CNA155 - Nursing - Clinical Reasoning Report Writing Assessment Answer

Assessment Task:

CNA155: Nursing Assessment Answer

Case Study: John Wells

Background: John is an 82 year old dairy farmer brought in the emergency department by his son, Sam. Sam received a call from his mother Mavis, as she was concerned about her husband. Mavis noticed that John appeared somewhat quiet, and hasn’t eaten his dinner tonight. John had told Mavis that he was returning home from the dairy for morning tea, pulled up outside their home on the two-wheeled motorbike and became unbalanced. The bike was stationary at the time and John fell clear of the bike, striking the left side his head on the hard summer ground. John rarely wears a helmet, or any other protective equipment when he works on their property, and today he wasn’t wearing any. John has sustained a minor skin tear to his left forearm and small abrasion to his left elbow. John denies any other injuries and denies pain, stiffness or reduced range of movement to his neck, chest and limbs. Mavis was concerned about John, so she asked Sam to take John to the hospital.

Consider the patient:
82 year old farmer with no previous history of head injury or concussion. He is usually well, diagnosed with mild hypertension but not yet prescribed
antihypertensive medication. John is local to the rural area where he resides, lives with his elderly but otherwise well wife. John and Mavis’s only son Sam lives on the neighbouring property. John and Mavis value their independence, and Sam is usually happily able to assist his parents if required.

Patients notes: Emergency Department
82 year old male brought to the emergency department after experiencing headache, nausea and mild confusion after hitting his head following a fall
from a stationary motorbike. Currently states he is ‘feeling hazy’ and complains he is experiencing a headache 4/10. He states he was initially ‘dizzy’ after hitting his head and denies losing consciousness. He states he is ‘just not feeling right’.

John Vital Signs:
Temperature:36.7 degrees Celsius
Blood pressure: 148/84 mmHg
Pulse: 81 bpm
Respiratory Rate:17 bpm
SpO2: 97% on room air

Assessment Task:

a) Consider the patient situation: Discuss what is significant about the patient’s profile making links to how you think this information relates
specifically to the situation. It is critically important that you discuss John’s risk factors.

b) Collect cues and information: Review the patient’s notes from both the emergency department and the information prior to presentation. Note
the subjective and objective data, differentiate normal from abnormal. Also indicate potential significance of any changes you identify. 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 might 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 bioscientific principles underlying the case.

c) Process the information, relate and infer: Cluster the cues in the case to identify and support a problem that you think may be occurring with the
patient. From what you know about John’s background, the cue s you have clustered, and the sign and symptoms he is experiencing, explain
your interpretation of his condition. In other words, what do you think is going on?

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