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HEAD INJURY
INTRODUCTION
• Traumatic brain injury is defined as damage to the brain resulting
from external mechanical force, such as rapid acceleration or
deceleration, impact, blast waves, or penetration by a projectile.
Brain function is temporarily or permanently impaired and
structural damage may or may not be detectable with current
technology. Traumatic brain injury is usually classified based on
severity, anatomical features of the injury, and the mechanism (the
causative forces).
• Mechanism-related classification divides brain injury into closed
and penetrating head injury. A closed (also called no
penetrating, or blunt) injury occurs when the brain is not
exposed. A penetrating or open, head injury occurs when an
object pierces the skull and breaches the dura mater, the
outermost brain. A large percentage of the people killed by brain
trauma do not die right away but rather days to weeks after the
event; rather than improving after being hospitalized, some 40%
of traumatic brain injury patients deteriorate.
• Primary brain injury (the damage that occurs at the moment of
trauma when tissues and blood vessels are stretched, compressed,
and torn) is not adequate to explain this deterioration; rather, it is
caused by secondary injury, a complex set of cellular processes and
biochemical cascades that occur in the minutes to days following
the trauma. These secondary processes can dramatically worsen
the damage caused by primary injury and account for the greatest
number of traumatic brain injury deaths occurring in hospitals.
• We chose this study since it deals primarily
with cognition. Our patient has had a head
injury. This caught our attention for this will
add more knowledge on how does brain injury
can cause alteration in cognition.
OBJECTIVES
• General Objectives:
• Our group aims to formulate a comprehensive
case analysis that would provide essential
knowledge and skills in delivering quality
health care to patient’s diagnosed with head
injury.
SPECIFIC OBJECTIVES:
• Present biographical information of the patient, reasons for seeking health care, history of the past and present illness including the family health history and family history.
• Discuss an overview on the anatomy and physiology of the Nervous System.
• Explain the pathophysiology of the said disease both actual and ideal.
• Enumerate and discuss the drugs and its pharmacologic effects.
SPECIFIC OBJECTIVES
• Enumerate important nursing management to improve the client’s condition.
• Identify the actual and potential prognosis of the case presented.
• Note down problems in relation to the client’s current health status base on Gordon’s typology of 11 health problems.
• Compose an effective nursing care plan to address the identified problems.
• Identify the necessary health teachings and recommendations.
DEMOGRAPHIC PROFILE
• Personal Data– Name: “Yi Jeong”– Age: 17 yrs old– Sex: Male– Civil Status: Single – Religion: Islam– Nationality: Filipino– Address: Prk. Sta. Lucia Poblacion Tupi, South
Cotabato
DEMOGRAPHIC PROFILE
• Admission impression:– Depressed Fracture
• Attending Physician: – Dr. Narciso Mirabueno Jr.
• Final diagnosis:– Open depressed fracture with dural laceration,
right parietal to occipital
DEMOGRAPHIC PROFILE
• Brief history: – NOI- Mauling– TIC- 9pm– DOI- 6/12/10– POI- Tupi South Cotabato
• Was mauled 2 days ago by known assailant thereby sustained injury.
Past Medical History:
• The patient’s usual illnesses were fever, cough, and
colds but he never consults a doctor for check up.
However, he goes to “Hilot” and uses pharmacologic
treatment such as analgesics and antipyretics to treat
fever. The patient verbalized “Wala man jud kaayo ko
gasakit bixan tong una. Kana lang ang mostly na
akung sakit”
Present Medical History:
• The patient was mauled, and through that, he sustained
a laceration on the parieto-occipital area of his head. He
stated that during the incident, he loss his consciousness
and directly admitted to a nearby hospital. Few days
after, he was rushed at General Santos Hospital for he
was experiencing severe headache and dizziness. He was
under the care of Dr. Mirabueno.
PHYSICAL AND CEPHALOCAUDAL ASSESSMENT
General survey
• A 17 year old patient, conscious and coherent.
