Republic of the Philippines

Naval State University

Naval, Biliran

Traumatic
Brain Injury
Submitted by:
Bangcoyo, Venne Jack
Bronola, Maricar
Dalumpines, Macey
Elatico, Ma. Gorgie
Loon, Sheila Mae
Machete, May-Ann
Monteroso, Sheila
Ostia, Divine Grace
Pantas, Mikee
Sanchez,Lovely Ceria
Silvano, Arfe
Medical Diagnosis :
Traumatic Brain Injury
Psychiatric Diagnosis :
To be considered Neurocognitive Disorder due to Traumatic Brain Injury
with Behavioural Disturbances
Traumatic Brain Injury from alleged MVC
TBI is generally the result of a sudden, violent blow or jolt to the head. The brain
is launched into a collision course with the inside of the skull, resulting in possible
bruising of the brain, tearing of nerve fibers and bleeding.
TBI severity varies enormously depending on which part of the brain is affected,
whether it occurred in a specific location or over a widespread area, as well as
the extent of the damage.
Epidemiology
TBI is a leading cause of death and disability around the globe and presents a
major worldwide social, economic, and health problem. It is the number one
cause of coma. It plays the leading role in disability due to trauma, and is the
leading cause of brain damage in children and young adults .
Findings on the frequency of each level of severity vary based on the definitions
and methods used in studies. A World Health Organization study estimated that
between 70 and 90% of head injuries that receive treatment are mild, and a US
study found that moderate and severe injuries each account for 10% of TBIs,
with the rest mild.

NURSING ASSESMENT
Patients Profile
Name: Gonzaga, Gerardo Age: 61 years old Sex: Male
Occupation: Carpenter Civil Status: Married Religion: Roman Catholic
Address: Brgy. Hibucawan, Jaro, Leyte Nationality: Filipino
No. of Children: 4 Work of Wife: Housewife
Date of Admission: February 13, 2017 Time of admission: 7:00 PM
Admitting Physician: Dr. Jay Stephen Cantay
Admitting Diagnosis: Traumatic Brain Injury from altered MVA
Source of Data: Patient and wife

HEALTH HISTORY
PRESENT HEALTH HISTORY
He was going home from work when another motorcycle bumped on his near
side. That one vehicle came into contact with another. According to the patient, his head
bumped into the road cement.
He was immediately brought in to Jaro Municipal Health Office and was referred
to Eastern Visayas Regional Medical Center for further evaluation at 7:00 PM last
February 13, 2017 and was examined by Dr. Jay Stephen Cantay, hence admission.
PAST MEDICAL HISTORY
Patient claimed that he was hospitalized at Carigara District Hospital due to
hypertension last December 2016. Before admission, he added that he was already
been prescribed with Metropolol and took it once a day. He confirmed that no other
hospitalization was experienced other than that.
FAMILY HEALTH HISTORY
Patient claimed of heredo-familial disease of asthma on his maternal side and
hypertension on his paternal side. No other known heredo-familial disease noted.

GORDONS FUNCTIONAL HEALTH PATTERN

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
Before admission, patient G describes his health as okay man la, nakakatrabaho
man gihap bis amo na it akon edad as verbalized. According to him, he eats three
times a day in order for him to get rid and to prevent diseases.
During admission, patient describes his health as alkanse na ha kinabuhi kay
waray na kita dong. He claimed that there were some medications that they have not
comply because of financial constraints.
He stated that due to his condition, it would be hard for him to take care of
himself and children as well. Patient added that he had complains of vision deficit but
not able to seek proper eye care but instead he just bought an eyeglasses, gilid-gilid
ko man la gipalit dong as verbalized.
NUTRITIONAL-METABOLIC PATTERN
Before admission, patient GG eats three times a day and snacks twice a day.
Patient consumed 1-2 litre of water per day. He stated that his appetite was good and
he has no food restrictions and any allergy.
Patient claimed that he does not take any supplemental vitamins prior to
admission.
Currently, Patient was prescribed to Diet as Tolerated but he claimed that his appetite
has changed.
ELIMINATION PATTERN
Before admission, patient GG claimed that he defecates once a day without
experiencing discomforts usually in the morning with a brown colored stool and is well-
formed. He also stated that he voids three times a day with yellow colored urine. No
pain when voiding as he claimed.
During admission, patient claimed that he defecates once every two to three
days with a hard stool. He also added that he voids via catheter and does not feel any
urge to urinate.
SLEEP-REST PATTERN
Before admission, patient claimed that he sometimes worked 7 days per week.
Patient verbalizes okay man la dong, makapahuway man gihap ak. He rated his
tiredness as 5 out of 10. Patient also added that he usually sleeps at 9 to 10 PM and
wakes up 4:30 in the morning. He does not use any sleeping aids and does not have
any difficulties when sleeping.
Currently, patient experiences disturbed sleeping pattern because of some interruptions
such as giving medications and noise in the surroundings. He claimed that he almost
sleeps 8-10 hours a day.
ACTIVITY-EXERCISE PATTERN
Before admission, patient works as a carpenter. ang mga baskog man ang
patrabahuon sa mga lisud2x dong as verbalized by the patient so he rated his
tiredness as 5 out of 10 with 10 the most tiring. He stated that he can do his activities of
daily living.
During admission, he claimed that his activities of daily living is already limited due to
his condition and relies on his wife in his self care. Patient verbalizes that di man
kaayo ko makalihok2x dong. Makuri gihap ngan maol-ol kung maglihok akon tuda.
COGNITIVE-EXERCISE PATTERN
He claimed that he has some complaints of difficulty concentrating and reading
on small letters. He added that he does not seek proper eye medical care yet bought an
eyeglasses, gilid-gilid ko man la gipalit dong as patient verbalizes.
Patient claimed that when using the eyeglasses, he experienced headache.
Patient can speak and understand Waray-waray, Cebuano, Tagalog and a little bit
English.
SELF PERCEPTION PATTERN
Patient claimed that he is concerned about the financial sources for his hospital
bills. ako la an may trabaho ha amon dong, mayda ako anak na pulis pero bago
paman la hiya naka sulod as stated by the patient.
ROLE RELATIONSHIP PATTERN
Patient claimed that he is living with his wife and four children. He also added
that he usually decides for his family until the accident happened.
During confinement, he is accompanied by his wife and stays with him most of
the time.
SEXUALITY-RELATIONSHIP PATTERN
Patient GG claimed that he was married at the age of 23. They were married for
15 years and got separated. Patient now has a common-law-wife and they have 4
children. They are now living for almost 21 years.
COPING-STRESS MANAGEMENT PATTERN
Patient claimed that his mother died at the age of 93 last December 2016. He
stated that there is nothing he would like to change in his self. He also added that when
he is stressed, he usually seeks guidance from God and counsels his wife.
VALUE-BELIEF SYSTEM PATTERN
Patient claimed that he is a Roman Catholic. He stated that diri man ako
makasimba kada dominggo dong labi na kung may trabaho pero mutuo ngan nagsalig
ako ha Ginoo, priority ko man gihap it pagsimba. The patient also added that there are
no practices that affect his hospitalization. He claimed that a strong faith in God will
accounts for his fast progress.