BNURS20 Nursing


Case Study: Katie McConnell 23 yrs. Mild traumatic brain injury

Katie McConnell is a 23 year old woman who has been admitted to your unit. She sustained a subdural haematoma 18 hours ago when she was hit by a slow moving car. She has been diagnosed with a mild traumatic brain injury, and has been transferred to the neurosurgical trauma unit to receive ongoing assessment and rehabilitation. The previous nurse hands over to you: HR 89, BP 142/78, Sp02 96%, RR 13. Glasgow Coma Score 14. Katie was also noted to have some difficulty with remembering recent information but can recall with some prompting. You introduce yourself to Katie and her partner and inquire about her past medical history. Katie says that she also has a painful ankle from years of basketball, but that she doesn’t really like to use painkillers. You will need to complete the admission assessment(s) for Katie.

Utilising elements of Levett-Jones (2013) Clinical Reasoning Cycle below, write an essay, incorporating the following the information.

  1. Consider the person’s situation: Identify and discuss the key elements of the demographic data recorded in your chosen scenario: Is this a typical complaint for this age and/or gender?
  2. Collect cues and information: Review handover information. Describe any additional information that you think is missing that may be relevant to this clinical presentation.
  3. Process information: Interpret what you currently know about their presenting problem – how would you expect this person to present? What are the expected assessment findings for this person’s situation?
  4. Identify problems/issues Describe what focused health assessment/s you think you would need to conduct and why Describe how your chosen person’s findings differ from someone NOT experiencing this condition
  5. Detail the assessment Detail how you are going to undertake the health assessment – ensuring you describe the technique and person considerations.
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