Able to cooperate during procedure. Clean
and neat, no body odor noted. The patient
appears weak and frequent yawning noted
head
• smooth contour, hair evenly distributed in the scalp, no presence of dandruff noted. Laceration at right area of the head noted.
eyes
• eyebrows and eyelashes are evenly distributed
and symmetrically aligned. Pupil is reactive to
light. Pink and moist conjunctiva. No
discharges noted. Sleepy eyes noted. Both
eyes are coordinated, moves
nose
• straight and symmetrical. Mucus membranes
are moist and pink in color. No lesion and
presence of exudates noted. Airs move freely
when the patient breathes through the nares.
No flaring noted.
mouth
• able to pursed lip. Soft, moist and pink mucosa
noted. No lesion noted. Absence of left lateral
incisor noted. Pink and moist gums noted.
ears
• symmetrical. Color same as facial skin. Auricle
aligned with outer canthus of the eye mobile,
firm and not tender; pinna recoils after it is
folded. No discharges noted. Sound is heard in
both ears
neck
• symmetrically aligned and in the midline.
Muscle equal in size; head is centered.
• neck muscles are equal in strength as patient
can flex, hyperextend and laterally rotates his
head
chest
• Symmetrical contour, skin color same with
facial skin. Skin is intact. Chest wall is intact; no
tenderness; no masses noted.
• Spinal column is straight,
• Right and left shoulder and hips are at the same
height. Full and symmetric chest expansion
abdomen
• Symmetric contour. Symmetric movements
caused by respiration. No evidence of
enlargement of liver or spleen. Flat and
rounded contour of abdomen. Unblemished
skin noted
Upper extremities
• Equal size on both sides of the body. Able to
abduct, adduct, flex and extend
Lower extremities
• Equal size on both sides of the body. Has
upright posture and steady gait with opposing
arm swing; walk unaided and can maintain
balance. Able to abduct, adduct, flex and
extend
REVIEW OF ANATOMY
NERVOUS SYSTEM
• The brain is a highly specialized organ. It serves as the control
center for functions of the body and allows us to cope with
our environment. Words, actions, thoughts, and feelings are
centered in the brain. It is so complex that some theorists
believe we will never be able to fully understand it. We do,
however, know that each part of the brain has a specific,
important function, often a profoundly important function,
and each part contributes to the healthy functioning of our
body.
• Cerebrum is the largest part of the brain and is
associated with conscious thought, movement and
sensation. It consists of two halves, each controlling
the opposite side of the body. The halves are
connected by the corpus callosum, which delivers
messages between them. Four lobes make up the
cerebrum: the frontal, temporal, parietal, and occipital
lobes.
• Frontal Lobe is one of the four lobes of the cerebral
hemisphere. It controls attention, behavior, abstract
thinking, problem solving, creative thought, emotion,
intellect, initiative, judgment, coordinated movements,
muscle movements, smell, physical reactions, and
personality.
• Occipital Lobe is one of the four lobes of the cerebral
hemisphere. It is located in the back of the head and
controls vision.
• Parietal Lobe is one of the four lobes of the cerebral
hemisphere. It controls tactile sensation, response to
internal stimuli, sensory comprehension, some
language, reading, and some visual functions.
• Temporal lobe is one of the four lobes of the cerebral
hemisphere of the cerebral hemisphere. It controls
auditory and visual memories, language, some hearing
and speech, language, plus some behavior.
• Brain Stem is located at the bottom of the brain and connects the cerebrum to the spinal cord. The brain stem controls many vitally important functions including motor and sensory pathways, cardiac and respiratory functions, and reflexes.
