CNA155 - Clinical Reasoning Report: Analysis of John Wells Case Study

This report applies the Clinical Reasoning Cycle to the case of John Wells, an 82-year-old dairy farmer admitted to the emergency department after a bike accident resulting in a head injury. The report begins by considering the patient's profile, including his age, medical history of hypertension, and the circumstances of the accident. It then details the collection of cues and information, including both subjective and objective symptoms such as dizziness, headache, and confusion. The processing of information leads to the conclusion of a mild traumatic brain injury, with recommendations for further diagnostic tests like MRI or CT scans. The report emphasizes the importance of a systematic assessment and the need for healthcare professionals to identify and address all potential health complications in elderly patients, providing effective interventions to improve their well-being. The report also references several academic papers related to clinical reasoning and mild traumatic brain injury.

Running head: CLINICAL REASONING
CLINICAL REASONING
Name of the Student
Name of the University
Author note

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Table of Contents
Introduction......................................................................................................................................2
Consideration of the patient.............................................................................................................2
Collecting cues and information......................................................................................................3
Processing the information..............................................................................................................5
Conclusion.......................................................................................................................................6
References........................................................................................................................................7

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Introduction
As mentioned by Karter et al. (2015), with increasing age, there are multiple
complication that impacts the health condition of the elderly population. In such condition, there
are multiple aspects that the healthcare professionals need to think about so that their health
complications could be effectively addressed and they could be provided with effective
interventions for their health complications. Priority based nursing practice is one such approach
that identified the care needs of the patient and then arranges their treatment so that the care
needs could be addressed with effective intervention (Suhonen et al. 2018). Clinical reasoning
cycle, developed by Levett-Jones implements the priority based nursing practice and provides
the patients with critical healthcare interventions (Dalton, Gee and Levett-Jones 2015).
The primary aim of this paper is to apply the Clinical Reasoning Cycle (CRC) to align it
with the case study of John Wells (82) so that care process of the patient could be prioritised and
could be provided with effective interventions.
Consideration of the patient
The case study provided discusses about John Wells (82 years), a former dairy farmer
who lives with his wife. While returning from his farm, he suffered from an accident as he could
not control his balance while he was riding on his bike. He knew that it was always necessary to
wear a helmet while driving, but on that day he forgot to use the mask. His had trapped on the
ground while he falls to his left side. The immediate response of the accident was that the patient
started feeling very dizzy as his head had hit the hard ground. Leaving these the other side effects
of the accident were severe headaches, loss of hunger, fatigue and nausea. However, he did not
care much about his matter and had gin back to his work. After he returned from his work, the

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members of his family noticed that he seemed to be much quieter than other times. The family
members also thought that it would be better if he were admitted to the emergency department.
John had no medical history of head injury or concussion. If his condition of health is
considered, then it can be said that he had been leading a healthy life. According to medical
history, he has only diagnosed with hypertension, but he was not administered with any
hypertensive medicines (Gardner and Yaffe, 2015). The risk factors which are associated with
hypertension are obesity, medical history of the family, physically sedentary, smoking, salt and
potassium comprising diet, taking alcohol. The other risk factors are becoming stressed, several
chronic health issues like improved blood pressure, kidney diseases and diabetes (Levin and
Diaz-Arrastia, 2015). It should also be mentioned that due to his head injury, concussion could
also be a critical condition due to which the patients started feeling dizzy, nauseated and suffered
from mild to moderate headache (Max 2016).
Collecting cues and information
The patient of the case study John took admission in the emergency department as he was
suffering from severe headache, nausea and mild confusion after the accident in which he hit the
ground. John was feeling hazy, and also he was suffering from the pain and the pain score was
4/10. He also admitted that he was not looing his consciousness. The health issue was facing was
that he was not feeling healthy. After he took admission in the hospital his vital signs were
checked. His temperature was found to be 36.7 degree Celsius, the blood pressure was 148/84,
and the pulse rate was 81 beats per minutes. The respiratory rate was17 beats per minutes and the
oxygen concentration level was 97% on room air.

