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Health Assessment

Patient Consideration

Mr. Zac is an 18-year-old male, a university student living away from his family in the campus hostel. He works part-time – 15 hours a week and helps in supporting his education. He has no immediate family or local guardian around and he only has a friend whose house he visits occasionally. He is mostly on his own in this place and visits his parents from time to time. Currently, he was brought in to the ED due to a laceration on his head because of a fall on the road curb. He was in an altercation with a person outside a pub, who later pushed him on the road, causing Zac to hit his head and bleed a little. He was rushed to the ED for the same in an ambulance.

Zac displayed risky behavior in terms of alcohol intake and consumption. Drinking five or more drinks at a time is considered binge drinking and comes in the category of heavy drinking for men (Knott et al. 2018). Zac’s laceration in the head is directly related to the risky behavior he displayed in terms of heavy alcohol consumption. It could be triggered in the form of a mild attack or an exacerbation due to binge alcohol drinking. Even though he is currently on no medication or has no allergies, he still has a history of childhood asthma (Skaaby et al. 2019). On admission to ED the vitals of the patient was checked by a triage nurse.

Information Collection

Mr. Zac presented to the ED in an ambulance post an injury-laceration to the occipital part of his head. While in the ambulance, the paramedics assessed a Glasgow coma scale of 15 for Zac indicative of a mild head injury, and he explained the entire incident to them, the way it had occurred. The laceration was bandaged by the paramedics. They measured vitals and found them to be normal and the security in-charge outside the pub mentioned that he did not look like he lost his consciousness.

On reaching the ED, his assessment showed a head injury in the form of a 4 cm laceration in the occipital region with blood oozing out. The pain score of the patient was 5/10 at the occipital region. His vital signs showed a blood pressure of 141/88 mmHg which is towards the higher side. The normal blood pressure range for a human being is 120/80 mmHg or 90/60 mmHg (NHS 2019). The heart rate of the patient was 90 bpm seems towards the higher side, respiratory rate of 17 bpm- normal; and SpO2 – 99%- normal, as well. His GCS was found to be 14 indicative of mild head injury. He denied any loss of consciousness and appears alert but, teary-eyed. On questioning by the nurse, he was clearly unable to recall all the events. He mentioned no history of drug consumption and only mentioned drinking five beers in the past 4 hours. His breath alcohol showed a concentration of 0.06% which is indicative of the concentration of alcohol at which alcohol begins to show the effect on body movement control in terms of standing upright- perturbed or unperturbed (Modig et al. 2012). A diagnosis of mild head injury was given for Zac in terms of a head laceration for which the required suturing or stapling was to be done.

Based on the assessment and examination, a new diagnosis or assessment should be made based on his symptom of the inability to recall all the events from the evening. His GCS was also reduced from 15 to 14 gradually when measured in a gap of half an hour. Further examination and tests need to be done in order to establish the diagnosis of his new developing condition of memory loss. Based on the functional state of his brain, as indicated by his symptoms, a CT scan should be undertaken to find out if there is any abnormality, intracranial lesion or associated focal lesion. Also, his GCS should be measured and monitored continuously along with his vitals to note any decrease in the same. A skull X-ray will also help in noticing any depression or fracture in the skull (Levin et al. 2016). A diagnosis of a mild traumatic brain injury can be made for the functional state of his brain whose symptoms include the presence of any loss of memory of events immediately before or after the accident, a GCS score greater than 12 and associated absence of a specific focal lesion on CT. It is also associated with any kind of alteration at the time of the accident (Levin et al. 2016). All the mentioned symptoms are present in Mr. Zac’s case and the results of the CT will further help in establishing the diagnosis.

