Physical Examination and Health Assessment †MyAssignmenthelp.com

Question: Discuss about the Physical Examination and Health Assessment. Answer: Introduction The essay describes the case study of Katie McConnell. She was hit by a slow moving car. She is a young woman aged 23 years old who sustained a subdural hematoma in the past 18 hours. Injuries due to road accidents are commonly reported in the age group of 15 to 44 years old (AIHW, 2012). Such accidents on road are a result of carelessness which may be of the driver due to alcohol consumption, using mobile phones by either of the injured person while road crossing or the person who is driving the vehicle. One of the main reasons of deaths among the age group of 15-29 is reportedly due to injuries during road accidents (WHO, 2016). Majority of the people suffer huge economic losses irrespective of income and age due to unfortunate accidents which leads to death, hospitalization, disability and trauma which lasts for life-long. Consequently, minor or major injuries in such traffic accidents require hospital stays for long duration, clinical interventions which are usually expensive and high quality nursing care. Based on the case study Katie on diagnosis with mild traumatic brain injury has been directed to obtain appraisal and therapy to recover at neurosurgical trauma centre. Her vital signs mentioned are BP is 147/78, respiration rate is 13, oxygen pressure is 96% and heart rate is 89. It is recommended that vital signs in brain injury cases are to be inferred in relation to the diagnosis of patient and outcomes based on neurologic assessment (Rank, 2013). For example, the reason for elevated blood pressure may be due to accidental trauma or any other medical reason. Katies Glasgow Coma Score (GCS) is 14. According to the existing reports 95% of patients who survived head injury and experienced normal or slight drop in conscious level scored above 12 on GCS (NICE, 2014). This supports Katies present condition that she has mild traumatic brain injury based on GCS. The information which is essential to be recorded or missing in the records is regarding loss of conscious level just after the injury. Has she experienced any pain in the body parts such as headache or cervical area? Why has she come to hospital whether to report any existing problem or behavioural change since the accident? Katie is unable to recall present information, but she can recollect roughly some data when provoked by her partner. It is recommended that for a complete health assessment detailed medical history and appropriate physical examination has to be achieved as both are of utmost importance (Forbes and Watt, 2015). Physical examination should be done by the nurse to find out if there is any pain in the cervical or spine area, swelling or other relevant sign. She suffers from ankle pain due to basketball playing but avoids consuming painkillers. Katie was dressed neatly and was avoiding eye contact. The nurse discussed the medical history with her and the partner accompanying Katie. It has been asked if she was on any medication or any blood anticoagulant was consumed. Did she have blood clotting disorder or any brain surgery in the past? Was she feeling uncomfortable or had any post-traumatic seizure. While talking to her, it was observed that speech tone was slightly slurred and she was not certain about her health information. It is reported that tone, rate and quality of speech reveal mental status o f a person and anxious patients may get irritated (Daines et al., 2016). After physical examination and data collection on health history neurological assessment has to be carried out. It is recommended that a neurological assessment performed must encompass vital signs, loss of conscious level, and functions of motor and cranial nerves as well as pupils (Rank, 2013). The present situation of Katie can be evaluated in a detailed way by computed tomography (CT) scan. She had subdural hematoma 18 hours ago, and her GCS is not 15, therefore CT scan can provide with some data on occurrence of any lesions in the intracranial spaces or not. All the data assessment carried out so far is focussed and will aid to understand potential risks of the injury. Therefore, phases of assessment have been presented by Alfaro-Lefevare, which are important to decide on diagnosis and data collected in an organised manner so that skills are used in logical advances (Alfaro-Lefevare, 2013). These phases guide us to evaluate the symptoms and signs in a critical manner so as to de rive a diagnosis and medical intervention. Post-concussive symptoms occur during recovery process; therefore Katie has been guided by the nurse regarding the risk factors such as sleep disturbances, headaches or concentration problems. Duration of recovery may vary from patient to patient and proper care and family support is the main requirement. The drawback of performing a CT scan is cognitive or behavioural problems cannot be noticed. If there are no lesions or acute haemorrhages in Katies CT scan then performance dependent assessment of neuropsychology has to be done for cognitive skills. Mild traumatic brain injury or post-concussive symptoms are to be evaluated in addition to comprehensive mental health examination. At rehabilitation centre, she can be facilitated with a care-plan to attain optimal health. She will be under observation so that nurses can keenly observe any degenerating neurological activity for example disturbed balance while walking, abnormal response of pupil, and changes in vision, numbness in legs or arms, anxiety or speech problems. She needs support and care to recover from the trauma of injury both physically and psychologically. Family support is very important in managing trauma patients. Hence, family assessment is also advised to nurses (Gordon, 2016). On discharge Katie will be provided with instructions to be followed at home. In case of any health problem she should contact her physician or neuropsychologist at emergency department. With time and adequate rest she may recover gradually and can continue her regular activities. Conclusion Mild traumatic brain injuries are enormously common during road accidents. Comprehensive assessment of clinical history, physical examination, vital signs, technology based neuroimaging for lesions and fracture followed by neuropsychological assessment altogether play an important role in evaluating condition of patient. Doctors who are treating such patients reveal that recovery from mild traumatic brain injury is rapid only if patients get adequate rest and should slowly resume work. References AIHW: Henley, G., Harrison, J.E. (2012). Serious injury due to land transport, Australia 200809. Injury research and statistics series no. 67. Cat. No. INJCAT 143. Canberra: AIHW Alfaro-LeFevre, R. (2013). Applying nursing process: The foundation for clinical reasoning (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams Wilkins. Daines, J., Baumann, L., Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St Louis: Mosby. Forbes, H., Watt, E. (2015). Jarviss physical examination and health assessment (Australian and New Zealand ). Chatswood, NSW: Saunders/Elsevier. Gordon, M. (2016). Manual of nursing diagnoses. Burlington, Ma: Jones Bartlett. National Institute for Health and Care Excellence (2014). Head injury assessment and early management. Clinical guidelines. Retrieved from: nice.org.uk/guidance/cg176. Rank, W. (2013). Performing a focused neurological assessment. Nursing, 43(12), 37-40. Wolters Kluwer Health /Lippincott Williams Wilkins. WHO (2016). Road traffic injuries. Retrieved from: https://www.who.int/mediacentre/factsheets/fs358/en/