Name: Irene Smith Age/Sex: 16 years 10 months/female Accompanied by: Taylor Smith (Brother, 20 years/Male)
Present Medical History Irene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding a bike in the street in front of her home and bumped into a parked car on the street, fell, and hit her head. She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time. However, she started having a headache after half an hour of the injury. There were multiple abrasions on the elbow and knee and swelling on her left forehead.
Past Medical/Surgical History Acne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple times Current medications: Roaccutane, Olanzapine (poor concordance- she misses taking medications regularly as prescribed) Allergies: Peanuts (Anaphylaxis) Perinatal history: Vaginal birth, other details are not available Immunization history: Incomplete. Irene does not remember receiving any vaccination.
Family and Social history Irene`s parents are divorced, and she lives with her father. Irene is enrolled in TAFE for a vocational course. However, her engagement with the course has been poor with sporadic attendance for classes. She works in a local grocery store two days a week. Irene mentioned that she does not have many friends and she has been bullied at school because of her looks and feels very depressed about it.
Physical Examination Irene appears very tired, is crying, looks anxious and distressed, pain 6/10 Anthropometry: Height: 160 cm, Weight: 40 kg Vital signs: Respiratory rate: 20 breaths per minute, Oxygen saturation: 96% on room air, Heart rate: 98 beats per minute, Blood Pressure: 108/65 mm of Hg, Temperature: 37.6°C Neurological assessment: Glasgow Coma Scale - E3 V4 M6 13/15, Pupils - B/L 4mm and reactive Head and Neck: Swelling (3x3 cm) and bruising on the right forehead, neck feeling stiff and has limited mobility Respiratory: B/L air entry equal on auscultation, No increased work of breathing Cardiac: Nil issues noted Abdomen/GIT: Nausea (since an hour), abdomen soft and non-tender, last oral intake - food (3 hours ago), fluid (sips of water 2 hours ago) Musculoskeletal: Limited range of motion and pain right upper and lower limbs, Swelling on the right elbow Skin and mucous membranes: Dry skin and lips, Abrasion on the forehead right side (2x2 cm) on Right elbow (3x2cm), Laceration on right knee (2X1 cm) Multiple small scars noticed on both thighs (anterior and medial aspects). Irene mentioned the scars have resulted from previous injuries from self-harm attempts.
Medical/Clinical diagnosis Head injury for evaluation
Treatment plan Admission Neurosurgeon/team to review (regarding further management) Vital signs monitoring and neurological assessment every 30 minutes, continuous SPO2 monitoring Spinal immobilization Nil by mouth IV cannulation Bloods - FBE (Full Blood Evaluation), Urea and Electrolytes Wound dressing Urgent CT scan - Head and Spine IV fluids - 0.9% sodium chloride (normal saline) and 5% Glucose as continuous infusion IV Paracetamol STAT, IV Metoclopramide STAT IV Morphine PRN IV Antibiotics
Additional Information Irene`s father is on the way to the hospital. Irene does not want her mother to be notified as they do not get along and thinks that mother is non-sympathetic.
Discuss any psychosocial, emotional, and/or cultural needs that should be factored into nursing care and care planning. Identify the child protection responsibilities of an RN in a clinical setting and discuss the collaborative processes with a multidisciplinary team in the case of Irene. Discuss whether the adolescent in the scenario can provide informed consent and make independent medical decisions, based on your knowledge of Gillick competence, and legislation in your state and territory. Outline and discuss the Registered Nurse`s role in the safe administration and management of medications for adolescents.
