NURSING PROCESS FORM: PART I – ASSESSMENT
Date of Care: 3/4/13
Client’s Initial: WB Room # 1011
Age: 59 Sex: F Race: Black Religion: Christian
Admission Date: 3/1/13 Primary Language: English
Role in family: Widowed from husband
Stage in Life Cycle:
Generativity vs. StagnationSurgery date(s) this admission: N/A
Brain Dysfunction/Traumatic, closed injury
Post Blunt Force (Head) Trauma
Type 2 DM; HTN; DM related Neuropathy
Past Medical/Surgical History (dates)
11/29/10 Dx w/ Pancreatitis & Hep B
Current Medical History:
59 y/o female AA pt w/ PMH of Type 2 DM; HTN; DM related Neuropathy, suffering from closed injury head trauma caused by basketball hoop and backboard falling on her head. A CAT scan of her head & cervical spine came back negative for fractures. She was scheduled for DC from ED but b/c of her vision; gait problems; and persistent headache, she was admitted to West Towerfor inpatient rehab and continued med evaluation.
No Hx of tobacco, alcohol or illicit drug use. Lives in own one-story home. Widowed for 5 yrs. Has 25 yrs as a school teacher, Has family support (daughters).
NURSING PROCESS FORM: PART I
PATHOPHYSIOLOGY OF CURRENTDIAGNOSIS
Diagnosis and Definition of Diagnosis:
Dx: Post Blunt Force (Head) Trauma
Definition: a usually serious injury caused by a blunt object or collision with a blunt surface (as in a vehicle accident or fall from a building)
While various mechanisms may cause TBI, the most common causes include motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents), falls, assaults, sports-related injuries, and penetrating trauma. Motor vehicle accidents account for almost half of the TBIs in the United States, and in suburban/rural settings, they account for most TBIs. In cities with populations greater than 100,000, assaults, falls, and penetrating trauma are more common etiologies of head injury. The male-to-female ratio for TBI is nearly 2:1, and TBI is much more common in persons younger than 35 years.
The physical examination and the history of the exact details of the injury are the first steps in caring for a patient with head injury. The patient's past medical history and medication usage will also be important factors in deciding the next steps. Plain skull X-rays are rarely done for the evaluation of head injury. It is more important to assess brain function than to look at the bones that surround the brain. Plain X-ray films may be considered in infants to look for a fracture, depending upon the clinical situation. Computerized tomography (CT) scan of the head allows the brain to be imaged and examined for bleeding and swelling in the brain. It can also evaluate bony injuries to the skull and look for bleeding in the sinuses of the face associated with basilar skull fractures. CT does not assess brain function, and patients suffering axonal shear injury may be comatose with a normal CT scan of the head. Numerous guidelines exist to give direction as to when a CT should be completed in patients who present awake after sustaining a minor head injury.
The Ottawa CT head rules apply to patients age 2 to 65.
•Glasgow Coma Scale less than 15, two hours after injury •Suspect open or depressed skull fracture
•Sign of basilar skull fracture
•Vomiting more than once
•Older than 65 years of age
•Amnesia before impact greater than 30 minutes
•Dangerous mechanism of injury
Signs, Symptoms, and Course of the Disease/Disorder:
It is important to remember that a head injury can have different symptoms and signs, ranging from a patient experiencing no initial symptoms to coma. A high index of suspicion that a...