Neuro HDU – Nursing – 3000 words

Case study



X was a 50-year-old male who was admitted to the neuro-high dependency unit with complaints of a severe headache, the nature of which was explained to the staff on duty to be a blow on the head. Upon physical examination the patient also demonstrated drowsiness and the Glasgow coma scale have a score of 14 at this point. It was found that his pupils were normal in size and bilaterally reactive to light. The temperature was recorded to be of 36.8°c, a blood pressure of 180/60 mm Hg, pulse rate of 98 bpm and the respiration was recorded to be of 18 breaths per minute with an oxygen saturation of 98%on air. The physical test also indicated his ability to move all limbs with ease. Based on the 2007 Nice Guidelines an urgent CT (computerized tomography) scan of the patients head was conducted and according a smallish nodule with in the anterior communicating artery with evidence of subarachnoid blood was detected. To tackle this Paracetomol (tablet form), IM codeine alongwith a four hourly dose of regular antiemitics and nimodipine 60mg and IV normal saline 125ml was administered. This controlled the complaint of a splitting headache.


At the same time the patient’s hourly neuro observation along with chart records was maintained and he was given flat bed rest for 24 hours. On the following day a cerebral angiogram was performed to observe the movements in his cerebral vessels and this confirmed anterior communicating artery aneurysm. It should also be noted that a routine of brain tissue oxygen monitoring was applied here due to the detection of subarachnoid hemorrhage (SAH). (Addision, 2001) This technique enables the optimization oxygen delivery to the injured brain (Ibid.). Once this cerebral oxygen supply is optimized it is hoped that the SAH victim will suffer less long-term damage. In addition to this in line with good practice, since this was a case of a patient suffering from subarachnoid hemorrhage, his subsequent electrocardiographic (ECG) complications have been noted (Baker et al, 1995).





Literature review and analysis of the Case Study


The case at hand indicates the scrutiny of a patient suffering from subarachnoid hemorrhage (SAH), which can play havoc with a patients neurological condition and can be fatal to an extent that its mortality rate is often recorded to be between twenty-five to fifty percent (Cook,2008). Every year almost ten percent of its victims die before reaching the hospital. This is a fatal type of stroke and survivors are reported to suffer from serious cognitive impairment and a permanent inability to lead a normal life (Bostwick and Sneade, 2001).


The aim of effective nursing management thenceforth is simple, i.e. to manage such a patient in a manner not only to ensure his life is saved but also prevent the morbid, complicated aftermath of the same which will include reducing the risk of future bleeding events and the likelihood of brain rupture(Brouwers et al ,1989).


The occurrence of SAH means rupture between and bleeding between the anchored matter and the cerebral surface and claims the health of fifteen out of every hundred individuals with in the United Kingdom every year (Lindsay and Bone, 2003). It is well known with in medical literature particularly that relating to nursing care that the nursing care of a SAH victim is a rather challenging task and involves the multifaceted issue of providing physical as well as moral support to the affected person who is now risking cognitive impairment for the rest of his or her life (Davies,2009). Therefore this paper will look at the nursing care of one such patient after the SAH attack. It must be remembered at the outset that such care involves not only care of a medical nature but also of a more personalized and rehabilitative paradigm (Cook et al, 2004)





In this vein the author seeks to promote a problem-focused approach based on the patients uneconomical and pathphysiological features (Davis et al, 2009). In the case study at hand the cause of the SAH was identified as one of the most typical ones, that is the one coming from the incidence and occurrence of cerebral aneurysm which translates into cerebral arteries malfunctioning possibly due to hypertension, smoking and excessive alcohol abuse(Fisher et al,1980). In addition to this the patient in the case study fell in the typical age group most commonly affected with the risks of SAH that is between the age groups of 35 to 60 years of age (Hamilton et al, 2008). Since SAH is a direct attack on the brain functions it will first and foremost impair the respiratory and cardiac functions of a patient. Infact in its early manifestations the SAH symptoms are likely to mimic cardiological disorders. Therefore, in line with good nursing practice and the NICE guidelines, it was felt necessary to monitor the ECG functions of the patient (Haley et al, 2002).



