Question

your patient is a 78-year-old female admitted to the neurology unit via the emergency department for observation and pain Management of worsening headache related to a fall 4 days ago what are your primary concerns for this patient and what assessments and interventions would be associated with your concerns and why

Answer 1

In the above question, the problem of the patient is worsening headache after fall 4 days ago. here our responsibility is to identify the primary concern by assessing the patient and treat the patient accordingly.  

• primary concerns related to the patient condition: increased ICP(intracranial pressure), hematoma, to rule out meningitis and tension headache.which might be the cause of worsening headache in patient.
• assessment of the patient to rule out the cause and prognosis of headache:

1. health assessment and physical examination to rule out cause of head ache:

• it includes asking the patient about type of head ache (sinus, tension or pressure feeling)
• any history of vomiting after fall.(present in increased ICP)
• inspection of pupils.(pupils will be constricted in increased ICP)
• inspection for battles sign, raccoon eyes ( Indicates head injury)
• assessing Cushing's triad,(Hypertension and widening pulse pressure (the difference between the systolic and diastolic BP), Bradycardia, Bradypnoea(an indication of increased ICP)
• assessing for nuchal rigidity,kernigs sign,brudzinskis sign. (An indication of meningitis)

2. investigation to find out the cause.

• ICP monitoring is done through intraventricular catheter. (which gives the reading of ICP which helps to identify the reason).
• CSF(cerebro spinal fluid analysis): if blood present it may indicate bleeding from the cranial vault which indicates increased ICP.
• BLOOD AND CSF culture to rule out meningits.
• Computerised Tomography and Magnetic Resonance Imaging: This gives a fair idea about tumors , hematoma.
• neurological assessment to find out other problems.

3. Intervention:

• paracetamol for pain management.
• Limit fluid intake to 1200 mL/day.( to decrease ICP)
• Instruct the client to avoid straining activities, such as coughing and sneezing.( to avoid raise in ICP)
• Instruct the client to avoid Valsalva’smaneuver. (to avoid raise in ICP)
• For the client with increased ICP, elevate the head of the bed 30 to 40 degrees, avoid the Trendelenburg position, and prevent flexion of the neck and hips. (to avoid raise in ICP).
• Provide calm and dim light environment to avoid raise in ICP.
• Antibiotics if the cause is meningitis or if any infection present
• INJ.MANNITOL to be infused on regular basis until ICP decreases.
• if the medical management is not working surgical management is needed which includes Ventriculoperitoneal Shunt: A ventriculoperitoneal shunt diverts cerebrospinal fluid from the ventricles into the peritoneum.
• surgical management if there is haematoma which is removed by craniotomy,
• surgical removal of tumors if present.