When a patient is admitted to a healthcare facility, it is essential for a nurse to assess the health status (Rothman et al., 2012). In this case, a head-to-toe assessment was used to evaluate the patient’s physical features, emotional factors and mental status condition (Rothman et al., 2012). She had a rounded skull indicating it was symmetrical and normocephalic. Her hair was neither brittle nor dry. However, the patient had blood clot and laceration on her left frontal scalp indicating the presence of a hematoma. The patient’s eyebrows, eyelashes, and eyelids were symmetrical. Additionally, the patient did not show any signs of discharge or discoloration from the eyes. A penlight was used to inspect the cornea, sclera, and pupils all of which had no abnormalities. The patient’s nose was symmetrical, straight and had a uniform color. Similarly, no discharge or lesions were noticed. Correspondingly, she did not show any signs of bleeding gums, and she had a pink buccal mucosa with moist and smooth lips. According to her physical examination results, they showed that the patient had an aware and oriented intermittent confusion. Her vital signs were likewise stable with a blood pressure of 138/60, a pulse rate of 74 and body temperature of 98.9 Degrees Fahrenheit. Moreover, the amount of oxygenated hemoglobin in her blood was 96% and her respirations held at 18. Her lungs were clear to auscultation bilaterally with no signs of rales, rhonchi or wheezing. Furthermore, she had an obese abdomen which was soft and tender. Nevertheless, her belly musings were positive. Her extremities indicated she had limited range of motion on her left shoulder most likely due to the pain. Moreover, her other extremities did not have any abnormalities as there was no sign of nail clubbing, edema or cyanosis. Encephalopathy is a general term used to describe an illness that affects normal brain functioning. There are a variety of encephalopathy defects which can be temporary or permanent. Encephalopathy can develop as a result of head trauma or occur during birth and growth (Mez et al., 2017). In the case of the patient, she most likely suffered from hypoxic-ischemic encephalopathy. Tests showed she had an A/O intermittent confusion which is encephalopathy’s main symptom (Arciniegas, 2010). Additionally, one can develop neurological complications such as having muscle weakness in some regions of the body as in the case of a patient (Arciniegas, 2010). Poor perfusion can also lead to various brain defects. Perfusion is the process through which a tissue’s capillary bed receives blood from the body’s lymphatic or circulatory system (Ekbal et al., 2013). In the case of the patient, she had reduced perfusion indicated the brain could not access enough oxygenated blood leading to the encephalopathy. Additionally, other body tissues did not have access to oxygenated blood resulting in increased body weakness (Ekbal et al., 2013. Therefore, this might have brought about the mechanical fall incident encountered by the patient as noted from the left upper extremity weakness thus leading to the fractures of her humerus and pubic rami. The patient similarly noted of an augmented pain during movement which most likely resulted from a cervical DJD. The cervical vertebra plays an essential role during motion at the C4-C5 and C6-C7 (Mekata et al., 2013). Maximum inflammation occurs at these sections as one gets older thus affecting locomotive abilities. The degenerative joint disease affected the patient’s joints leading to an inflammation that caused the irritation and pain (Gregory and Fellner, 2014).
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