Video Case Study - Caring for Pediatric Patients With Closed Head Injuries

Nurse Tyisha works in a pediatric primary care clinic and is caring for Justin, a 10-year-old who is being evaluated following a concussion that occurred during a soccer game one week ago.

In collaboration with the registered nurse, RN Christine, Nurse Tyisha goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Justin’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Tyisha recognizes important cues, including Justin’s vital signs which are temperature 98.9 F or 37.1 C, heart rate 100 beats per minute, respirations 16 breaths per minute and blood pressure 104/70 mmHg.

Justin reports a mild headache and rates it as a 2 out of 10 on a numeric pain scale. Justin is alert and oriented to person, place, and time.

There’s also a small, healing bruise above his left eyebrow. Nurse Tyisha gathers additional information from Justin and his caregiver, Mary, who’s at the bedside.

Nurse Tyisha: Hi Justin. How are you feeling?

Justin: Uhm, okay, my head feels kind of… Mary: (Interrupting Justin) He just hasn’t been acting like himself since the injury.

He’s been irritable and forgetful, especially with his chores, which just isn’t like him. He’s especially tired after school, and I noticed he gets frustrated when working on his computer or even when he’s playing video games or watching television.

Justin: I can answer for myself, Mom. I just feel tired.

It’s making me grumpy, and my head is kind of fuzzy. Next, Nurse Tyisha analyzes these cues.

She reviews the electronic health record, or EHR and notes that Justin’s concussion occurred following head-to-head contact during a soccer game one week ago.

Although he didn’t lose consciousness, he had poor coordination following the event. Nurse Tyisha knows a concussion is a type of closed head injury that occurs when an event, like the head striking a hard object, causes the brain to hit against the skull.

This leads to a temporary disruption of neural activity, resulting in symptoms like a headache, fatigue, and altered mental status.

She also knows that during recovery, patients with concussions need to reduce the time they spend on activities that require concentration, like using a computer, playing video games, or sending texts on a phone; and avoid activities that could cause another concussion, like contact sports.

Next, Nurse Tyisha reviews his score on the Glasgow Coma Scale, or GCS, which was 13 at the time of the injury, and today RN Christine scored the GCS at 15.

Nurse Tyisha realizes Justin and Mary need support to improve Justin’s concussion symptoms. Now, using the information she's gathered, Nurse Tyisha reports her findings to RN Christine, and together they choose a priority hypothesis of altered cognitive function.

Nurse Tyisha collaborates with RN Christine to generate solutions to address Justin’s altered cognitive function; and they establish the expected outcome that after intervening, Justin will demonstrate decreased forgetfulness and irritability by his follow-up visit.

Nurse Tyisha then takes action to implement these solutions. She reviews with Justin and Mary what to expect during recovery from a concussion.

She stresses the importance of avoiding activities that could result in another head injury and to limit activities that can exacerbate concussion symptoms.

She also reminds them to ask Justin’s teachers for additional time to complete his schoolwork and to continue to use the medical excuse note from the healthcare provider.

Nurse Tyisha: Do you have any additional questions? Justin: Does this mean I can’t play soccer at tomorrow’s game?

Nurse Tyisha: Unfortunately, yes. You’ll need to be cleared by the healthcare provider before you can start playing again.

Mary: We’re just going to focus on rest and relaxation for the next week. No more screen time until you're feeling better.

Justin: Ugh, fine. But what about chores?

Mary: No more chores for you either. Justin: Yes!

Nurse Tyisha: That sounds like a good plan. One week later, Justin returns to the clinic and Nurse Tyisha evaluates the outcomes of her actions.

She takes Justin’s vital signs which are temperature 98.9 F or 37.1 C, heart rate 90 beats per minute, respirations 15 breaths per minute and blood pressure 100/80 mmHg.

Justin reports that he’s feeling less tired and doesn't have headaches anymore. Mary also reports that Justin is no longer irritable or forgetful.

Alright, as a quick recap… Nurse Tyisha recognized and analyzed cues related to Justin’s altered cognitive function, and in collaboration with RN Christine, prioritized hypotheses and generated solutions to address this problem.

Nurse Tyisha then took action by implementing measures to address Justin’s altered cognitive function, and evaluated his outcomes, comparing them to the expected