PATIENT PROFILE

Name: Herman Lopez

Age/Sex: 51 years old/Male
Occupation: None, due to previous operation
Educational attainment: High school graduate
Religion: Roman Catholic
Address: Itogon, Benguet
Social Status: Married
Date of admission: March 08, 2016
Chief complaint: Gunshot wound
PATIENT HISTORY
History of present Illness
The patient was fetching his wife from work when suddenly an armed guy
attacked him from behind and declared a hold up. The patient tried to resist and the
perpetrator then fired a single gunshot at the patient occipital area. The wife then
heard what happen and rushed to the patient seeing the patient fall down on the
ground. The wife then asked for help and brought the patient to Baguio General
Hospital and Medical Centre where he is currently admitted. The patient was then
subjected to different laboratory and diagnostic tests. Patients CT scan reveals
occipital bone fractures and subarachnoid haemorrhages in the bilateral sylvian
fissures and interhemispheric fissure and cortical haemorrhages in the basi-frontal
region.
Since then the patient has been admitted in the surgery ward of BGHMC,
where the wife claims that the patient have had a change in behaviour since
incident. Irritability and restlessness are also noted. The patients doctors are still
contemplating on whether the shrapnel of the bullet used that was lodged into the
occipital area near the C5-C6 vertebrae should be extracted or not.
Past Medical History
On the year 2011, the patient was diagnosed to have a cyst in the urinary
bladder. He was then subjected to chemotherapy and other anti neoplastic agents
that was claimed to be unrecalled by the wife. After a few months of medication use
and compliance to medical advice no significant improvement have been noticed,
the patients doctor then decided to subject the patient to removal of cysts in the
urinary bladder. The cancer remained dormant until a few months later, a new
growth of cyst has been identified and necrosis of the urinary bladder was noted.
The patient was then subjected for operation at the BGHMC operating theatre for
removal of the urinary bladder and attachment of an indwelling catheter to the
tubules where the urine is flowing from the kidneys. This impaired the ability of the
patient to perform activities of daily living. The wife than decided to let the patient
rest and stay at home and stop working since she can handle their financial needs.
Social and Environmental History
The patient is a high school graduate and previously works as a taxi driver
before being diagnosed with cancer of the urinary bladder. Patient is married and
with two children who lives with them at Itogon, Benguet. The house is with good
ventilation and far from roads where air pollution can be easily observed. The house
is found in a non-congested area. Water being used for drinking and cooking
purposes comes from a water refilling station near them and water for domestic use
come from Baguio Water District. The patient is an occasional alcoholic drinker and
has already quit smoking a long time ago. The wife claimed that the patient has a
good relationship with their children and other relatives.
Family History
The patient has no history of any heredofamilial disease such as
Hypertension, Diabetes and etc. The patient also does not have any history of any
mental or psychiatric disorders in their family.

PATHOPHYSIOLOGY
Precipitating Factors

Impaired Skin
integrity related to
tissue trauma

Predisposing Factors
51 years old
Male

Penetration of gunshot
wound to the Skin

Break in the skin and

damage to the nearby
tissues
Penetration of gunshot
wound to the Skull

Stimulation of nearby nerve

endings at the site of
penetration
Transduction happens where
translation of the noxious
stimuli takes place

A-delta and C fibers respond

maximally to the noxious
stimuli
Transmission occurs as the
stimuli are being sent to the
brain through the
neospinothalamic tract of
the spinal cord

Modulation then takes place

where dampening or
amplification of the stimuli
Stimuli are also sent to the
ascending tract where other
parts of the brain tend to
respond to the noxious
stimuli

Risk For infection

related
compromised 1st
level of defence
Sulbactam
Ampicillin IV

After continuous stimulation,

descending inhibition happens
where pain is dampened or
completely blocked in the gate of
the dorsal horn

Perception then takes place

where the patient becomes
aware of the tissue trauma that
took place interpreted in the pain
and perceived as pain
Deeper penetration of the wound
causes rupture of blood vessels
that are passed through by the
bullet

Leakage of the blood in the brain

cavity causes increased
intracranial pressure and
decreased cerebral tissue

Risk for seizures

Increased Hear
rate and
respirations

Imbalance in the
neurotransmitters causes rapid
firing of impulses by the neurons
as compensation to the
decreased perfusion
Irritability and
restlessness

ACUTE PAIN
RELATED TO TISSUE
TRAUMA
KETOROLAC
IV PUSH

Risk for ineffective

cerebral tissue
perfusion related to
subarachnoid
hemorrhages

Levetiracetam
500mg BID

Vasodilation of blood
vessels for better
blood flow

After prolonged stress and failure

to compensate, decompensation
occurs where a rebound of early
signs take place

Alteration on
mental or
cognitive status

Risk for falls related

to altered mental
status

Lethargy or
excessive
desire for sleep

BetaHistine PRN
for DIzziness

Vasoconstriction
causing cerebral
hypertension

Nimodipine 30mg
2 tabs every 4
hours

PRIORITIZATION OF PROBLEMS
1. ACUTE PAIN RELATED TO TISSUE TRAUMA
This is the priority problem because pain is considered to be the fifth vital
sign where affectation of the other vital signs can be noted due to stimulation
of sympathetic nervous system that can further aggravate the patients
condition. Pain is also a factor to consider the patient receptiveness to
teachings and compliance to interventions being rendered. Being in pain can
cause the patient not to participate in his care regimen.
2. Risk for fall related to altered mental status
Though being a potential or a risk problem, this outweighs the other
identified problem because it is directly endangering the patient which can
lead to further aggravation of the condition. Injury that would develop can
cause further problems to the patient.
3. Risk for infection related to inadequate 1st level of defence
Infections in the brain must be prevented for it can further aggravate the
condition the patient is in. Infections can cause further damage the brain
which can again cause other complications and other problems that are
harder to manage. According to Maslows hierarchy of needs physiologic
needs should always be addressed first because other needs cannot be met
until a person satisfies these needs.
4. Impaired skin integrity related to tissue trauma
An open wound can serve as a portal on entry for microorganism and a
break in the skin can cause another noxious stimuli for the brain to interpret
as pain. Knowing these, the patients skin should be treated and cared for in
order to prevent complication such as pain or infection.
5. Risk for ineffective cerebral tissue perfusion related to haemorrhages in the
brain
Cerebral tissue perfusion can be monitored by assessing the patient
behaviour and cognitive status. The patient so far, does not manifest any
pathogpneumonic sign of inadequate cerebral tissue perfusion making it the
leat prioritized proble