Reference no: EM133164111

EXAMINATION:

Natalie Hill (pronouns she/her) is a 42-year-old female admitted to University Hospital by ambulance at 0420am following a motor vehicle accident (MVA) at 80km/hr. The car had impact with the metal lane barrier. Natalie was the driver, with no other persons in the car at the time of the crash.

Natalie's primary survey upon immediate arrival to the Emergency Department (ED) of University Hospital (UH) demonstrated the following:

A: Airway cleared, Yankeur suctioning required to remove vomitus. Blood noted in mouth, 3 front teeth loose. Speaking inappropriate words, drowsy. C-spine collar in situ

B: Respiratory rate (RR) 26 per minute, laboured. Decreased breath sounds to right lower lobe, and left lung. Equal chest symmetry. Sp02 84% at scene, 99% 10 L oxygen via Hudson mask (HM).

C: Heart rate (HR) 121 beats per minute, pulse thready and regular. Blood pressure 90/S8 mmHg. Skin is cool, pale, clammy. Capillary refill (CR) > 3 seconds. 2L 0.9% Normal Saline IVT administered by paramedics. 2 x IV cannula inserted left and right antecubital fossa. Positive focused assessment with sonography in trauma (FAST) scan. Hb 94g/L.

D: Glasgow coma score (GCS) 10 (E2V3M5). PEARL size 3+. Blood glucose level 11.1mmol/L mmol/L.

E: Temperature 35.5 degrees Celsius, Bair Hugger warming blanket applied. Multiple lacerations and contusions evident on all limbs, abdomen and face. Significant bruising and swelling to right lower leg, toes mottled and cool.

Question 1. (approx. 250 words)

The above data outlines what is involved in the primary assessment of Natalie. From this information, rationalise one actual/priority problems and two potential problems. Underpin your responses with possible underlying pathophysiological causes to justify your decision making. Link to other signs and symptoms as applicable.

You have now performed a secondary survey of Natalie. Some diagnostic results and physical assessment data gathered from this includes:

Vitals: BP 99/60mmHg; RR 28; Sp02 94% 10LHM; HR 134bpm, Temperature 36.1

GCS 12 (E3V4M5); C-spine collar remains in situ. Periorbital bruising noted. PEARL 3.sluggish. Await head/neck/spine CT scan. Lung sounds remain unchanged from primary survey, nil signs of subcutaneous emphysema, nil tracheal deviation. Weak and thread radial pulses, heart sounds Si S2. Hb 79g/L.

log-roll performed: palpation of spine NAD (No Abnormalities Detected) and posterior inspection NAD. Tenderness and localising to abdominal palpation, bowel sounds decreased. Not passed urine. Right leg: immobilised in splint, CR 4 seconds, cool peripherally, dark bruising if- to leg and foot with right dorsalis pedis and posterior tibialis pulses weak.

Question 2: (approx. 250 words)
From the secondary survey data, rationalise one actual problem (different from Q1). Then discuss one independent nursing intervention and one dependent nursing intervention for the actual problem Underpin your responses with possible underlying pathophysiological causes to Justify your decision making. Link to other signs and symptoms as applicable.

That evening Natalie goes to operating theatre for a laparotomy, splenectomy, and stabilisation of the right open comminuted fracture tibial/fibula with an external fixation device. She returns to the trauma unit with an T9.710 Epidural (8upivacaine) in situ.

Six hours later, Natalie is drowsy but complaining of abdominal pain 5/10 only on the left flank when she is awake. Vital signs are BP 95/SOmmHg. T 36 2C. RR 10 (asleep) RR 14 (awake), Sp02 94% on 2LNP, HR 60 regular.

Question 3. (approx. 175 words)
Rationalise two immediate actions interventions related to epidural care that you would undertake (before escalating to your preceptor) in this scenario, while linking causative factors underpinning these signs and symptoms.

Question 4: (approx. 175 words)
Natalie has an external fixation device insitu to the right tibia and fibula. Identify and rationalise what signs and symptoms would alert you to compartment syndrome in this case considering the mechanisms by which Natalie's epidural could mask compartment syndrome.

Day 9 post admission Natalie has developed a respiratory nosocomical-acquired infection which has caused type 1 respiratory failure. A MET call was issued for signs of respiratory distress and hypoxaemia, and non-invasive ventilation bi-level positive airway pressure (BiPAP) was commenced, with IPAP 12cmH20 and EPAP 6cmH20, 1102 0.6.

Within 15 minutes of NIV therapy, there is an increase in Sp02 from 88% (on 1102 0.6) to 91%, and BP drop from 112/65mmHg to 94/SOmmHg.

Question 5: (approx. 250 words)
Discuss how positive pressure ventilation and the settings of IPAP and EPAP both influence work of breathing and oxygenation, considering the implications to the patient's respiratory function if these settings are incorrectly applied.

Question 6: (approx. 100 words)
Rationalise how positive pressure ventilation affects haemodynamics, to justify the decrease in Natalie's blood pressure.