INTRODUCTION

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Traumatic Brain Injury (TBI) is a leading cause of death and disability in the U.S. The national head injury foundation defines TBI as a traumatic insult to the brain capable of causing physical, intellectual, emotional, social and vocational changes. Head injury known as traumatic brain injury, is the disruption of normal brain function due to trauma (blunt or penetrating injury).Neurologic deficits result from shearing of white matter, ischemia and mass effect from the hemorrhage, and cerebral edema of surrounding brain tissue. TYPES OF BRAIN INJURIES: 1) Concussion = involves jarring of head without tissue injury. Temporary loss of neurologic function lasting for a few minutes to hours. 2) Contusion = involves structural damage. The patient becomes unconscious for hours. 3) Epidural hematoma = blood collects in the epidural space between skull and dura matter. Usually due to laceration of the middle meningeal artery, symptoms develop rapidly. 4) Subdural hematoma = a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels, symptoms usually develop slowly. 5) Diffuse axonal injury = is a brain injury in which a high speed acceleration-deceleration injury, typically associated with motor vehicle crashes, causes widespread disruption of axons in the white matter.

Risk Factors:
>adults age 15-30 >being over the age of 75 >male to female ratio of 3:1

Causes:
>motor vehicle accidents >increased blood alcohol levels >falls >sports injuries >occupational injuries >assaults >gunshot wounds

GENERAL OBJECTIVES:
After our case presentation, we will be able to gain knowledge, skills and attitudes on how to handle patient with brain injury and fracture of the skull.

SPECIFIC OBJECTIVES:
After 1 hour of case presentation, we will be able to:
1. 2. 3. 4.

Deal patient with brain injury. Care patient with neurologic disorders. Provide spiritual care to the patient. Provide emotional support to the patient.

5.Render different nursing interventions.

Mandaue City Production worker February 27.) Fx. 1980 Marfa.m 122677 Neuro-surgery Male 2 1. Maguikay. 2011 11:40 p.) PATIENT’S HISTORY • PATIENT’S PROFILE NAME: AGE: Sex: Nationality: Religion: Date of Birth: Address: Occupation: Date of Admission: Time of Admission: Case number: Ward: Bed number: Admitting Diagnosis: Patient X 30 years old Male Filipino Christian October 10.) Diffuse axonal injury 2. Sasing Loss of consciousness and vomiting Debridement and suturing (L) hand 3rd- . closed depressed (R) frontal with contusion Hematoma Physician: Chief Complaint: Operation Performed: 5th digits Dr. ASSESSMENT A.

admitted for the first time via ambulance (EMERGENCY RESCUE UNIT FOUNDATION) due to collisions of vehicles resulting to the loss of his consciousness. • VITAL SIGNS Temperature= 36.• HISTORY OF PRESENT ILNESS A case of Patient X. single. • PAST HEALTH HISTORY No previous hospitalization. Mandaue City. MAGUIKAY. Filipino from Marfa. Family background shows a history of hypertension. male. 30 years old.8 degrees Celsius Respiratory Rate= 16 cycles per minute Pulse Rate= 70 beats per minute Blood Pressure= 130/90 mmHg 1) GENOGRAM LEGEND:  FEMALE  MALE  PATIENT  DECEASED .

 HYPERTEENSIV E PATERNAL SIDE MATERNAL SIDE B.) GORDON’S 11 FUNCTIONAL HEALTH PATTERN .

lunch. 2) NUTRITIONAL-METABOLIC PATTERN Before: Patient has complete meals (breakfast. Now: . male and single. the doctor ordered him on NPO (Nothing per Orem) status for further observation. He cannot describe thoroughly about his condition due to his unconsciousness. 3) ELIMINATION PATTERN BLADDER: Before: He can void 5x a day without any pain felt.1. Later. and dinner) and has usual fluid intake of 8-10 glasses/day. ) HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Patient is a 30 years old. Now: He’s on blenderized feeding with 1600kcal/meal and has parenteral intake of PNSS running at 30gtts/min. BOWEL: Before: He can defecate once a day with a formed stool. Now: He wears diaper that is fully soaked weighing 800gms (800ml) after the end of the shift. The patient gained weight over short period of time due to excess fluid volume in the body as evidenced by edema of the face and hands. He consumed 300cc after the end of the shift.

