Case Study

J. Pacheco

Admitting Diagnosis:
Post Traumatic Hydrocephalus

Admission Date: 2/6/2016
Discharge Date: 4/15/2016

Discharge Location:
Home with family providing 24 hour care


Patient is a 70 year old male admitted to RIH from St. Anne’s hospital 9/29/15. Patient had an unwitnessed fall at home and found by wife. He was having difficulty breathing and became combative and confused. Patient was immediately intubated for airway protection. CT head showed large right frontoparietal and intraparenchymal hemorrhage surrounded by edema and right temporal skull fracture. He underwent right craniectomy for temporal hematoma evacuation and partial temporal lobectomy on the right side. EVD (external ventricular drain) was placed intraoperatively and admitted to ICU for further medical care. Patient then developed healthcare associated PNA and started on antibiotics. His course was also complicated by respiratory failure and hypoxic respiratory failure, which resulted in a PEG placement on 10/13/15. He had developed a R UE DVT but was treated and ultrasound now shows no DVT. Patient was transferred to RIH on 12/15/15 for schedule cranioplasty and shunt placement, this hospital course was uneventful and was sent back to New England Sinai Hospital for management of respiratory failure and hydrocephalus s/p cranioplasty.
Patient was admitted to the Brandon Woods of Dartmouth Sub Acute Unit. Due to his medical complexity, immobility and the potential for multisystem failure, our assessment and treatment plan was also multisystem to include cardiovascular, pulmonary, endocrine, neurological, gastrointestinal, nutritional, skin and prophylaxis.

The patient was seen regularly by his in-house physician. Following thorough initial assessments by the interdisciplinary team, a comprehensive plan of care was developed and communicated to the caregivers. He was not deemed a safe candidate for any oral intake and had a G-tube placed prior to admission. Attempts at bolus feeding proved intolerable, therefore, he was managed without complication on a 24-hour feeding pump. Wound management was done daily with significant healing of the Stage II pressure ulcer. Abundant tracheotomy secretions were managed with Scopolomine, frequent suctioning and nebubulizer treatments were provided to also assist in management of his airway. Sepsis was treated and resolved with antibiotic therapy. Deep vein thrombosis was prevented with passive range of motion, frequent total body repositioning and daily anticoagulant therapy.

Patient participated with Rehabilitation Services. He presented to therapy with decline in independence and functional mobility due to complicated medical status including intracranial hemorrhage with craniectomy due to fall, sepsis, wounds and pneumonia. Patient presents with increased fatigue and unable to arouse on evaluation in afternoon. Patient was total assist for all mobility, limited activity tolerance, unable to communicate, and at risk for contractures and skin breakdown. During patients’ skilled therapy stay, he demonstrated some improvement with the use of his right upper and lower extremity, improved bed mobility, and his ability to communicate via gestures. The focus of rehab was to decrease the amount of assistance required by his caregivers, prevent skin breakdown and contractures, and to develop a home exercise program that caregivers could perform with patient.

Family support was and continues to be significant and discharge plans began to be discussed. Nursing spent many hours teaching his wife and children how to administer medications to include insulin, blood sugar monitoring and feeding tube setup and delivery. His tracheotomy tube was eventual removed by his pulmonologist. Ultimately, the resident was deemed medically stable to return home with his wife and family that have demonstrated competency in carrying out his care in their home.
Family and caregivers were able to take him home by providing safe transfers, positioning and performing his home exercise program.