The following clinical report is about Zac, who is an 18 years old university student. After a minor accident, he was taken to the emergency department of a hospital. The injuries suggested that he might have a concussion. The report mentioned below will cover the three steps of clinical reasoning, nursing assessment, patient’s situation, collecting information, and cues by the incident.
Zac, a young university student, is at risk of concussion. There are chances that the brain might cure itself if provided with proper medication and guidance from the doctors. Zac was under the influence of alcohol when the accident occurred. The influence of alcohol can contribute hazards to the brain. As stated in the case study, Zac had five pints of beer. Alcohol and traumatic brain injury is correlated. The intoxicated brain can fall into a risky situation. It increases the chance of TBI three times than that of the normal. Under the influence of alcohol, one loses the balance of the body. Under the influence of alcohol, 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 has been enjoying his life having alcohol with the group is not to be surprised about. The alcohol tolerance is high which is obvious as he consumes 4 strengths of beer. When he was attacked by the abuser, the abuser might not have done major movements, but due to the inability to control his body movement, Zac fell down and had his head injury in the occipital region. He did not consume any drug but had full strengths of beer that has caused dizziness and made him unable to control his balance.
The vital signs were taken that were recorded 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 seen were pain, unable to recall incidents, dizziness, and mild confusion. Other signs were within the normal range. He had a 4 cm long laceration in the occipital region that required dressing. He was conscious but had problems while recalling the events. He had a laceration and the wound was oozing which required immediate management and dressing. It was suggested by the wound that an in situ dressing was required.
According to Zhang et al., (2016) a concussion is a type of common injury to the brain accompanied by small brain 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 (Zhang et al., 2016). Brain concussion has been a serious issue for the last few years. It also affects the neurological functioning of the brain resulting in loss of memory or unable to recall incidents and also can cause damage to the cell enhanced by the chemical present in the brain. On evaluating Zac’s case, a mild blood pressure rise was observed with loss of memory. The head of the patient was pushed into the cement curb on the road and was stuck there. While evaluating the brain clinically, it can be assumed that there can be damage to the grey matter of the brain. A big laceration was also found in the backside of the brain. It can be considered sensitive as the area is near to oblongata which helps in many brain activities. The last observation was the patient was unable to recall the events. While going through the medical history of Zac Smyth, it was observed that he had no specific allergies or any other problem related to his body. It meant that his body will be able to take any type of medications without any problems. The one thing that was encountered is childhood asthma. The tetanus doses were also given to him making the body immune to the tetanus virus.
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 the diagnosis of concussion 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). The second 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 has proved quite a successful way in comparison to the concussion in the different age groups of people (Prichep et al., 2013 p269).
Other forms of tests such as neuropsychological testing can be done. A neuropsychological test is a series of questions that are asked by the doctors. It includes testing of attention and memory such as 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 (Pérez & Duñabeitia, 2019 p262).
Glasgow Coma Scale (GCS) score can be used to measure his level of consciousness if Zac feels disoriented due to the accident.
A lot of patience and perseverance are required while treating a concussion. It must be realized that it would take some time. 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).
According to the protocol, Zac’s vitals were recorded every 30 minutes and are put 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. Zac’s current BP is mildly high denoting hypertension. Cerebral diseases can occur due to Hypertension (Donnelly et al., 2016 p699). The oxygen level at room air is 99% and that is a good sign because 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 (Weil & El-Gebali, 2013 p270) in a positive way. The pt level is 5/10 which is taken as on a moderate level and the patient must be provided with medication which will help in relieving the pain. The headache is the sign of a slight change in the morphology of the brain. Any vital changes observed while recording can conclude his health is deteriorating. 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 p1395).
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 (Kehoe et al., 2016 p382). The medical history of Zac stated that he never had a history of concussion. After the release, he might face a 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 p109). His medical history assessed that he can be given any medicine because he had no specific allergies. The tetanus dose was given to him which can help him tackle the side effects of the wound. One thing that has to be kept in mind avoiding those medications that can trigger the slightest of the asthma effect that he had in his childhood.
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