Nursing Assignment 2022

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
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NURSING ASSIGNMENT1
Considering the patient situation:
This is considered as the first step of clinical reasoning cycle, which focuses on
considering and highlighting the patient’s situation. This study will focus on the case scenario
of the patient named, John Wells, 82-years-old man, who was admitted to emergency
department for his behavioural changes. John was a farmer and had exhibited no past medical
condition of concussion or head injury. He was initially diagnosed with the condition of mild
hypertension and had also reported to not consume any antihypertensive medicines. After
completely evaluating the patient, it was exhibited that he lost his balance while returning
from his work and had injured his left part of the head by hitting the ground. After the
accident, his wife had observed some behavioural changes in him and had therefore
approached her son to take John to the hospital. He had abrasion on his left forearm and tear
on his left elbow and apart from the above physical injury no other major injury was detected.
After evaluating the patient, the primary health complaint exhibited by John was
confusion, fatigue, appetite loss, nausea and headache. After falling from his stationary two-
wheeler bike, he had hit his left part of the head really hard on the summer ground and hence
it was highly possible that his cognitive function would have been disturbed and he might
exhibit the complaint of internal brain injury (Zacks et al. 2016). The other major reason for
his loss of balance could be hypertension as he was taking any antihypertensive medicines.
Hence, the two major risk factors that could be responsible for the condition of headache and
fatigue followed by nausea are hypertension and head injury (Levin and Diaz 2015).
Collecting cues and information:
This is considered as the second step of clinical reasoning cycle, which focuses on
gathering relevant information and medical history of the patient in order to demonstrate and
execute an effective care plan for the patient (Dalton, Gee and Levett-Jones 2015). The

NURSING ASSIGNMENT2
subjective and objective cues are collected in this phase and thus based on the above
mentioned cues a care plan is devised for a better health outcome of the patient.
In this case scenario, the subjective cues of the patient is gathered after interviewing
him which consist of headache, dizziness confusion, poor consciousness, nausea and loss of
appetite. In order to evaluate the consciousness level of the patient, Glass coma scale test is
performed, particularly for the individual who are suffering from any form of brain injury
(Olson and Ortega 2019).
The consciousness level is evaluated through the verbal response, eye response and
motor response and based on the response, an individual score is provided. The score can
vary from the range of 3-15, and hence if the score is less than 8, it will exhibit that the
patient had low level of consciousness and might also experience from severe brain injury
(Wilde et al. 2016). If the score result is in between 9 to 12, it is exhibited that the patient has
moderate consciousness level and might experience from moderate brain injury, whereas
score result between 13-15 exhibit normal health conditions with no chance of brain injury.
To guarantee if the patient had not experienced any internal brain injury, PERRLA
test is performed by evaluating the pupil dilatation of the patient, the level of internal cranial
injury is assessed. Along with the above mentioned test MRI and CT scan can also be
performed to evaluate the subjective cues of the patient and diagnose the health condition of
the patient (Huang et al. 2015).
In this case scenario, the objective cues of the patient is collected by performing a
vital assessment test which consist of pulse rate, oxygen saturation rate, blood pressure, body
temperature and respiratory rate. After evaluating the vital signs it was observed that the
patient had exhibited optimal body temperature (37.6 degree Celsius), pulse rate (82 beats per
minute), oxygen saturation (greater than 95%) and respiratory rate (17 breaths per minute)