He was not able to defecate since the day he was admitted. He cannot spontaneously open his eyes due to periorbital swelling and cannot talk. Now: He is experiencing eye problem. February 27. 6) COGNITIVE-PERCEPTUAL PATTERN Before: He graduated at Asian College of Technology with a Bachelor of Science in Computer Science. He usually sleeps at 9pm and wakes up at 6am due to his job. SLEEP-REST PATTERN Before: He has a good sleep-wake cycle. 4) ACTIVITY-EXERCISE PATTERN Before: He is working at San Miguel Corporation as a production worker. Now: He has sleep pattern disturbance due to pain on his eyes as evidenced by restlessness. According to the significant others. . He works 8hours/day and sometimes he also works over a long period of time. Now: He 5) is on the bed over a long period of time. 2011. he has no deficit in his sensory perception (hearing and sight) and he’s able to read and write.

he shares it to his family members inorder to solve it. He is very dedicated to his work as a production worker. he is in a relationship with his 3 months girlfriend. He is not an alcoholic and smoker. that whenever he has a problem. 11) VALUE-BELIEF SYSTEM According to the significant others.7) SELF-PERCEPTION PATTERN According to the significant others. He just nods when his family members talk to him. He assists his family with their finances. 9) SEXUALITY-SEXUAL FUNCTIONING According to the significant others. before his speech is clear and he can speak English and Tagalog language. patient is a Catholic but due to the influence by his eldest brother. Mandaue City with his sister for easy access to his workplace. 10) COPING-STRESS MANAGEMENT PATTERN According to the significant others. the patient is a good brother and son. 8) ROLE-RELATIONSHIP PATTERN COMMUNICATION: Before: According to the significant others. he was . RELATIONSHIP: He is currently residing at Maguikay. He doesn’t have any previous history of hospitalization. Now: He is incoherent and unable to communicate.

Ears. every Sunday. and Throat) doctor. LYMPH NODES: non tender.converted into Christian and has been baptized.8 degrees Celsius skin temperature. LEFT: with blood and pus Noted during the inspection of the EENT (Eyes.) REVIEW OF SYSTEMS 1. SCALP: Clean and no dandruff d. RIGHT: with blood b. FACE: multiple abrasions and edema noted c. C. b. HAIR: Short curly hair c.) EYES: Periorbital swelling on both eyes with hematoma noted. can be palpated 3. multiple abrasions noted. HEAD: bulging head b. NAIL: Nails turn to pink tones when performing Capillary Refill test at 1-2 seconds. Nose. .) NOSE: With Nasogastric tubing inserted and Oxygen inhalation at 4L/min via nasal prong. NECK: no presence of lumps d.) HEAD AND NECK a. good skin turgor. 2.) EARS a. 5. But. SKIN: Light brown complexion. 4.) INTEGUMENTARY SYSTEM a. he attends mass at the Catholic Church. unable to open his eyes when giving command. edema of the hands and periorbital regions. 36.

f. INSPECTION: PALPATION: (-)palpitations presence of visible pulsations.6.) SINUSES: No inflammation noted 7. cracked Moist BUCCAL MUCOSA: GUMS: Moist and pinkish TEETH: 32 white teeth with no dentures TONGUE: Moist and pale. d. d.) MOUTH AND OROPHARYNX a. pulse rate=70beats/minute c. no lesions noted. PALPATION: non tender PERCUSSION: (+) resonance AUSCULTATION: normal breath sounds heard (bronchovesicular sound) 9. LIPS: Pale. c. b. respiratory rate=16cycles per minute. c. b.) CARDIOVASCULAR SYSTEM a. dry.) RESPIRATORY SYSTEM a. g. h. with oxygen inhalation at 4L/min via nasal cannula. INSPECTION: He is not using his accessory muscles to assist breathing. b. Pinkish and moist Moist and whitish in color SOFT PALATE: HARD PALATE: TONSILS: No inflammation 8. PERCUSSION: (+)resonance . e.

