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 saturation on room air 90%, Respiratory rate, 24. He is mobilized with a cervical collar on a gurney. Rescue 29 over! Emergency department preparing for arrival over! As a nurse working in the Pediatric Emergency Department, the writer recognized that rapid assessment and evaluation is essential for a positive outcome in head trauma victims. According to the Neurological Disabilities Center, “every 11 minutes one child in the United States has a brain injury which results in permanent disabilities (30,000 children per year).” The article goes on to say “Only one percent of the children admitted to trauma units after a bicycle injury were wearing helmets” (National Disabilities center, 2001). This writer also notes that the mortality rate of head injury is high and can lead to physiological, cognitive, and physical impairment lasting a life time. With this in mind, initial observation, assessment, diagnosis and management is crucial to the outcome in a head trauma patient. For any patient entering the emergency department, a proper history taking is essential to their care and subsequent treatment. Observations at the scene (using forensic nursing assessment skills) may provide valuable information, which maybe gathered from the paramedics or bystanders. Pertinent information about the speed of the vehicle, how big was the vehicle, the height of the fall, any loss of consciousness at the site, and bleeding may be critical in determining the course of treatment. Focused health assessment for injuries also asks questions similar to forensic nursing. Rapid initial assessment would be airway, work of breathing, circulation for life-threatening hemorrhage, and level of consciousness. In an emergency situation, it is imperative that a focus assessment be the top priority. This will allow the nurse and the physician to focus on any immediate life threatening symptoms. Observation of the patient should always be done before touching. A quick observation should include the child’s behavior and activity, skin color, breathing, and positioning. Gaining the cooperation and confidence of the pediatric patient is of utmost importance, even in the presence of the parent. In this case, the child needs to be reassured that his parents are on their way. Use simple terms and do not make promises that cannot be done. They should always be told what is happening and the outcome. The nurse should remain calm and talk in a quiet voice. Trauma patients are prone to hypothermia, especially in pediatrics due to their body surface. In assessing the child exposed only the body part needed, traumatic children are very susceptible to hypothermia. Once the child has been stabilized, initial vital signs should be noted and recorded. A priority in head trauma is neurological screening to evaluate the degree of injury to the head. The involvement of other body systems should also be the focus of this assessment. According to the Canadian medical association journal “children are more predisposed than adults to head injury because of their head. A child’s body ratio is greater, their brains are less myelinated, and thus prone to injury, and their cranial bones are thinner.” (Canadian Medical Association Journal.2002, p.948 (9). Careful examination of the head is necessary to identify any tenderness or deformity of the skull, skull fontanels, and facial bones for facture. While the child is awake and semi-alert, questions such as “where did you hit your head?” or what part of your head hurts?” should be asked. 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, “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 examined for ecchymosis and the ears and nose for bleeding or watery discharge, which may indicate spinal fluid. In the book clinical manual of emergency pediatrics the Cain and Gershel state, “spinal cord injury is sometimes overlooked during the initial evaluation of the severe brain injury patient” (Crain & Gershel, 2004. p.642). The head in humans is connected to the neck bone, therefore injury to the cervical spine should be ruled out. To evaluate this, ask the child if any numbness or tingling in any body part or does it feel like pins or needles. The toes or sole of the feet should be touched to detect sensation then ask, “can you feel your toes being touched.” “Paresthesia is an abnormal sensation,” says Jarvis (2002. p.670). The goal is to detect any spinal cord injury. If there are any indications of a suspected traumatic brain injury a CAT scan of the brain should be done as long as no spinal injury is detected. The nurse should continually be alert to the signs and symptoms of increases in intracranial pressure, such as restlessness, nausea and vomiting, altered mental status, and changes in vital signs. Monitor closely for seizure activity. The child that was riding a bicycle and was struck by a vehicle is more prone to injuries to the head, spine and the abdomen. According to Cook, Schweer, Shebesta, Kaaren& Falcone “The flexible skeletal structure in young children may allow traumatic forces to extend to deeper structures, creating injury without fracture.” (Society of trauma Nurses, 2006. p 58) The child’s chest should be examined for any broken ribs, tenderness or instability of the chest wall while asking him/her “does your chest hurt when you breathe?” This is done to ensure there is no cardiac involvement or ribs facture. Observation of the thorax says Gilligan “may reveal the ‘see-saw’ respiratory pattern of a high spinal injury or upper airway obstruction, or a paradoxical segment (‘flail chest’), usually due to the mechanical instability of extensive rib-cage injury” (Gilligan, 2006. p.279). The child’s abdomen should be evaluated for internal bleeding. Asked questions like “is there any tenderness when your abdomen is touched?” Palpate abdomen while monitoring facial grimace for signs of pain. Once the life threatening assessment is completed and the patient is stabilized; and there is no physical evidence of fracture, the child should be log rolled to assess the spine and back for any injuries. Pertinent scans, x-rays, abdominal sonograms, and any labs can be completed. Risk factors related to the brain injured child’s condition can be numerous, depending on the severity of the injury and the organs involved. Paralyses from spinal cord injury can
be an unfavorable outcome in head trauma patients. Seizures are also very common in patients with head injury. Bleeding in the brain is also a major risk factor. Small children can revert to an earlier stage of development, while others suffered memory loss. The parents or care-giver should be involved in the care of the child. Education of the child and parents to the importance of helmet while riding a bicycle must be emphasized. The parents or caregiver should also be educated on the care of the child to ensure continuation of care after leaving the hospital. Managing patients with head injury can be complex and can result in post traumatic disability and death. Proper diagnosis, treatment, and management can aid in alleviating some of the long-term complications associated with head trauma in children. Many traumatic injuries could be from abuse at home, but blamed on a fall. A good nurse will use her health assessment skills to assess the patient but also questions about the circumstances of the injury. References (2002, January). Management of children with head trauma. Canadian Medical association journal, 142, 949. Retrieved December 14 2006, from htt:// Cook, R.; Schweer, L. Kaaren, F.; & Richard, A. (2006, April-June). Mild traumatic brain injury in children just another bump on the head. Retrieved December 14, 2006 from Health reference center, from Crain, E.Gershel, J. (2004, November). Retrieved December 12, 2006 from Gilligan, J. (2006, October). From accident site to the Trauma Center, p.279. Retrieved December13, 2006, from http:/ book/book.html Jarvis, C. (2002). Physical Examination & health assessment (4th ed). Elsevier Philad

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