Case Study 1: Head Injury

Miss Emily Corathers has just celebrated her 21st birthday, for her birthday her parents gave her a new car, it was this car she was driving when she collided with a car at an intersection on her way into town. There was side impact with large deformity to both cars. There were no fatalities, Emily sustained a full thickness laceration approximately 5cm long on her occipital region of her head, she has scratches to her face and neck and a possible head injury, she has a GCS of 14/15. She is c/o a headache and has vomited once on scene. Her observations are as follows:
•Temperature: 36.2
•Heart rate: 105 bpm
•BP: 110/70
•RR: 18 breaths per minute
•SpO2: 97% on 6L via a face mask
•GCS 14 (E=4, V=4, M=6)

Blood is taken for FBC, EUC, lactate, glucose and blood group and hold. A 12 lead ECG is performed, a 14g IVC inserted into her right cubital fossa. A provisional diagnosis of a Base of skull fracture with extradural haematoma is made. While in the Emergency Department Emily is referred to the neurology team for consultation. It is decided by the neurology team she will need surgical intervention and therefore, need to be transferred to the appropriate tertiary facility. The retrieval team are contacted but it will be a number of hours before they will be there as they are busy at present. Therefore, Emily will remain in the Emergency Department under close observation until the team arrive.

2 hours has past and there is still no sign of the retrieval team, you notice during your next round of observations that Emily is harder to rouse, she now only responding to pain and is speaking using inappropriate words. Your set of observations reveals:
•Temp: 36.2
•HR: 110 (sinus tachycardia) bpm
•BP: 110/60 mmHg
•RR: 30
•SpO2: 88% on room air
•GCS: 11 (E=2, V=3, M=6), pupils unequal L=3, R=4, limb power equal

Questions

1.Does this patient’s condition indicate a rapid response or a clinical review as per the NSW Health Between the Flags? Discuss your answer.

2.Outline your ISBAR communication with the Doctor.

3.Emily is displaying signs of a traumatic brain injury, discuss the pathophysiology behind the patient’s signs of deterioration.

Case Study 2: Cardiogenic Shock

Mr Jae-Kwang Lee, a 65-year-old male who presented to the Emergency Department stating his chest felt heavy. At the triage desk he was holding his chest, when asked if the heaviness went anywhere he said yes and then proceeded to rub his left arm. When questioned further during the triage process he had associated symptoms of shortness of breath and dizziness. He had not had pain as severe as this before, he said he “has been having pains in his chest for a few months but it stops when I sit down, but it didn’t stop this time, I have been waiting for it to stop, it started yesterday”. Mr Lee was taken into the Emergency Department, and connected to cardiac monitoring, a 12 lead ECG was taken which showed an Inferior Myocardial Infarction (STEMI). Mr Lee also had bloods taken including UEC, FBC, CK-MB, Trop T, Coags. Mr Lee was also given sub lingual GTN for pain 300mcg x2 – 5 minutes apart without effect, he was then given morphine 5mg, in 2.5mg increments with effect.

Due to the business of the Department it was decided to transfer my Lee to the Coronary Care unit to wait for cardiology review. You accept the care of Mr Lee. About 2 hours into your shift, you are assessing Mr Lee and note Mr Lee has become tachycardic, hypotensive and hypoxic his observations are as follows:

Temp: 36.5

HR: 133

BP: 87/53

RR: 25

SpO2: 88%

His oxygen saturation’s are at 88%, you start him on oxygen via a simple face mask at 6LO2. Mr Lee is awake but lethargic and responds appropriately to questions.

Questions
Discuss your answer.
2.Outline your ISBAR communication with the Doctor.
3.Discuss the pathophysiology behind the patient’s signs of deterioration including the pathophysiology of shock including cardiogenic shock.

*paragraph fact sheet
Paragraphs: Academic writing
Academic paragraphs are the body paragraphs of your essay and account for about 90% of your word count and marks. They may also be the structure of short answer questions in other types of writing. Academic paragraphs contain the points you want to make with supporting arguments and evidence. These paragraphs use a basic pattern (recipe) you can follow. The sentences in your body paragraphs may include citations from information sources, examples and anecdotal evidence. Each support sentence must contribute to the argument you are developing in the paragraph and the rest of the essay. You will need to know about: 1. Paragraph structure 2. Checklist for writing a paragraph 1. Paragraph structure A paragraph consists of a topic sentence, a number of support sentences and an optional concluding sentence.
Topic Sentence
Support Sentence 1 Support Sentence 2 Support Sentence 3 Support Sentence n
Concluding Sentence (optional)
EXAMPLE OF AN ACADEMIC PARAGRAPH A number of problems associated with the traditional routines of handover practices have been identified. Baldwin and McGinnis (1994, pp. 61-64) find that many handovers are unnecessarily lengthy which means that there is an unacceptable period of time during each shift when nurses are not available in the ward or unit. Another area that has received attention is the content and presentation of handover information. Wills (1994, p. 36) observes that “an unprofessional approach has been noted among some nurses, with derogatory comments about patients or their families”. Lastly, there is the issue of what information nurses actually pass on during the handover. It appears that: Nurses frequently report on their own activities over the shift rather than providing patient centred information. Information obtained from discussions with relatives is rarely relayed onto other nursing staff, and of the patient information reported, most is described from a medical perspective rather than focusing on the discussion of nursing related information. (Professional Nurse, 1997, p. 637) Thus, many serious problems have been identified in traditional handover practices which may reflect on the professional standing of nurses in this profession.
Note the use of in-text references, paraphrases, short & long direct quotes to support the writer’s argument.

The topic sentence In most cases, the first sentence of a paragraph is the topic sentence. The topic sentence tells you what the paragraph will be about. From a good topic sentence, you should be able to predict the content of the paragraph. The support sentences The topic sentence is followed by the support sentences. Support sentences expand on the topic sentence. The material in the support sentences should be presented in a systematic way. Order of importance, chronological order, order of operations or space order are most frequently used. The concluding sentence The concluding sentence summarises the main point of the paragraph. It often re-states the idea in the topic sentence using different words. Not all paragraphs have a concluding sentence. 2. Checklist for writing a paragraph Step 1 – Write the topic sentence The best starting point for a paragraph is a topic sentence. If you are writing the paragraph in response to a specific question, this should not be a difficult task because the wording of the question will assist you. Step 2 – Brainstorm Once you have written the topic sentence, you need to think of ideas to support it. Try brainstorming. Jot down anything that relates to your topic sentence: facts, details or examples. This might only take a few minutes, but it is an important part of the writing process. Step 3 – Plan Brainstorming will probably provide you with more ideas than you require. Read over what you have written, and cross out those ideas which do not obviously relate to the topic sentence. Arrange the remaining ideas in the order you wish to present them in your paragraph. Step 4 – Write the first draft The first draft should include all the ideas in your plan. It is a good idea to use every second line if you are writing the first draft on paper. This makes revision and editing much easier. Once you have finished writing the first draft, think about what you have written. You might consider a concluding sentence. Write one if you think it is necessary to complete the paragraph. Step 5 – Revise and edit Revising and editing your paragraph means rethinking and rewriting. It may involve making additions or corrections, rewriting sentences or rearranging details. Ask yourself the following questions 1. Is the topic sentence clear and relevant? 2. Do the facts, details and examples explain/develop the topic sentence? 3. Is there enough support? 4. Is the material presented in a systematic way? 5. Does one sentence lead smoothly to the next? Step 6 – Check grammar, spelling and punctuation Step 7 – Write the final draft Step 8 – Proofread your paragraph