Clinical Reasoning Case-Study Rubric By Robert Brown

Consider the patient situation

Mr Robert Brown is a 30 year old male who was hit by a car that failed to give way whilst he was crossing at a pedestrian crossing.  The impact caused him to be thrown into a nearby garden bed.  Passers-by came to his aid immediately. They helped him up and noticed he was bleeding from a laceration to the back of the head. He sustained no other obvious injuries.  An ambulance was called.  He has been at hospital for nearly 24 hours and was transferred to your ward overnight.  It is now 0800 and you have just come on shift.  You enter his room and he seems to be unsure of where he is (requires orientation) and keeps asking other patients the location of his dog (whom Robert was walking at the time of the accident).

Collect Cues

Review:

The next phase of clinical reasoning cycle is reviewing the given information

The laceration at the back of head was attended.

Pain control with Paracetamol

No neurological deficit

Active bleeding was stopped, wounds were cleaned and dressed.

Gather new information (patient assessment):

Upon undertaking an assessment of Mr Brown you obtain the following new information:

Vital signs

BP: 160/95

Pulse: 111bpm

RR: 18

SaO2: 98%

Temp 36.6

Other data

GCS: 13 (patient seems confused/agitated) and keeps rubbing at his head and mumbling that it hurts.  Whilst his movements seem purposeful, he does not obey commands or accurately answer specific questions).  There appears to be no GCS documentation since transfer to the ward.

Patient in bed opposite refers to Mr Brown and tells you: ‘that poor young bloke, he’s been up half the night.  He keeps going on about his dog and gets lost when he goes to the bathroom’

Wound chart: no further documentation evident.  However, upon looking at Mr Browns head wound from a distance, dressing appears blood soaked and has partly come off.  There are smears of blood on his pillow.

Recall:

The condition of Mr Browns suggests that he is having difficulty in functioning, sleeping, understanding and sleeping. The condition signifies that he might have developed cerebral haemorrhage after being hit by the car.

Process Information

Interpret:

Normal

Abnormal

Absence of active bleeding

No to mild headache

Can understand properly and respond to the questions

Aware of surroundings and properly oriented

Active bleeding seen

Moderate to severe headache

Difficulty in understanding and responding to questions

Confused and disoriented

Relate& Infer:

Relate the two most significant abnormal findings to the underlying physiology/pathophysiology to justify why it is considered abnormal in this context.

Based on your interpretation of all the information/cues presented, form an overall opinion on what may be happening and justify your answer

When a person is hit on head violently, then loss of cognitive abilities gives few possible diagnoses like haemorrhage. Mr. Brown was a perfectly normal person before the accident but after the accident he had difficulty in understanding what was being said to him and he also failed to obey the commands. It suggests that some of his brain area which is related to the function of comprehension is affected. However, his memory remains intact as he could recall walking his dog. Also he was unaware of his surroundings, he looked confused and disoriented which further suggested a possibility of internal injury of brain as these symptoms would not have appeared if it was only a superficial wound.The bleeding which smeared Mr. Brown’s pillow and didn’t stop suggests an cerebral haemorrhage. In normal condition if it was a superficial wound like thought by the professional, the bleeding would have stopped. But the continuous bleeding suggests that blood is oozing from inside and on accumulation the blood mass can dissect through and compress adjacent brain tissues which can result in neuronal dysfunction. If the haematoma is large or grows to be large if not unattended can raise cranial pressure. Pressure from supratentorial hematomas and the accompanying edema may cause transtentorial brain herniation, compressing the brain stem and often causing secondary hemorrhages in the midbrain and pons (Foresberg et. al, 2014). Also, if a rupture of the hemorrhage occurs into the ventricular system, blood can lead to acute hydrocephalus. The hematomas can grow to block the 4th ventricle and may cause acute hydrocephalus, or they can dissect into the brain stem. The hematomas that are more than 3 cm in diameter may cause midline shift or herniation. Herniation, midbrain or pontine hemorrhage, intraventricular hemorrhage, acute hydrocephalus, or dissection into the brain stem can impair consciousness and cause coma and death(Tanner, 2006).The bleeding leads to compression of brain and prohibiting the flow of oxygen-rich blood into the brain tissue. The lack of oxygen can result in brain swelling. The extra pressure created as a result of the reduced oxygen results in death of brain cells.

Predict:

What may happen to your patient if you take NO action and why?

Mr. Brown suffers from an internal injury in brain which was not attended to on his admission. He developed a complication possibly a haematoma was developed. The haematoma can grow to be massive if not attended immediately. The developed haematoma will require immediate surgery for its removal and if not operated then the areas of the brain it affects can lose its function. Mr. Brown can become irreversible cognitively impaired, may slip into indefinite period of coma or even die.

Identify the Problem/s

List in order of priority at least three key nursing problems

1.       Improper wound management

2.       Lack of reporting of newly developed symptoms to senior professionals

3.       Lack of review of Mr. Brown’s condition in night

Establish Goals & Take Action

From the above (identify problems), use the top 2 nursing problems identified and for each of these establish one goal and thenlist related actions you would undertake, including detailing any relevant nursing considerations

Evaluate outcomes& Reflect on new learning

Briefly describe how you would evaluate the effectiveness of the care providedand reflect on how this encounter has informed your nursing practice if you were to encounter a similar situation in the future

The care provided to Mr. Brown was of substandard nature risking his life and not adhering to the guidelines of patient safety. If the service provision was effective in Brown’s case his case may have been saved from developing complications.

However, I learnt from Mr. Brown’s case that no wound should be taken lightly and a proper wound assessment and management should be undertaken. I also believe that it is important to review patients regularly as the patient may develop certain symptoms or develop complications later. It becomes important to communicate and document accurately regarding the condition of the patient so that the doctors can his condition accurately and formulate therapeutic interventions. In future, if I will ever encounter such situation I will ensure that I have assessed the wound properly and will regularly check on the patient or ask the other nurse on shift to check on patient’s condition timely(Meissner, 2011).