INTRODUCTION:

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.

ASSESSMENT

A.)

PATIENTS HISTORY
PATIENTS 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, 1980 Marfa, Maguikay, Mandaue City Production worker February 27, 2011 11:40 p.m 122677 Neuro-surgery Male 2 1.) Diffuse axonal injury 2.) Fx, closed depressed (R) frontal with contusion Hematoma

Physician: Chief Complaint: Operation Performed:

5th digits

Dr. Sasing Loss of consciousness and vomiting Debridement and suturing (L) hand 3rd-

 HISTORY OF PRESENT ILNESS

A case of Patient X, 30 years old, male, single, Filipino from Marfa, MAGUIKAY, Mandaue City, admitted for the first time via ambulance (EMERGENCY RESCUE UNIT FOUNDATION) due to collisions of vehicles resulting to the loss of his consciousness.

PAST HEALTH HISTORY

No previous hospitalization. Family background shows a history of hypertension.

VITAL SIGNS
Temperature= 36.8 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.) GORDONS 11 FUNCTIONAL HEALTH PATTERN

1.

) HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Patient is a 30 years old, male and single. He cannot describe thoroughly about his condition due to his unconsciousness.

2)

NUTRITIONAL-METABOLIC PATTERN
Before:
Patient has complete meals (breakfast, lunch, and dinner) and has usual fluid intake of 8-10 glasses/day.

Now:
Hes on blenderized feeding with 1600kcal/meal and has parenteral intake of PNSS running at 30gtts/min. He consumed 300cc after the end of the shift. Later, the doctor ordered him on NPO (Nothing per Orem) status for further observation. 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. 3)

ELIMINATION PATTERN BLADDER:

Before:
He can void 5x a day without any pain felt.

Now:
He wears diaper that is fully soaked weighing 800gms (800ml) after the end of the shift.

BOWEL:
Before:
He can defecate once a day with a formed stool.

Now:

He was not able to defecate since the day he was admitted, February 27, 2011.

4)

ACTIVITY-EXERCISE PATTERN
Before:
He is working at San Miguel Corporation as a production worker. 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.

SLEEP-REST PATTERN
Before:
He has a good sleep-wake cycle. He usually sleeps at 9pm and wakes up at

6am

due to his job.

Now:
He has sleep pattern disturbance due to pain on his eyes as evidenced by restlessness. 6)

COGNITIVE-PERCEPTUAL PATTERN
Before:
He graduated at Asian College of Technology with a Bachelor of Science in Computer Science. According to the significant others, he has no deficit in his sensory perception (hearing and sight) and hes able to read and write.

Now:
He is experiencing eye problem. He cannot spontaneously open his eyes due to periorbital swelling and cannot talk.

7)

SELF-PERCEPTION PATTERN
According to the significant others, the patient is a good brother and son. He is not an alcoholic and smoker. He is very dedicated to his work as a production worker. He doesnt have any previous history of hospitalization.

8)

ROLE-RELATIONSHIP PATTERN COMMUNICATION:

Before:
According to the significant others, before his speech is clear and he can speak English and Tagalog language.

Now:
He is incoherent and unable to communicate. He just nods when his family members talk to him.

RELATIONSHIP:
He is currently residing at Maguikay, Mandaue City with his sister for easy access to his workplace. He assists his family with their finances. 9)

SEXUALITY-SEXUAL FUNCTIONING
According to the significant others, he is in a relationship with his 3 months girlfriend.

10)

COPING-STRESS MANAGEMENT PATTERN

According to the significant others, that whenever he has a problem, he shares it to his family members inorder to solve it.

11)

VALUE-BELIEF SYSTEM
According to the significant others, patient is a Catholic but due to the influence by his eldest brother, he was

converted into Christian and has been baptized. But, every Sunday, he attends mass at the Catholic Church.

C.) REVIEW OF SYSTEMS 1.) INTEGUMENTARY SYSTEM

a. SKIN: Light brown complexion, good skin turgor, edema of the hands and periorbital regions, multiple abrasions noted, 36.8 degrees Celsius skin temperature. b. HAIR: Short curly hair c. SCALP: Clean and no dandruff d. NAIL: Nails turn to pink tones when performing Capillary Refill test at 1-2 seconds.

2.) HEAD AND NECK

a. HEAD: bulging head b. FACE: multiple abrasions and edema noted c. NECK: no presence of lumps d. LYMPH NODES: non tender, can be palpated 3.)

EYES:

Periorbital swelling on both eyes with hematoma noted, unable to open his eyes when giving command.

4.) EARS
a. RIGHT: with blood b. LEFT: with blood and pus Noted during the inspection of the EENT (Eyes, Ears, Nose, and Throat) doctor. 5.)