Processing Information

A clear cut assessment can be given based on the cues and the signs and symptoms of Mr. Zac post-admission to the ED. As evidenced above, the patient can be diagnosed definitely as suffering from a mild traumatic brain injury affecting the functional state of his brain. It is also associated with a head laceration in the occipital region. He is also suffering from risk to further injury related to the complications of his existing mild TBI. These nursing assessments can be established based on the processing of the available information and by ordering further examination and diagnostic testing for Mr. Zac, as described in the above section. The 4cm laceration and edema in the case may have been resulted due to the tearing of underlying tissues and skin. This mechanical insult results in alteration of blood flow and cerebral metabolism and may lead to the risk of various secondary injuries which include hypotension, seizures, hypoxia and cognitive impairment ranges from mild to severe (Kaur and Sharma 2018). The decrease in GCS reading from 15 to 14 in the case of Mr. Zac is indicative of mild cognitive impairment. However, other vitals of the patient seem normal and are not indicative of any serious impairment in the case of Zac. Moreover, his current condition can be linked to the consumption of alcohol as both are linked with each other and it is bi-directional. A great number of TBIs occur in individuals post alcohol consumption because of the intoxicated state of the individual which could worsen due to physical injury as in the case with Zac (Weil 2018). TBI is characterized by the presence of neurological dysfunction associated with neurological damage, inflammation or cerebral edema which will impair the functioning of the brain and might also decrease brain blood flow. This cerebral edema or neurological dysfunction can manifest itself as either a transient loss of memory or temporary amnesia or a greater focal or neurological deficit depending on the extent of injury and damage to the brain (Prins et al. 2013). Specific nursing interventions, in this case, would include- Continuous monitoring of the GCS and vitals in order to note for any deterioration in his condition which can be indicative of any neurological or cognitive deficit in the patient, assessment and measurement of pain, in case it worsens or increases indicating increased intracranial pressure or edema; and notifying the medical officer in case any deterioration is noted or observed (Hodgkinson et al. 2014).

References for Mr. Zac Case Study

Einarsen, C.E., van der Naalt, J., Jacobs, B., Follestad, T., Moen, K.G., Vik, A., Håberg, A.K. and Skandsen, T. 2018. Moderate traumatic brain injury: Clinical characteristics and a prognostic model of 12-month outcome. World neurosurgery, 114, pp.e1199-e1210.

Hodgkinson, S., Pollit, V., Sharpin, C. and Lecky, F. 2014. Early management of head injury: summary of updated NICE guidance. BMJ348.

Kaur, P. and Sharma, S. 2018. Recent advances in pathophysiology of traumatic brain injury. Current neuropharmacology, 16(8), pp. 1224-1238.

Knott, C.S., Bell, S. and Britton, A. 2018. The stability of baseline‐defined categories of alcohol consumption during the adult life‐course: A 28‐year prospective cohort study. Addiction113(1), pp.34-43.

Levin, H.S. and Diaz-Arrastia, R.R. 2015. Diagnosis, prognosis, and clinical management of mild traumatic brain injury. The Lancet Neurology14(5), pp.506-517.

Modig, F., Fransson, P.A., Magnusson, M. and Patel, M. 2012. Blood alcohol concentration at 0.06 and 0.10% causes a complex multifaceted deterioration of body movement control. Alcohol46(1), pp.75-88.

NHS. 2019. What is blood pressure? [Online]. Available at: https://www.nhs.uk/common-health-questions/lifestyle/what-is-blood-pressure/

Prins, M., Greco, T., Alexander, D. and Giza, C.C. 2013. The pathophysiology of traumatic brain injury at a glance. Disease Models & Mechanisms6(6), pp.1307-1315.

Skaaby, T., Kilpeläinen, T.O., Taylor, A.E., Mahendran, Y., Wong, A., Ahluwalia, T.S., Paternoster, L., Trompet, S., Stott, D.J., Flexeder, C. and Zhou, A. 2019. Association of alcohol consumption with allergic disease and asthma: A multi‐centre Mendelian randomization analysis. Addiction114(2), pp.216-225.

Weil, Z.M., Corrigan, J.D. and Karelina, K. 2018. Alcohol use disorder and traumatic brain injury. Alcohol Research: Current Reviews39(2), p.171.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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