Real-Life Case Study with Embellishments: Vanessa Anderson Traumatic Head Injury and Clinical Outcome

Situation

• Vanessa is a 16yo, healthy active female living in Darwin

• Admitted after experiencing a traumatic head injury after being struck on the R) side of her head, behind her ear by a golf ball at approx 0825

• Paramedics attended and brought her into ED

• Sent for urgent CT → diagnosed depressed focal right temporal skull fracture

• Bone fragments in brain matter and dural lacerations present

• Complaining of a headache, GCS 14-15

• Transferred to the CDU Neurological ward for continuing care, Sunday 1300

Background

• Lives with parents and older brother Jason

• Plays golf 3-4x a week

• Yr11 at High School

• PMH – Asthma – Seretide and Ventolin

• Allergies – Shellfish and nuts

• Weight: 60kgs, normal BMI

Assessment

• Airway: Own, patent

• Breathing: RR 23, O2 Sats 98% on RA

• Circulation: HR 68bpm, BP 120/65 mmHg

• Disability: GCS 14/15, intermittently confused, PEARL 3mm, BGL 5.0mmol/L

• Exposure: Temp 36.5 oC

• 1 x PIVC inserted to R) ACF, patent

Recommendations / Read Medical Orders Back

• Routine ward assessments and observations

• 4/24 full neuro observations

• Administer analgesia as prescribed

• Diet and fluids as tolerated

• TED stockings and DVT prophylaxis

Medication orders

• Panadeine Forte 1000mg/60mg QID

• Oxycodone 5mg PRN (Max dose 30mg in 24hrs)

• Phenytoin 100mg IV over 6hrs

Nursing orders

• Devise a plan of care for your patient

Events Over the Next Few Shifts

Monday – 0830

• Medical review: GCS 15

• Continue with regular Panadeine Forte

• Oxycodone changed to 5-10mg 3hrly PRN

Monday Nightshift – 2100hrs

• On handover: last analgesia

  • 1900 – Panadeine Forte

  • 2000 – PRN Oxycodone 10mg

• Assessment:

  • Airway: Own, patent

  • Breathing: RR 16, O2 Sats 96% on RA

  • Circulation: HR 62bpm, BP 105/58 mmHg

  • Disability: GCS 14/15, intermittently confused, PEARL 3mm, BGL 6.0mmol/L

  • Exposure: Temp 36.2 oC

2300hrs

• Vanessa rings the bell, complains of continual headache

• PRN Oxycodone 10mg administered

0000hrs

• Review: pain remains 9/10

• Scheduled Panadeine Forte administered

0100hrs

• Vanessa rings bell, distressed, says she cannot move

• Attempted neuro obs: unable to lift arms, frightened

• No shaking, no stiffness, breathing normal

• Warm to touch, normal skin colour

• No other limbs or GCS assessed

• Assumed bad dream → reassurance given, left room for urgent admission

• Within 10 minutes: full neuro obs performed, no deficits noted

0200hrs

• Vanessa requests toilet assistance → mobilises with help

• Pain unresolved → PRN Oxycodone 10mg given

0400hrs

• Routine and neuro obs due → skipped (decided not to conduct)

• Father asleep in room, Vanessa finally settled after analgesia → not disturbed

0530hrs

• Vanessa checked → found unresponsive

• MET call initiated

0635hrs

• Vanessa pronounced dead despite resuscitation attempts

Coroner’s Post-Mortem Review

• Blunt head injury and mechanism of death most likely a seizure

• Unable to be formally determined

• Difficult to determine whether analgesia contributed – may have caused respiratory depression

This assessment required students to analyse a real-life clinical scenario involving a 16-year-old girl, Vanessa Anderson, who sustained a traumatic head injury from a golf ball strike. The key requirements of the assessment included:

• Patient Background and Medical History – reviewing Vanessa’s personal, social, and medical details.

• Initial Assessment – covering airway, breathing, circulation, disability, and exposure (ABCDE approach).

• Medical and Nursing Orders – applying prescribed interventions such as analgesia, DVT prophylaxis, and neuro observations.

• Care Plan Development – devising a nursing care plan to monitor, manage, and reassess the patient.

• Shift Events & Clinical Decisions – evaluating the series of events leading up to Vanessa’s deterioration.

• Critical Reflection – identifying gaps in care, recognising missed clinical signs, and applying duty of care principles.

• Outcome & Ethical Implications – linking the clinical outcome to professional accountability and safe practice standards.

Academic Mentor’s Step-by-Step Guidance

The academic mentor approached the assessment with a structured, reflective, and clinical reasoning-based method to guide the student:

1. Understanding the Case Context

   • Mentor encouraged the student to map out the timeline of Vanessa’s injury, treatment, and deterioration.

   • Emphasis on the importance of background (age, health status, asthma history, medication use).

2. Applying the ABCDE Assessment Framework

   • Guided the student to interpret each set of observations systematically (Airway patent, Breathing stable, Circulation within normal limits, Disability fluctuating GCS, Exposure normal).

   • Highlighted red flags such as ongoing headache, confusion, and neurological changes.

3. Reviewing Medical & Nursing Orders

   • Step-by-step breakdown of orders: Panadeine Forte, Oxycodone PRN, Phenytoin infusion, and routine neuro obs.

   • Mentor asked the student to consider risk factors of opioid use in head injury patients.

4. Critical Incident Analysis

   • Mentor supported the student in identifying critical decision points:

     • Pain not resolving despite strong analgesia.

     • Neuro obs skipped at 0400hrs.

     • Early signs of seizure activity misinterpreted as a “bad dream.”

   • Encouraged the student to connect these missed interventions with Vanessa’s eventual collapse.

5. Developing the Nursing Care Plan

   • Mentor guided the student to build a care plan focusing on:

     • Pain management with regular reassessment.

     • Strict neuro obs compliance.

     • Clear communication during handovers.

     • Escalation protocols when symptoms do not resolve.

6. Reflection and Ethical Considerations

   • Mentor asked the student to reflect on duty of care, accountability, and vigilance.

   • Students were guided to link the case to broader clinical practice standards, emphasising patient safety and advocacy.

Outcome of the Assessment

Through this process, the student:

• Demonstrated the ability to interpret clinical data in real-time.

• Identified errors in judgment and missed care opportunities.

• Linked theoretical knowledge of neurological nursing and pharmacology to practice.

• Developed a care plan incorporating evidence-based guidelines.

• Reflected on the professional responsibilities of nurses when monitoring patients at risk of deterioration.

Learning Objectives Covered

By the end of the assessment, the student achieved the following learning objectives:

• Applied the ABCDE framework in systematic patient assessment.

• Recognised the importance of neuro obs and escalation protocols.

• Critically analysed medication safety and opioid risks in head injury patients.

• Developed clinical decision-making and reflective practice.

• Strengthened awareness of duty of care and accountability in nursing practice.

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