ASSESSMENT 1:Instructions: 1. Read through Alexandra’s notes and try and make sense of her diagnosis, clinicalpresentation and management. 2. Work through the two self assessment quizzes related to this case study. 3. Answer the questions (dispersed though out the case study) in approximately 1,500words. Your responses are not expected to be in essay format. However, it is expectedthat you use references to identify the source/s of the information supplied. Case Study 4: Alexandra BatesNICU09-46-7407Alexandra BatesRel: R/CAdm: 10/7/2007DOB: 15/6/198210/7/07 Nursing 0920Patient presented after attempting suicide by shooting 3 inch nail into the righttemporal area.
? ? changes to LOC afterwards. Vomited after event. O/A GCS 15. Droveto hospital. PEARL. Haemodynamically stable. Recent tetanus booster. Emergency registrar 0930History of manic depression – Diagnosed last year. Strong family history of M-D. Swinging mood from day to day. Not compliant with medications. This morning feltdepressed about work, society and life in general. Shot herself with flat mate’s nail gunover the right temporal area. Now does not want to kill herself. Drove to the emergencydepartment herself. No symptoms or signs except for headache. PH: Nil of note. Seeing a psychiatrist. Meds: was on Lithium and LorazepamSmoker > 1 pkg/day, occasional marijuana and has used heroin on and off. Fully immunised against tetanus last booster last yearOE: GCS 15Oriented TPPHaemodynamically stableSmall entry wound right temporal region.
Small amount of bleedingCN11 – Fundus = normal – difficult in circumstancesCN111, CN1V, CNV1No dyplopia; nystagmus, has full extra occular movementPEARLCNV, CNV11, CN1X, CNX1, CNX11Gait – not testedCo-ordination – finger to nose Sensory grossly normalCT Scan: Right temporal frontal nail from skull with depressed fracture to the anterior horn Large amount of subarachnoid blood over the right cerebral cavity tracking to basalcisterns Nail appears to be close to the middle cerebral arteryQ1.
Explain how Alexandra’s GCS was able to be maintained at 15 initially despite the damage caused by the penetrating injury of the nail. Damage caused by a three inch nail could result like a punctured wound causing little amount of bleeding and damage to brain function. The area of the brain that was injured, which is the fronto-temporal lobe, does not affect much of the function of the vital organs like respiratory papillary reflex. . depressed fracture of the anterior horn may have caused some pressure to the brain but primarily what had caused the increase in the intracranial pressure is the subarachnoid bleed extending towards the base.
The subarachnoid is the area where there are a lot of minute interconnecting blood vessels, probably having a chronic subarachnoid bleed. The site of the nail which had absorbed much of the impact is the area near the middle cerebal artery which probably could have caused some bleed thereby creating a space occupying a lesion-causing impingement of the ventricles.
This explains why a ventricular shunt device was placed to release the cerebral fluid and to reduce the intracranial pressure. The damaged cause by increase in intracranial pressure affect the entire brain function. The pressure build up caused by bleeding pushes the brain further out of the skull and through the foramen magnum, the largest hole at the base of the skull where the spinal cord passes through. Once the lower brainstem was pushed towards the foremen, the cardio-respiratory function is affected