This Clinical Reasoning Report discusses the process of diagnosing and planning nursing care for a patient with a head injury. It explores the patient's symptoms, assessment, and the pathophysiology of concussion. The report also highlights the potential complications related to age and head injury in elderly patients.
Contribute Materials
Your contribution can guide someone’s learning journey. Share your
documents today.
Clinical Reasoning Report Consider the patient situation Consideration of patient situation is the primary step in the clinical reasoning cycle. In this step, a nurse considers the present medical condition of the patient. Mr. John is an elderly person with a history of hypertension but not on any hypertensive medication. On the day of the incident, he fell down from the bike, striking the left side of the head. John had minor skin tear to his left forearm and a small abrasion to his left elbow. John did not have any other injuries, pain stiffness and reduced range of movement to his neck. Mr. John was admitted in the emergency department with the complaints of headache, nausea, and mild confusion after the hit. According to the present medical condition, he is feeling hazy and complaining of the head ache. His head ache is mild andscores 4/10 on the pain scale. He was stating that ‘he is not feeling well’. His vital signs are normal at the time of admission. His blood pressure was slightly elevated.Conditions that need to be considered are the age and head injury. Any head injury may get worse for elderly people. Aged people bones are soft and prone to damage after a fall.The recovery process is slower for aged people(Varriano2019). Another complication that is related to age and head injury is the older people are prone to develop dementia even after a single head injury. Collect cues and information Patient’s present and past medical history help to cluster the needed information to diagnose and plan the nursing care.Subjective data of the patient’s condition helps the nurse to gather the actual symptoms of the patient’s condition. Mr. John is 82 years old male, married and he was works on a dairy farm(Varriano2019). When he pulled his bike outside the home he lost his balance. He fell striking the left side of his head.He was not wearing the helmet or any
Secure Best Marks with AI Grader
Need help grading? Try our AI Grader for instant feedback on your assignments.
other protective equipment. John had minor skin tear to his left forearm and a small abrasion to his left elbow. John did not have any other injuries, pain stiffness and reduced range of movement to his neck. Objective data, in this case, is also an essential factor that helps the nurse to diagnose and planthenursingcareaccordingly.Mr.Johnwaslookingconfusedandnotlooking comfortable. On observation, his vital signs are normal. His temperature was 36.7C, Pulse was 81/mt, His Respiratory rate was 17/mt and the blood pressure was 148/84 mmHg. His SpO2 on the room air was 97%. His signs and symptoms after the concussion were slightly abnormal. He was complaining of head ache which scored 4/10 on the pain scale. He was also complaining of nausea, mild confusion, and hazy feeling. He stated that he was not losing consciousness but he was not feeling well. All the subjective complaints of the patient were abnormal. Changes that were identified are the signs and symptoms of concussion. A concussion is common in older people after a head injury (Mehta2019). Mr. John’s signs and symptoms in the emergency department shows that he is having a medical condition called concussion (Matuszak 2016).Mr. John states that he is feeling nauseated has head ache, mild confusion, and hazy feeling which are the common signs and symptoms of concussion. The potential problem is a concussion. The Nurse has to do an assessment and collect more data to conclude the diagnosis of the patient. The proposed new assessment is head to toe assessment. The nurse has to do optical examination, mental status assessment, and the nurse has to check the range of motion,and musculoskeletalassessment(Matuszak2016).Thenursehastomonitorthepatient continuously. Monitor the vital signs every half an hour. The mental status examination has to be done every two hours to rule out any changes in the conscious level (Combs 2019).
