NUR356 Complex Care Case Studies Homework Answer

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Question :

NUR356 Complex Care Case Studies 2021

Case Study

Jenny is a 37 year old female who has been admitted to the ward for a cholecystectomy.

On her return to recovery, Jenny is noted to be in pain, and she was prescribed Morphine 2.5 - 5 mg Intravenously (IV) on the PRN side of her medication chart. She was given an initial dose of 5mg IV.

3 minutes after having the morphine administered, Jenny starts to feel unwell and is short of breath, she also states she feels itchy and feels like her tongue is swelling. She is noted to have a rash that has suddenly appeared over her chest and upper back. The doctor attends and verbally requests 'point 5

of adrenaline' to be given. The RN on duty gives 5mL of adrenaline 1:10,000 IV.

The patient suddenly complains of severe, crushing chest pain before losing consciousness and suffering a cardiac arrest. The patient is resuscitated and survives the event, however will have cardiac issues for the remainder of her life.

Questions related to the case study

Questions surrounding the case study

Question 1 - Looking at this case study, which of the mistakes could have been prevented and why? (3 Marks)

Name each mistake and evidence using current literature how it could have been prevented. Reference your work.

Question 2 - Was the doctors request for 'point 5 of adrenaline' a valid request? (2 marks)

Argue your decision and refer to legislation

Question 3 - Was the nurse at fault for giving the adrenaline through the IV route? (3 Marks)

Argue your decision and refer to legislation

Question 4 - Describe the most likely cause of Jenny's cardiac arrest? (2 Marks)

How did you come to this conclusion? support your argument with literature

Airway and Breathing

Case Study

PLEASE READ THE CASE STUDY CAREFULLY AND COMPLETE THE QUESTIONS ON THE FOLLOWING PAGES

Atsuto is an 80-year-old Japanese man who has lived in Australia for 25 years. He speaks limited English and lives with his wife and two sons. Both sons were born in Australia and attend university. Atsuto used to work at the Sydney Fish Market until his retirement some 10 years ago. Since then he has kept busy with his small garden in the inner suburb of Sydney. His enjoyments in life are talking with his sons, gardening and sitting on the front veranda smoking cigarettes. He does not drink alcohol but does smoke about one and a half packets of cigarettes a day and has done so since he was 17.He was diagnosed with emphysema when he was 62 caused by his smoking. His father died from lung cancer when he was 45 years old and his mother died from coronary artery disease 15 years ago. Both of his brothers also have coronary artery disease and chronic obstructive pulmonary disease (COPD). Atsuto was diagnosed about 20 years ago with hypertension and 8 years ago with COPD.

His current medications are:

  • Quinapril 40 mg b.d.
  • Frusemide 20 mg b.d.
  • Atorvastatin 10 mg b.d.
  • Salbutamol 200 mcg every 4 hours when required.
  • Prednisolone 20mg b.d

Pathophysiology

Atsuto has lately been experiencing a persistent cough throughout the day. This cough is producing large amounts of tenacious green sputum. He has also been experiencing increased breathlessness, which he has been noticing as he tries to work in the garden. His wife notices that his appetite is not what it used to be and that his clothes no longer fit very well. He is looking thinner than previously. Atsuto’s sons notice this too and encourage him to go to the doctor. The oldest son, Kabuto, volunteers to go with him to act as a translator. Atsuto, his wife and Kabuto go to the doctor. Kabuto is able to translate for the doctor. They tell the doctor that Atsuto has been getting increasingly out of breath. He can’t work as fast as he used to. His cough has been getting worse and producing more sputum. On examination the doctor finds the following:

  • BP 155/80
  • Pulse 100
  • Respiration 28
  • SP02 94%
  • Temperature 37.8°C
  • Auscultation of the chest: widespread expiratory wheeze with reduced air entry on both sides

The GP has recommended Atsuto be admitted to a respiratory ward for further assessment, CXR and continued management. Atsuto was taken to hospital by his son where he has been admitted for the past 24hrs. Following a CXR Atsuto has been diagnosed with exacerbation of COPD caused by left lower lobe pneumonia.

