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Acute Care Case Study Analysis: Differential Diagnoses
Eye Socket Fracture
According to the details of the case, the patient has eye swelling. The identified information may imply that there is a possibility of an eye socket fracture. The specified type of injury is quite common in car crashes (Wang, Lim, & Teng, 2017). Therefore, the problem needs to be investigated closer.
Wound Hematoma
Seeing that the surgical dressings were saturated heavily with fresh blood, it could be assumed that the patient may suffer from wound hematoma. The latter is typically defined as a collection of blood and clot in the patients wound and is fraught with numerous negative effects.
Intracerebral Hematoma
Furthermore, since the patient has been suffering from hemorrhagic contusion, there is a threat of intracerebral hematoma development. Seeing that the problem is likely to affect the brain tissue, immediate measures must be taken. Therefore, detailed guidelines for testing must be provided.
Questions: Confirming the Final Diagnosis
At present, the intracerebral hematoma seems to be the most likely diagnosis. Therefore, it is crucial to make sure that the necessary tests should be run to determine the correctness of the assumptions. The following questions will have to be asked to confirm it:
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Has there been a penetrating head trauma?
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Is there swelling around the wound?
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Are there clots that prevent blood from circulating?
Answering the identified questions will help one determine whether the initial diagnoses are correct. Particularly, the information to be provided once the identified questions are answered will serve as the foundation for determining whether the intracerebral hematoma can be crossed out the range of problems that the patient currently has, or whether the issue will have to be addressed in a timely and efficient manner.
Risk Factors for the Final Diagnosis
It should be noted that there are several risk factors that may complicate the process of diagnosis. For instance, when considering the possibility of the intracerebral hematoma, one must keep in mind that swelling may be caused by other factors. Therefore, other aspects of the problem will have to be taken into account so that the possible issue could be determined with high precision and accuracy.
Furthermore, when determining whether the patient has an eye socket fracture, one will have to consider the possibility of X-rays failing to provide clear identification of the problem. Therefore, an in-depth analysis of the case will have to be carried out.
Finally, determining the presence of a wound hematoma, a nurse must bear in mind that the identified issue may be confused with the extension of parenchymal bleeding into the identified brain areas. As a result, the process of diagnosing maybe not only complicated but jeopardized, with the threat of inaccuracy increasing (Kinon, Nakhla, Brown, Bhashyam, & Yassar, 2016).
Adult-Gerontology Patients: Difference
In gerontology patients, the issue would likely manifest itself in the same way as in a younger population. For instance, inflammatory issues will have to be managed so that the patients health could be improved.
It should be noted that, in adult patients, hypertension issues may trigger a rapid aggravation of the problem, thus, requiring immediate management of the problem. Therefore, keeping track of the changes in the patients well-being and the overall health status is imperative so that the slightest deviations from the expected norm should be registered and managed immediately.
Labs, Diagnostics, and Clinical Tests
To determine the presence of intracerebral hematoma, one should consider using MRI as the key test. MRI will provide an opportunity to examine the patients brain tissue very closely, therefore, detecting the instances of possible intracerebral bleeding.
Specialists, Departments, and Healthcare Providers
It is imperative that neurosurgeons should be involved in the management of the patients needs.
Problem List and Rationale
Among the essential issues that need to be addressed at present, the following problems must be listed:
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Intracerebral hematoma;
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Eye socket fracture;
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Wound hematoma.
Each of the conditions poses a serious threat to the patients well-being, which means that adequate measures for managing the associated risks must be provided.
Final Diagnosis: EBP Plan of Care
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Carrying out regular neurological examinations of the patient (i.e., MRIs, consultations with the healthcare team, etc.);
Rationale: the slightest change in the patients neurological state may trigger significant consequences.
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Maintaining a consistent dialogue with the neurosurgery department;
Interdisciplinary communication is crucial due to the multiple complexities that the case incorporates.
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Taking the patents vitals on a regular basis;
The patient is currently in an extremely severe condition, which means that every change must be addressed accordingly.
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Monitoring the changes that occur to the patient (electrolyte analysis).
The electrolyte analysis will allow preventing possible complications.
Admission Orders
Intracerebral Hematoma, Eye Socket Fracture, and Wound Hematoma (Possible)
Age: 60 years
Gender: Male
Admitting diagnosis: Intracerebral Hematoma
Condition: critical
Nursing: checking vital signs every hour
Medications: Warfarin 5mg by mouth daily, Levothyroxine 50mcg PO Q day, Flomax 0.4mg by mouth Qday
Consult: neurosurgery experts
Patients Needs
At present, the patient requires consistent monitoring carried out by a nurse. Furthermore, the issue regarding the possible intracerebral hematoma needs to be addressed. Particularly, the necessary tests must be taken.
In other words, it is crucial that the changes in the patients state should be registered carefully, and that adequate responses to these changes should be provided in a timely and efficient manner. For this purpose, nurses must watch the patient closely, taking the necessary tests (e.g., the blood test) within the required time periods. The nurses schedule should be managed in the way that will allow avoiding workplace burnouts. Thus, the premises for reducing the number of errors made in the course of analyzing the test results, the patients responses, etc., will be driven to a minimum (Mendelow et al., 2015).
Health Promotion Services
Environmental
It is crucial that the patient should not be disturbed by loud noises. Thus, the sedation will be effective. Although family visits should be allowed, a nurse must instruct the family members about the necessity to maintain a calm and quiet environment in the ward so that the patients needs could be met successfully.
Furthermore, the nurses should carry out the necessary interventions in the way that will not disturb the patient. Put differently, the staff members will also require extensive guidelines about how the patients case must be handled. As a result, the foundation for a recovery can be created.
Nutritional
The patient must be provided with essential nutrients. For this reason, enteral feeding should be considered. Thus, the patient will receive the required nutrients. The use of enteral feeding will help make sure that the patient should be provided with the support that will help him recover faster (Sabir et al., 2015).
References
Kinon, M. D., Nakhla, J., Brown, K., Bhashyam, N., & Yassar, R. (2016). Ultra-delayed lumbar surgical wound hematoma. Surgical Neurology International, 7(S1089-9), 1089-1091.
Mendelow, A. D., Gregson, B. A., Rowan, E. N., Francis, R., McColl, E., McNamee, P., & Mitchell, P. M. (2015). Early surgery versus initial conservative treatment in patients with traumatic intracerebral hemorrhage (STITCH[trauma]): The first randomized trial. Journal of Neurotrauma. August, 32(17), 1312-1323.
Sabir, S. H., Armstrong, R., Elting, L. S., Wallace, M. J., Gupta, S., & Tam, A. L. (2015). Microglial polarization and inflammatory mediators after intracerebral hemorrhage. Molecular Neurobiology, 54(3), 1874-1886.
Wang, S. H., Lim, C. C., & Teng, Y. T. (2017). Airbag-associated severe blunt eye injury causes choroidal rupture and retinal hemorrhage: A case report. Case Reports in Ophthalmology, 8(1), 13-20. Web.
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