CNA155 - Health Assessment Answer - Report Writing Assessment Answer

Assessment Details:

Case Study: Mia Roberts

Mia Roberts is a 12-year-old grade six student playing in a weekend basketball tournament for her school. Mia was the point guard who sustained a head injury in the second game of the tournament. Mia was pinned between two players and was struck on the left side of the frontal bone. She was fouled during the play, and recalled feeling dizzy and light-headed at the time, but was composed enough to make both free throws and complete the rest of the game. Immediately following the game, her chief complaints were headache, nausea, loss of appetite and fatigue.
Following the day's play, at the team dinner, her teammates noticed that she was uncharacteristically quiet. She also felt tired, experienced a lack of appetite and the onset of a headache. As the night progressed Mia began to feel nauseated and had an increase in what she described as a “hazy” feeling. Also, when she returned to the hotel room where the team was staying, she felt confused and began crying for no particular reason for which she was aware. At this point her teammates called the coach who made the decision to bring Mia to the local emergency department where you are an RN on shift for the evening

For this assessment item, you will be required to write a clinical reasoning report, demonstrating your understanding of the clinical reasoning cycle by applying the first three components of the cycle to the case of Mia Roberts (case study document below).
In this report you will be required to:

a)Consider the patient situation:

This requires you to study the patient's profile in the case and consider how it shapes your clinical reasoning.

Discuss what is significant about the patient’s age, gender, and medical history, making links to her chief complaint. Also, consider what risk factors are present in relation to the chief complaint.

b)Collect cues and information:

Review the available information

• The patient’s notes from the emergency department. The background information in the case study.
• The subjective and objective data and differentiate normal from abnormal.
• Propose new assessment data/cues to collect and describe the nursing assessments that you will use to collect those cues, as well as the frequency with which those assessments need to be performed.
• Link the nursing assessments to a clear understanding of what is occurring from a functional and structural perspective within the brain. Making these links requires you to recall knowledge of the bio scientific principles underlying the case.

c)Process the information:

Relate and Infer: Cluster the cues in the case to identify and support the problem that you think might be occurring with the patient. From what you know about Mia's background, the cues that you have clustered, and the signs and symptoms she is experiencing, explain your interpretation of her condition. In other words, what do you think is going on?

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