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Shadow Health Pediatrics TBI
Concepts of Nursing IV (BSN 366)
Nightingale College
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SHADOW HEALTH PEDIATRICS
TRAUMATIC BRAIN INJURY
DAMIEN BROOKS
1 Safety Equipment Followed Up
Description: Damien has expressed that he rarely uses a helmet and other safety equipment when he skateboards.
Were you wearing safety equipment? (Clarified to: Do you use safety gear?)
Question 01:36 PM MDT
Safety gear? I mean come on, that even sounds nerdy. Me and my friends sometimes wear helmets... but it just looks clunky on film. (Clarified to: if I use safety gear)
Wearing safety equipment protects your body from injuries.
Educate 01:36 PM MDT
Ok, I'll keep it in mind.
Model Statement: "I understand wearing a helmet, knee pads, elbow pads, or other safety equipment may feel unnecessary or even silly. However, it is important to wear these items every time you skateboard. Safety equipment, especially helmets, can protect you from serious, long term-injuries as well as more minor injuries and pains."
2 Pain
Followed Up
Description: Damien has expressed that he has been in pain since his fall.
How are you feeling now?
Question 03:02 PM MDT
My head has been killing me since the fall. It feels like the room is spinning sometimes, too.
Do you feel any better?
Empathize 03:02 PM MDT
Thanks.
I do have concern for your son. We will do everything we can for him.
Empathize 03:03 PM MDT
I appreciate that.
Model Statement: "I understand you’re in pain right now. Thank you for being patient and answering these questions, I know it can be a lot while you are also dealing with pain. We will make sure you get the best care possible and get your pain to a manageable level as soon as possible."
3 Concern for Son
Followed Up
your son about his helmet use and safety practices. You may consider including in your discussion the importance of safety equipment and their potential impact on a young person’s health."
ED Nursing Note
Student DocumentationModel Documentation
Chief Complaint Patient, Damien Brooks, is a 15-year-old Black male patient brought to the Emergency
Student DocumentationModel Documentation
15-year-old black male with head injury after falling during skateboarding.
Department at 5:30 PM after presenting with a head injury and mild confusion that started around two hours prior to arrival. Patient was brought to the ED by his step father, Tim Parker.
History of Present Illness Reports falling off skateboard with finding of scalp hematoma. Patient verbalizes was unconsciousness and reports headache, dizziness, and confusion since accident.
Damien Brooks is a 15-year-old boy who came to the ED experiencing symptoms of a Traumatic Brain Injury, including confusion, head pain, left-side head hematoma, light sensitivity, vomiting, and memory loss. His symptoms began approximately two hours prior. Damien was skateboarding when he fell from a rail three- feet high. Damien landed on the left side of his head and was unconscious for approximately one minute. Damien was with a friend during the incident, who recorded the fall on his phone. Damien and the friend walked home from the skate park to Damien’s house. When Damien got home, his step father Tim was updated and watched the video. Damien complained of head pain and light sensitivity. Damien’s step father dimmed the lights and got an ice pack for the hematoma, which Damien reports did not noticeably relieve symptoms. Damien vomited a small amount once, at which point the father drove the patient to the ED. Damien reports memory loss surrounding the events of the incident. Damien ranks his current head pain as a 5/10.
Allergies No known allergies.
Negative for food, medication, latex, or environmental allergies.
Home Medications acetaminophen prn
Patient’s step-father did not give the patient any medication to treat pain. Patient does not take prescription medication or regularly take OTC medication.
Past Medical History None
Patient has no past medical conditions, previous traumatic injuries, previous hospitalizations or previous surgeries. Patient is up to date on all vaccines.
Social History Denies any tobacco, illicit drugs, or alcohol use.
Damien reports that he does not wear a helmet or safety gear due to peer pressure and it “not looking good on video”. Damien’s step-father
14/15 on the Glasgow Coma Score
14/15 on the Glasgow Coma Score
Damien exhibits acute confusion related to his head injury as evident by a score of 14/15 on the Glasgow Coma Score and disorientation to place.
0 out of 0.
Lack of Orientation to Place
Lack of Orientation to Place
Damien exhibits acute confusion related to his head injury as evident by a score of 14/15 on the Glasgow Coma Score and disorientation to place.
0 out of 0.
Self Assessment
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
PromptStudent Response
Model AnswerExplanation
Why would a nursing diagnosis of acute confusion be correct, compared to distorted thinking process?
Damien's condition indicates he is experiencing acute confusion.
The most effective nursing diagnosis for Damien is acute confusion because his symptoms are a lack of orientation to place and a 14/15 on the Glasgow Coma Scale. This indicates that the patient is dealing with confusion rather than a distorted thinking process or post trauma response.
Your nursing diagnosis should always take into account what condition is most serious, receiving the greatest benefit from your help. Acute confusion is the most accurate diagnosis, as the diagnosis of distorted thinking process isn't supported by Damien's symptoms or mechanism of injury.
Planning
2 out of 2.
Short-Term Goal
Student ResponseModel AnswerExplanationPoints Earned
The patient will demonstrate stable memory status by the end of shift
The patient will demonstrate stable memory status by the end of shift
Addressing Damien's acute confusion will have the highest impact on the patient's current condition.
0 out of 0.
Interventions
Student ResponseModel AnswerExplanationPoints Earned
Promote continuity of care by avoiding frequent changes in staff and surroundings
Promote continuity of care by avoiding frequent changes in staff and surroundings
These interventions work towards addressing the patient's most urgent needs, which is his acute confusion.
0 out of 0.
Reduce sensory exposure by eliminating excessive noise, using appropriate lighting based on time of day, and establishing a calm environment
Reduce sensory exposure by eliminating excessive noise, using appropriate lighting based on time of day, and establishing a calm environment
These interventions work towards addressing the patient's most urgent needs, which is his acute confusion.
0 out of 0.
Reorient patient to time, place, and person as needed, providing information in small quantities
Reorient patient to time, place, and person as needed, providing information in small quantities
These interventions work towards addressing the patient's most urgent needs, which is his acute confusion.
0 out of 0.
Intervention Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
PromptStudent ResponseModel AnswerExplanation
In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal.
The interventions will address Damien's most urgent needs which is acute confusion.
These interventions will address Damien's acute confusion in a variety of ways. The proposed interventions will assist in restoring Damien to a stable memory status, while being careful to not overstimulate or overwhelm him.
Addressing acute confusion requires a multi-faceted approach, so it's important that your interventions address Damien's most immediate needs.
Data Collections
Student ResponseModel AnswerExplanationPoints
Shadow Health Pediatrics TBI
Course: Concepts of Nursing IV (BSN 366)
University: Nightingale College
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