Question 1- (6 marks)

Discuss in detail the pathophysiology of emphysema and how this is related to COPD. How is this related this to Atsuto's current condition as described above, support your discussion with evidence from literature

Question 2 - (4 marks)

Identify the clinical manifestations of COPD presented by Atsuto. Discuss if Atsuto is having an exacerbation of COPD and justify your discussion with evidence.

Question 3 - (4 marks)

Explain the single most effective intervention to reduce the progression of COPD and why.

Question 4 - (6 marks)

What is the likely progression of Atsuto's disease and why? Discuss management strategies for Atsuto's condition and how you would evaluate the effectiveness of his treatment.

PharmacologyAtsuto has regular medications prescribed by his GP:

Quinapril 40 mg b.d.

  • Frusemide 20 mg b.d.
  • Atorvastatin 10 mg b.d.
  • Salbutamol 200 mcg every 4 hours when required.
  • Prednisolone 20mg b.d

In addition to this, since his admission to the respiratory ward he has also been prescribed the following: Ipratropium Bromide 500mcg NEB TDS

Amoxcillin 1G IV TDS Paracetamol 1G PO QDS

Question 1 (2 Marks)

Atsuto is has been prescribed Frusemide. Discuss the pharmacodynamics of frusemide and the indications for this medication in relation to this case.

Question 2 (3 Marks)

Discuss the indications for Paracetamol being prescribed and provide an argument as to why this should or should not be prescribed. Provide evidence for your argument including an alternative drug if indicated.

Question 3 (3 Marks)

Discuss the pharmacodynamics and pharmacokinetics of amoxicillin and if it is appropriate for this patient. Provide justification for your discussion

Question 4 (2 Marks)

Choose 2 of the medications Atsuto is taking and explain, in lay terms, to Atsuto the adverse effects of these medication and when he should seek help.

Circulation

Case study

PLEASE READ THE CASE STUDY CAREFULLY AND COMPLETE THE QUESTIONS ON THE FOLLOWING PAGES

Rainey is a 64-year-old woman of Maori descent who has been married for 42 years and has two grown- up children. Both of Rainey’s parents died when they were in their mid-60s of ‘heart attacks’. Two of her four brothers have had heart attacks and have high blood pressure, and her remaining uncle has had ‘two heart attacks and a stroke’. Rainey leads a sedentary life and her diet is moderately high in fat and sugar. Rainey is 162cm Tall and 105KGs. Her body mass index (BMI) is 40 and her waist measurement is 101 cm.

Rainey began experiencing central chest pain radiating to her back and neck after walking up stairs at the shopping centre. She was short of breath and sweaty and sat down clutching her chest. Her daughter was with her who called an ambulance and that arrived after 5 minus and took her to ED

Pathophysiology

Question 1 (3 Marks)

Identify what you believe is occurring from a clinical diagnosis perspective and link your answer to the associated pathophysiological processes.

On presentation to the paramedics, Rainey's observations were:

BP 178/92 HR 128

RR 26

SP02 97%

Paramedics inserted a 12G cannula in her Right ACF, connected her to a cardiac monitor whilst constantly reassuring her and advising he of which hospital they were taking her to.

Question 2 (4 Marks)

Should the paramedics have applied supplementary oxygen? Discuss your answer and with evidence from the literature.

Question 3 (6 Marks)

On arrival at ED, Rainey was connected to the cardiac monitor, a 12 lead ECG was taken and bloods were taken for FBC, U&E, Troponin and Triglycerides. The ED team began treating Rainey with a preliminary diagnosis of ACS.

Discuss the pathophysiology of ACS and based on Rainey's presentation and underlying pathophysiology describe what the potential diagnosis/diagnoses you believe she may have.

