CNA155 Zac Smyth Clinical Reasoning Report Sample

Subject Code : CNA155
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Subject Name : Nursing

Health Assessment

Consider the Patient’s Situation

Zac Smyth was an 18 years old engineering student who would stay on the campus of his university and his parents would stay in another region. The concerned patient Zac was engaged in a part-time job at a hypermarket wherein, he would work for 15 hours in a week. In the night prior to the incident, Zack had visited a pub with his friends, where he found that there was a new group of musicians to be playing in the pub and Zack was interested to go for the event. It was because of this only, the Zack decided to meet his friends for the pre-drink gathering at his friend’s house with an attempt to save some money so that he can go for the event. In that party, itself he was determined to have taken four bottles of beers, after which was pushed violently by the boyfriend of the girl with whom he was talking outside the pub. In this event, Zack’s head was hit hard on the cement, he was determined to be bleeding and no other kind of injury was visible on the concerned patient.

Collect Cues & Information

In this context, all the vital signs of the patient were determined to be normal when he was examined after this incident, hence he was just bandaged on his wound. The key determination made in this situation was that the patient claimed to be conscious during the course of this event, however, he was unable to remember all the events that has occurred to him. Furthermore, the patient had also not taken pain-killer prior to his examination in the hospital, he was only experiencing 50% pain in the occipital region and his incision was 4cm with an abated leakage from the wound he had sustained. Considering the overall aspect, the patient was fit and fine. However, the key consideration here is to determine the reason due to which the patient was unable to recall the events that had occurred to him, in spite of being in a conscious state of mind. The past history of the patient suggests that he was an asthmatic patient since his childhood, all vaccinations were given to him and also, he had taken tetanus a year back.

Considering the above condition of the patient, it can be suggested that the patient might be suffering from Traumatic Brain Injury ( TBI), wherein the normal function of the brain gets disrupted due to a hit or a jostle on the head or even the head aggressively hits an object or in a case in which a pricky objects enters the tissue of the brain. This can be relevant because even Zack was hit hard against the cement that resulted him in a state of bleeding with no other visible injury. Furthermore, the indications of the TBI can be negligible, acute or even result in the death of the patient (Gardner et al. 2018, p. 889-906). In the context, of the given case study, there was only a little change in the mental functioning of the patient, wherein he was conscious but was not able to recall events. As per the symptoms of the TBI which states that the patient might lose his memory either prior or after the occurrence of a particular incident and the same was determined to be found in the case of Zack.

Nursing Assessment Methods

X-Ray- This is an assessment method that can be used to determine any kind of a damage on the brain of an individual, clotting or even the damaging of the brain tissue. However, it is not always successful in finding out the occurrence of a TBI in the patient. Moreover, in the case of Zack, GCS ( Glasgow Coma Scale) assessment was created, suggesting possibilities to conduct a CT scan (Jain et al. 2019, p. 1794-1803) .

Furthermore, X-Ray is suggested to be the most initial assessment method that could be used to find out the cause of the condition of Zack and then only proceed with the CT Scan as per the GSC score.

CT Scan- The NCCT is the most popular technique used by the clinical practitioners to scan the brain of a patient with an attempt to find out any indication of TBI ( Traumatic Brain Injury). The potential of this assessment method is such that it instantly identifies any kind of a traumatic wound on the brain, brain injury as well as blood clot in the brains. This should be the most basic assessment to be conducted on the patient suspected with a brain injury (Wintermark et al. 2015, p. e1-e14). Hence, even in the case of Zack, a CT scan is required to be conducted even if it appears to be minor to go ahead with further assessments as and when required.

Furthermore, this assessment method is greatly recommended for those patients who has a Glasgow Coma Scale ( GCS) that is below 15 and, in this context, the GSC score for Zac was 14, hence CT scan would be considered to be a vital requirement in his case.

MRI- There are some cases when the CT scan’s result seems to be normal for a particular patient, however, it is not a clear diagnosis that the patient is not having any kind of a brain injury. In such a situation MRI is required to be conducted which will enable to identify any kind of an axonal hemorrhage wound of the patient. This assessment method has been widely used in the past ten years for the treatment of the TBI patients in case no findings is being determined in relation to the condition of their brain (Delouche et al. 2015, p. 25-30) .

Since, there was no visible injury for Zack, in spite of him not being able to recall events that had happened with him, it becomes essential to conduct the MRI scan to determine the exact cause of his inability to recall things.

Furthermore, through the execution of all the above assessment method, there is a high possibility that the exact condition of the concerned patient would be determined and the reason for him not being able to recall things could also be identified.

Process Information

Through the above assessments of the concerned patient it can be suggested that the patent has a high chance of suffering from the TBI ( Traumatic Brain Injury) as it is very clear that his head had hit hard on the cement, which is known to be a prime cause of the TBI. Moreover, on of the symptoms of the TBI suggests that the patient will not be able to remember any event prior to or after the occurrence of a particular incident and this was only determined to be happening with Zack. Furthermore, it can also be suggested that the extent was brain injury in the case of Zack was minor because there was only a minor change in the condition of his brain due to which he was unable to recall any event that had happened to him, additionally, the concerned patient has also claimed to be in a conscious state of mind, which makes it clear that it was a minor injury which needs to be identified (Wang et al. 2017, p. 344-353).

Among all the three suggested assessment methods, the CT Scan would be highly recommended in the case of Zack because of his GCS score which was determined to be 14 as per the cues collected in the prior stage.

References for Zac Smyth Clinical Reasoning Report

Delouche, A., Attyé, A., Heck, O., Grand, S., Kastler, A., Lamalle, L., Renard, F. & Krainik, A., 2016. Diffusion MRI: pitfalls, literature review & future directions of research in mild traumatic brain injury. European Journal of Radiology, 85(1), pp.25-30. https://www.sciencedirect.com/science/article/abs/pii/S0720048X15301467

Gardner, R.C., Dams-O'Connor, K., Morrissey, M.R. & Manley, G.T., 2018. Geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, & future directions. Journal of neurotrauma, 35(7), pp.889-906. https://www.liebertpub.com/doi/abs/10.1089/neu.2017.5371

Jain, S., Vyvere, T.V., Terzopoulos, V., Sima, D.M., Roura, E., Maas, A., Wilms, G. & Verheyden, J., 2019. Automatic quantification of computed tomography features in acute traumatic brain injury. Journal of neurotrauma, 36(11), pp.1794-1803. https://www.liebertpub.com/doi/full/10.1089/neu.2018.6183

Wintermark, M., Sanelli, P.C., Anzai, Y., Tsiouris, A.J., Whitlow, C.T., Druzgal, T.J., Gean, A.D., Lui, Y.W., Norbash, A.M., Raji, C. & Wright, D.W., 2015. Imaging evidence & recommendations for traumatic brain injury: conventional neuroimaging techniques. Journal of the American College of Radiology, 12(2), pp.e1-e14. https://www.sciencedirect.com/science/article/abs/pii/S1546144014006760

Wang, W., Zhang, H., Lee, D.H., Yu, J., Cheng, T., Hong, M., Jiang, S., Fan, H., Huang, X., Zhou, J. &Wang, J., 2017. Using functional and molecular MRI techniques to detect neuroinflammation & neuroprotection after traumatic brain injury. Brain, behavior, & immunity, 64, pp.344-353. https://www.sciencedirect.com/science/article/abs/pii/S0889159117301290

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