Since the Nursing profession plays a key role in care delivery, their actions have to demonstrate adequate aspects of evidence based practice (NMC, 2002) and clinical governance. With regard to the case study and from a practitioner nurse’s perspective it will be also be seen whether there was an effective application of urgent and unscheduled nursing care dispensed to the patient and whether enough co-operation was shown on behalf of the on duty nursing department. Unscheduled care has been in the code of conduct for the NHS and its guidelines a: “NHS care which cannot reasonably be foreseen or planned in advance of contact with the relevant healthcare professional, or is care which, unavoidably, is out with the core working period of NHS. It follows that such demand can occur at any time and that services to meet this demand must be available 24 hours a day.”(Unscheduled Care, 2008:1) There will also be a stress on the relevant issues of clinical governance and ethical considerations due to the fact that the patient Y whose case is being discussed was concealing certain current events of his life from his family, which could have been one reason for his worsening condition.


The effective role of the nursing department in this scenario would have entailed the early on prevention, early detention and correction of any early of occurring symptoms particularly if they were manifesting themselves as cardiological malfunctions (Hebert, 2001). An important aspect of the nursing care of SAH based neurovascular changes is the fact that more often that not ECG changes will tend to camufoulage themselves as ischemic heart disease (Barker, 2002). Patients are likely to suffer a higher QT prolongation and depression due to a high outflow of catecholamines in the early stage of such neurological disease (ibid.). Furthermore it is discernable from literature about SH and its symptoms that a few rare cases might even report hypertension during such abnormalities (Cook, 2008). It should be noted that even during   the early stages of subarachnoid hemorrhage (hereafter referred to as SH or SAH) there is likely to be a significant outflow of catecholamines which can lead to a very high BP (Blood Pressure) count for the same (Cook, 2008). This will however not always be matched with an occurrence of hypertension (Hunt, 1968).



In this case the aspects of management, confidentiality and clinical governance will also be dealt with. In addition to the above, it was observed with in the case study that aneurismal SAH mandates the use of two main types of intervention (Miyaoko, 1993). This would be to treat the surviving patient through either clipping or coiling (Cook, 2008). Endovascular coiling as advocated by Molyneux et al (2002) has now become a popular means of achieving mortality and morbidity. However recent academic opinion has indicated that there is still a controversy as to which one of these can be a better life saving technique in terms of its long-term effects. Coiling has, however, found support in the works of Wilkens et al (1996); more recently and the nursing decision taken to apply coiling to the anterior communicating artery in the nursing theatre was well supported by good practice (Zaroff et al, 1999).



It is also worth mentioning the application of the Glasgow Coma Scale (GCS) with regards to the nursing management of the patient. This is a standardized tool for the assessment of neurological functions post trauma for the SAH affected patient. A more thorough review of the same can be found in the recent works of Hickey (2009) who has supported a closer neurological and cardiological observation of the SAH patient during the nursing management of the affected.


It was observed by the nursing team that X was going through a traumatizing neurological and physical post recovery trauma including symptoms of confusion and drowsiness, which are typical of an SAH patient during recovery. This is mainly due to the altered chemical function of the cerebral type. According to the Nice Guidelines, these changes were recorded every two hours and due to the patient’s worsening condition ultimately in a quarter hourly fashion. From a nursing perspective where as ample use was made of clinical assessment tools like the World Federation Neurological surgeons scale (WFNS) (discussed in detail by Davies, (2009), which is essentially a variation of the Glasgow coma scale (GCS), it was also acknowledged that such scales often lack precision and often displays irregular variations.


Furthermore, these techniques may not always give a precise measurement of the SAH (Bostwick and Sneade, 2001) and independent monitoring was undoubtedly carried out in this case. Nonetheless in accordance with the 2003 NICE guidelines an effort was made to include the WFNS and GCS in the frequent monitoring of the patient at hand. Support can be found for such monitoring in the works of Addison (2001. Cook (2008) however warned against the use of the same in patients with tracheotomy. X in this case was not suffering from this condition but members of senior nursing management were asked to intervene during the assessment of the verbal response here.