Question 4 (4 Marks)

Discuss the pathophysiology of cardiac cell damage associated with ACS

Question 5 (3 Marks)

Identify and briefly discuss the 3 structural and functional changes that occur in myocardial infarction

Pharmacology

When on route to ED, Rainey was administered 5mgs IV Morphine:

Question 1 - When on route to ED, Rainey was administered 5mgs IV Morphine. (2 Marks)

Discuss the pharmacodynamics of Morphine and why it was administered in this case over other analgesia

Rainey has been prescribed the following medication:

Aspirin 300mgs PO

Glyceryl Trinitrate IV infusion 50mgs/50mls at 5mcgs/min

Question 2 - Pharmacodynamics (2 Marks)

Discuss the pharmacodynamics of these two medications using evidence from the literature to support your discussion. Also, identify how you would describe to Rainey (in layman's terms) how these work on her body

Question 3 - Indications (2 Marks)

Discuss using the literature, what are the indications are for these medications and what considerations you would make in relation to Rainey's case

Question 4 - Contraindications (2 Marks)

Describe the contraindications these medications. Is there any reason why Rainey should not be on these medications? Explain why/why not. Support your conclusions with evidence from the literature

Question 5 - Adverse effects (2 Marks)

Explain to Rainey the adverse effects of this medication and when she should seek help.

Case study

PLEASE READ THE CASE STUDY CAREFULLY AND COMPLETE THE QUESTIONS ON THE FOLLOWING PAGES

Lydia Schwartisky is a 23-year-old woman from rural Western Australia who was involved in a head-on car incident with another car. She did not have any passengers and the driver of the other car was killed instantly. On arrival at the scene, the ambulance noted that Lydia was unconscious, had a strong pulse and even respirations, with pupils equal and reacting. Lydia was airlifted to a tertiary referral hospital in Perth. On arrival in the emergency department two hours after the incident, she was classified as ATS 1.

Primary and secondary surveys were completed by the resuscitation team. These were some of their findings:

  • Temperature 37°C, pulse 98, respirations 20, oxygen saturation 100%
  • Incomprehensible words
  • Pupils: equal (5 mm) and sluggish
  • Motor: bilateral upper and lower abnormal flexion
  • Eyes open to pain only

The team intubated Lydia, attached a portable ventilator, reinserted the intravenous cannula that the ambulance officers had put in, inserted a urine catheter and accompanied her to have a CT scan. The CT without contrast showed a significant right subdural haematoma (SDH), cerebral oedema and an intact C- spine.

Lydia was continually monitored in the emergency department. Blood was taken for a full blood examination, as well as for arterial blood gases. The neurosurgeon decided that an urgent craniotomy was required to evacuate the SDH. Consent for the operation was given by Lydia’s parents, who were travelling to Brisbane after being told the news of their daughter’s car incident. When Lydia arrived at the operating theatre, the nurse reassessed Lydia’s GCS score. It had dropped to 6. There was no longer any response from Lydia. In addition her right pupil was sluggish in its response to light. A right hemicraniotomy was performed to evacuate the right subdural haematoma. This entailed the removal of a bone flap and the opening of the dura to remove the haematoma, followed by the replacement of the bone flap (Brown & Edwards 2011:1613). The operation took place within four hours of the incident. This timeliness gave Lydia the best chance of functional survival (Wilberger, Harris & Diamond 1991). An intraventricular catheter was also inserted to monitor the intracranial pressure (Brown & Edwards 2011:1595, Figure 56.8).

Pathophysiology

Question 1 (3 Marks)

Discuss the pathophysiology of a Sub Dural Haemorrhage (SDH)

Question 2 (4 Marks)

Discuss why it is important to measure intercranial pressure (ICP), justify your discussion with evidence.

Question 3 (6 Marks)

Discuss the pathophysiology relating to brain herniation including the clinical manifestations

Question 4 (4 Marks)

Describe to Lydia's parents what a normal ICP is and what the doctors mean when they discuss the possibility of brain herniation.

Question 5 (3 marks)

What angle should Lydia's head be kept at, and why - describe the pathophysiology related to this.

Pharmacology

Lydia is prescribed the following medications: Mannitol 0.25g/kg

Phenytoin 15mg/kg

Question 1 - (2 Marks)

Describe to Lydia's parents (in layman's terms) the Pharmacodynamics how the above 2 medications work on her body and why she is on them.

