Essay on Health Assessment

1613 Words Jul 31st, 2007 7 Pages
Focused Health Assessment
Lola Lewis-Walker
University of Phoenix NUR/420: Health Assessment
Gina Robinson, MSN, RN, CLNC
December 18, 2006

Focused Health Assessment
Trauma one Pediatric Emergency Department! Trauma one Pediatric Emergency Department responding over! Rescue Unit 29 transporting a 12 year-old boy, named Mike, hit by a car while riding his bicycle. This is a hit and run accident, but other motorists called a rescue unit. The child was not wearing a helmet. Facial bleeding is under control, but he suffered facial and head trauma. There appeared to be no facture of the extremities. Presently he is awake and semi-alert. Vitals signs: BP 120/56, Pulse 120, Oxygen
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This will give the examiner an indication of the area of injury and which part of the brain that may be affected. The child's response will help the nurse to evaluate his neurological state such as level of alertness, orientation, speech and comprehension. Using the Glasgow coma scale (GCS) will provide in depth incite to his neurological state. The score is calculated from best eye opening response (1to 4), verbal response (1 to 5), and motor response (1 to 6). A score of 15 is good while 3-8 is considered serious. According to Gilligan "patients with GCS less than 9 usually required intubations via the oral route" (Gilligan, 2006. p.277). The Glasgow coma scale should be used when the patient is initially evaluated and after each intervention.
Pupillary response is critical for the head trauma patient. The child should be asked if he/she has any difficulty seeing or blurry vision. Pupil size, shape, reaction to light and symmetry of both eyes should be checked to detect any cranial nerve involvement. Jarvis states that "in a brain-injured person, a sudden; unilateral; dilated; and non-reactive pupil is ominous. Cranial nerve II runs parallel to the brain stem. When an increase in intracranial pressure pushes the brain stem down (uncal herniation), it puts pressure on cranial nerve III and causes pupil dilatation" (Jarvis, 2002. p.702). Around the eye should be

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