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The symptoms, the objective ones showed by the patient were dizzy feeling, headache
and nausea, loss of hunger, exhaustion and symptoms of absentmindedness (Marshall et al.,
2015). The family members of the patient observed that he was not able to remember everything
performed by him on that day. The subjective symptoms shown by the patient was that his blood
pressure has got decreased, his heart rate had improved, and rate of respiration had decreased.
The significant cues of the patient were that he was not being able to recall all the
happened occurrences (Faul and Coronado, 2015). This had happened to the patient because of
the accident. The other signs were elevated heart rate, decreased the rate of respiration, decreased
craving, fatigue and severe headaches.
For improving the health conditions of the patient, firstly, the nurse needs to connect
correctly with the patient. The nurse has to establish a stable beneficial relationship with the
patient. The nurse should know the exact cause of memory loss and then continue with the
treatment. John was suffering from improved heart rate. The reason for the improved heart rate
was nothing but hypertension. The nursing assessment to decease the heat rate is monitoring all
of the vital signs regularly and after that applying the proper medicines, specifically the anti-
hypersensitive ones. For the concussion associated health condition, the patient will undergo
Glasgow Coma Scale assessment so that his level of awareness and consciousness could be
assessed. If the GCS score comes below 8, then the consciousness level of the patient would be
considered impaired. Whereas, from 8 to 12, it would be considered as moderate. Finally, in the
score is above 12, then the patient would be considered as cognitively effective and no internal
damage or negative effect if concussion would be confirmed.
Both the objective and the subjective symptoms of the patient displayed that he had been
suffering from the disease mild traumatized brain injury after the accident. The symptoms of the

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disease consist of headaches, disturbances of sleep, faintness, loss of memory, nausea, getting
lost or becoming sometimes confused, mood changes and decrease in thinking something. So it
could be concluded that the patient was suffering from mild traumatized brain injury (Losoi et
al., 2016). The real way to evaluate a patient suffering from mild traumatic injury was a
systematic assessment of the patient. This consists of reviewing the symptoms, patient
surveillance, and palpation of the head for determining more severe neurologic injury (Koski et
al., 2015). Some special tests for defining the mental status and monitoring the mental condition
can also be done.
Processing the information
After gathering the cues and evidence of the patient, it can be concluded that the patient
had been affected with mild traumatized brain injury. The traumatic brain injury is soft when the
awareness or the misperception and confusion is less than 30 minutes (Papa et al., 2016). MRI
and CAT scans are the recommended diagnoses for an individual who had been affected with
mild traumatic brain injury. The person mostly suffers from different cognitive issues like
reduced skills of thinking, headaches remembrance loss, problems of attention, changes in mood
and obstruction. (Webster et al., 2015) The CAT and MRT both are used for capturing the body
images, but the essential difference is the CAT uses he X-rays while MRI used the radio waves.
The MRIs are used for diagnosing joints, wrists, ankles, breasts, hearts and the blood vessels.
The CT scans are used to identify the fractures of the bones, tumors, monitoring if cancer and in
finding the internal bleeding. CAT is used mostly as it is less expensive than MRI. The benefits
of CAT are this it provides pictured of organs, tissues and structure of bones (Perry et al., 2016).
Usually, the doctors and the nurses do not notice many mild injuries. Though this disease had
been designated as mild the family members mostly suffer, and the impacts may be devastating

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sometimes. About 15% of people suffering from mild TBI are unnoticed through the early
stages as the indications last for one year or more. The condition can also be defined as the
consequence of the head movement if done forcefully or the effect producing a sudden change in
mental status (confusion or loss of memory) or losing the common sense for fewer than 30
minutes. The signs of the post-injury are often defined as post-concussive syndrome. The
indications of mild traumatic injury are exhaustions, visual disorders, and loss of meditation, loss
of remembrance, light-headedness, and loss of equilibrium, unhappiness and seizers. The patient
faced the accident because of his sudden fall from the bike. All the symptoms that John had been
suffering from were alike with the symptoms of mild traumatized injury (Di Pietro et al., 2017).
The patient had stated the circumstances of severe light-headedness, extreme headaches,
weaknesses and loss of remembrance. Usually, the patients disregard the disorders of mild
traumatized injury, but in this case, the family members of John admitted him to the emergency
department, which led to the correct assessments at the right time. Besides this, the patient would
be asked to undergo MRI, CT scan and other imaging diagnosis tools so that presence of any
internal brain injury or level of his concussion could be identified and treated with effective
interventions.
Conclusion
While concluding the paper, it would be mentioned that this case study analysis identified
the fact that while providing an elderly patient with healthcare treatment, it is important that the
healthcare professionals identifies all the possible health complication affecting the patients’
health. Further, after identifying the causes, the patient should be provided with effective
interventions targeting each of these aspects for their health and wellbeing.