Question 2 - (2 Marks)

Discuss the pharmacokinetics of Mannitol and why it is used in patients with TBI

Question 3 - (4 Marks)

Describe the contraindications for the 2 medications Lydia has been prescribed. Discuss if there Is there any reasons why Lydia should not be on these medications? Justify your answer with supporting literature.

Question 4 - (2 Marks)

As the RN caring for Lydia, what are the adverse effects you should be looking out for in Lydia, remembering she is sedated and ventilated and describe what might you see if your patient can't tell you about these adverse effects?

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Answer :

CASE STUDY

LAW AND ETHICS

Question 1 - Looking at this case study, which of the mistakes could have been prevented and why? 

Name each mistake and evidence using current literature on how it could have been prevented. Reference your work.

In this case, cardiac arrest condition among Jenny can be prevented so that further complication can be prior managed. Here, the nurse had committed the first mistake that before administering Morphine I/V, the nurse did not check Jenny's vital signs. As per guidelines, the patient's vital parameters, including blood pressure,  heart rate, respiratory rate and oxygen saturation, and pain rating, have to be assessed before, during and after administration of drug morphine. It has been estimated that a nurse requires 2 minutes for collecting baseline data of a patient or pain levels. 

Secondly, she administered an injection in 3 minutes. However, it has been studied that a total time of 7.9 minutes required for morphine preparation and drug administration, 3.7 minutes needed as it is also recommended in the label of Morphine that time that approx 4 to 5 is advised for administration (Casamayor et al., 2018).

Question 2 - Was the doctors request for 'point 5 of adrenaline' a valid request? 

Argue your decision and refer to legislation

As per Jenny, the anaphylactic reaction after morphine administration adrenaline request followed by ABC management is appropriate. As per the medication guidance point, five adrenaline is 1:1000 for intramuscular is recommended for adults (50- 100 kg weight) (Anaphylaxis wall chart. (Victorian agency for health information, 2021).

Question 3 - Was the nurse at fault for giving the adrenaline through the IV route? 

Argue your decision and refer to legislation

Yes, the nurse was at fault. She diluted adrenaline in 1:10000, recommended in children of weight up to 25 kg as per medication guidance. Therefore, she diluted the drug inappropriately, which effected the drug outcome (Victorian agency for health information, 2021).

Question 4 - Describe the most likely cause of Jenny's cardiac arrest?

How did you come to this conclusion? support your argument with literature

The most common side effect of morphine drug is respiratory depression, leading to sudden hypoxia and respiratory arrest. Here, Jenny expressed symptoms of anaphylactic reaction itching, tongue swelling, breathing difficulty etc., after morphine administration. It has been studied that Morphine may induce myocardium depression resulting in bradycardia and decreased cardiac output (Agewall, 2017). 

Case 2

Airway and Breathing

Pathophysiology

Question 1-Discuss in detail the pathophysiology of emphysema and how this is related to COPD. How is this relatedthis to Atsuto's current condition as described above, support your discussion with evidence from literature

Cigarette smoking around 1.5 packets per day since age 17 is the main cause of emphysema in Atsutos case. Smoking releases noxious gases, which are harmful to the respiratory tract. The harmful compounds from cigarette smoke may harm the walls of alveoli through the process of apoptosis, imbalance anti-protease and oxidative stress, which results in the condition emphysema, may effect and causes inflammation in bronchiole, alveolar sacs and alveoli structure of respiration and results into the dilatation and damage to the air wall and reduces the surface area of in alveoli for the gaseous exchange and results in the hypersecretion of mucus (Hikichi et al., 2019). Moreover, due to his smoking, the production of alveolar macrophages and anti-proteolytic enzymes also get inhibits and results in respiratory infection showing symptoms of productive cough and tenacious green coloured sputum. Hence, it results in COPD and leads to impaired lungs function (Bartolome et al., 2018).

Question 2- Identify the clinical manifestations of COPD presented by Atsuto. Discuss if Atsuto is having an exacerbation of COPD and justify your discussion with evidence.

