CNA155 Zac Clinical Reasoning Report Sample

• Subject Code : CNA155
• University : University of Tasmania My Assignment Services is not sponsored or endorsed by this college or university.
• Subject Name : Nursing

Health Assessment

This clinical report is about 18 years old university student Zac. He was brought to the emergency department of the hospital. It was suspected to be a concussion. The following report will cover the three steps of clinical, reasoning, nursing assessment, patients situation, collect information and cues.

Consider the Patient’s Situation

Zac is a young adult who is at risk of concussion. The chances are the brain can cure itself if provided with proper medication and guidance from the doctors. When the accident occurred, Zac was under the influence of alcohol. It can contribute to more hazards to the brain. Under the influence of alcohol, one loses the balance of the body. As stated in the case study, Zac had five glasses of beer. Alcohol and traumatic brain injury is correlated. The intoxication brain when it gets damaged can fall in a risky situation. It increases the chance of TBI three times than that of the normal. The occurrence of TBI can produce more permanent and long term disability as compared to a single injury. Patients with TBI with intoxication can have a risk of injury. Zac is a university student and having alcohol with the group is not to be surprised about. Zac has been enjoying his life. He has alcohol tolerance which is evitable as Zac consumes 4 pints of beer. While being attacked by the abuser, he could not balance his movement due to the influence of alcohol. He accidentally falls down injuring his occipital part of the brain. The influence of alcohol might have been the reason for the accident. There are no signs of the previous injury to the body or brain. Zac had issues of asthma in childhood and had recently taken the tetanus dose. No allergies or other physical problems noted in patients’s health history.

Collect Information/cues

The vital signs taken in the emergency department were blood Pressure: 141/88 mmHg, Heart Rate: 90 beats/minute, Respiratory Rate: 17 breaths/minute Pulse Oximetry: 99% on room air Temperature 36.0 C. It was recorded that the blood pressure was a bit higher.

The symptoms which were obtained were pain, unable to recall incidents, dizziness, and mild confusion. Other signs were within the normal range. He had a 4 cm long lacerated wound in the occipital region that required dressing. He was conscious but had difficulties while recalling the events that took place. It was discovered that the lacerated wound had oozed from it. It required the dressing from inside. 

A concussion is a type of common injury to the brain accompanied by small bain impairment. It generally occurs when the brain is hit hard on the ground. It strikes the functioning of the brain due to a biomechanical force (Manzanero et al., 2017). Brain concussion has been a serious issue for the last few years. It also includes damage to the cell enhanced by the chemical present in the brain. It also affects the neurological functioning of the brain resulting in loss of memory or unable to recall incidents. In Zac’s case, he had mild blood pressure rise accompanied by loss of memory. The head was found stuck in the road curb which can point out that there can be damage in the grey matter or white matter volume. There is a lacerated wound at the occipital area. It is a sensitive area due to the presence of medulla oblongata and cerebellum. It controls the voluntary and involuntary actions of the body and is slightly responsible for memory. The patient is unable to recall that happened.

While assessing the case, it was found that the patient was under the influence of alcohol. The alcohol might have triggered the body imbalance and affected the memory. The pain scale in the occipital region is 5/10 which is moderate. The rise in BP can lead to contraction of vessels reducing the blood flow in the cerebrum that may result in brain edema. The nursing assessments that are to be followed in diagnosis are a CT scan of the brain. The scanning of the brain will allow doctors to intervene and will help doctors to assess what level of treatment is required(Zolot, 2018). Other tests such as neuropsychological testing can be done. A neuropsychological test includes answering questions or task performance asked by the doctor. It might include testing of attention and memory, the patient might be asked to answer several terms and repeat them again. For testing the language and speaking skills, one can be asked to name an object or asked to tell all possible words he can by the given letter. The neuropsychological tests have been extensively used by the doctors to provide rehabilitation to the concussion patients such as assessing alertness and response to the feelings of the body(Moser et al., 2012). If Zac feels disoriented, Glasgow Coma Scale(GCS) score can be used to measure his level of consciousness.

The third nursing assessment that can be followed is EEG or electroencephalogram. It provides the report of the layers in the gray matter of the brain. The readings are based on the electrodes put on the brain and the results are gained by seeing the fluctuations in the electrode caused by the brain. It had proved quite a successful way in comparison to the concussion in the different age groups of people(Prichep et al., 2013).

The treatment of a concussion requires patience and the patient must realize that the process can take time. Though in many cases it is seen that it cures in 7 to 10 days in adults. The rate of healing depends on the right amount of medications required, avoiding alcohol, and a decrease in playing video games for kids that would put pressure on the nerves of the eyes(Graham et al., 2014).

