Shadow Health Focused Exam: Pediatric Traumatic Brain Injury (Damien Brooks)

asked guardian about onset/duration {Ans: reports pt headache, confusion, dizziness, and light sensitivity lasting at least since he came home reports pt lost consciousness for about a minute reports the fall happened 2 hours ago}confirm guardian relationship to pt {Ans: reports he is step dad}intervention & evalueation {Ans: fully complete}asked guardian about hx of present illness {Ans: reports pt falling at skatepark after school reports pt being with a friend when he fell reports pt walked home reports driving pt to ED reports seeing the fall on video}asked pt about characteristics of pain {Ans: reports dull pain from headache report pain is steady}explain the rationale behind your nursing dx {Ans: Damien, you are exhibiting symptoms of acute confusion related to your head injury. I'm going to go over some basic information with you so that you can feel more comfortable with your diagnosis. I will also go over my plan to help treat your acute confusion, including simple things you and your stepfather can do to help you feel better.}asked pt onset and duration {Ans: reports headache started when he fell reports confusion started when he fell reports dizziness started when he fell