• Cerebellum is located at the lower back of the head and is connected to the brain stem. It is the second largest structure of the brain and is made up of two hemispheres. The cerebellum controls complex motor functions such as walking, balance, posture, and general motor coordination
• Dura mater or dura, is the outermost of the three
layers of the meninges surrounding the brain and
spinal cord. The other two meningeal layers are
the pia mater and the arachnoid mater. The dura
surrounds the brain and the spinal cord and is
responsible for keeping in the cerebrospinal fluid
PATHOPHYSIOLOGY
• Depressed skull fractures: These are common after
forceful impact by blunt objects-most commonly,
hammers, rocks, or other heavy but fairly small
objects. These injuries cause "dents" in the skull
bone. If the depth of a depressed fracture is at least
equal to the thickness of the surrounding skull bone
(about 1/4-1/2 inch), surgery is often required to
elevate the bony pieces and to inspect the brain for
evidence of injury
• The skull is made up of a variety of bones; the dura, the
thick membrane that wraps around the brain, attaches
at the suture lines where the bones come together. If
bleeding occurs in the enclosed space between the dura
and the bone, and a hematoma (blood clot) forms, there
is nowhere for it to accumulate and pressure within the
epidural space can build quickly. The increasing pressure
pushes the hematoma against the brain tissue and may
cause significant damage
• Presentation varies according to the injury. Some patients with head
trauma stabilize and other patients deteriorate. A patient may present
with or without neurologic deficit.
• Patients with concussion may have a history of seconds to minutes
unconsciousness, then normal arousal. Disturbance of vision and
equilibrium may also occur.
• Common symptoms of head injury include coma, confusion,
drowsiness, personality change, seizures, nausea and vomiting,
headache, during which a patient appears conscious only to
deteriorate later
LABORATORY RESULT
CT SCAN OF THE HEAD
• Multiple plain axial CT images of the head reveal a segmental, depressed
fracture in the posterior parietal occipital bones, right. This has an
aggregate width of 2.5 cm. Small pockets of air are also noted in a small
lenticular, extra axial hyperderse focus opposed to the fracture site
medially. This is immediately lateral to the posterior interhemispheric
fissure. Small hemorrhagic conclusion with mild to moderate
surrounding edema is seen in the underlying posterior parietal and
occipital lobes, right. It involves the right posterior optic tract
• Ventricles are symmetrical in size and
configuration. Midline structures and not
displaced laterally
• Posterior fossa, petromastoids and visualized
paranasal sinuses are unremarkable
Impression:
• Depressed fractures as described w/ small
pneumocephalus and epidural hematoma,
right occipito- parietal
• Hemorrhagic contusion, right posterior
parietal and occipital lobes
Skull AP/L
• A double bone density is seen in the left posterior
occipital bone. This is associated with moderate
swelling of the overlying remarkable findings
• Impression:
• Depressed fractures, Left posterior occipital bone with
soft tissue hematoma.
Complete blood count (CBC) platelet Count
Examination Result Normal Value
WBC 13.42 5x10x10 9/L x 10 9/L
Segmeters 0.74 0.55- 0.65
lymphocytes 0.12 0.25- 0.35
menocytes 0.13 0.03- 0.06
eosinophil 0.01 0.02- 0.04
hemoglobin 149 140-170g/L
hematocrit 0.42 0.40-0.50 vol % vol %
platelet count 337 150- 350 x 10 g/L x 10 g/L
RECORD OF OPERATION
• Time started: 12:25PM• Time ended: 1:43PM• Surgeon: Dr. Mirabueno• Anesthetist: Dr. B Anislag• Anesthetic: GA – intubation
• Pre- op Diagnosis:– Open deprsessed fracture Right posterior parietal;
cerebral contusion/ pneumocephalis, Right posterior Parietal lobe; Epidural hematoma Right P-O.
• Post op Diagnosis:– Same + Dural laceration 1cm
• Operation performed:– Debridement / craniotomy/elevation of depressed
skull fracture phic # 61312; evaluation of epidural hematoma; repair of plural laceration
• Surgical Technique Procedure:
– Laceration extended at both ends. Craniotomy
done to removal done to removal bone fragments.
Evacuation of EDH. Cauterization of bleed
elevation or repair of depressed fracture. Flushing
with NSS. Layer closure of skin sterile dressing
applied.
