Physical Assessment

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Katie McConnell
23 yrs
Mild traumatic brain injury
Katie McConnell is a 23 year old woman who has been admitted to your unit. She sustained a subdural haematoma 18 hours ago when she was hit by a slow moving car. She has been diagnosed with a mild traumatic brain injury, and has been transferred to the neurosurgical trauma unit to receive ongoing assessment and rehabilitation. The previous nurse hands over to you: HR 89, BP 142/78, Sp02 96%, RR 13. Glasgow Coma Score 14. Katie was also noted to have some difficulty with remembering recent information but can recall with some prompting. You introduce yourself to Katie and her partner and inquire about her past medical history. Katie says that she also has a painful ankle from years of basketball, but that she doesn’t really like to use painkillers. You will need to complete the admission assessment(s) for Katie.

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