Focused Health Assessment

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 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 in rural Belle Glade Florida, 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 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.

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