Clinical Exemplar

Running Head: CLINICAL EXEMPLAR 1
Clinical Exemplar
Magnetic Resonance Imaging with Intracranial Hemorrhages
Jeanne Zamith
University of South Florida

CLINCAL EXEMPLAR 2
Magnetic Resonance Imaging with Intracranial Hemorrhages
Patient History
Trauma intensive care unit (ICU) patient presented to the emergency department from EMS
on June 15th as a result of a motor vehicle accident. There was prolonged extrication, and she was
positive for methamphetamines and marijuana on the scene. The patient’s boyfriend was found
dead on arrival (DOA). The injuries she sustained were a pelvic hematoma, subarachnoid
hemorrhage (SAH), intraparenchymal hemorrhage (IPH), lung contusions, and a splenic
laceration. All injuries sustained were fixed via consulted physicians. The only residual issue that
remains is the altered mental status, possibly due to the SAH or IPH. She has a RASS of -4, and
she still does not follow commands, despite the discontinuation of Fentanyl, Diprivan, and
Precedex, and her only sedation being Haldol and Valium for agitation. Neurology and Trauma is
following her case, and they believe the reason she is still confused, disoriented, and agitated is
due to both her IPH and SAH and her recent history of illicit drugs, which may have altered the
effects of the previous sedations and pain relief, causing residual magnified effects.
Almost all patient with traumatic brain injuries (TBIs) experience some level of altered
mental status; however, most of those issues are usually resolved within a week, if caused by a
bleed that is able to be broken down on its own. This patient had been admitted for 11 days, and
she showed no improvements from a neurological perspective.
Interpretation
In order to make a decision, in trauma rounds, I requested for the patients to receive a
magnetic resonance imaging (MRI). The patient had not received any type of head scan since the
16th of June to ensure the bleed was not worsening, and she never received an MRI. Also, the
patient remained in a cervical collar from the accident, despite the negative CT, because she was
CLINICAL EXEMPLAR 3
unable to report pain. A negative MRI could both show more about the brain, possibly revealing
the reasoning behind the altered mental status, and rule out a cervical fracture, allowing us to
take of the cervical collar, thereby decreasing some of the agitation as well. While removing the
cervical collar, the altered mental status was. The attending agreed with my recommendations, so
we scheduled an MRI for the next morning.
Responding
While hemorrhages can take several days to self-resolve completely, it had been 11 days,
and the patient showed no improvements. The healthcare team originally decided to sit and wait;
however, after 11 days, we needed to start thinking of alternative reasoning behind the persistent
altered mental status. A head CT helped to see the peak of the IPH and SAH, but a head CT can
be non-diagnostic for altered level of consciousness. We, as medical professionals needed to
have the ethical principle of beneficence in this case (Guido, 2014). An MRI can help rule in
more diagnoses (Han & Wilber, 2013).
Reflecting
I have not been able to determine the outcomes of recommending the MRI; however, I
believe the physicians were probably able to see more into the problem and alter the plan of care.
I believe I presented my patient in trauma rounds in a way that made the physician understand
the importance of needing the MRI, stressing the altered mental status and inability to follow
commands. Looking back, I should have asked the family more questions. I could have asked
them if she had ever been affected this way after any of the medications she received or if she
could even receive an MRI in the first place.

CLINCAL EXEMPLAR 2
References
Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Vancouver, WA: Pearson.
Han, J., Wilber, S. (2013). Altered mental status in older emergency department patients. Clinics
in Geriatric Medicine, 29(1). doi: 10.1016/j.cger.2012.09.005
Pacini, C.M. (2006). Writing Exemplars. Nurse Action Days. Retrieved from
https://www.ucdmc.ucdavis.edu/cppn/documents/bridges_to_excellence/Writing_Exemplars.pdf

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Running Head: CLINICAL EXEMPLAR 1

Magnetic Resonance Imaging with Intracranial Hemorrhages

University of South Florida

Magnetic Resonance Imaging with Intracranial Hemorrhages

hemorrhage (SAH), intraparenchymal hemorrhage (IPH), lung contusions, and a splenic

she showed no improvements from a neurological perspective.

we scheduled an MRI for the next morning.

be non-diagnostic for altered level of consciousness. We, as medical professionals needed to

more diagnoses (Han & Wilber, 2013).

could even receive an MRI in the first place.

in Geriatric Medicine, 29(1). doi: 10.1016/j.cger.2012.09.005

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