According to subjective data obtained that he is progressively reducing his weight, appetite also decreases and having shortness of breath. As per his obtained objective data, he has elevated vital signs: blood pressure (systolic) is high 150/ 80mmhg, respiration rate 28 breaths/ minutes, the pulse is 100 beats/ minutes. Hence, Atsuto has evidence of the progressive disease characterized by changes in his baseline information that are found to be beyond normal values in his day-to-day variations, representing acute changes of COPD (Hikichi et al., 2019) as his respiratory tract is inflamed and shows increased cough and sputum production that indicates exacerbation of COPD (Crisafulli et al., 2018).

Question 3 - Explain the single most effective intervention to reduce the progression of COPD and why.

As per Atsuto clinical symptoms, inhalation of steroid therapy or oral intake of 30–40 mg of prednisolone per day for 10–14 days will be effective. In this case, neutrophils are inflamed due to COPD and eosinophils level also increases, resulting in more sputum production. Corticosteroid has an effective role as anti-interleukin (Henriksen et al., 2020; Brandsma et al., 2020). Furthermore, steroid treatment helps in improvements in the quality of life of Atsuto.

Question 4 - What is the likely progression of Atsuto's disease and why? Discuss management strategies for Atsuto's condition and how you would evaluate the effectiveness of his treatment.

According to the collected information, Atsuto is experiencing shortness of breath (hypoxia), resulting in dilation of blood vessels in systemic circulation and constrictions among the blood vessels of the vascular bed. His family history of cardiac disorders and smoking is correlated with his current progressive COPD and emphysema reflected as high blood pressure. 

Along with the treatment of COPD, emphysema preventive management of cardiac diseases is also required. As per management strategies following treatment is suggested:

Statins therapy is useful for the reduction of serum cholesterol levels (Trinkmann et al., 2019). Beta-blockers may be suggested for the management of high blood pressure (André et al., 2018)

Cessation of cigarette smoking is helpful as prevention (Liang et al., 2018).

Airway and Breathing

Pharmacology

Question 1- Atsuto is has been prescribed Frusemide. Discuss the Pharmacodynamics of frusemide and the indications for this medication concerning this case.

Atsuto has been prescribed frusemide 20 mg twice a day. Frusemide is a loop diuretic that complements the action of the prescribed Quinapril because both drugs are antihypertensives. Quinapril can cause hyperkalemia which Frusemide can counterbalance. It reduces BP by reducing blood volume and can also increase the excretion of Potassium which will reduce the chances of hyperkalemia due to the Quinapril.

Frusemide inhibits NaK2Cltransporters in the epithelial membrane in ascending loop of Henle and reduces the Nareabsorption, which reduces the blood volume, thereby reducing the BP (Whelton et al., 2018).

Question 2-Discuss the indications for Paracetamol being prescribed and provide an argument as to why this should or should not be prescribed. Provide evidence for your argument, including an alternative drug if indicated

This patient has no history of hepatic impairment, and also, he is not consuming alcohol, so there is a contraindication for Paracetamol in this patient. So, Paracetamol can be prescribed as a pain-killer.

But this patient has also been prescribed prednisolone, a corticosteroid and a strong anti-inflammatory, antipyretic and analgesic (Puckett et al., 2020). So in this patient, Paracetamol should not be prescribed. 

Question 3-Discuss the Pharmacodynamics and pharmacokinetics of amoxicillin and if it is appropriate for this patient. Provide justification for your discussion

Pharmacodynamics of amoxicillin: Amoxicillin is an aminopenicillin which belongs to the beta-lactam group of antibiotic. Amoxicillin is a broad-spectrum antibiotic. Amoxicillin inhibits an enzyme transpeptidase and prevents cell wall synthesis (Zamoner et al., 2016).

Pharmacokinetics of Amoxicillin: 

Absorption:- Amoxicillin has good oral absorption. Food does not interfere with absorption. It is well absorbed in the systemic circulation and achieves good plasma concentration.

