CNA155 Case Study: Healthcare Assessment and Analysis

This case study analyzes two patient scenarios, Mr. John, an 82-year-old man who fell from his bike and Mia Roberts, a 12-year-old basketball player who sustained a head injury during a game. The assignment focuses on clinical reasoning, patient assessment, and the identification of potential diagnoses, including concussion and the impact of hypertension. The analysis includes a review of patient notes, symptom interpretation, and the importance of comprehensive assessments such as neuropsychological and psychosocial evaluations. The study highlights the significance of considering patient history, age-related factors, and the need for appropriate interventions. The case studies emphasize the importance of clinical thinking, data collection, and evidence-based care in delivering effective healthcare, particularly in emergency situations. The student's analysis provides insights into potential risks associated with head injuries and hypertension, emphasizing the need for careful observation and timely medical interventions.

Running head: Health care
Health care
Name of the student:
Name of the university:
Authors note:

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Case summary
a) Mr John is an old man aged 82 years who fell from his bike and fell unconscious.
Due to this minor accident, he suffered minor abrasion in his elbow and tear in the skin. He
does not have any serious history of injury in his head. Initially, He complained of mild
headache and fatigue after the accident. The injury in his head did not cause any blood loss or
severe pain from a mild blow to the head. Mr John was suffering from hypertension but did
not take any medication. He suffered from mild nausea and haziness after the hit from
motorcycle but did not lose consciousness (Ayres 2018). Most cranial cerebral injuries are
due to compression injury in the head. In concussion, the patients are less able to concentrate
and often results in patients’ loss of interest, which was seen in Mr John's condition. Mr John
claimed that he did not have any problem in movement or stiffness in the neck. He was
feeling mild pain in his head and slight dizziness. The dizziness can be from the fall in the
minor accident. Aged persons must be careful as their physiology is weak and are prone to
fall due to control in balance.
Mr John was suffering from a mild headache but he was unable to determine the
reason for her pain. He was feeling the dizziness from the time he was hit during the
motorcycle accident. Therefore, it can be said that the pain and the conditions have arisen
from the minor blow in his head. From the symptoms, it can be said that she was suffering
from grade one concussion as the symptoms prevailed for a long time. The old man had no
such medical history and never experienced a headache like this. Hence, there may not be
other reasons for his sudden headache. In concussion, the headache is related to ‘slowed
down’ feeling with no such throbbing action. When a person suffers from hypertension the
person often suffers from a mild headache. Mr John was suffering from hypertension but
never took any form of medication, which is vital in such age (Benetos et al. 2016). In old

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age, even a minor injury can prove fatal and be a traumatic experience for them. Therefore,
Mr John could not the injury due to the accident and lost consciousness. As reported Mr John
lost consciousness and that lead to the accident. It is important to control hypertension as
hypertension can result in sudden dizziness before the accident took place (Brooks et al.
2016). John denied any pain in neck or stiffness, which minimizes the risk factor from the
accident and could make him paralyzed. Mr John stayed quiet last night in his dinner as
stated by his wife but there is no such psychological distress, as we know Mr. John lives with
his wife and his son pays a visit sometimes.
Review from patients notes
b) From the patient's notes and symptoms displayed by him in the emergency
department, it can be said that the patient is suffering from concussion. The symptoms of
dizziness after the hit of her head can be correlated to a concussion. There is a need to
propose a clinical assessment as there may be serious consequences that may affect several
aspects of brain functioning. Neuropsychological testing can be conducted to establish the
symptoms that Mr. John is suffering from. Electroencephalogram readings can be a vital form
of assessment that can state the electrical activity of neuron and are effective in detecting
changes in the electrical procession of the brain (Buford 2016). A psychosocial assessment is
an important nursing assessment, which assesses cognitive function, evaluate concentration
levels and checking for hallucinations. The assessment would help to evaluate the symptoms
of Mr. John and find out the clinical reasoning of her condition.
It is important from the assessment point of view to ascertain if Mr. John was
suffering from any kind of psychological distress that triggered the condition. Such a form of
comprehensive assessment aids in evidence-based care to the patients. This kind of
assessment needs to be regularly performed and evaluate the progress in health care plan