NOSE: With Nasogastric tubing inserted and Oxygen

inhalation at 4L/min via nasal prong.

6.)

SINUSES:

No inflammation noted

7.) MOUTH AND OROPHARYNX

a. b. c. d. e. f. g. h.

LIPS:

Pale, dry, cracked Moist

BUCCAL MUCOSA: GUMS:

Moist and pinkish

TEETH: 32 white teeth with no dentures TONGUE:

Moist and pale, no lesions noted. Pinkish and moist Moist and whitish in color

SOFT PALATE: HARD PALATE: TONSILS:

No inflammation

8.) RESPIRATORY SYSTEM

a.

INSPECTION:

He is not using his accessory muscles to assist breathing, with oxygen inhalation at 4L/min via nasal cannula, respiratory rate=16cycles per minute.

b. c. d.

PALPATION:

non tender

PERCUSSION: (+) resonance AUSCULTATION:

normal breath sounds heard (bronchovesicular sound)

9.) CARDIOVASCULAR SYSTEM

a. b.

INSPECTION: PALPATION:

(-)palpitations

presence of visible pulsations, pulse rate=70beats/minute

c.

PERCUSSION:

(+)resonance

d.

AUSCULTATION:

Blood Pressure=130/90mmHg

PULSE SITES: Temporal: Carotid:

78bpm

Popliteal:

79bpm 65bpm 70bpm 73bpm

80bpm 75bpm

Doralis pedis:

Brachial: Radial: 10.) BREAST

a. b.

Posterior tibial: Femoral:

70bpm

INSPECTION: PALPATION:
palpation.

No lesions noted

No mass and pain noted upon

11.) ABDOMEN
a.

INSPECTION: Free of lesions and rashes, pale,

umbilicus is midline at lateral line, noted abdominal movement during respiratory movements.

b. c. d. 12.)

AUSCULTATION: PERCUSSSION: PALPATION:

(+)tympanic sound

Free of swellings and masses

GENITO-URINARY REPRODUCTIVE SYSTEM:

No Foley Bag Catheter attached, with diaper weighing 800mL after the end of the shift.

13.) 14.)

ANUS AND RECTUM:

move.

unable to assessed the patient joints can easily

MUCULOSKELETAL SYSTEM:

15.) NEUROLOGIC SYSTEM GLASGOW COMA SCALE

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 4.8-10.8 30.30 10^g/L 10^g/L SIGNIFICANCE Increased:
leukemia, bacterial infection,

HEMOGLOBIN HEMATOCRIT MCV MCH RBC COUNT MCHC RDW MPV PLATELET COUNT DIFFERENTIAL COUNT NEUTROPHILS

140180g/L 0.42-0.52 80-94 27-31 4.70-6.10 330-370 11-16 7.2-11.1 150-400

143g/L 0.43L/L 87.00fL 28.80pg 4.98 10^12/L 333g/L 12.70fL 7.60fL 242.00 10^g/L

severe sepsis Normal Normal Normal Normal Normal Normal Normal Normal Normal

40-74

86.40%

Increased:
acute infections, trauma or surgery, leukemia. malignant disease, necrosis

LYMPHOCYTES 19-48 MONOCYTES EOSINOPHILS BASOPHILS 3-9 0-7 0-2

6.90% 4.90% 1.30% 0.50%

Decreased:

aplastic anemia, SLE. Normal Normal Normal

ANATOMY AND PHYSIOLOGY

The nervous system is your bodys decision and communication center. The central nervous system (CNS) is made of the brain and the spinal cord and the peripheral nervous system (PNS) is made of nerves. Together they control every part of your daily life, from breathing and blinking to helping you memorized facts for a test. The brain is made of three main parts: the forebrain, midbrain, and hindbrain. The forebrain consists of the cerebrum, thalamus, and hypothalamus (part of limbic system). The midbrain consists of the tectum, and tegmentum. The hindbrain is made of the cerebellum, pons and medulla. Often the midbrain, pons, and medulla, are referred to together as the brainstem. The Cerebrum: The cerebrum or cortex is the largest part of human brain, associated with higher brain function such as thought and action. The cerebral cortex is divided into four sections, called lobes: the frontal lobe, parietal lobe, occipital lobe, and temporal lobe. Frontal lobe associated with reasoning, planning, parts of speech, movement, emotions, and problem solving. Parietal lobe associated with movement, orientation, perception of stimuli. Occipital lobe associated with visual processing. Temporal lobe associated with perception and recognition of auditory stimuli, memory, and speech.

The Cerebellum: The cerebellum, or little brain, is similar to the cerebrum in that it has two hemispheres and has a highly folded surface or cortex. This structure is associated with regulation and coordination of movement, posture, and balance.