Distribution: It easily diffuses into the tissues and body fluids and usually does not cross the blood-brain barrier (Zamoner et al., 2016).

Metabolism: It is mainly metabolized in the liver.

Excretion: It is excreted in the urine.

Question 4-Choose 2 of the medications Atsuto is taking and explain, in lay terms, to Atsuto the adverse effects of these medications and when he should seek help.

The main side effects of Quinapril are Dry cough, Angioedema, Loss of taste, and Hypotension (Bennett et al., 2017).

Side effects of Frusemide are joint pain, dry mouth, increased thirst, fatigue, and increased urination  (Whelton et al., 2018). 

Circulation

Pathophysiology

Question 1-Identify what you believe is occurring from a clinical diagnosis perspective and link your answer to the associated pathophysiological processes

As per the clinical diagnosis of coronary artery syndrome, I believe that while climbing stairs, Reney's is under stress and blood flow to the heart decreases. Under the influence of low blood supply, the compensatory heart mechanism will start to fulfil tissue demands for perfusion. Deficit supply may also result in ischemia condition (Wang et al., 2020).

Question 2- Should the paramedics have applied supplementary oxygen? Discuss your answer and with evidence from the literature.

Supplementary oxygen should not have been applied because it is not required because Renay's SP02 is more than 93%

Question 3- Discuss the pathophysiology of ACS, and based on Rainey's presentation and underlying pathophysiology describe what the potential diagnosis/diagnoses, you believe she may have.

In Rainey's conditions, the underlying risk factors of high BMI, overweight, elevated vitals parameter, and clinical features indicate that she has unstable angina. Here, due to etiological factors like thrombus formation, a decreased blood supply to the heart, which results in ischemia, may cause myocardial infarction (Lee et al., 2020

Question 4- Discuss the pathophysiology of the cardiac cell damage associated with ACS

Decreased coronary artery perfusion may result in acute coronary syndrome, which can be because of distal thrombus dislodgement. Obstructed blood supply and increased cardiac demand while climbing stairs results in poor tissue perfusion and deficit cardiac blood supply. Therefore, decreased blood flow towards the heart effects the decompensation function of its contraction and relaxation and resulted in cardiac cell death (Wang et al., 2020).

Question 5- Identify and briefly discuss the three structural and functional changes that occur in myocardial infarction

Changes that occur over the course time of myocardial infarction condition are:

 At 0 times, there will be no changes, but within 0.5 to 4 hours, at the periphery in the tissue region, waviness of fibres will be present. 

Afterwards, at 4 to 12 hours, glycogen level will also decline and result in necrosis and edema in the tissues of the myocardium. 

Within 12 to 24 hours, cardiac tissues turn into a dark and mottled coloured and contraction band necrosis. Neutrophil predominance will appear furthermore at 3 to 7 days, the appearance of macrophages for removal apoptosis cells will be found (Mechanic & Grossman, 2020)

Circulation

Pharmacology

Question 1 -When on route to ED, Rainey was administered 5mgs IVMorphine. 

Discuss the Pharmacodynamics of Morphine and why it was administered in this case over another analgesia

In acute ACS, if the pain is not controlled, Morphine is used because, along with strong analgesic effects, it also reduces the sympathetic outflow.

Question 2- Pharmacodynamics

Discuss the Pharmacodynamics of these two medications using evidence from the literature to support your discussion. Also, identify how you would describe to Rainey (in layman's terms) how these work on her body

Pharmacodynamics of Aspirin: Aspirin is an irreversible inhibitor of COX enzyme, which results in inhibition of cox enzyme in platelets till the life of platelets, whereas in other nucleated cells, cox enzyme is regenerated. This selective inhibition of COX-1 blocks the formation of Thromboxane A2 in platelets which inhibits platelet aggregation. This explains the Antiplatelet effect of Aspirin (Rana, 2020; Thomsett & Cullen, 2018). 

In layman's term, it will be said that Aspirin will help in dissolving blood clots which obstruct blood flow.

