Clinical Reasoning Report

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 and scores 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 (Varriano 2019). 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 (Varriano 2019). 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

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
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/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 (Mehta 2019). 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
musculoskeletal assessment (Matuszak 2016). The nurse has to monitor the patient
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).