d. umbilicus is midline at lateral line. No lesions noted No mass and pain noted upon 11.) ABDOMEN a. b. c. Posterior tibial: Femoral: 70bpm INSPECTION: PALPATION: palpation. AUSCULTATION: Blood Pressure=130/90mmHg PULSE SITES: Temporal: Carotid: 78bpm Popliteal: 79bpm 65bpm 70bpm 73bpm 80bpm 75bpm Doralis pedis: Brachial: Radial: 10. d. INSPECTION: Free of lesions and rashes.) BREAST a. with diaper weighing 800mL after the end of the shift. 13. 12. pale.) NEUROLOGIC SYSTEM GLASGOW COMA SCALE . noted abdominal movement during respiratory movements.) ANUS AND RECTUM: move.) AUSCULTATION: PERCUSSSION: PALPATION: (+)tympanic sound Free of swellings and masses GENITO-URINARY REPRODUCTIVE SYSTEM: No Foley Bag Catheter attached. unable to assessed the patient joints can easily MUCULOSKELETAL SYSTEM: 15.) 14. b.

bacterial infection. .8-10.8 30.PARAMETERS BEST EYE OPENING RESPONSE (1) BEST VERBAL RESPONSE (3) FINDING Spontaneously To speech To pain No response Oriented Confused Incoherent Inappropriate words No response SCORE 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 BEST MOTOR RESPONSE (5) Obeys command Localizes pain Flexion withdrawal Abnormal flexion Abnormal extension No response TOTAL SCORE: [E1V3M5] =9  DIAGNOSTIC EXAM HEMATOLOGY CBC WBC COUNT REFERENCE RESULT 4.30 10^g/L 10^g/L SIGNIFICANCE Increased: leukemia.

52 80-94 27-31 4.60fL 242.00fL 28.1 150-400 143g/L 0.90% 1.70fL 7. trauma or surgery. malignant disease.42-0.30% 0.00 10^g/L severe sepsis Normal Normal Normal Normal Normal Normal Normal Normal Normal 40-74 86. SLE.90% 4. leukemia.10 330-370 11-16 7.80pg 4. Normal Normal Normal  ANATOMY AND PHYSIOLOGY .2-11.HEMOGLOBIN HEMATOCRIT MCV MCH RBC COUNT MCHC RDW MPV PLATELET COUNT DIFFERENTIAL COUNT NEUTROPHILS 140180g/L 0.40% Increased: acute infections.50% Decreased: aplastic anemia.98 10^12/L 333g/L 12. necrosis LYMPHOCYTES 19-48 MONOCYTES EOSINOPHILS BASOPHILS 3-9 0-7 0-2 6.70-6.43L/L 87.

The midbrain consists of the tectum. The Cerebellum: The cerebellum. parts of speech. are referred to together as the brainstem. memory. emotions. movement. The brain is made of three main parts: the forebrain. and speech. The central nervous system (CNS) is made of the brain and the spinal cord and the peripheral nervous system (PNS) is made of nerves. Temporal lobe – associated with perception and recognition of auditory stimuli. . The cerebral cortex is divided into four sections. Together they control every part of your daily life. is similar to the cerebrum in that it has two hemispheres and has a highly folded surface or cortex. and balance. and tegmentum. associated with higher brain function such as thought and action. and hindbrain. thalamus. • • • • Frontal lobe – associated with reasoning. Often the midbrain. Occipital lobe – associated with visual processing. and problem solving. from breathing and blinking to helping you memorized facts for a test. parietal lobe. called “lobes”: the frontal lobe. and medulla. posture. The hindbrain is made of the cerebellum. pons and medulla. and hypothalamus (part of limbic system). This structure is associated with regulation and coordination of movement.The nervous system is your body’s decision and communication center. pons. or “little brain”. planning. The Cerebrum: The cerebrum or cortex is the largest part of human brain. and temporal lobe. The forebrain consists of the cerebrum. Parietal lobe – associated with movement. midbrain. orientation. perception of stimuli. occipital lobe.

