Health Assessment

Consider the Patient Situation

The given case study is of a I8-year-old male named Zac. He has been admitted to the emergency ward as he has been struck head on road curb at 2300 hours in an alleged argument. Patient denies for his loss of consciousness but, he was unable to recall all the events that have happened with him when he was asked regarding this. Patient was seen to appear alert but he was teary. When he was being examined 4cm laceration was noted along with slow ooze from wound. The patient has a past medical history of childhood asthma that was up-to-date with immunisations, his last immunisation was 12 months ago of tetanus. The patient was not on any medications and no known allergies were reported. His vital signs and GCS were recorded. A GCS of 15 was reported. The GCS revealed the score of Eyes 4, Verbal 4, and Motor 6. From this it was revealed that the score 4 and 6 for eyes and motor is considered to be the best eye and best motor responses. However, verbal 5 shows that the patient is slightly oriented (Jain & Iversion, 2020). No other obvious injuries were reported. The other vitals showed that his blood pressure was 141/88 mm Hg which shows that he has stage 1 hypertension which could be due to his injury also. His heart rate, pulse oximetery, temperature, and respiratory rate were reported normal. When he was asked that if he had used drugs or not, he denied to that but has stated that he had approximately five beers and was pushed by an aggressive male in a heated argument. This push led him to falling and hitting his back of head on the cement. Because of this hitting he got injured at the occipital lobe. The patient was able to tell this incidence by himself he was totally fine except a head injury. The pain assessment of the patient reported 5/10 score at the occipital lobe. Breath alcohol reading was taken and showed 0.06%. The main point of concern in this scenario is actually focused on four aspects. The first one is patient’s head injury even if the GCS showed 15 that means patient is conscious but, there are chances of infection as 4cm laceration was noted along with slow ooze from wound and infection in head injuries can lead to serious illnesses. The second concern is patient’s BP as it is stage 2 hypertension still no risk could be taken in this condition and this should get addressed. The third concern is the alcohol intoxication and the last is pain.

Collect Cues

As stated above the three main concerns in this scenario are the chance of infection in patient’s head injury though the patient is conscious and has shown GCS 15 but, there are chances of infection as 4cm laceration was noted along with slow ooze from wound and infection in head injuries can lead to serious illnesses. The second concern is patient’s BP as it is stage 2 hypertension still no risk could be taken in this condition in order to avoid any other medical issue, the third concern is the alcohol intoxication as it can affect the patient’s mental health along with the physical health. The last concern is patient’s pain as it has been reported 5/10 on pain assessment.

For the head injury the triage nurse must keep a close eye on the drainage. As both type of wound i.e., surgical as well open wounds could have different types of drainage. It’s very important to know the type of fluid patient’s wound oozes and that is needed to be examined. Purulent drainage is one among the type of fluid that could be released from a wound. It also looks “milky” in appearance and has been considered as a sign of infection. The main complication from a wound infection is that sometimes it gets so severe that it becomes a non-healing wound and doesn’t heal for a long time. This often results in the considerable pain as well as discomfort. It also affects patient’s mental health (Iqbal et al., 2018).

Regarding BP, it has been reportedly seen that after traumatic brain injury the mechanism that is involved in the elevation of the blood pressure focuses on the catecholamine excess state. A severe head injury can potentially trigger the pathways of catecholamine release through the elevation in intracranial pressure and in case of injury even a slight elevation in the blood pressure must treated (Krishnamoorthy et al., 2017).

Alcohol intoxication has been seen in patient and according to Weil & Karelina, (2017) it is stated that alcohol has been a risk factor in case of traumatic brain injuries due to falls. Alcohol intoxication in case of head injury can often leads to confusion and disorientation of the patient. It could also be resulted into certain dangerous brain swelling. A considerable changes in the impulse control, trouble in concentrating, and depression has been seen in such patients.

On pain assessment patient has shown 5/10. This means pain management is needed by the patient. Providing measures I order to relieve pain sooner than it becomes severe is important and the goal should be to display a satisfactory level of pain control i.e., less than 3 (Le-Wendling, Glick, & Tighe, 2017).

Process Information

As per the cues collected it has been seen that there are certain issues that have seem to be mild but there is a need to get them addressed in order to avoid them turning them into a serious issue for the patient. In order to avoid the infection in patient’s injury carefully sutures or staples must be done immediately so, that no source of contact and infection would be there. For the patient’s BP as it is stage 1 hypertension for this indicated medications must be administered and effective and careful monitoring of the blood pressure’s response towards the medications must be taken. Cognitive behavioral therapy and effectual counseling must be done in order to address the issue of alcohol intoxication. At last for the pain management of the patient certain pharmacological as well as non-pharmacological strategies should be used (Worley, 2016) in order to achieve the goal of satisfactory level of pain control by the patient i.e., less than 3 (Le-Wendling, Glick, & Tighe, 2017). The non- pharmacologic approach will manage the pain of the patient by some nursing interventions such as acupressure (Maciel et al., 2019). While, the pharmacologic approach will manage the pain of the patient by the administration of pharmaceutical drugs (Guerriero et al., 2016).

References for Zac Smith Clinical Reasoning Cycle Case Study

Guerriero, F., Bolier, R., Van Cleave, J. H., & Reid, M. C. (2016). Pharmacological approaches for the management of persistent pain in older adults: What nurses need to know. Journal of Gerontological Nursing42(12), 49–57. https://doi.org/10.3928/00989134-20161110-09

Iqbal, A., Jan, A., Wajid, M. A., & Tariq, S. (2017). Management of chronic non-healing wounds by hirudotherapy. World Journal of Plastic Surgery6(1), 9–17.

Jain S, Iverson LM. Glasgow Coma Scale. (2020). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513298/

Krishnamoorthy, V., Chaikittisilpa, N., Kiatchai, T., & Vavilala, M. (2017). Hypertension after severe traumatic brain injury: friend or foe?. Journal of Neurosurgical Anesthesiology29(4), 382–387. https://doi.org/10.1097/ANA.0000000000000370

Le-Wendling, L., Glick, W., & Tighe, P. (2017). Goals and objectives to optimize the value of an acute pain service in perioperative pain management. Techniques in Orthopaedics (Rockville, Md.)32(4), 200–208. https://doi.org/10.1097/BTO.0000000000000245

Weil, Z. M., & Karelina, K. (2017). Traumatic brain injuries during development: implications for alcohol abuse. Frontiers in Behavioral Neuroscience11, 135. https://doi.org/10.3389/fnbeh.2017.00135

Worley, Susan L. (2016). New directions in the treatment of chronic pain: National pain strategy will guide prevention, management, and research.” P & T : A Peer-Reviewed Journal for Formulary Management, 41(2), 107-14.

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