Based on the advice of Cook (2008) the pupil movements of X were closely monitored to check his cerebral movements and brain response due to his sedated state (Fisher et al, 1980). Good nursing practice indicates that frequent monitoring of the changing size of the patients pupils and their reaction to light can confirm or negate an upcoming intracranial pressure (Hamilton et al, 2008)). It is possible to see from the case study that X’s sluggish and irregular pupil movements were immediately acknowledged and followed up with an immediate nursing response of having a CT scan done


In addition to the above since SAH gives rise to an acute headache pain relief was kept a priority for X and medicine was dispensed as a part of responsible nursing management accordingly. In this regard pertaining to dosage and administration, Hickey (2003) and Hunt (1968) have stressed upon Paracetomol as an effective remedy to be preferred over Morphine as that can cause massive cerebral deformation later on. This view has however been opposed by Herbert (2001).


In line with proper medical management the patient was administered with stool softening medication as the SAH affects bowel functions and movements and an SAH patient is generally also dehydrated like a typical stroke patient. (Young et al, 1999) Other interventions, which were carried out in order to ensure effective nursing management of X were to ensure that he was provided with a flat bed rest to avoid damage from blood pressure, based fluctuations. When Mr X was admitted to the unit nurses maintained a quiet atmosphere. The use of a flat bed has been however disputed in academic opinion and some commentators are of the opinion that a light 30% elevation can actually benefit the patient (Zaroff and Rordorf, 1999).


With in a few days X’s arms were noted to be getting weak and this was worse for the right arm. The nursing staff directed the patient to another CT scan and a narrowing of the cerebral blood vessels was revealed accordingly. Such a condition can cause ischemic deficit, Vasospasm and cerebral infarction if left untreated (Hickey, 2009). To deal with this the nursing department admitted X to the high dependency unit and he was administered Nimodipine tablets every four hours which is a necessary treatment for SAH treatments and is often continued for over a month post recovery (Hickey and Buckley, 2009)


As a part of effective nursing practice X’s BP was monitored regularly as it regulates in a SAH recovering patient can have serious connotations in terms of neurological malfunction (Davies, 2009). Based on the NMC (2009) and Youman’s (1996) opinion fluid replacement therapy was also continued to treat any lasting effects of dehydration and the nursing staff on duty accordingly monitored his fluid intake. Accordingly to avoid a case of Hyponatraemia due to mineral loss in the body appropriate medication was dispensed with the fluid intake (Barker, 2002)



Reflection and Conclusion


The occurrence of SAH can be an emotionally difficult time for a patient and his family. This can be improved by effective communication between the nursing staff and the patient’s family through a sympathetic and encouraging approach. The patient will suffer from self-esteem issues and an over all lack of confidence. The pith and substance of good nursing care lies in due vigilance.



Cultural and etiological issues are also of the greatest significance here. It should be noted that despite having a relatively healthy past few months the patient was having intense stress from financial difficulties after retirement. The author recommends a strong emphasis on an empathetic and responsible nursing approach to tackle such issues. Furthermore there was a strong issue of confidentiality involved here. It was not possible to let the family of Y know as was later found out by Police records that he was going through legal action for financial fraud, money laundering and possible drug dealing’s had kept this information secret from his family. When inquired about the cause of the SAH and stress the nurses duly kept this secret from the family according to the McKenzie (2002) guidelines, which define the concept of confidentiality within neurological patient care, and care generally, “as applied to information obtained by health professionals has ethical, legal and clinical dimensions…. (With) three basic ethical principles relating to confidentiality: autonomy, duty of care and

non-maleficience” (2002:1).


Furthermore, the NMC Code of Conduct (2004, para 5.1) requires medical staff of duty to “treat information about patients and clients as confidential, and use it only for the purposes for which it was given” (NMC, para 5.1) and that, “you must guard against breaches of confidentiality by protecting information from improper disclosure at all times” (NMC, Para, 5.1). It was decided that the ongoing litigation against Y, which he wanted to keep confidential, was not subject to disclosure under the NMC codes para 5.3 and 5.4 as there was firstly no informed consent or a matter of public interest involved here (para 5.3 and 5.4, NMC Code, 2004).



It has been observed through the case study that the role of the senior registered nurses and doctors is really important in promoting ethical steps to preserve the integrity and confidentiality of the patient. Also the senior nursing management should be able to take solid decisions at the earliest based on the observed symptom fluctuations and should have a clear subscription to proper diagnosis and treatment measures to erase all doubts about the proper nature of the patient’s condition in order to get them effective treatment.





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