Pharmacodynamics of Glyceryl Trinitrate: GTN causes vasodilation with more vasodilatory effect than artery dilation. Venodilation leads to a reduced venous return to the heart, which reduces end-diastolic volume, reducing the preload on the heart and decreased myocardial oxygen demand will relieve angina pain (Rana, 2020; Thomsett & Cullen, 2018).

In layman’s term, GTN will help dislodge the obstruction by increasing the size of blood vessels and improving blood flow in the body.

Question 3 – Indications 

Discuss using the literature, what are the indications are for these medications and what considerations you would make concerning Rainey's case

Indications of Aspirin: 

Aspirin in high doses is used as anti-inflammatory, antipyretic and analgesic medication in various inflammatory conditions.

Low dose (75mg – 150mg) is indicated in various cardiovascular and cerebrovascular diseases due to its Antiplatelet action. 

In Rainey's case, as she suffered ACS, Aspirin low dose is indicated to her so that it could inhibit platelet aggregation and should arrest the further progression of unstable plaque and atheroma (Thomsett &Thomsett, 2018).

Indication of Glyceryl Trinitrate: Glyceryl Trinitrate is used for the treatment of angina, acute myocardial infarction, severe hypertension, and acute coronary artery spasms

In the case of Rainey, Glyceryl Trinitrate is indicated for the acute coronary syndrome to relieve the severity and symptoms of unstable angina, which, if not treated, could lead to Myocardial infarction.

Question 4 - Contraindications

Describe the contraindications these medications. Is there any reason why Rainey should not be on these medications? Explain why/why not. Support your conclusions with evidence from the literature

Contraindications of Aspirin: 

Aspirin should be avoided in patients with increased bleeding tendencies like hemophilia, dengue fever, GI bleeding etc. 

Aspirin should be used with caution in people with renal disease, hyperuricemia or gout.

Contraindications of Glyceryl Trinitrate: The common side effects of Glyceryl Trinitrate are Reflex Tachycardia, hypotension and throbbing headache

There is no significant reason for the contraindications of these drugs in Rainey.

Question 5 - Adverse effects

Explain to Rainey the adverse effects of this medication and when she should seek help

Rainey has to consult immediately with the doctor if she experienced adverse sign of gastritis, bleeding, shortness of breath etc. after Aspirin intake and the problem of headache, increased heart rate or palpitations or hypotension etc., after glyceryl trinitrate intake should be informed accordingly without delay (Rana, 2020; Thomsett & Cullen, 2018).

Pathophysiology

Question 1-Discuss the pathophysiology of a Sub Dural Haemorrhage (SDH)

Subdural hemorrhage may result immediately after a blow on her head, followed by blood accumulation rapidly. Blood can be accumulated in the extra-cerebral site between the dura mater and the subarachnoid layer of the brain (Subdural Hematoma, 2020). Accumulation of blood may cause increase pressure inside the brain and may result in impaired conscious level (Lee et al., 2018) and expressed clinical features. 

Question 2-Discuss why it is important to measure intercranial pressure (ICP), justify your discussion with evidence.

ICP monitoring is important for the prediction and prevention of inordinate cerebral tissue perfusion pressure (CPP). This CPP can be evaluated by finding the association and difference between mean arterial pressure (MAP) and ICP. Moreover, CPP findings also help to determine the stress on the function of the myocardium in Lydia's condition for the prevention of heart failure (Nag et al., 2019) 

Question 3- Discuss the pathophysiology relating to brain herniation including the clinical manifestations Elevated ICPpressure in the cranium 

Brain hemorrhage results in the accumulation of blood into the cranium; however, its capacity is limited, and accumulation causes shifting of brain tissue which results in herniation can cause compression of cerebellar and vertebral arteries of brain tissue, consequently affect body function as Lydia showing abnormal flexion of upper and lower extremities. Additionally, she is also showing symptoms of the Cushing triad, which involves elevated ICP, decreased tissue perfusion resulted in impaired conscious level and activation of the sympathetic nervous system evident by tachycardia (Munakomi & Das, 2020). 

Question 4-Describe to Lydia's parents what a normal ICP is and what the doctors mean when discussing the possibility of brain herniation.

