an afternoon shift. Patient information
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 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 headache after half an hour of injury. There were multiple abrasions on 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 to take medications
regularly as prescribed)
Allergies: Pea nuts (Anaphylaxis)
Perinatal history
Vaginal birth, other details are not available
Immunisation 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 to 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 in 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 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 right elbow
Skin and mucous membranes
Dry skin and lips, Abrasion on 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 immobilisation
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 hospital. Irene does not want her mother to be notified as they do not get
along and thinks that mother is non-sympathetic
ques :
3) Discuss any psychosocial, emotional and/or cultural needs which should be factored into
nursing care and care planning.
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