Patient Case Assessment

What 8 questions would you ask this patient that would provide the most essential information to assist in your assessment?

1. Primarily, the demographic information of the patient is asked.

- What is the patient’s name, age, gender, current physician (if possible) and relatives or people he lives with?

2. Ask the main complaint of the patient.

- Aside from your bruises, what other part of the body aches?

- Where is the pain or discomfort located?

- Does it spread out?

- How does the patient describe the severity of the pain?

- use appropriate terms such as mild, moderate, or severe or the words of the patient.

3. Inquire on the patient’s associated symptoms such as nausea, vomiting, headache, sweating, irregular-heartbeat, or the urge to urinate or defecate?

- Can you breathe?

- Are you dizzy?

5. When did the accident happen? Describe the accident.

- What vehicles are involved?

6. What was the point of impact to the vehicle?

- Specify the patient’s location.

- Was the patient trapped or thrown from the vehicle? If trapped, what was the rescue time?

7. Ask on the patient’s pertinent health history. Does the patient have a history of injury to the same area?

- What was the diagnosis?

- What was the treatment?

8. Does the patient take any medicine before going to the hospital? Does he take routine medications?

- What is the name, dosage, route, and frequency of the medication?

- When was the last dose?

- Does the patient have allergies to drugs or foods? What is the name of the allergen? What was the reaction?

- When was the patient’s last tetanus immunization?

Aside from this expected questions, the intervening circumstances such as the interrogation of the paramedics’ staff who attended the patient beforehand is also necessary. Further, the case involved unlawful activity. Medical personnel are responsible to the immediate report of the accident to authorized individual for appropriate law enforcement.

2. Identify body system(s) to be included in your assessment and provide the rationale for each. This is a focused assessment based on the patient’s situation, so conducting a complete history and head-to-toe assessment is not appropriate.

Basing it to the most affected area, the highest probable body system that will be included in the assessment is the head and brain. The nervous system is the first thing to consider when evidences of head trauma are evident to patients. Thus, the examination of the potential and underlying mechanism in the nervous system is necessary and standard. Assessment of the head goes as far as the involvement of the brain and the skull. As to this case, head trauma is common to children of the same age range. Seriousness of the case varies according to the injury, its cause and nature. The detection of valid and invalid symptoms related to mild head trauma often is the responsibility of a neuropsychologist. Further, if concerns exist about possible ocular problems, an ophthalmologist will join the emergency team early in the treatment program to determine if the trauma has caused impairment to the sight.

3. Discuss risk factors in the patient’s condition.

Anxiety

Since the patient is 8 years old, the tendency of emotional distress caused by the accident is highly probable. Anxiety is the most usual condition. Specifically, anxiety is the composite combination of negative emotions such as fear, worry, apprehension or nervousness that is often accompanied by physical sensations. Palpitations, chest pain and/or shortness of breath are observable. Anxiety can possibly affect the condition of the patient. Relating to the somatic perspective, anxiety increases the blood pressure, heart rate, sweating, blood flow to the major muscle groups, and inhibit immune and digestive system functions. External manifestations of anxiety include pale skin, sweating, trembling, and pupillary dilation.

With this condition, the patient’s condition may turn adverse and affected. The possibility of phobia is not far at hand. Because the patient is a kid, the chances of having more severe effects the next time he encounter the same emergency situation will require a more complex medical application.

Pain

Pain may be classified as acute or chronic. As to this case, the pain felt by the patient is not only to the wounds itself but also to the succeeding effects of the accident. Technically, children on this age (8 years old) are more sensitive to pain. Researches have been conducted to show the coping mechanisms of children to pain. Since children are not actually potent in rejecting pain, its identification will help in its eventual avoidance, treatment, and minimization.

Risk of injury

The presence of wound to the skin that causes bleeding is an injury itself. But the further damage in head may be delicate. Thus, the medical team needs to further monitor and evaluate the condition. After the recovery, the potentials of frequent occurrence or onset of headache, dizziness, visual impairment, and other symptoms is plausible.

Risk of infection

Due to the presence of wound, the risk of infection is high. Thus, the medical team must be aware of the tetanus immunization of the patient. During the assessment, it is vital to ask about the history of the patient in relation to immunization. As implied, ask if When was the patient’s last tetanus immunization? This will help to alleviate the risk of infection.

Reference

---. (1995). Harrison’s Principles of Internal Medicine. (13th ed.) New York:

McGraw-Hill.

---. (2004). Physicians’ Desk Reference. (58th ed.) Montvale, NJ: Medical

Economics Company.

Emergency Nurses Association. (1998). Sheehy’s Emergency Nursing Principles

and Practice. St. Louis: Mosby.

Emergency Nurses Association. (1995). TNCC Trauma Nursing Core Course

Provider Manual. (4th ed.) Des Plaines, IL: Author.

Handysides G. (1996). Triage in Emergency Practice. St. Louis: Mosby.

Kidd, P.S. & Sturt, P. (1996). Mosby’s Emergency Nursing Reference. St. Louis:

Mosby.

Kim, M.J., McFarland, G.K., & McLane, A.M. (1993). Pocket Guide to Nursing

Diagnoses. (5th ed.) St. Louis: Mosby.

Padula, W.V. & Shapiro, J.B. (1993). Head Injury and the Post­ Trauma Vision

Syndrome. RE: view. 24(4), 153.

Potter, P.A. (1990). Pocket Guide to Physical Assessment. (2nd ed.) St. Louis:

Mosby.

Price, J.R. (1997). Psycholegal Implications of Malingered Head Trauma. Applied

Neuropsychology. 4(1), 75.

Sheehy S.B. & Lenehan, G.P. (1999). Manual of Emergency Care. St. Louis:

Mosby.

Skidmore-Roth, L. (1996). Mosby’s Drug Guide for Nurses. St. Louis: Mosby.

Vonfrolio, L.G. (1998). Emergency Nursing Examination Review. (3rd ed.) New

York: Power Publications.