, vol. 83, no. 6, pp. 996-1001, viewed 27 July 2018, Wiley Online Library.

Lee, J, Lee, Y, Bae, J &Seo, M 2016, ‘Registered nurses’ clinical reasoning skills and reasoning process: A think aloud study,’ Nurse Education Today, vol. 46, no. 6, pp. 75-80, viewed 26 July 2018, Elsevier Health. 

 Levett-Jones, T, Hoffman, K, Dempsey, J, Jeong, S.Y.S, Noble, D, Norton, C.A, Roche, J & Hickey, N 2010, 'The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients’, Nurse Education Today, vol. 30, no. 6, pp. 515-530, viewed 26 July 2018, Elsevier Health.

 Liaw, S, Wong, L, Goh, H, Ignacio, J, Rashasegaran, A, Deneen, C, Cooper, S &Levett-Jones, T 2018, ‘Development and psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing nursing students’ abilities to recognize and respond to clinical deterioration’, Nurse Education Today, vol. 62, pp. 74-79, viewed 27 July 2018, Elsevier Health.

 Maher, A.B 2016, ‘Neurological Assessment,’ International Journal of Orthopaedic and Trauma Nursing, vol. 22, no. 3, pp. 44-53, viewed 27 July 2018, CINAHL Complete, EBSCOhost.

 Nguyen, H, Li, L, Patel, M & Mueller, W 2016, ‘Density measurements with computed tomography in patients with extra-axial hematoma can quantitively estimate a degree of brain compression,’ The Neuroradiology Journal, vol. 29, no. 5, pp. 372-376, viewed 27 July 2018, CINAHL Complete, EBSCOhost.

 Pruitt, P, Ornam, J, Borczuk, P &Panagos, P 2017, ‘A decision instrument to identify isolated traumatic subdural hematomas at low risk of neurologic deterioration, surgical intervention or radiographic worsening,’ Academic Emergency Medicine, vol. 24, no. 11, pp. 1377-1386, viewed 27 July 2018, CINAHL Complete, EBSCOhost.

 Scheetz, L, Horst, M &Arbour, R 2016, ‘Early neurological deterioration in older adults with traumatic brain injury,’ International Emergency Nursing, vol. 37, no. 3, pp. 29-34, viewed 26 July 2018, Wiley Online Library. 

Wang, H, Zhao, J, Li, Y, Feng, Y &Bie, L 2015, ‘Surgical management of the patients with chronic subdural hematoma and contralateral subdural effusion: Operation or no-operation?’, Brain Injury, vol. 29, no. 5, pp. 618-622, viewed 27 July 2018, CINAHL Complete, EBSCOhost.

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