NOOTAN COLLEGE OF NURSING

VISNAGER

sub : CLINICAL SPECIALITY-1

MEDICAL SURGICAL
NURSING

Topic: HEALTH ASSESSMENT on

“head injury”

SUBMITTED TO:- SUBMITTED

BY:-
Ms. Srushti Contractor Mr.Dharmendra Patel
Assistant Proffecer F.Y M.Sc Nursing
NCN , Visnager NCN, Visnager

INDEX
SR.N CONTENT PAGE NO

O
1 PATIENT PROFILE 3
2 FAMILY HISTORY 4
3 MARITAL HISTORY 4
4 ENVIRONMENTAL HISTORY 5
5 SOCIOECONOMIC HISTORY 5
6 NUTRITIONAL HISTORY 6
7 PERSONAL HISTORY 7
8 HISTORY OF ILLNESS 10
9 PHYSICAL EXAMINATION 11-13
10 DIAGNOSTIC EVALUATION 14
11 MEDICAL MANAGEMENT 14
 PATIENTS PROFILE

Ptients Name : Mr. Suresh Mevala Jaiswal

Age : 45Years

Sex : Male

Address : Piparia, Vadodara

Religion : Hindu

Marital status : Married

Education : 10th Std

Occupation : Driver

Income : Rs.3000 / month

Ward : SICU

Date of Admission : 25/03/18

I.P No : I10114414

DIAGNOSIS : Head injury

Operation : ‘F’ ‘T’ ‘P’ Craniotomy

 FAMILY HISTORY
S.No Name Age in Sex Relation Education Occupation Health
years with head of status
family

1. Mr. Suresh 45 M Head of Illiterate Driver Head injury

family

2. Mrs .Leelaben 40 F Wife Illiterate House wife Healthy

5. Mr. Sunil 22 M Son 10th std Labour Healthy

6. Mr .Ravi 17 M Son 11th Std Student Healthy

7. Ms .Kinjal 12 F 6th Std Student Healthy

Family Tree

Mr.Suresh Jaiswal Mrs.Leela Suresh

Mr.Sunil Suresh Mr.Ravi Suresh Ms kinjal

NUTRITIONAL HISTORY:
Patients is come from hindu family. He is taking all types of vegetarian food. He
likes spicy food. He takes 3 meals per day. At present patient is taking feed with NG tube.
They occasionally eat the fruits and salad in the diet. Thus they eat the balanced diet daily.
 ENVIRONMENTAL HISTORY:
 HOUSE:He having his own house .
 LOCALITY: He lives in town.
 TYPE OF HOUSE: His house is pucca type.
 VENTILATION: There is proper ventilation in the house.
 NUMBER OF DOORS AND WINDOWS: DOORS:- 1
WINDOWS:- 3
 BATHROOM: There is a separate bathroom in the house.
 LATRINE: There is a latrine in the home.
 WATER SUPPLY: There is a tape water supply in the house.
 KITCHEN: Kitchen is attached in the house.
 GARBAGE DISPOSAL FACILITY: There is adequate garbage disposal faciltity.
 DRAINAGE: Drainage is proper.
 CLEANLINESS HOUSE:- House tends to be kept clean.
 SURROUNDING:- Surroundings are clean.

SOCIOECONOMIC HISTORY
He belongs to low socioeconomic family. He and his son is earning member of the
family. They are having good relation with society and friends. They took part in all religious
activity. He earns approximately Rs.3000/- per month.

PRESENT ILLNESS
Mr. Suresh came in the hospital with the complain of vehicular accident. He dashed
with truck and got head injury. At the time of admission he was unconscious only but having
no history of nasal bleeding and bleeding from ear.

After coming in hospital he undergone investigation and had MRI and diagnosed as
having subarachnoid hemorrhage. Then after craniotomy & clot has evacuated on
26/02/2012.

Soon after craniotomy he kept on ventilator support on CPAP mode and then shifted
to SIMV mode as patient maintained Spo2 level.