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References
Dalton, L., Gee, T. and Levett-Jones, T., 2015. Using clinical reasoning and simulation-based
education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing,
The, 33(2), p.29.
Di Pietro, V., Ragusa, M., Davies, D., Su, Z., Hazeldine, J., Lazzarino, G., Hill, L.J., Crombie,
N., Foster, M., Purrello, M. and Logan, A., 2017. MicroRNAs as novel biomarkers for the
diagnosis and prognosis of mild and severe traumatic brain injury. Journal of
neurotrauma, 34(11), pp.1948-1956.
Faul, M. and Coronado, V., 2015. Epidemiology of traumatic brain injury. In Handbook of
clinical neurology (Vol. 127, pp. 3-13). Elsevier.
Gardner, R.C. and Yaffe, K., 2015. Epidemiology of mild traumatic brain injury and
neurodegenerative disease. Molecular and Cellular Neuroscience, 66, pp.75-80.
Karter, A.J., Laiteerapong, N., Chin, M.H., Moffet, H.H., Parker, M.M., Sudore, R., Adams,
A.S., Schillinger, D., Adler, N.S., Whitmer, R.A. and Piette, J.D., 2015. Ethnic differences in
geriatric conditions and diabetes complications among older, insured adults with diabetes: the
diabetes and aging study. Journal of aging and health, 27(5), pp.894-918.
Koski, L., Kolivakis, T., Yu, C., Chen, J.K., Delaney, S. and Ptito, A., 2015. Noninvasive brain
stimulation for persistent postconcussion symptoms in mild traumatic brain injury. Journal of
neurotrauma, 32(1), pp.38-44.
Levin, H.S. and Diaz-Arrastia, R.R., 2015. Diagnosis, prognosis, and clinical management of
mild traumatic brain injury. The Lancet Neurology, 14(5), pp.506-517.

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Losoi, H., Silverberg, N.D., Wäljas, M., Turunen, S., Rosti-Otajärvi, E., Helminen, M., Luoto,
T.M., Julkunen, J., Öhman, J. and Iverson, G.L., 2016. Recovery from mild traumatic brain
injury in previously healthy adults. Journal of neurotrauma, 33(8), pp.766-776.
Marshall, S., Bayley, M., McCullagh, S., Velikonja, D., Berrigan, L., Ouchterlony, D. and
Weegar, K., 2015. Updated clinical practice guidelines for concussion/mild traumatic brain
injury and persistent symptoms. Brain injury, 29(6), pp.688-700.
Max, J.E., 2016. Concussion and psychiatric outcome in adults and children.
Papa, L., Brophy, G.M., Welch, R.D., Lewis, L.M., Braga, C.F., Tan, C.N., Ameli, N.J., Lopez,
M.A., Haeussler, C.A., Giordano, D.I.M. and Silvestri, S., 2016. Time course and diagnostic
accuracy of glial and neuronal blood biomarkers GFAP and UCH-L1 in a large cohort of trauma
patients with and without mild traumatic brain injury. JAMA neurology, 73(5), pp.551-560.
Perry, D.C., Sturm, V.E., Peterson, M.J., Pieper, C.F., Bullock, T., Boeve, B.F., Miller, B.L.,
Guskiewicz, K.M., Berger, M.S., Kramer, J.H. and Welsh-Bohmer, K.A., 2016. Association of
traumatic brain injury with subsequent neurological and psychiatric disease: a meta-
analysis. Journal of neurosurgery, 124(2), pp.511-526.
Suhonen, R., Stolt, M., Habermann, M., Hjaltadottir, I., Vryonides, S., Tonnessen, S., Halvorsen,
K., Harvey, C., Toffoli, L. and Scott, P.A., 2018. Ethical elements in priority setting in nursing
care: A scoping review. International journal of nursing studies, 88, pp.25-42.
Webster, K.M., Wright, D.K., Sun, M., Semple, B.D., Ozturk, E., Stein, D.G., O’Brien, T.J. and
Shultz, S.R., 2015. Progesterone treatment reduces neuroinflammation, oxidative stress and brain
damage and improves long-term outcomes in a rat model of repeated mild traumatic brain
injury. Journal of neuroinflammation, 12(1), p.238.

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