Review the subjective and objective data sets provided in the 3 cases. You are to construct a subjective and objective data set for each case that demonstrates your knowledge of how to construct problem focused subjective and objective data sets.
Document your 3 subjective and objective data sets in a Word file.
CASE STUDY 2
Patient Scenario-1
Two individuals come to the emergency department with head injuries. One, 25 years old, has
just been in a motor vehicle accident (MVA) and has a temporal lobe injury. The other, 65 years
old, has increasing confusion after a fall that happened earlier in the week.
Extradural Hematoma vs Subdural Hematoma
McCance and Huether (2014) define extradural hematomas as 1% to 2% of major head
injuries, common in 20 to 40 year olds. Bleeding is located between the dura mater and skull.
The most common mechanism for extradural hematomas to occur is a result of motor vehicle
accidents (MVAs) with 90% being caused by temporal fracture and the temporal fossa being the
primary location. In 85% of extradural hematomas an artery is the main culprit for bleeding.
“The resulting shift of the temporal lobe medially precipitates uncal and hippocampal gyrus
herniation through the tentorial notch” (p. 585). Those with extradural hematomas initially lose
consciousness then have a lucid time period for a few hours to a day or two after depending on if
the bleeding is arterial or venous. During that lucid time is when the bleeding is increasing. This
is ultimately followed by severe headache, drowsiness, nausea, vomiting, potentially seizures,
and confusion (McCance & Huether, 2014). If the patient is not treated in time, herniation
followed by death can occur.
Subdural hematomas account for 10% to 20% of traumatic brain injuries. The most
common cause is motor vehicle accidents (McCance & Huether, 2014). In older adults, falls can
be linked to chronic subdural hematomas. Additionally, subacute hematomas can develop slower
over the course of two days to two weeks. Chronic hematomas develop over two weeks to two
months. Subdural hematomas are a result of venous blood occurring between the dura mater and
arachnoid mater (McCance & Huether, 2014). Depending how many veins are torn will depend
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CASE STUDY 3
on amount of bleeding. When bleeding begins, the blood will begin to compress the brain and
cause the intracranial pressure (ICP) to increase. As the ICP increases, the bleeding veins are
compressed eventually slowing the bleeding. Symptoms include headache, drowsiness,
confusion, slowed cognition and generalized rigidity (McCance & Huether, 2014).
Most Emergent Patient
The patient requiring immediate emergency surgical intervention would be the 25 year
old. This is in part due to the fact of extradural hematomas primarily come from the artery
causing rapid bleeding. McCance and Huether (2014) report the prognosis to be good prior to
bilateral dilated pupils noted. The authors also note these hematomas to be medical emergencies
almost always. This is not to say the 65 year old patient doesn’t need an intervention. They most
likely will due to becoming symptomatic. However with the subdural hematoma most likely
being venous it is a slower bleed than arterial. Additionally, with the fall occurring earlier in the
week and more recently developing increased confusion, he has the potential of remaining more
stable than the 25 year old patient.
Patient Scenario 2
A 38 year old was driving his 1970 Chevy Corvette to a Milwaukee Brewers baseball game when a deer jumped out in front of him on the highway. He swerved his car and hit a telephone pole instead. His head hit the windshield and he suffered severe head trauma.
Type of Head Injury
The patient ultimately suffered a focal traumatic brain injury, more specifically a coup
and contrecoup brain injury. Upon hitting his head, it threw his head forward hitting the
windshield (coup). This was then followed by his head going backward (contrecoup). “The focal
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CASE STUDY 4
injury may be a coup injury (directly below the point of impact) or contrecoup (on the pole
opposite the site of impact)” (p. 583).
Treatment Plan
Treatment will depend on how much injury occurred. According to the Mayo clinic
(2019), there is usually no treatment for mild traumatic brain injuries other than rest and pain
relievers. It is recommended, however, for the patient to be monitored and watched for
worsening symptoms. For moderate to severe injuries, it’s crucial to prevent further injury to the
head or neck and also to maintain sufficient blood supply and blood pressure. Additionally,
further treatment may be needed (Mayo Clinic, 2019). This could involve surgery to remove and
stop bleeding in the brain or repairing skull fractures. Medications such as diuretics, anti-seizure
medications and coma-inducing drugs to allow the body to rest may also be indicated. Lastly,
treatment for the patient may include rehabilitation. Specialists this may include are psychiatrist,
occupational therapist, physical therapist, speech pathologist, neuropsychologist, rehabilitation
providers and recreational therapist (Mayo Clinic, 2019).
References
Mayo Clinic. (2019). Traumatic brain injury: Diagnosis and treatment. Retrieved from
https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/diagnosis-
treatment/drc-20378561
McCance, K. & Huether, S. (2014). Pathophysiology: The biologic basis for disease in adults and children. 7th Edition. Elsevier Mosby: St. Louis, MO.
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