Process Information

Zac’s vitals were recorded every 30 minutes in the deterioration chart. It was thoroughly done to take a note on the necessary changes that are to be taken and the evaluation of his condition. If there are any changes observed in his vitals, it can be concluded that his health is deteriorating. Zac’s current BP is mildly high denoting hypertension. Cerebral diseases can occur due to Hypertension(Krishnamoorthy et al., 2017). The oxygen level at room air is 99% which is a good sign. The low oxygen level can harm the brain functioning leading to a coma. The oxygen supply must be kept in the way which provides the functioning in TBI(Sharf & El-Gebali, 2013). The pain level is 5/10 which is moderate and the patient must be provided with medication which will help in pacifying the pain level. The headache is the sign that the brain’s morphology is slightly changed. The patient must strictly follow his abstinence from alcohol. Alcohol increases the chances of disturbing the cognitive functioning of the brain. The alcohol restricts the mental abilities that can be performed by the brain for its recovery(Pagulayan et al., 2016).

The GCS of the patient indicates less than 15 that made the doctors conduct the assessment again. The deterioration in the patient's level of consciousness is measured by GCS(Brenen et al., 2018). Going through the health history of Zac, he never had a history of concussion. After the release, he may come across symptoms like lack of sleep, headache, pain in the wound, difficulties in concentration, and difficulty in recalling events. It might sign out that these are the symptoms that occurred in the post-concussion period(Quinn et al, 2018).

References for Zac Clinical Reasoning Report

Brennan, P. M., Murray, G. D., & Teasdale, G. M. (2018). Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. Journal of Neurosurgery, 128(6), 1612–1620. https://doi.org/10.3171/2017.12.jns172780

Graham, R., Rivara, F. P., Ford, M. A., Spicer, C. M., Youth, C. on S.-R. C. in, Board on Children, Y., … Council, N. R. (2014). Concussion Recognition, Diagnosis, and Acute Management. In www.ncbi.nlm.nih.gov. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK185340/#ref_000580

Krishnamoorthy, V., Chaikittisilpa, N., Kiatchai, T., & Vavilala, M. (2017). Hypertension After Severe Traumatic Brain Injury. Journal of Neurosurgical Anesthesiology, 29(4), 382–387. https://doi.org/10.1097/ana.0000000000000370

‌Manzanero, S., Elkington, L. J., Praet, S. F., Lovell, G., Waddington, G., & Hughes, D. C. (2017). Post-concussion recovery in children and adolescents: A narrative review. Journal of Concussion, 1, 205970021772687. https://doi.org/10.1177/2059700217726874

‌Moser, R. S., Glatts, C., & Schatz, P. (2012). Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sports-Related Concussion. The Journal of Pediatrics, 161(5), 922–926. https://doi.org/10.1016/j.jpeds.2012.04.012

Pagulayan, K. F., Temkin, N. R., Machamer, J. E., & Dikmen, S. S. (2016). Patterns of Alcohol Use after Traumatic Brain Injury. Journal of Neurotrauma, 33(14), 1390–1396. https://doi.org/10.1089/neu.2015.4071

‌Prichep, L. S., McCrea, M., Barr, W., Powell, M., & Chabot, R. J. (2013). Time Course of Clinical and Electrophysiological Recovery After Sport-Related Concussion. Journal of Head Trauma Rehabilitation, 28(4), 266–273. https://doi.org/10.1097/htr.0b013e318247b54e

Quinn, D. K., Mayer, A. R., Master, C. L., & Fann, J. R. (2018). Prolonged Post-concussive Symptoms. American Journal of Psychiatry, 175(2), 103–111. https://doi.org/10.1176/appi.ajp.2017.17020235

Sharf, M. S., & El-Gebali, M. A. (2013). Correlation between the Glasgow coma scale and Jugular venous oxygen saturation in severe traumatic brain injury. Egyptian Journal of Anaesthesia, 29(3), 267–272. https://doi.org/10.1016/j.egja.2013.02.008

Weil, Z. M., Corrigan, J. D., & Karelina, K. (2018). Alcohol Use Disorder and Traumatic Brain Injury. Alcohol Research : Current Reviews, 39(2), 171–180. Retrieved from http://ncbi.nlm.nih.gov/pmc/articles/PMC6561403/

Zolot, J. (2018). First Guidelines for Diagnosing and Managing Concussion in Kids. AJN, American Journal of Nursing, 118(12), 14. https://doi.org/10.1097/01.naj.0000549677.81876.1b

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