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(Howell et al. 2016). Clinical assessment is the first process and needs clinical thinking and
data collection of both objective and subjective data. This form of nursing assessment is
important for better care delivery to the patients and understand the symptoms better. The
assessment data would help to gather data of Mr. John's physiological, psychological and
social conditions to conclude the illness of his condition. The physical examination is based
on signs and symptoms. Based on the symptoms of his nursing assessment can give an
important perspective for clinical reasoning. John's vital signs were normal during admission
in the emergency department. He had elevated blood pressure and this indicates he is
suffering from hypertension. He is suffering from hypertension stage 1 as his systolic
pressure is higher and diastolic pressure is lower than normal. Pulse rate was found to be 81
bpm during his check-up which is not normal and shows the risk of heart disease.
Processing the information
c) Based on clinical assessment and after studying the symptoms it can be said that
the patient is in the major risk of head injury and if proper treatment is not provided cognitive
development may get in danger. A concussion is related to similar symptoms where the onset
is gradually more and detection can be late. Dizziness, vomiting and temporary pressure in
the head are common symptoms characterized in concussion. It can largely affect the
functioning of the brain and can have a permanent effect. Upon inspecting the symptoms and
closely examining her I saw that she was constantly touching his head and was complaining
of haziness. This fact is crucial in establishing the fact that Mia has concussion due to the
minor injury in her head. Mia is suffering from difficulty in concentration and haziness that is
resulting out of concussion. The physical tests conducted can also help to determine the exact
cause of the condition.

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The physical and neurological examination is an important perspective for the
evaluation of the given interpretation. The patient was not suffering from any past medical
condition, which can be correlated, to the present condition of feeling dizziness. Therefore,
after taking the considerations of clinical assessment and common symptoms of concussion it
can be concluded that the patient is suffering from concussion (Harvey, Montezano and
Touyz 2015). In this age, hypertension can also result in dizziness that can result in loss of
balance and warning signs of a stroke. In this aging body, physiological functions are weak
and even a slight blow can be traumatic. Mr John is an aged person and this blow turned to be
a traumatic injury for him. Hypertension can result in unconsciousness that may have played
a role in Mr John's hospitalization. Mr John has no past injuries in his head. It was also found
out that he did not take medication for hypertension. The patient was not suffering from any
past medical condition, which can be correlated, to the present condition of feeling dizziness.
Therefore, it can be concluded that Mr John suffered a fall from his motorcycle due to the
high level of hypertension. Balance and psychotherapy can be prescribed to Mr John for
curing his dizziness.
References
Ayres, A., 2018. Dizzy and Balanced: Vestibular Rehabilitation on Post-Concussion
Symptoms.
Benetos, A., Bulpitt, C.J., Petrovic, M., Ungar, A., Agabiti Rosei, E., Cherubini, A., Redon,
J., Grodzicki, T., Dominiczak, A., Strandberg, T. and Mancia, G., 2016. An expert opinion
from the European Society of Hypertension–European Union Geriatric Medicine Society
Working Group on the management of hypertension in very old, frail
subjects. Hypertension, 67(5), pp.820-825.

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Brooks, J., Kemp, S., Newth, A. and Sylvester, R., 2016. Managing recovery from
concussion. BMJ: British Medical Journal (Online), 355.
Buford, T.W., 2016. Hypertension and aging. Ageing research reviews, 26, pp.96-111.
Harvey, A., Montezano, A.C. and Touyz, R.M., 2015. Vascular biology of ageing—
Implications in hypertension. Journal of molecular and cellular cardiology, 83, pp.112-121.
Root, J.M., Yensen, K., Atabaki, S.M., Breslin, K., Herrera, N. and Madati, J., 2018. Is
cognitive rest following a head injury associated with prolonged concussion symptoms?.
Schmidt, J., Rubino, C., Boyd, L.A. and Virji-Babul, N., 2018. The role of physical activity
in recovery from concussion in youth: a neuroscience perspective. Journal of neurologic
physical therapy, 42(3), pp.155-162.
Seifert, T., 2018. The relationship of migraine and other headache disorders to concussion.
In Handbook of clinical neurology (Vol. 158, pp. 119-126). Elsevier.
Stillman, A., Alexander, M., Mannix, R., Madigan, N., Pascual-Leone, A. and Meehan, W.P.,
2017. Concussion: evaluation and management. Cleve Clin J Med, 84(8), pp.623-630.