Paramedics When the ambulance arrived, Zac had a GCS of 15 and could recall the whole incident. Zac appeared to have no other injuries. The paramedics undertook vital signs which they stated were 'normal' and applied a bandage to Zac's head wound. The security guard stated that he 'didn't think Zac lost consciousness'. Triage 18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs. Patient is denies loss of consciousness but unable to recall all events. Patient appears alert but teary and takes a couple of moments to answer questions. On examination, 4cm occipital laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries. Patient denies drug use, states has had approximately 'five beers since 7pm'. Breath alcohol taken at 2330 hours 0.06%. Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation. Patient states is usually fit and well. Past medical history Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago). Not on any medications and no known allergies. Assessment and investigation data Vital signs Respiratory Rate: 17 breaths/minute SpO2: 99% on room air Blood Pressure: 141/88 mmHg Heart Rate: 90 beats/minute Neurological observations GCS: Eyes 4 Verbal 4 Motor 6 Pupillary response - bilateral 4+ Limb strength - bilateral, upper and lower limbs: normal power CT report Exam Information Modality: CT Body Part: NEURO Description: CT Brain and C-Spine Performed Date: 25/3/Year Time: 0015 Final Report CT BRAIN AND C-SPINE CLINICAL NOTES: Witnessed awkward fall after physical altercation, head knock with no reported loss of consciousness Findings: A non- contrast CT has been acquired. No acute intracranial abnormality is seen. There is no intra or extra-axial haemorrhage noted. There is no cerebral oedema, midline shift or hydrocephalus. Unremarkable posterior fossa structures. No skull fractures are seen. No obvious fractures from C1 to T2. IMPRESSION: No acute abnormality on the examination. Other Zac complains that his hand is hurting. Medical Review - soft tissue injury from extending his hand to break his fall. Actions and interventions Interventions The decision is made to keep Zac in hospital overnight, for observation. Paracetamol is charted for pain. No other medications are charted. Vital signs and neurological observations to be undertaken hourly. At 7.00 You are the nurse who is allocated to care for Zac. You review all Zac's documentation and go to attend his observations at 0700. You gather the following data: Vital signs: RR: 18 breaths/minute Sp02: 98% BP: 146/98 mmHg Pulse: 106 bpm Temp: 37.3oC Pain: he mumbles that his "head is hurting", but cannot rate the pain; he is holding his head with his hands Neurological Assessment: Best Eye Response: Eye opening to verbal stimuli Best Verbal Response: Confused Best Motor Response: Obeys commands - slow to respond Pupils: Right - size 3 mm, sluggish reaction; Left - size 3 mm, sluggish reaction Limb Movements: Right arm - mild weakness, Left arm - normal power; Bilateral legs - normal power Question: A very important intervention for any deteriorating patient is to increase in the frequency of observations undertaken. If Zac were to significantly deteriorate, what trend in his HR might be observed? Explain the pathophysiological mechanisms which would cause these changes.

Paramedics When the ambulance arrived, Zac had a GCS of 15 and could recall the whole incident. Zac appeared to have no other injuries. The paramedics undertook vital signs which they stated were 'normal' and applied a bandage to Zac's head wound. The security guard stated that he 'didn't think Zac lost consciousness'. Triage 18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs. Patient is denies loss of consciousness but unable to recall all events. Patient appears alert but teary and takes a couple of moments to answer questions. On examination, 4cm occipital laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries. Patient denies drug use, states has had approximately 'five beers since 7pm'. Breath alcohol taken at 2330 hours 0.06%. Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation. Patient states is usually fit and well. Past medical history Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago). Not on any medications and no known allergies. Assessment and investigation data Vital signs Respiratory Rate: 17 breaths/minute SpO2: 99% on room air Blood Pressure: 141/88 mmHg Heart Rate: 90 beats/minute Neurological observations GCS: Eyes 4 Verbal 4 Motor 6 Pupillary response - bilateral 4+ Limb strength - bilateral, upper and lower limbs: normal power CT report Exam Information Modality: CT Body Part: NEURO Description: CT Brain and C-Spine Performed Date: 25/3/Year Time: 0015 Final Report CT BRAIN AND C-SPINE CLINICAL NOTES: Witnessed awkward fall after physical altercation, head knock with no reported loss of consciousness Findings: A non- contrast CT has been acquired. No acute intracranial abnormality is seen. There is no intra or extra-axial haemorrhage noted. There is no cerebral oedema, midline shift or hydrocephalus. Unremarkable posterior fossa structures. No skull fractures are seen. No obvious fractures from C1 to T2. IMPRESSION: No acute abnormality on the examination. Other Zac complains that his hand is hurting. Medical Review - soft tissue injury from extending his hand to break his fall. Actions and interventions Interventions The decision is made to keep Zac in hospital overnight, for observation. Paracetamol is charted for pain. No other medications are charted. Vital signs and neurological observations to be undertaken hourly. At 7.00 You are the nurse who is allocated to care for Zac. You review all Zac's documentation and go to attend his observations at 0700. You gather the following data: Vital signs: RR: 18 breaths/minute Sp02: 98% BP: 146/98 mmHg Pulse: 106 bpm Temp: 37.3oC Pain: he mumbles that his "head is hurting", but cannot rate the pain; he is holding his head with his hands Neurological Assessment: Best Eye Response: Eye opening to verbal stimuli Best Verbal Response: Confused Best Motor Response: Obeys commands - slow to respond Pupils: Right - size 3 mm, sluggish reaction; Left - size 3 mm, sluggish reaction Limb Movements: Right arm - mild weakness, Left arm - normal power; Bilateral legs - normal power Question: A very important intervention for any deteriorating patient is to increase in the frequency of observations undertaken. If Zac were to significantly deteriorate, what trend in his HR might be observed? Explain the pathophysiological mechanisms which would cause these changes.

