Nursing

Thank you for receiving my order. I am going to attach the ”Grading Rubic” with the Headings that should be included for this assignment. *You can use the following scenario or make one up*.
A 32-year-old man comes in complaining of a headache after falling off a ladder at work. The patient fell on the left side and hit his head on the concrete but stated that he did not lose consciousness. Patient reports feeling dizzy over the last two weeks on and off. Patient also reports that he often has frequent and server headache.

ANSWER

Neurologic and Respiratory System

Subjective Assessment

A 32-year-old Caucasian white man comes in complaining of having headaches after falling off a ladder at work. The patient fell on their left side and hit their head on concrete. The patient did not lose consciousness. However, he reported feeling dizzy over the past two weeks after the accident. The dizziness is not constant. It is on and off. The patient is, however, experiencing severe headaches, which he believes could be a result of the accident. He came because he was concerned about the headaches, and he thought it would be wise to get checked.

Objective Assessment

The patient is alert and oriented to person, place, and time. Their facial expressions are symmetrical, and their speech is clear and appropriate. The patient can follow the instructions without trouble. However, the patient’s pupils are unequal in size (Shahrokhi & Asuncion, 2022). The patient has a poor balance due to the dizziness they are experiencing. They are also experiencing severe headaches, which make them spend time with their eyes closed to prevent the light from causing more pain. The patient’s facial expression is symmetrical, with no drooping on the face.

Potential Risk Factors

The patient is experiencing persistent post-concussive symptoms. The unequal sizes of the pupils show that the brain injury might have been severe, and the patent needs immediate care. The patient is at risk of having a potential brain injury (Shahrokhi & Asuncion, 2022). The other potential risk factor in this patient is Encephalitis. This is the infection of tissues surrounding the brain. The manifestation of the disease varies depending on the arts infected. The symptoms include headaches, nausea, irritability, and decreased consciousness. The patient needs to get checked immediately to overrule any potential risk factors and get the right treatment.

References

Shahrokhi, M., & Asuncion, R. M. D. (2022). Neurologic exam. In StatPearls [Internet]. StatPearls Publishing.