Nursing care of a pediatric patient with traumatic brain injury

¶ … Nursing Process

Description of the Patient

LD is a 12-year-old female born on February 10, 994. She has four brothers, one is residing with his own family, while the other three are living with her along with her father and a sister at Massillon, OH. Her mother died of cancer in the spring of 2006. The family maintains a health insurance through the Golden Rule Insurance Company.

LD has not started menstruating yet. She has no known allergies. She has past medical record related to surgery - she undergone hip surgery in 2004 because her growth plates were not fusing. She has no history of sleeping problems (used to sleep at 10:00 or 11:00 in the evening) and maintains a regular diet. She is being home schooled, usually 7:30-3:45 PM everyday. LD acts older than her stated age. She enjoys indoor activities like working on a puzzle, watching movies, playing piano and sleeping. She has pets (3 cats and a dog). She seems a bit shy because she is very distant when she listens to other people to talk.

LD had a motor vehicle accident on September 8, 2006. She was ejected from the jeep into a patch of poison ivy. She spent one whole week in the surgical intensive care unit and was eventually admitted to the pediatric unit. When admitted, her vital signs were:

Temperature: 97.3°F

BP: 99/62

Pulse ox: 97%

Respirations

Apical Pulse

After the accident, LD is suffering from poor appetite, blurry vision and headaches especially when reading (which was dwindling within the last few days), nausea (which was caused by the Morphine in the ICU) and ptosis of right eyelid (which is related to traumatic brain injury). Her capillary refill is less than 3 seconds.

LD receives CT scans between 1:00 AM to 2:00 AM while in the hospital. Her CT scan results include:

September 2006: CT of the brain without contrast - 2mm depressed fracture on right anterior and mid-temporal bone with right middle cranial fossasubdural hematome. There is an extension of extra-axial fluid collection moving upwards into the right lateral frontal region as well as the presumably hemorrhage contusion in the left anterior temporal lobe. The fluid filling the sphenoid and right maxillary sinus suggests occult fracture with hemorrhage.

September 2006: CT cervical spine without contrast - Reversal of the normal cervical lordosis, which can be linked to the positioning and/or spasming; no fractures identified

12 September 2006: Single view of the lateral C-spine - No acute process seen at the C1-C6

18 September 2006: CT scan of the brain. The components of the right frontal lobe is unchanged in size - 2.4 cm in thickness

Blood tests conducted for LD shows abnormal results:

September 2006: Potassium - 2.9 Eq

September 2006: Glucose - 133; BUN - 60 mg/dL

10 September 2006: Glucose - 112

13 September 2006: Potassium - 3.0 Eq

16 September 2006: Glucose - 118

LD's current prescribed medications include:

Hydrocortisone 1% cream; 8 hourly (applied to the legs)

PRN: Acetaminophen 32mg/mL; 4 hourly

Zofran 4 mg IV 4 hourly (for the nausea)

Developmental Assessment

On Medical Results

The normal Glucose level is: 70-110 mg/dL (tested after fasting) while the average Potassium level is 3.5-5.0 mEq/L (http://www.bloodbook.com/ranges.html,2006). Thus LD has too much glucose and a below minimum potassium level. Bu this all can be attributed to the fact that she has not been eating well after the accident. Her sleeps are also not normal because she has not had a very good sleep. What is good with her results is that the latest tests conducted revealed that her results is becoming very close to the normal levels.

On Behavior

LD has been showing signs that she is different as compared to other girls or children with the same age. It must be noted that with her age (12 years old), it is normal to have certain issues regarding competence or inferiority. Children who are under the age of 6-12 are learning to make things, use tools, and acquire the skills to be a worker and a potential provider. These, they all do while making the transition from the world of home into the world of peers (http://psychology.about.com/library/weekly/aa091500a.htm,2006). However LD has no significant peers of her age.

LD is just being home schooled. The only friends that she can talk about are her only sister and/or the family friends from the church. She has low interaction when it comes to children of her age. She is always at home, playing with her indoor games or with her pets. This also could be the reason why she seemed a bit distant when talking with other people. She seemed not used to be with other people and thus she show signs of low self-esteem.

Meanwhile, if seeing LD as an adolescent (which usually happens to the children under the age 12-18), LD is also different from the other adolescents under this stage. It must be noted that this phase of life (adolescence), issues regarding identity and role confusion usually arises. This is the time when the adolescent integrate the healthy resolution of all earlier conflicts. Adolescents who have successfully dealt with earlier conflicts are ready for the "Identity Crisis," which is considered as the single most significant conflict a person must face (http://psychology.about.com/library/weekly/aa091500a.htm,2006). However, guidance from the older person is very important for a kid to successfully overcome such confusion.

The best possible source of guidance is the parent, and since LD is a girl, a mother is the best possible source of guidance for her. Since LD's mother just died, she has no one to look up to when it comes to 'girl things'.

Hence, LD's peculiar behavior can all be attributed to her situation wherein she has not had any chance of interacting with other children her age and her lack of mother whom she can turn to.

Planning and Implementation

Nursing Action

Nursing intervention with regards to the foods to be served to LD will be done every meal. The nurses should also notify the parent, siblings and other friends or relatives who will visit LD (and who will bring some foods for her) about the kind of diet that LD should be having. Every time the nurses will check and visit LD, these people will always be reminded about the said diet and food intake.

The nurse' intervention regarding the suggested activity of listening to music instead of reading will be done immediately. If it has been done, the nurse will then check from time to time if LD still suffers from blurry vision and headaches (even if she has gradually stopped reading or over using her eyes).

List of References:

Blood Test Results - Normal Ranges," (2000) [online] http://www.bloodbook.com/ranges.html

Erikson's Eight Stages of Human Development." 2005. About.com. 30 September 2006. http://psychology.about.com/library/weekly/aa091500a.htm

Selekman, Janice (2000) "The State of the Art of Pediatric Nursing." Department of Nursing, University of Delaware, Newark, DE. Jannetti Publications, Inc.