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History Taking Strategies Essay

1135 words - 5 pages

In this case study an 8-year old male named Mike was brought into a small rural ER after being a hit and run victim. He had been riding his bicycle in the street and was not wearing his helmet at the time of the crash. Mike sustained facial and head trauma. The paramedics were able to control his facial bleeding prior to entering the ER. He appears to have no extremity fractures. The study will cover risk factors, history and assessment questions required to determine the level of head injury Mike sustained.History Taking StrategyHead InjuryHead injury is an injury to the scalp, skull, or brain. A brain injury is classified as either closed or penetrating. They can be minimal or devastating to the patient. Signs of brain injury can occur immediately or develop over several hours. The skull does not need to sustain a fracture in order for the patient to obtain a head injury. In the United States 1.4 million Traumatic Brain Injuries occur each year. Out of these figures, 50,000 die, 225,000 are hospitalized and 1.1 million are treated and related from emergency rooms each year. TBI in children ages 0-14 result in 2,685 deaths, 37,000 hospitalizations and 435,000 emergency room visits each year. (National Center for Injury and Prevention Control, 2007)Upon entering the ER, several questions that must be asked in order to determine a head injury. During the question and answering process special attention should be focused on how does the patient respond to the questions? Can the child speak fluently; is the speech garbled or disorganized? Can they mentally put the words together? Can the patient hear what has been said to them? Can he see what is in front of him? Can he move his extremities? These are all indicators of possible head trauma resulting in a neurological deficit and injury. (Head Injury, 2007)Initial AssessmentWhen presented with an 8-year old child awake and semi-alert, alone and frightened. The first question should be what is your name and can you tell me where you live? This should only be done after you introduce yourself and tell the child where they are. The entire experience is overwhelming. Mike has no parent or loved one present to provide a sense of security. A child of this age should be able to recite his address or phone number. This question is important in determining level consciousness and cognitive ability. He can developmentally provide information, yet a parent can provide information of history in greater detail. A detailed history is need as prior injuries, illness, and medications can affect the present outcome. Mike is only 8-years old and consent for treatment can only come from a parent or guardian.The second question should be what happened? This is to determine the child’s memory of the event. An amnesic state of accident is not uncommon but can be a sign of concussion. As the healthcare provider you need to assess the patient for any memory deficits. Mike can only tell you he was riding his bike and...

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