PERSONAL HISTORY
He is having bad habit of alcoholism. He has no any bad habit of tobacco chewing.
MARITAL HISTORY
 YEARS OF MARRIAGE: It has been 22 years of marriage life to her.
 MARITAL RELATIONSHIP: The marital relationship is satisfactory
 STAYING TOGETHER: They stay together.
  ANY MARITAL DISCORD: There is no marital discord.
 NUMBER OF CHILDREN: He has 3 children.
 HEALTH OF SPOUSE: Spouse is healthy.
 HEALTH OF CHILDREN: Good health
 ANY CONGENITAL DISEASE IN CHILDREN: There is no children to them.

PHYSICAL EXAMINATION

1) GENERAL OBSERVATION:
a) Constitution
b) Stature
c) State of Nutrition
d) Personal appearance
e) Posture
f) Emotional stage
g) Skin
h) General Appearance
: Thin body built
: Normal
: Malnourished
: clean
: Good
: no responce
: Pallor
: Unconscious, not oriented

2) VITAL SIGNS:
1. Temperature: 100°F 2. Pulse: 82/min 3. Respiration:
22/min

4. Blood Pressure: 130/90 3) HEIGHT : 155 CMS

[APPROXIMATEL 4) WEIGHT : 45 KGS
[APPROXIMATELY

5. SKIN AND MUCUS MEMBRANE

a) Colour of skin : Pallo

b) Edema : Absent

c) Moist Temperature : Normal

d) Turgor : Normal

e) Texture : Dry
6) HEAD : left tempo – parital craniotomy, swelling in
Left side, extradural hematoma present.
a) Skull :contusion present over left temporal region
b) Hair :black hair, hair distribution normal,
dandruff present.
c) Movements of the head :voluntary movement is absent
d) Fore head :abrasion present
e) Face :no expression
7) EYES :
a) Expression : Anxious & fear
b) Eye brows : Equal
c) Eye lids : No lesion
d) Lacrimation : Clear fluid
e) Conjunctiva : Pale
f) Sclera : pallor
g) Cornea : Clear and moist
h) Iris : Normal
i) Pupils : left pupil is reacting towards the light
8) EARS :
a) Appearance : No mass
b) Discharge : blood clot present
c) Hearing : not identified
d) Lesion : Absent
9) NOSE :
a) Appearance : No Septal deviation, N.G. lube is inserted
b) Discharge : No
c) Patency : Both nostrils are patent
d) Sense of smell : Good

10) MOUTH AND THROAT:

a) Lips : Dry
b) Tongue : coated halitosis present
c) Teeth : Intact in upper and lower jaw, dental carries
present
 d) Gums : Pink and moist
e) Buccal mucosa : No lesion, Secretion present
f) Tonsil : Redness present
d) Taste : Normal
11) NECK:
a) General appearance : Tracheotomy tube is present
b) Trachea : Normal in position
c) Lymph node : not palpable
d) Thyroid gland : Feel smooth and firm
e) Cyst and tumor : Absence

12) CHEST AND RESPIRATORY SYSTEM:

a) Inspection : Size and shape normal, chest
expansion equal in both side and
respiration are shallow and short breath
b) Palpation : No local swelling, no lymph node
enlargement.

c) Percussion : Normal resonance in both lungs

d) Auscultation : Bilateral Crackle sound heard, high pitchein both

side. Respiratory rate 24 bpm S1 and S2 heart normal, heart rate – 140 bpm

13) CARDIO VASCULAR SYSTEM

a) Inspection : Size and shape of the chest is with in

normal limit

b) Palpation : Carotid pulse and peripheral pulses

which is regular; normal sinus rhythm; 74 bpm

c) Percussion : Cardiac borders well with in normal Limits.

d) Auscultation : S1 and S2 heard well. No abnormalities

noted. HR _ 74/ mt and regular.

