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.
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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. Deal patient with brain injury.
2. Care patient with neurologic disorders.
3. Provide spiritual care to the patient.
4. Provide emotional support to the patient.
5.Render different nursing interventions.
ASSESSMENT
A.) PATIENT’S HISTORY PATIENT’S PROFILE
NAME: Patient X
AGE: 30 years old
Sex: Male
Nationality: Filipino
Religion: Christian
Date of Birth: October 10, 1980
Address: Marfa, Maguikay, Mandaue City
Occupation: Production worker
Date of Admission: February 27, 2011
Time of Admission: 11:40 p.m
Case number: 122677
Ward: Neuro-surgery
Bed number: Male 2
Admitting Diagnosis: 1.) Diffuse axonal injury
2.) Fx, closed depressed (R) frontal with contusion Hematoma
Physician: Dr. Sasing
Chief Complaint: Loss of consciousness and vomiting
Operation Performed: Debridement and suturing (L) hand 3rd-5th digits
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
HYPERTEENSIVE
PATERNAL SIDE MATERNAL SIDE
B.) GORDON’S 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:
He’s 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 PATTERNBefore:
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 is on the bed over a long period of time.
5) SLEEP-REST PATTERNBefore:
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 PATTERNBefore:
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 he’s 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 doesn’t have any previous history of hospitalization.
8) ROLE-RELATIONSHIP PATTERNCOMMUNICATION:
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 FUNCTIONINGAccording to the significant others, he is in a relationship with his 3 months girlfriend.
10) COPING-STRESS MANAGEMENT PATTERNAccording to the significant others, that whenever he has a problem, he shares it to his family members inorder to solve it.
11) VALUE-BELIEF SYSTEMAccording 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 SYSTEMS1.) 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 NECKa. 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.) EARSa. RIGHT: with blood
b. LEFT: with blood and pusNoted 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 OROPHARYNXa. LIPS: Pale, dry, cracked
b. BUCCAL MUCOSA: Moist
c. GUMS: Moist and pinkish
d. TEETH: 32 white teeth with no dentures
e. TONGUE: Moist and pale, no lesions noted.
f. SOFT PALATE: Pinkish and moist
g. HARD PALATE: Moist and whitish in color
h. TONSILS: No inflammation
8.) RESPIRATORY SYSTEMa. 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. PALPATION: non tender
c. PERCUSSION: (+) resonance
d. AUSCULTATION: normal breath sounds heard (bronchovesicular sound)
9.) CARDIOVASCULAR SYSTEM
a. INSPECTION: (-)palpitations
b. PALPATION: presence of visible pulsations, pulse rate=70beats/minute
acute infections, trauma or surgery, leukemia. malignant disease, necrosis
LYMPHOCYTES
19-48 6.90% Decreased: aplastic anemia, SLE.
MONOCYTES 3-9 4.90% Normal
EOSINOPHILS 0-7 1.30% Normal
BASOPHILS 0-2 0.50% Normal
ANATOMY AND PHYSIOLOGY
The nervous system is your body’s 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
PATHOPHYSIOLOGYBRAIN INJURY
PREDISPOSING FACTORS CAUSE>adults age (15-30) >motor vehicle accidents>over the age of 70 Brain>living in a high crime area>male to female ratio 3:1
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.
>Disturbance in level of consciousness>headache>vertigo>agitation>restlessness>CSF leakage at ears and nose >contusions about eyes and ears>pupillary abnormality>sudden onset of neurologic deficits
DIAGNOSTIC EXAMINATION>CT scan>skull x-ray>complete blood count>neuropsychological test
Date: March 02, 2011CT 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
NAME OF DRUG
DOSAGE
CLASSIFICAT-ION
MECHANISM OF ACTON
INDICATION
CONTRA-INDICATION
SIDE EFFECTS
NURSING RESPONSIBLITIES
TRAMADOL HC
50mg IVTT q8 hrs.
Analgesic
Binds with mu- receptor and inhibits the reuptake of
To relieve moderate to
Alcohol intoxication excessive
CNS:Dizziness, fati
BEFORE:>Check the medication record.>performed skin test.DURING:>monitored the patient every now and then.
L(ULTRAM)
norepinephrine and serotonin, which may account for tramadol’s effect.
moderately severe pain.
use of central acting analgesics, hypnotics ,opiods or other psychotropic drugs.
Produces a bacteriostatic effect or susceptible organisms by inhibiting protein synthesis, thereby preventing amino acids from being transferred to growing polypeptide chains.
To treat bacteremia or meningitis.
Hypersensitivity to chloramphenicol or its components.
CNS:Confusion, feverCV:Grey syndromeEENT:Optic neu
BEFORE:>Check the medication record>performed skin test.DURING:>assess the patient for any unusualities.AFTER:>Report to prescriber signs of blood dyscrasias.
DATE CUES/ NURSING SCIENTIFIC EXPECTED NURSING RATIONALE
EVIDENCES DIAGNOSIS BASIS OUTCOME INTERVENTIONS
March 5, 2011
Subjective:
Objectives:
Risk for infection related to possible access to the cranial contents through a tear in the dura
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:
Medical-Surgical Nursing, Vol.2, 3rd ed. By Priscilla Lemone
After >Monitor for otorrhea or rhinorrhea.
>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.
>Open fractures of the skull increase the possibility of leakage of CSF from the ears or nose.
>Wet dressings facilitate movement of organisms.
>Using aseptic technique reduces the possibility of introducing infection.
>Clear drainage that tests positive for glucose indicates leakage of CSF.
S:
O:
BP=130/90nnHg
PR=70bpm
RR=16cpm
Temp=36.8 degrees Celsius
Edema of the hands and periorbital regions
Skin cool and pale, dry lips
Fluid Volume Excess
Self Care Deficit
Nursing care for the client with fluid volume excess includes administering diuretics and maintaining fluid restrictions.
SOURCE:
Medical-Surgical Nursing, Vol.2, 3rd ed. By Priscilla Lemone
The client needs assistance
After 2 hours of nursing care interventions, there is decrease of edema.
After 2hours of nursing care interventions,
>Measure intake and output.
>Assess vital signs and breath sound every 4hours.
>Turn the patient every 2hours.
>Provide oral care every 2-4hours.
>Elevate head of the bead at 30-45degrees.
>Assess the extent of edema particularly in the lower extremities and periorbital regions
>To determine the I&O of the patient.
>Hypervolemia can cause hypertension.
>To prevent skin breakdown.
>Oral hygiene contributes to client comfort and keeps mucous membranes intact; it helps relieve thirst if fluids are restricted.
>To facilitate good breathing.
>To determine if there is decrease of edema.
with dressing, grooming, and feeding. The help needed can range from minimal guidance to total dependence.
SOURCE:
Medical-Surgical Nursing, Vol.2, 3rd ed. By Priscilla Lemone
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 don’t forget to visit his house every Sunday and asked guidance Objectives Methodology
EvaluationGeneral:
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
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