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Question: Case Study Joshua Thomson is an active 13-year-old who was riding his bike with friends when he f...

Case Study

Joshua Thomson is an active 13-year-old who was riding his bike with friends when he fell while attempting to jump over a ditch. His friends helped him home, and his mother has brought him to the urgent care center with complaints of a slight headache and a painful left wrist. As the triage nurse at the clinic, you interview Joshua and his mother. According to Joshua, he was attempting to jump the ditch when his bike tire caught on the curb. He flipped forward over the handlebars of his bike and landed on his back. He does not remember hitting his head on the ground but does remember putting his hands down to brace his fall. His biggest complaint at this moment is the pain he experiences when he moves his left wrist, but he is also nauseated and has a “small headache.” Joshua’s other thinks that the headache and nausea may be due to the fact that Joshua has not eaten anything since 7:00 a.m. and it is now 4:00 p.m. The attending physician prescribes an x-ray of Joshua’s wrist and acetaminophen (Tylenol) 650 mg for pain. The x-ray shows that Joshua’s left wrist is fractured. He is placed in a cast and given prescriptions for Tylenol for the pain and ondansetron (Zofran) for the nausea and sent home. As the nurse, you give Joshua’s mother some discharge instructions for caring for the cast, using both the Tylenol and Zofran, and watching Joshua for any sign of neurological damage.

Question 1

What neurological alterations would you educate Joshua’s mom to watch for?

Question 2

What should Joshua’s mother do if she makes any of these observations?

Question 3

What prevention education should be given to Joshua and his mother?

Question 4

What focused assessment should you perform?

Answer 1

1. The neurological symptoms to look for at home include:

• Vomitting
• Dizziness and loss of consciousness
• Slurred speech and blurred vision
• Disorientation
• Balance and coordination difficulty
• Stiff neck
• Muscle weakness or paralysis
• Any CSF or blood leak from nose and ear
• Seizure

2. In case of any of the above symptoms his mother should try to keep the head and neck in straight position. Try to keep Joshua awake.

She should immediately call the doctor and rush to the hodpital.

3. Prevention is the only cure for brain injury. Once brain injury occurs it cannot be cured completely. The prevention measures include protecting the head from any kind of injury. This can be achieved by wearing helmet while riding, avoid any kind of bike stunts, avoiding slippery surfaces. Play area for kids should be safe without any bumps, slippery areas and oil.

4. Focused assessment after head injury includes:

• Checking for GCS and correlating the score significantly
• Checking for any external cuts, bruises and bleed to head
• Looking for fracture of skull bone
• Checking for csf leak through ear or nose
• Pupillary response
• Orientation to time, date and place
• Balance and coordination assessment
• Manual muscle testing
• Reflexes
• Sensory function
• Checking for anosmia, dysphasia, hearing impairment
• Cranial nerves testing
• Facial expressions
• Check for rigidity, spasticity or flaccidity
• Check for tremors
• brain CT and MRI to rule out any hemorrhage, internal bleed or contusions and concussions