Assess the patient’s , vision, and speech. Assess the patient’s level of concentration. Monitor the headaches using the pain scale. Assess the light and noise sensitivity of the patient. The nurse has to monitor the sleep pattern of the patient to rule out whether the patient has the complication of concussion. Pathophysiology of the concussion state that the injury causes biomechanical changes in the brain. Injury followed by typical symptoms like memory impairment, nausea, vomiting, confusion attention deficit, head ache, and changes in the conscious level (Mehta, 2019).The changes in the mental condition caused due to neuron dysfunction(Choe 2016).Sudden head injury leads to changes in the metabolic events of the brain and neurons. Concussion signs and symptoms are caused due to neurotoxicity, which leads to mitochondrial dysfunction of the neuron cells. The injured brain cell exposed to the next level of a concussion that may irrecoverably be damaged and causes swelling. Process the information, relate and infer Mr. John is an 81 year old male with a history of fall down from the bike, striking the left side of the head. John did not have any other injuries, pain stiffness and reduced range of movement to his neck. Mr. John was admitted in the emergency department with the complaints of headache, nausea, and mild confusion after the hit. According to the present medical condition, he is feeling hazy and complaining of the head ache. Any head injury may get worse for elderly people (Mehta2019. Another complication that is related to age and head injury is the older people are prone to develop dementia even after a single head injury. Objective data, in this case, is also an essential factor helps the nurse to diagnose and plan the nursing care accordingly. Mr. John was looking confused and not looking comfortable. On observation his vital signs are normal. His temperature was 36.7C, Pulse was 81/mt, His Respiratory rate was 17/m and the blood pressure was 148/84 mmHg. His SpO2 on the room
air was 97%. His signs and symptoms after the concussion were slightly abnormal. He was also complaining of nausea, mild confusion, and hazy feeling. He stated that he was not losing consciousness but he was not feeling right. Mr. John’s signs and symptoms show that the patient has a common medical condition called concussion. The nursing assessment also confirms the diagnosis. A concussion is the common medical condition that is experienced by an individual after a head injury. Patient’s signs and symptoms prove that the patient is suffering from a mild state of concussion. The brain cells are damaged due to the fall or accident. Injury followed by typical symptoms like memory impairment, nausea, vomiting, confusion, attention deficit, head ache, and changes in the conscious level (Choe 2016).The changes in the mental condition caused due to neuron dysfunction. Sudden head injury leads to changes in the metabolic events of the brain and neurons. Concussion signs and symptoms are caused due to neurotoxicity, which leads to mitochondrial dysfunction of the neuron cells (Mehta2019). The injured brain cell exposed to the next level of concussion that may irrecoverably be damaged and causes swelling. The patient is suffering from the common brain damage that happens after the fall or accident in an individual. Especially in older people the chances are more. Mr. John is suffering from the common medical condition called concussion (Signoretti 2011). References Choe,M.C.,2016.Thepathophysiologyofconcussion.Currentpainandheadache reports,20(6),p.42 https://www.sciencedirect.com/science/article/abs/pii/S1934148211004990 Combs,J.,Puskar,A.,Blaney,N.,Collins,M.,andKontos,A.,2019.Preliminary Examinations of Concussion in Older Adults.Archives of Clinical Neuropsychology,34(5), pp.768-768https://academic.oup.com/acn/article-abstract/34/5/768/5539148
Paraphrase This Document
Need a fresh take? Get an instant paraphrase of this document with our AI Paraphraser
Matuszak, J.M., McVige, J., McPherson, J., Willer, B. and Leddy, J., 2016. A practical concussionphysicalexaminationtoolbox:evidence-basedphysicalexaminationfor concussion.Sportshealth,8(3),pp.260-269 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4981071/ Mehta, C. and Poole, K., 2019. Head injury in the elderly.Clinical Medicine,19(3), pp.262- 263.https://search.proquest.com/openview/9b5d1af75d4e47e3e5db3d8ba885eda6/1?pq- origsite=gscholar&cbl=40163 Signoretti, S., Lazzarino, G., Tavazzi, B. and Vagnozzi, R., 2011. The pathophysiology of concussion.Pm&r,3(10), pp.S359-S368https://www.ncbi.nlm.nih.gov/pubmed/27184060 Varriano, B., Tomlinson, G., Tarazi, A., Wennberg, R., Tator, C. and Tartaglia, M.C., 2018. Age, gender and mechanism of injury interactions in post-concussion syndrome.Canadian journalofneurologicalsciences,45(6),pp.636-642 https://www.cambridge.org/core/journals/canadian-journal-of-neurological-sciences/article/ age-gender-and-mechanism-of-injury-interactions-in-postconcussion-syndrome/ EF1FEB417F6C3AC2D9CAC326114FC2E8