. This system.Limbic system: The limbic system. even with no break in the skull. and medulla. and blood pressure. often referred to as the “emotional brain”. from a midsagittal view of the human brain.    Midbrain Pons Medulla  PATHOPHYSIOLOGY BRAIN INJURY PREDISPOSING FACTORS >adults age (15-30) >over the age of 70 >living in a high crime area >male to female ratio 3:1 CAUSE >motor vehicle accidents Brain A blow to the head. such as reptiles (who appear early scale) resemble our brain stem. Scientists say that this is the “simplest” part of the human brains because animas’ enter brains. can cause serious and diffuse brain injury. heartbeat. Brai stem: Underneath the limbic system is the brain stem. T his structure is responsible for a basic vital life functions such as breathing. pons. The brain stem is made of the midbrain. is found buried within the cerebrum.

COMPLICATIONS Infections immobility hydrocephalus neurologic deficits MANIFESTATIONS: >Disturbance in level of consciousness >headache >vertigo >agitation >restlessness >CSF leakage at ears and nose >contusions about eyes and ears SIADH .Injury to the axons Disrupts oligodendroglia and direct mechanical disruption caused by debris and leakage. There is immediate vascular response to the injury. Results in increased capillary permeability to solutes.

2 x 1. There is resolving soft tissue swelling and hematoma in the left frontal scalp.8 previously 1.>pupillary abnormality >sudden onset of neurologic deficits DIAGNOSTIC EXAMINATION >CT scan >skull x-ray >complete blood count >neuropsychological test Date: March 02. MEDICAL MANAGEMENT >Placement of NGT with intubation to prevent aspiration >Administer antibiotics SURGICAL MANAGEMENT >Shunting to relieve persistent fluid build up >evacuation of intracranial hematomas >debridement of penetrating wounds . 2011 CT scan Procedure: Brain (Completion) Findings: Follow up study with examination done last February 28. There is more pronounced perilesional edema noted in the right frontal lobe and basal ganglia. 2011 shows there is slight interval increase in the size of the contusion hematoma in the right frontal parenchyma now measuring 2. The frontal horns appear compressed.5 cm.8 x 1.

>subdural tapping to remove fluid NURSING MANAGEMENT >monitor for declining LOC >elevate the head of bed at 30 degrees as ordered >turn patient every 2 hours >monitor potential complications >provides skin care every 4 hours  SUMMARY OF FINDINGS  DRUG THERAPEUTIC RECORD NA ME OF DR UG DOSA GE CL AS SIF IC AT IO N MECHANIS M OF ACTON INDI CATI ON CONT RAINDIC ATION SID E EFF ECT S NURSING RESPONSIBLITIES TR AM AD 50mg IVTT q8 An alg esi Binds with mureceptor To reliev e Alcoh ol intoxi CNS : Dizz BEFORE: >Check the medication record. .

vom itin g GU: Urin e rete ntio n SKI N: Pru ritu s. DURING: >monitored the patient every now and then. mode rate to mode rately sever e pain. nau sea.opiod s or other psych otropi c drugs.O to notify prescriber about unusualities. hypno tics . which may account for tramadol’s effect.OL HC L hrs. c (UL TR AM ) and inhibits the reuptake of norepineph rine and serotonin. ines s. EEN T: Dry mo uth GI: Con stip atio n. cation exces sive use of centra l acting analge sics. AFTER: >urge S. fati gue CV: Vas odil atio n >performed skin test. ras .

This actions inhibit.pyog enes or Staph yloco ccus aureu s. DURING: >Instruct S. mal aise CV: Ven tricula r BEFORE: >Check the medication record. causing them to diet To treat mild to mode rate skin and soft tissu e infect ions cause d by S . QID Ant ibi oti c Binds the 50s ribosomal subunit of the 70s ribosome in many types of aerobic and anaerobic grampositive bacteria. vom itin g GU: Vag . CNS : Fev er. Hyper sensiti vity to erythr omyci n or their compo nents. arrh yth mia s EEN T: Hea ring loss GI: Diar rhe a.O not to let the patient to scratch his eye >Report for any reactions.h Ery thr om yci n (er yth roc in) Eye ointm ent to both eyes. RNA dependent protein synthesis in bacterial cells. nau sea.

na use a. vom itin g BEFORE: >Check the medication record >performed skin test.inal can didi asis SKI N: jau ndic e 1g IVTT (ANS T) q6 hrs. To treat bacte remia or meni ngitis . Hyper sensiti vity to chlora mphe nicol or its compo nents. AFTER: >Report to prescriber signs of blood dyscrasias. DURING: >assess the patient for any unusualities. feve r CV: Gre y syn dro me EEN T: Opti c neu ritis GI: Diar rhe a . Ant ibi oti c Produces a bacteriosta tic effect or susceptible organisms by inhibiting protein synthesis. CNS : Con fusi on. Chl ora mp he nic ol Na (ch lor om yce tin) . thereby preventing amino acids from being transferred to growing polypeptid e chains.

