Epidural hematomas are a severe complication of head injuries and are considered to be a medical emergency. Although they may not be seen as often as subdural hematomas, they are much more serious and require emergency surgery. If epidural hematomas are not picked up quickly, they can result in severe neurologic deficits and even worse, death. A major concern in a patient with an epidural hematoma is failure to rescue by healthcare professionals. Failure to rescue is when healthcare professionals do not notice signs of a patients declining condition and subsequently fail to stabilize the patient (Gravey, 2015, p.145). This has become an increasing problem and has lead to numerous preventable disabilities and death. In order to avoid unnecessary harm to our patients it is essential that nurses are able to detect and notify any suspicion of epidural hematomas. Since nurses spend the majority of the time with the patient, they hold a significant role in early detection.
Epidural hematomas are defined as
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bleeding in the brain that is occurring between the skull and the dura matter (National Institute of Health, 2016). One of the leading causes of epidural hematomas are related to blunt trauma to the head. With head injuries it is imperative that nurses not only be cognizant of the primary injury that has already occurred but also any secondary injuries that may develop. A majority of the secondary injuries that we see result from rising intracranial pressure, swelling, bleeding, hypoxemia, and decreased perfusion (Schimpf, 2012, p.160). In patients with epidural hematomas the initial injury is usually due to a laceration of a major artery which will lead to massive hemorrhage. Since the brain is a closed compartment there is no where for the blood to go and pressure in the brain increases rapidly. This increased pressure leads to brain tissue necrosis and herniation. According to Lewis, Dirksen, Heitkemper, Bucher, Harding (2014) classic manifestations of a patient with an epidural hematoma include “An initial period of unconsciousness at the scene, followed by a brief lucid interval followed by a decrease in level of consciousness” (p.1370). The brief lucid period that patients exhibit may throw off healthcare providers on the correct diagnosis. It is crucial that nurses are aware of signs of increased intracranial pressure (ICP) because this can make a tremendous difference in the outcome for the patient. When caring for a patient with an epidural hematoma the main focus for majority of cases is to get the patient to the operating room as quickly as possible to help relieve pressure on the brain. A crainectomy or burr hole procedure is usually performed for immediate removal of blood. After the surgery there is still a great concern with the patient having increased intracranial pressure. Being able to identify the symptoms of increased ICP is a must. One of the first and most important signs that a nurse should be aware of is an altered level of consciousness. Frequent neurologic assessments and use of the Glasgow Coma Scale are very helpful when evaluating a patient’s neurological status. Another way to measure the patients ICP is the use of a ventriculostomy. By using the ventriculostomy healthcare professionals are able to not only monitor the pressure in the brain but are also able to drain cerebrospinal fluid to help lower rising pressures. There is also a cerebral oxygenation monitoring device called LICOX catheter that is frequently used to help measure the brain oxygenation. It has been stated that LICOX is more sensitive to changes in brain tissue hypoxia than other standard devices for measuring ICP (Keddie, Rohman, 2012, p.207). Other signs of increasing intracranial pressure are changes in vitals known as Cushing’s Triad, a decrease in motor function, projectile vomiting and headaches. With patients that are being monitored for increased ICP it is important to remember to implement nursing interventions to help decrease ICP. Keeping the head of bed elevated to 30 degrees and the head in a midline position will help to make sure the brain is being perfused adequately and help decrease ICP. Limiting activities that cause vagal stimulation such as suctioning, coughing, and straining will also help decrease ICP. It is important that the patient gets adequate rest periods and nurses should make a plan to space care throughout the day. Pain management with medications such as sedatives, paralytics, and analgesics can help reduce the incidence of increased ICP. A major nursing consideration to be aware of when administering these medications to patients with increased ICP is they may mask true neurological status. It is crucial that nurses do not continuously sedate the patient with increased intracranial pressure because then there is no way to truly assess the neurologic status to see if the patients condition is deteriorating. Propofol has gained popularity because it has a short half life. According to Skidmore-Roth, (2015) “Propofol has a half life of only 1-8 minutes” (p.994). This means the patients neurologic status can be assessed soon after discontinuing the medication which is imperative in this patient’s case. As a nurse it is our ethical obligations to protect our patients from harm.