Limbic system: The limbic system, often referred to as the emotional brain, is found buried within the cerebrum. This system, from a midsagittal view of the human brain. Brai stem: Underneath the limbic system is the brain stem. T his structure is responsible for a basic vital life functions such as breathing, heartbeat, and blood pressure. Scientists say that this is the simplest part of the human brains because animas enter brains, such as reptiles (who appear early scale) resemble our brain stem. The brain stem is made of the midbrain, pons, and medulla. 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, even with no break in the skull, can cause serious and diffuse brain injury.

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.

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

>pupillary abnormality >sudden onset of neurologic deficits

DIAGNOSTIC EXAMINATION >CT scan >skull x-ray >complete blood count >neuropsychological test

Date: March 02, 2011 CT scan Procedure: Brain (Completion) Findings: Follow up study with examination done last February 28, 2011 shows there is slight interval increase in the size of the contusion hematoma in the right frontal parenchyma now measuring 2.2 x 1.8 previously 1.8 x 1.5 cm. There is more pronounced perilesional edema noted in the right frontal lobe and basal ganglia. The frontal horns appear compressed. There is resolving soft tissue swelling and hematoma in the left frontal scalp.

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

>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.

OL HC L

hrs.

(UL TR AM )

and inhibits the reuptake of norepineph rine and serotonin, which may account for tramadols effect.

mode rate to mode rately sever e pain.

cation exces sive use of centra l acting analge sics, hypno tics ,opiod s or other psych otropi c drugs.

ines s, fati gue CV: Vas odil atio n

>performed skin test. DURING: >monitored the patient every now and then. AFTER: >urge S.O to notify prescriber about unusualities.

EEN T: Dry mo uth GI: Con stip atio n, nau sea, vom itin g GU: Urin e rete ntio n SKI N: Pru ritu s, ras

Ery thr om yci n

(er yth roc in)

Eye ointm ent to both eyes; QID

Ant ibi oti c

Binds the 50s ribosomal subunit of the 70s ribosome in many types of aerobic and anaerobic grampositive bacteria. This actions inhibit, RNA dependent protein synthesis in bacterial cells, causing them to diet

To treat mild to mode rate skin and soft tissu e infect ions cause d by S .pyog enes or Staph yloco ccus aureu s.

Hyper sensiti vity to erythr omyci n or their compo nents.

CNS : Fev er, mal aise CV: Ven tricula r

BEFORE: >Check the medication record. DURING:

>Instruct S.O not to let the patient to scratch his eye >Report for any reactions.

arrh yth mia s EEN T: Hea ring loss GI: Diar rhe a, nau sea, vom itin g GU: Vag

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

Chl ora mp he nic ol Na

(ch lor om yce tin)

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

 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, hair, or other debris. SOURCE: MedicalSurgical Nursing, Vol.2, 3rd ed. By Priscilla Lemone

EXPECTED OUTCOME After

NURSING INTERVENTION S >Monitor for otorrhea or rhinorrhea.

RA

March 5, 2011

Subjective:

Objectives:

>O fra th inc po lea fro or

>Keep the nasopharynx and the external ear clean. Place a piece of sterile cotton in the ear, or tape a sterile cotton pad loosely under the nose; change dressings when they become wet. >Use aseptic technique at all times when changing head dressings and insertion sites. >Test drainage of clear fluid from ear and nose for glucose by using a glucose reagent strip, such as Dextrostix.

>W dr fac mo or

>U te re po int inf

>C dr te fo ind lea CS

S:

Fluid Volume Excess

O: BP=130/90nnH g PR=70bpm RR=16cpm Temp=36.8 degrees Celsius Edema of the hands and periorbital regions Skin cool and pale, dry lips

Nursing care for the client with fluid volume excess includes administering diuretics and maintaining fluid restrictions. SOURCE: MedicalSurgical Nursing, Vol.2, 3rd ed. By Priscilla Lemone

After 2 hours of nursing care interventions, there is decrease of edema.

>Measure intake and output. >Assess vital signs and breath sound every 4hours. >Turn the patient every 2hours. >Provide oral care every 24hours.

>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. >Assess the extent of edema particularly in the lower extremities and periorbital regions

>T go br

>T if de ed

Self Care Deficit

The client needs assistance with dressing, grooming, and feeding. The help needed can range from minimal guidance to total dependence. SOURCE: MedicalSurgical Nursing, Vol.2, 3rd ed. By Priscilla Lemone

After 2hours of nursing care interventions, the significant others will be able to perform daily care activities.

Discharged Planning Medication

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

 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

food like fruits and vegetables and have a proper diet. Spiritual Encouraged patient to always pray to God and dont forget to visit his house every Sunday and asked guidance
Objectives Methodology
Evaluation

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