Clinical reasoning cycle is considered to be important skills in the nursing patient assessment that help to link the different patient information to identify the right assessment. There are eight steps in the clinical reasoning cycles that are utilized to improve patient assessment (Yazdani et al., 2017). The report is going to use the three-step of the clinical reasoning cycle concerning patient health status and medical history. The use of clinical reasoning cycle will improve the patient assessment to identify the right intervention to improve the health status.
The patient is 18 years old and he is a student of engineering with a part-time job in a supermarket to support his expenses. The study presented by Lea et al. (2018) discussed that age is one of the important factors to reframe the care design and teenagers should be treated with extra care due to different behavioural aspect. Age-appropriate care is important to address the specific issue of the patient by providing person-centred care. The social situation of the patient indicates that he does not have his direct family in the town that decreases the lack of support but his parent's friends visit him routinely to have a check upon him. He has a group of friend with then he enjoys his time after his job and he was also enjoying the night with his friend in the pub that day. The article presented by Hämmig (2019) added that teenage is the major phase when an individual requires social support to deals with stress and improve the performance. The lack of social support can lead to a poor mental and behavioural issue in the individual that includes irritation or substance abuse.
The medical history of the patient indicates that he is a patient of asthma that also increase the breathing issue that can be analysed after vital sign assessment that indicates the reduced respiratory rate which is 17 breath/minute. The article presented by Quirt et al. (2018) discussed that asthma is one of the most chronic respiratory disorder that increase lifetime complication for the patient. Severe asthma leads to the Bradypnea state which is deterioration in the respiratory state. The two risk factors that are directly linked with the patient chief complaint are substance use and risk behaviour due to the misbalance in fight and flight responses. Center for Disease Control and Prevention (2020) discussed that heavy drinking leads to physical as well as mental health deterioration which leads to increase chances of injuries and violence due to poor motor control. The study presented by Kozlowska et al. (2015) discussed that risky behaviour is directly associated with the poor regulated fight and flight responses that lead to a negative consequence.
The blood pressure of the after admitting to the emergency department was 141/88 that directly indicates the hypertensive state which is not good for the patient as it can increase heart-related complication. The study presented by Singh et al. (2017) indicates that hypertension is a silent killer and if remain unaddressed can increase the risk for heart attack or failure. The blood pressure above the 140 level comes under the second stage of hypertension which is dangerous for the patient and need to be urgently addressed. The laceration at the back of the head also experienced by the patient due to the violence faced by him lead to the bleeding that is 4 cm. the study presented by Almulhim & Madadin, (2020) the laceration in the brain is different from other body part and there is need to understand the layer that is involved to stop the bleeding.
The patient has also reported the 5/10 level of the pain in the occipital region of the brain due to the laceration occur after the incident. The study presented by Ahmed et al. (2017) discussed that brain injury has a great impact over the physical as well as mental being which sometimes lead to the pain that can increase chances of insomnia.
The three assessments that are important to be conducted as per the patient current health status are FOUR score assessment, neuroimaging, wound assessment that will help to understand the intensity of the injury. The study presented by Foo et al. (2019) discussed that FOUR score assessment is important for the patient encountered the brain injury to understand the current health status. The FOUR score assessment includes eye, motor responses, brainstem reflexes and respiratory pattern. According to Brandmaier et al. (2018), neuroimaging is important to scan the brain internal structure to identify the sign of any injury that lead to internal complication in the brain. It includes different method like computer tomography, magnetic resonance and functional magnetic resonance. The article presented by Liew et al. (2017) discussed that wound assessment is important to decrease the chances of infection and improve the wound management technique
The patient medical information and vital sign reveal that the patient brain injury due to the wound and bleeding which has increased her pain. Due to the injury, he is not able to recall the information related to the accident and that also increase the blood pressure of the patient. There is a need for further assessment to understand the part of the brain that has been injured to improve the treatment that is important to improve patient health status.
The report can be concluded by adding that there is a need for further assessment to identify the intensity of the injury in the brain to provide the right care to the patient. The patient medical information indicates 4cam laceration in the occipital region that need further assessment by conducting FOUR scores, neuroimaging and wound assessment. This assessment will improve the issue diagnosis that is important to frame the treatment to provide person-centred care to the patient concerning the age of the patient. The right treatment framed as per the person issue so that specific care can be provided to improve the health status.
Ahmed, S., Venigalla, H., Mekala, H. M., Dar, S., Hassan, M. & Ayub, S. (2017). Traumatic brain injury and neuropsychiatric complications. Indian Journal of Psychological Medicine, 39(2), 114–121. DOI: 10.4103/0253-7176.203129
Almulhim, A. M. & Madadin, M. (2020). Scalp Laceration. Treasure Island, United Kingdom: StatPearls Publishing.
Brandmaier, A. M., Wenger, E., Bodammer, N. C., Kühn, S., Raz, N. & Lindenberger, U. (2018). Assessing reliability in neuroimaging research through intra-class effect decomposition (ICED). eLife, 7. DOI: 10.7554/eLife.35718
Foo, C. C., Loan, J. & Brennan, P. M. (2019). The relationship of the four score to patient outcome: A systematic review. Journal of Neurotrauma, 36(17), 2469–2483. DOI: 10.1089/neu.2018.6243
Hämmig, O. (2019). Health risks associated with social isolation in general and in young, middle and old age. PLOS ONE, 14(7), 1-18. DOI:10.1371/journal.pone.0219663
Kozlowska, K., Walker, P., McLean, L. & Carrive, P. (2015). Fear and the Defense Cascade: Clinical Implications and Management. Harvard Review of Psychiatry, 23(4), 263–287. DOI: 10.1097/HRP.0000000000000065
Lea, S., Taylor, R. M., Martins, A., Fern, L. A., Whelan, J. S. & Gibson, F. (2018). Conceptualizing age-appropriate care for teenagers and young adults with cancer: A qualitative mixed-methods study. Adolescent Health, Medicine and Therapeutics, 9, 149–166. DOI: 10.2147/AHMT.S182176
Liew, B. S., Zainab, K., Cecilia, A., Zarina, Y. & Clement, T. (2017). Early management of head injury in adults in primary care. Malaysian Family Physician: The Official Journal of the Academy of Family Physicians of Malaysia, 12(1), 22–25.
Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F. & Kim, H. (2018). Asthma. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology, 14(50), 1-30. DOI: 10.1186/s13223-018-0279-0
Singh, S., Shankar, R. & Singh, G. P. (2017). Prevalence and associated risk factors of hypertension: A cross-sectional study in urban Varanasi. International Journal of Hypertension, 2017(5491838), 1-10. DOI: 10.1155/2017/5491838
Yazdani, S., Hosseinzadeh, M. & Hosseini, F. (2017). Models of clinical reasoning with a focus on general practice: A critical review. Journal of Advances in Medical Education & Professionalism, 5(4), 177–184.
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