– EST blood loss 150cc
NURSING CARE PLAN
Self Care Deficit r/t uncomfortable bathing
environment
Self Care Deficit r/t uncomfortable bathing environment
Subjective Cues
• “Gusto nako maligo pero dili ko ganahan kay daghan ug samok” as verbalized by the pt.
Objective Cues
• Dry skin noted• Diaphoresis noted• Clothes was not
changed for two days
• Unorganized bathroom noted
Self Care Deficit r/t uncomfortable bathing environment
NEED• PHYSIOLOGIC
Desired Outcome
• within 8° span of care, pt. will be able to:
• perform self care activities (bathing)
Self Care Deficit r/t uncomfortable bathing environment
NURSING INTERVENTION• establish rapport
• encourage verbalization of feelings
• assess the clients ability to participate in bathing
RATIONALE• establishing rapport gains
trust and cooperation through out the procedure
• discovers barriers to participate on intervention
• underlying conditions dictates level of deficit in choice of intervention
NURSING INTERVENTION
• assess barriers to participation in self care
• identify or plan for environmental modifications (maintain bathroom clean and organized)
• provide pts. privacy
RATIONALE
• assessing pts. participation can contribute on motivating pt. to observe hygiene
• prepares for increased independence, which enhances self esteem and can motivate pt. do bathing
• providing privacy increases motivation to do task
NURSING INTERVENTION
• provide positive feedback for efforts and accomplishments
• give information about other self care options (TSB)
• obtain bath supplies (soap, towel)
RATIONALE
• enhances sense of self worth, promotes independence
• provides other alternatives on self care activities
• encourages pt. to do bathing
goals met as evidenced by:
>able to perform self care
EVALUATION
Sleep Deprivation related to Uncomfortable Sleeping
Environment
Sleep Deprivation related to Uncomfortable Sleeping Environment
Subjective Cues
• “dili kayo ko makatulog” as verbalized by the pt.
Objective Cues
• restless• weakness noted• Lethargic• frequent yawning
noted• diaphoresis noted• disorganized bed
noted
Sleep Deprivation related to Uncomfortable Sleeping Environment
NEED
• PHYSIOLOGIC
DESIRED OUTCOME
• within 8° span of care, pt. will be able to:
• rest and sleep comfortably
Sleep Deprivation related to Uncomfortable Sleeping Environment
NURSING INTERVENTION• establish rapport
• encourage verbalization of feelings
• encourage walking and instructed to return to bed until feeling sleepy
RATIONALE• establishing rapport gains
trust and cooperation through out the procedure
• discovers barriers to participate on intervention
• enhances expenditure of energy so that client feels ready for sleep or rest
NURSING INTERVENTION
• provide with calm and quiet environment conducive for rest
• assist pt. on arranging his bed linens
• provide comfort measures such as touch therapy
RATIONALE
• reduces stimulation and promotes relaxation
• promotes relaxation
• reduces tension thereby promotes relaxation
NURSING INTERVENTION
• recommend quiet activities such as reading
• encourage to use relaxation techniques such as touch therapy
RATIONALE
• reduce stimulation so pt. can relax
• reduces tension thereby promotes relaxation
goals met as evidence by:
>able to rest and sleep comfortably
EVALUATION
DRUG STUDY
Nalbuphine HCL (Nubain)
INDICATION• This is indicated for
relief of moderate to severe pain.
MODE OF ACTION• Acts as an agonist at
specific opioid receptors in the CNS to produce analgesia and sedation but also acts to cause hallucination
ADVERSE EFFECTS• CNS: sedation, clamminess, sweating,
headache, confusion, hallucination• CV: hypotension, hypertension, bradycardia,
tachycardia• Dermatologic: pruritus, urticaria• GI: nausea and vomiting, dyspepsia, dry
mouth• GU: urinary urgency• Respiratory: dyspnea, respiratory depression
NURSING RESPONSIBILITIES• Observe for the 10 rights before giving the drug.• Educate the patient about the side effects of the
drug.• Taper dosage when discontinuing after prolonged
use to avoid withdrawal symptoms.• Keep opiod antagonist and facilities for assisted o
controlled respiratory depression.• Reassure patient about addiction liability; most
patients who received opiates for medical reasons do not develop dependence syndrome.
