The frontal lobe assault! The diagnosis: Orbital skull fracture with Subdural Hematoma (SDH) secondary to flip over bike head first to the black top, and no helmet on.
The scene: Trauma patient holding in the Emergency Department waiting for ICU bed availability. The patient has intermittent periods of aggression and anger. The patient is not directable. The patient continues to rip off the cervical collar. Sedation is not possible because of the need for frequent neurological assessment. The patient is placed in 4 point locking restraints. Intravenous Tylenol is administered for pain. The Emergency Department is loud, bright, and full of action. The family hovers over the bed attempting to console the patient worsening the agitation. The patient screams and then falls back to sleep.
ICU Arrival: The TBI patient continues aggression and agitation while awake. The stretcher arrives followed by RN and security with the key for the 4 point restraints. The patient is safely transferred to the ICU bed. This is followed by a large family trying to visit the patient. The patient is attached to the monitor and the nurse tells everyone to leave the room. The family feels insulted as evidenced by crying, dirty looks and running out of the unit.
The Care: The nurse turns off the lights and closes the blinds. The nurse completes a full neurological assessment. The patient does not follow commands. There are no focal deficits. The patient knows his name and the name of his mother. The patient becomes calm. Two family members are retrieved from the waiting room. Detailed explanation and education is given to the family about decreasing external stimulus. The patient wakes up screaming and the Mother runs to the bedside. The aggression and agitation starts all over again.
The Mother: “He is not like this. He is a sweet boy, you can’t keep me from my son.’
The Nurse: “We are on the same team. I do not want to keep you away from your son. I understand that you are worried and sick, but at this time your son needs a quiet room. I will care for you and your son, but the priority is to decrease the pressure in his brain. When he gets up screaming the pressure in his brain will increase. This is not acceptable. I also understand that he is not acting like his usual self, and this is common. He has a head injury ”
The Mother begins crying and doesn’t believe that her presence will not comfort him at this time. The nurse takes the Mother into the hallway and watches the patient fall back to sleep and rest calmly. The evidence of the care plan is witnessed.
It is that frontal lobe you know, the personality driver and the changes can be extreme and diverse. This is apparent during acute and after acute injury. We can’t predict the future of recovery. And to me as the primary nurse– I see good signs: the patient wakes up, the motor strength is strong enough to require restraints, his pupils are equal and brisk, he knows his mother’s name, and the bruise clot hematoma is not expanding on follow up repeat CT scan. There has been no surgery, no external ventricular drain, and I am happy as can be regarding this assessment. The orbital fractures will heal. To me personality changes are the least of his problems at this time.
For the Mother this is the worst scenario because she does not know the worst. It is not her fault.