In patients with epidural hematomas it is especially important that nurses be diligent when assessing their patients. The brain is a closed compartment and bleeding inside can go unnoticed easily. Many nurses could misconstrue sleeping with a decrease in level of consciousness. A more obvious and very avoidable reason in failure to rescue is nurses not following doctor’s orders properly. Frequent neurological assessments are essential and should be completed as ordered. Another reason epidural hematomas often get over looked is due to the signs that go along with the condition. The lucid interval that patients experience in epidural hematomas could be mistaken for the patient being stable and not needing intense monitoring. With continuous monitoring and being aware of the complications that follow epidural hematomas we can greatly reduce the risk of disability or death in these
patients. The following case study demonstrates examples of a nurse failing to rescue a patient with an unnoticed epidural hematoma. A 32-year-old male was brought to the emergency room after being involved in a motor vehicle accident. The patient seemed to become more lucid during transport to the hospital and had a Glasgow Coma Scale of 14/15 upon arrival. The patient was assessed and then transported to a local trauma center for care. The doctor at the trauma center diagnosed the patient with concussive head injury with multiple abrasions and contusions with possible basilar skull fracture. The patient was then admitted to the medical surgical floor for observation. From admission to the trauma center there were numerous mistakes made by the nurse. After review of the patient’s medical record the following was obtained, “The nurse failed to recognize the patients signs and symptoms of a deteriorating condition, failed to keep him under close observation, and failed to promptly report his condition to the physician (Iavagnilio, 2011, p.9). The nursing care this patient received was unacceptable and due to the lack of care this nurse provided the patient is now living with permanent neurologic impairments.
The current patient may be experiencing a range of traumatic injuries after his accident, the injuries that the paramedic will focus on are those that are most life threatening. These injuries include: a possible tension pneumothroax or a haemothorax, hypovolemic shock, a mild or stable pelvic fracture and tibia fibula fracture.
The nurse will check the patient’s pupils, this is done by shining a pen light into the patient’s eyes and checking how the pupils respond, and they should both be of equal size and respond to light. The next step it to complete another Glasgow Coma Scale so that the nurse can measure any changes to Alice’s consciousness. A pain assessment would them be completed on Alice to make sure that she is in no pain and if she is in pain the nurse may need to speak to a doctor regarding what medication she can give to Alice to relieve the pain. A mini-mental status examination will be assessed next.
Nobody is perfect. We all make mistakes. Some of the best lessons in life are learned from making a mistake. But in the healthcare world making mistakes means losing lives. This has started to happen so frequently there has been a term coined – Failure to Rescue or FTR. Failure to rescue is a situation in which a patient was starting to deteriorate and it wasn’t noticed or it wasn’t properly addressed and the patient dies. The idea is that doctors or nurses could’ve had the opportunity to save the life of the patient but because of a variety of reasons, didn’t. This paper discusses the concept of FTR, describes ways to prevent it from happening; especially in relation to strokes or cerebrovascular accidents, and discusses the nursing implications involved in all of these factors.
American Association of Nurse Anesthetists. Professional Aspects of Nurse Anesthesia Practice. Philadelphia: F. A. Davis Company, 1994. Print.
It is important that people are in control of what happens to them while under the care of their doctor, especially if they're alert and aware. A provider cannot force treatment; if a patient is unconscious, the situation changes because competency and informed consent are not present.
Diagnosing Epilepsy can be a long process with lots of steps to follow. When first going thru the process there will need to be a confirmation of parent history. Then there will be a full neurological exam followed by blood and clinical tests, to make sure it wasn’t some other type of episode such as fainting. Apart from the neurological exam, the EEG is the best tool to diagnosing seizures and epilepsy. Then the doctor will identify the type of seizures and do a clinical evaluation to determine the cause of epilepsy. Now depending on the results they will determine the best type of treatment.
Kothari, R., Jaunch, E., Broderick, J., Brott, T., Sauerbeck, L., Khoury, J. & Liu, T. (1998). Acute stroke: Delays to presentation and emergency department evaluation. Annals of Emergency Medicine, 33, 3−8. doi:10.1016/S0196-0644(99)70431-2
Patient falls is one of the commonest events within the healthcare facilities that affect the safety of the patients. Preventing falls among patients requires various methods. Recognition, evaluation, and preventing of patient falls are great challenges for healthcare workers in providing a safe environment in any healthcare setting. Hospitals have come together to understand the contributing factors of falls, and to decrease their occurrence and resulting injuries or death. Risk of falls among patients is considered as a safety indicator in healthcare institutions due to this. Falls and related injuries have consistently been associated with the quality of nursing care and are included as a nursing-quality indicator monitored by the American Nurses Association, National Database of Nursing Quality Indicators and by the National Quality Forum. (NCBI)
Patient safety is a major issue in health care, especially in the public sector. Studies show that as many as 10 patients get harmed daily as they receive care in stroke rehabilitation wards in hospitals in the United States alone. Patient safety refers to mechanisms for preventing patients from getting harmed as they receive health care services in hospitals. The issue of patient safety is usually associated with factors such as medication errors, wrong-site surgery, health care-acquired infections, falls, diagnostic errors, and readmissions. Patient safety can be improved through strategies such as improving communication within hospitals, increasing patient involvement, reporting adverse events, developing protocols and guidelines, proper management of human resources, educating health-care providers on the need for patient protection, and commitment of the leadership to the task. This paper talks about patient safety and how it can be improved in stroke rehabilitation wards of both public and private hospitals.
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