Lydias parents should be informed that ICP is the pressure present in the entire brain, 15 mm hg or less when a person is in a standing position. Lydia met with an accident that caused an accumulation of blood inside the brain. However, the brain's capacity is restricted by the skull, so accommodated clot can shift the brain tissue further, which results in herniation of brain structure. Under the effect of herniation condition of Lydia may worsen and may lead to abnormal body movement and impaired consciousness (Munakomi & Das, 2020).

Question 5- What angle should Lydia's head be kept at, and why - describe the pathophysiology related to this.

Mild head elevation of 15–30° has been shown to reduce

ICP with no significant detrimental effects on CPP

Mild head elevation of 15–30° has been shown to reduce

ICP with no significant detrimental effects on CPP

Lydia's head should be kept elevated up to the level of 30 degrees (A Guide For Nurses, 2016). Due to an increase in ICP, brain damage or brain death may occur either by global hypoxic-ischemic injury, resulting in decreased cerebral perfusion pressure (CPP) blood flow, or due to compression and herniation among brain tissue. Elevating the head by up to 30 degree facilitates the drainage of blood through cerebral venous drainage due to gravity (Freeman, 2015).

Pharmacology

Question 1 - Describe to Lydia's parents (in layman's terms) the Pharmacodynamics how the above 2 medications work on her body and why she is on them.

Mannitol is an osmotic diuretic. It is used in Lydia’s condition because she had a hemorrhage that increases cerebral edema and increases intracranial pressure (ICP). As the cranium can not expand, there is compression of the neuronal tissues that may lead to irreversible neurological problems. Mannitol will drain extra fluid from the brain and significantly reduce the ICP, thereby reducing the chances of damage to neuronal tissues.

Phenytoin: Due to hemorrhage, there is reduced blood perfusion in the affected area, which leads to hypoxia, i.e. reduced oxygen to the neurons. Hypoxic condition in neuronal tissue reduces ATP generation, which increases the release of excitatory neurotransmitter – glutamate responsible for increased electrical activities in the brain that leads to seizure which could be very dangerous to the patient. To avoid the chances of seizure, Lydia is given Phenytoin because it hyperpolarises the neurons, reduces the electrical activities in the brain, and prevents seizure in the patient (de Alencar Neto, 2018).

Question 2 -Discuss the pharmacokinetics of Mannitol and why it is used in patients with TBI

Pharmacokinetics of Mannitol: 

After IV administration Mannitol achieves a volume of distribution of 34..3 litres

Metabolism: Mannitol is metabolized to a very less extent in the liver into glycogen.

Route of elimination: Excreted primarily through kidneys. Total clearance of Mannitol after IV administration is 5.1 L/hour with a renal clearance of 4.4 L/hour. The plasma half-life of Mannitol is 4.7 hours (de Alencar Neto, 2018).

Question 3-Describe the contraindications for the two medications Lydia has been prescribed. Discuss if there Is there any reasons why Lydia should not be on these medications? Justify your answer with supporting literature.

Contraindications of Mannitol: Mannitol is contraindicated in a condition of Anuria, severe hypovolemia and the patients having pulmonary congestion or pulmonary edema.

Contraindications of Phenytoin: Phenytoin is contraindicated in patients of sinus bradycardia, sino-atrial block, second and third degree AV Block, and Adams patients Stroke Syndrome.

Lydia has no history of Anuria, hypovolemia or pulmonary edema or congestion, so to relieve the conditions of cerebral edema and reduce ICP, Mannitol should be administered to Lydia (de Alencar Neto, 2018).

Question 4-As the RN caring for Lydia, what are the adverse effects you should be looking out for in Lydia, remembering she is sedated and ventilated and describe what might you see if your patient can't tell you about these adverse effects?

While administering Mannitol, GFR and renal output should be monitored

During Phenytoin administration RN should be aware of Lydia's cardiac parameters like ECG, blood pressure, and heart rate because phenytoin can depress SA node, AV node and can cause cardiac arrhythmia (de Alencar Neto, 2018).