HE ME: Ane mia SKI N: Ras h Oth er: Ang ioed ema .

>W dr fac mo or >U te re po int inf >C dr te fo ind lea CS . >Test drainage of clear fluid from ear and nose for glucose by using a glucose reagent strip. Vol. such as Dextrostix.2. or tape a sterile cotton pad loosely under the nose. By Priscilla Lemone EXPECTED OUTCOME After NURSING INTERVENTION S >Monitor for otorrhea or rhinorrhea. hair. SOURCE: MedicalSurgical Nursing. 3rd ed. Place a piece of sterile cotton in the ear. RA March 5. change dressings when they become wet. 2011 Subjective: Objectives: >O fra th inc po lea fro or >Keep the nasopharynx and the external ear clean. or other debris. >Use aseptic technique at all times when changing head dressings and insertion sites. NURSING CARE PLAN DATE CUES/ EVIDENCES NURSING DIAGNOSIS Risk for infection related to possible access to the cranial contents through a tear in the dura SCIENTIFIC BASIS The client with a skull fractures it at high risk for infection through the wound that may be contaminated by dirt.

2.8 degrees Celsius Edema of the hands and periorbital regions Skin cool and pale. >Assess vital signs and breath sound every 4hours. SOURCE: MedicalSurgical Nursing. Vol.• S: Fluid Volume Excess O: BP=130/90nnH g PR=70bpm RR=16cpm Temp=36. By Priscilla Lemone After 2 hours of nursing care interventions. >Measure intake and output. >Assess the extent of edema particularly in the lower extremities and periorbital regions >T go br >T if de ed . >Provide oral care every 24hours. there is decrease of edema. 3rd ed. dry lips Nursing care for the client with fluid volume excess includes administering diuretics and maintaining fluid restrictions. >T th pa >H ac hy >T sk br >O co cli an mu me int re flu re >Elevate head of the bead at 30-45degrees. >Turn the patient every 2hours.

3rd ed. SOURCE: MedicalSurgical Nursing. The help needed can range from minimal guidance to total dependence. grooming. By Priscilla Lemone After 2hours of nursing care interventions. and feeding. Vol.Self Care Deficit The client needs assistance with dressing. the significant others will be able to perform daily care activities.2. .

• Discharged Planning Medication .

The medications are as follows:  Penicillin .Encouraged the patient to take the prescribed medications and follow instructions of dosage and time intervals as prescribed by the physician.

 Doxycycline 100mg 1 tab BID  Kalium ii tab TID Instructed patient for following check up after 1 week Environment Instructed the patient to use protective clothing and boots during getting .

food for the animals. Encouraged to clean the household to prevent pesticides from circulating the house Treatment Encouraged the patient to take vitamin C and medications as .

.prescribed by the physician Health Teaching Educated the patient to increase awareness about the disease and the importance of health maintenance and wearing of protective clothing and foot wear.

Observable Signs and Symptoms Instructed patient if he noticed signs and symptoms. immediately refer or report it to the nearest hospital Diet Instructed patient to always eat nutritious .

Spiritual Encouraged patient to always pray to God and don’t forget to visit his house every Sunday and asked guidance Objectives Methodology Evaluation .food like fruits and vegetables and have a proper diet.

General: After 8 hours of nursing intervention. the patient will be able to understand and participate of doing some dependent activities Specific: After 30 minutes of nursing interventions the patient will be able to gain knowledge about the disease Content • Therapeutic regime • Protective Clothing • Mode of Transmission • Signs and Symptoms Proper hygiene Methodology Demonstration Taking examples Health teaching .

Evaluation After 8 hours of nursing intervention the patient was able to verbalize knowledge and asked questions .