Intro To Health Care

4th Edition

ISBN:9781337338295

Author:Mitchell

Publisher:Mitchell

Chapter19: Documentation And Medical Records

Section: Chapter Questions

Problem 2AE

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Question

Paramedics

When the ambulance arrived, Zac had a GCS of 15 and could recall the whole incident. Zac appeared to have no other injuries. The paramedics undertook vital signs which they stated were 'normal' and applied a bandage to Zac's head wound. The security guard stated that he 'didn't think Zac lost consciousness'.

Triage

18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs.
Patient is denies loss of consciousness but unable to recall all events. Patient appears alert but teary and takes a couple of moments to answer questions.
On examination, 4cm occipital laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries.
Patient denies drug use, states has had approximately 'five beers since 7pm'. Breath alcohol taken at 2330 hours 0.06%.
Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation.
Patient states is usually fit and well.

Past medical history

Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago).

Not on any medications and no known allergies.

Assessment and investigation data

Vital signs

Respiratory Rate: 17 breaths/minute
SpO2: 99% on room air
Blood Pressure: 141/88 mmHg
Heart Rate: 90 beats/minute

Neurological observations

GCS:

Eyes 4
Verbal 4
Motor 6

Pupillary response - bilateral 4+

Limb strength - bilateral, upper and lower limbs: normal power

CT report

Exam Information

Modality: CT

Body Part: NEURO

Description: CT Brain and C-Spine

Performed Date: 25/3/Year Time: 0015

Final Report

CT BRAIN AND C-SPINE

CLINICAL NOTES:

Witnessed awkward fall after physical altercation, head knock with no reported loss of consciousness

Findings:

A non- contrast CT has been acquired.

No acute intracranial abnormality is seen.

There is no intra or extra-axial haemorrhage noted.

There is no cerebral oedema, midline shift or hydrocephalus.

Unremarkable posterior fossa structures.

No skull fractures are seen.

No obvious fractures from C1 to T2.

IMPRESSION:

No acute abnormality on the examination.

Other

Zac complains that his hand is hurting.

Medical Review - soft tissue injury from extending his hand to break his fall.

Actions and interventions

Interventions

The decision is made to keep Zac in hospital overnight, for observation.

Paracetamol is charted for pain. No other medications are charted.

Vital signs and neurological observations to be undertaken hourly.

At 7.00

You are the nurse who is allocated to care for Zac. You review all Zac's documentation and go to attend his observations at 0700.

You gather the following data:

Vital signs:

RR: 18 breaths/minute
Sp02: 98%
BP: 146/98 mmHg
Pulse: 106 bpm
Temp: 37.3^oC
Pain: he mumbles that his "head is hurting", but cannot rate the pain; he is holding his head with his hands

Neurological Assessment:

Best Eye Response: Eye opening to verbal stimuli
Best Verbal Response: Confused
Best Motor Response: Obeys commands - slow to respond
Pupils: Right - size 3 mm, sluggish reaction; Left - size 3 mm, sluggish reaction
Limb Movements: Right arm - mild weakness, Left arm - normal power; Bilateral legs - normal power

Question:

A very important intervention for any deteriorating patient is to increase in the frequency of observations undertaken. If Zac were to significantly deteriorate, what trend in his HR might be observed? Explain the pathophysiological mechanisms which would cause these changes.

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