14) ABDOMEN:
a) Inspection : No abnormality
b) Palpation : No organomegaly
c) Percussion : No fluid filled spaces could be found
d) Auscultation : Peristalsis present 7 per min
15) BACK:
a) Spine and curvature : No abnormalities is noted ,
b) Movements : Normal
c) Tenderness : No tenderness noted
16) GENITALIA:
Normal - no discharges, catheter is present
17) UPPER EXTREMITIES:
Normal joint movement , swelling present
No lymph node enlargement
18) LOWER EXTREMITIES:
Normal joint movement , swelling present
19) NERVOUS SYSTEM:
 Higher function – semiconsciousness
 Memory – immediate, recent, remote is not able to recall
 Speech – absent
 Sensory function – not responding
GLASSGOW COMA SCALE:

SCALE SCALE
FEATURE
RESPONSE NOTATION
Eye opening Spontaneous 4
To speech 3
To pain 2
None 1
Verbal response Oriented 5
Confused conversation 4
Word (inappropriate) 3
Sound (Incomprehensive) 2
None 1
Best motor response Obey command 6
Localize pain 5
Flexion – normal 4
- Abnormal 3

INVESTIGATIONS:
S.No Name of the Patient value Normal value Remarks
Investigation
1. Hematology
a. Hemoglobin 14.3 mg/dl 13.5 – 18 Normal
b. Total W.B.C 14,200 cells / cumm 4,000 – 10,000 Increased
Differential count
c. Polymorphs 80% 40-75% High
d. Lymphocytes 16% 20-45% Low
e. Eosinophils 04% 1-6 Normal
f. Monocytes 00% 2-10 Low
g. Basophils 00% 0-1% Normal
h. Platelets count 2,94,000 cells / cumm 150000-400000 Normal
i. RBC 5.20 mills / cumm 3.9 – 5-6 Normal
j. PCV 41.1% 36 – 47% Normal
k. Blood urea 24 mg/d/ 10-50 Normal
l. Blood sugar 85 mg/d/ 70 – 115 Normal
 2 Biochemistry
a. Serum sodium 137 mEq/L 135 – 145 Normal
b. Serum potassium 4.6 mEq/L 3.5 – 5.0 Normal
c. Serum creatinine 1.2 mg /dl 0.7 – 1.2 Normal
BT 2.30 minutes 1-7 Normal
CT 7.00 minutes 8-18 Low
3. Serological Test
HIV Non reactive __ Normal
VDRL Non reactive __ Normal

CT scan: Left Tempo – parital subdural hematoma causing mass effect. Multiple
hemorrhage contusion involving left tempo parital region with inner hemisphere bleeding

Doppler study: Thrombosis of right superficial femoral vein

X – Rays: Internal haemorrhage

MEDICATION:
Sr. Drugs Dos Rout time Action Side effects Nurses
No Name e responsibility
 1. Inj. 6 SC BD Anticoagulant Nausea, Vomiting  Use cautiously in
Fraxiparin mg. Heading, Giddiness hemorrhagic
shock, peptic
ulcer
 Check for side
effects

2. Inj. Rantac IM BD Histamine, H2  Dizziness  Check

50 receptor  Leucopenia hypersensitivity
 Hypersensitivity
mg
reaction
 Nausea
 Monitor ECG
 Confusion
 Monitor L.F.T.
 Headache
 Check side
3. Tab Epsolin PO BD Anticonvulsant  Dizziness
effects
CNS  Rush
 Administered
100 depressant  Vomiting
correctly.
mg  Administered
 Vomiting after crush the
 Constipation tablet.
 Headache  Closely observe
4. Tab PO BD  Pruritus for side effect.
Paracetamol Antipyretic  Nausea
800 with analgesics
mg

5. Tab. Strocit 500 PO BD Reduce drug  Headache  Administered

mg dependence  Vomiting properly
 Abdominal pain  Observed for side
effect
100
 Tremor  Monitor vitals
6. Inj. Manitol ml IV BD Induces  Check side
 Convulsion
diuresis by  Dizziness effects
raising osmotic  Nausea, vomiting  Maintain IO chart
pressure of
glomeruler
filtration

7 Inj. 2mg IV BD Anxiolytic,  Drowsiness  Administered

Loragepam sedative,  Weakness correct dose and
hypnotic,  disorientation slowly
 Depression  Check for side
skeletal muscle
 Sleep disturbance. effects
relaxant.  Avoid the tea &
coffee