Diphenhydramine HCL (Allerdryl)
INDICATION
• It is indicated for relief of symptoms associated with seasonal allergic rhinitis.
MODE OF ACTION
• Competitively blocks the effects of histamine h1-receptor site, has atropine like, anti-pruritic and sedative effects.
SIDE EFFECTS
• CNS: drowsiness, sedation, fatigue, confusion, tremor
• CV: hypotension, palpitation, bradycardia• GI: epigastric distress, increased appetite and
weight gain, diarrhea and constipation• Respiratory: thickening of bronchial
secretions, chest tightness, wheezing, stuffiness
NURSING RESPONSIBILITIES• Observe for the 10 rights before giving the drug.• Educate the patient as well as the significant
others with the side effects of the drugs.• Administer with food to avoid GI upset.• Monitor patient’s response and arrange for
adjustment of dosage to lowest possible effective dose.
• Instruct patient to avoid alcohol to prevent serious sedation.
Cefuroxime axetil (Zinnat)
INDICATION
• Lower and upper respiratory tract infections, GUT infections, skin and soft tissue infections, gonorrhoea including acute uncomplicated gonococcal urethritis and cervicitis
MODE OF ACTION
• Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs)
ADVERSE REACTION• GI disturbances, occasionally
pseudomembranous colitis; hypersensitivity reactions.
• Eosinophilia; headache, superinfection, eryrhema multiforme.
• Steven’s-Johnson syndrome
NURSING RESPONSIBILITIES• Observe for the 10 rights before giving the
medication• Assess bowel function• Monitor for allergic reaction• Monitor urine output• Assess for opportunistic infection (fever,
malaise, rash)
Mefenamic acid(Dolfenal)
INDICATION
• Relief of mild to moderately severe somatic and neurotic pain
MODE OF ACTION
• Anti-inflammatory, Analgesic and Antipyretic activities related inhibition of prostaglandin synthesis; exact mechanism of action are not known.
ADVERSE REACTION
• GI disturbance• GI hemorrhage• Drowsiness• Dizziness• Headache• Visual disturbances
NURSING RESPONSIBILITIES
• Observe for the 10 rights before giving the medication
• Instruct patient that swallow it whole do not chew or break the capsule
• Instruct patient to take drug with food for good absorption
• Maintain hydration• Instruct patient to report promptly if adverse
reaction occurs
PROGNOSIS
• In some cases, transient neurological disturbances may occur, lasting
minutes to hours. Recovery in patients with neurologic deficits will
vary. Patients with neurologic deficits who improve daily are more
likely to recover, while those who are vegetative for months are less
likely to improve. Most patients without deficits have full recovery.
However, persons who sustain head trauma resulting in
unconsciousness for an hour or more have twice the risk of
developing Alzheimer's disease later in life.
CONCLUSION
• You cannot hold yourself if unavoidable circumstances strikes. In this case, patient knows the assailant (a friend). The assailant was drunk and has altered on his level of consciousness. With this, he was mauled by a rock.
RECOMMENDATION
• Bed rest, fluids, and a mild pain reliever, for example, acetaminophen (Tylenol) may be prescribed. Ice may be applied to the scalp for pain relief and to decrease swelling.
• Eat a balanced diet.• Proper exercise. Exercise is very vital to the
body’s normal functioning.• Have a regular check-up.
RECOMMENDATION
• Have adequate rest and sleep periods. Avoid too much straining or performing strenuous activities especially during the few days after operation.
• Maintain a close relationship among family members and neighbours. Social interaction is vital for well-being. Spirituality must also be taken in consideration.