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A Case Study of a Patient with Severe Head Injury
Prepared by: Lady Diana T. Ortega
LTIM Department
I. Demographic Data
Name: Patient XAge: 19 years oldSex: MaleNationality: SaudiMarital Status: SingleDate of Admission: December 04, 2009
II. Physical AssessmentSkin warm, slightly moist,
smooth, hair evenly distributedHead skull slightly asymmetric, no
flaking of scalp, no lesions, no tenderness, scar noted in the craniotomy site, left tempoparietal area
Eyes no redness, no discharges, sclera white and clear, pupils reactive to light and accommodation,
unable to focus
Nose and Sinuses not perforated, no discharge,
NGT is present
Mouth no gum bleeding, tongue and uvula in midline position,
oral cavity is pinkish in color,
buccal mucosa smooth and moist, no ulcers, no swelling,
no palpable massesNeck no palpable lymph nodes,
trachea on midline positiontracheostomy tube is
present
Breasts nipples at the same level and protrude
slightly,no palpable masses, no
nipple dischargeThorax & Lungs thorax is symmetric, no
retraction of the Intercostal spaces, no
tenderness, back area slightly reddened
Upper Extremities decorticate position, arms are unable to extend, abduct and adduct
Nails convex curvature, smooth texture, good capillary refill
Abdomen slight abdominal distention, positive bowel sound
Lower Extremities malpositioned tibia and fibula, unable to flex, abduct and adduct
Genitalia skin of the glans penis is smooth, no ulceration, urethral meatus located ventrally on the end of the penis, no discharge, no palpable masses
III. A. Past Medical History
RTA(Dec 2003)
Intubated &
ventilated
CT scan &
skeletal exam
Craniotomy & ORIF
Weaned from
ventilation
III. A. Present Medical HistorySemiconscious, unable to speak, unresponsive to verbal stimulus
On tracheostomy tube, nasogastric feeding, voiding freely on diaper
Maintained with anticonvulsants, levetiracetam,
carbamazepine & phenytoin
Stable vital signs, good oxygen saturation, no
recent episodes of seizures
IV. Topic Presentation
“Head Injury”
V. Anatomy & Physiology
VI. EtiologyHead Injury
Acquired Traumatic
Closed Open
Diffuse Axonal
Concussion
Contusion
CoupCounter
coup
Penetrating
Cerebral edema
Increased ICP
Decreased cerebral bloodflow
Cerebral Ischemia
Confusion,coma,
seizure,loss of cognitive
&sensory function
AnoxicHypoxi
c
VII. Signs and SymptomsProlonged confusion, seizures, and multiple
episodes of vomiting Inability to awakendilation of one or both pupils, slurred
speech, aphasia, dysarthria, weakness or numbness in the limbs, loss of coordination, confusion, restlessness, or agitation.
do not respond with any body movement to pain,
do not have any speech, and do not open their eyes.
VIII. InterventionMaintain adequate cerebral blood flow, control increasing ICP by:
Proper Positioning Hyperventilation Hypertonic saline Diuretics Sedatives, analgesics & paralytics
IX. Treatment
Sedation, paralytics,
cerebrospinal diversion
Decompressive
craniectomy
Craniotomy
X. Complications Brain injury can cause prolonged or
permanent effects on consciousness (coma, brain death, vegetative state)
Lying still for long periods may cause many complications
Skull fractures & penetrating injuries may lead to meningitis & abscesses
Complications involving the blood vessels: vasospasm, aneurysms and stroke
XI. Prioritization of nursing problems① Altered cerebral tissue perfusion related to decreased cerebral blood flow secondary to head injury② Ineffective airway clearance related to accumulation of secretions and decreased
LOC③ Ineffective breathing pattern related to neurological dysfunction④ Risk for injury related to disorientation & restlessness⑤ Risk for impaired skin integrity related to
immobility
ASSESMENT
NSG Dx PLANNING INTERVENTION
RATIONALE EVALUATION
Subjective:Not applicable Objective: -semiconscious- unresponsive to verbal stimulus- unable to follow commands- unable to speak- on a decorticate position- poor motor function
Ineffective Cerebral Tissue Perfusion related to decreased cerebral blood flow secondary to head injury
° Maintain or improve level of conscious-ness,cognition,& motor/sensory function.° Demonstrate stable vitalsigns & absence ofsigns of increased ICP° Display no further deterioration in sensory, cognitive & motor function
° Monitor LOC, motor & sensory function ° Routinely orient the patient to time, place & surroundings ° Position with head slightly elevated and in neutral position, and prevent hip flexion
Assessment of improvement/ deterioration of cognitive & sensory functionMay help improve cognitive brain function &help minimized confusionReduces arterial pressure by promoting venous drainage, hip flexion can reduce venous drainage
Goal partially met.°Maintained level of conscious-ness, cognition, & motor/sen-sory function°Demons-trated stable vital sign & absence ofsigns of increasedICP°Displayed no further deterioration in sensory, cognitive and motor function
ASSESMENT
NSG Dx
PLANNING
INTERVENTION RATIONALE EVALUATION
°Maintain bed rest; provide quietenvironment; Provide structured care activities & provide rest periods between care activities, limit duration of procedures.
° Maintain a patent airway, administer supplemental oxygen as indicated. ° Prevent straining at stool, may administer stool softener or laxatives as ordered ° Administer medications as ordered including anticonvulsants, enoxaparin Na, carbamazepine, phenytoin
Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent stimulation Provides cerebral oxygenation Valsalva maneuver increases ICP and risk of cerebral hemorrhage to improve cerebral blood flow and prevent clotting, embolus and episode of seizures
ASSESMENT NSG Dx PLANNING NTERVENTION RATIONALE EVALUATION
Subjective:Not ApplicableObjective:+cough-frequent sneezing-secretions characterized as; yellowish in color, thick in consistency- respiratory rate: 24bpm
Ineffective Airway Clearance related to accumu-lations of secretions and decreased LOC
° Maintain a patent airway & will de-monstrate signs of reduction in respiratory congestion°Respiratory rate within normal range: 16 to 20bpm° Display decreasing amount of secretions
• Auscultate lung sounds before & after tx noting areas of de-creased venti-lation & presence of adventitious breath sounds
• Position the patient on semi fowler’s position
• Clear secretions from the mouth and trache. Suction as necessary
Assist in evaluating prescribed treatments and client outcomes
allows good lung expansion and maximum ventilationTo prevent obstruction/ aspiration.
Goal met.° Patient maintained a patent airway & demonstrated signs of reduction in respiratory congestion° Respiratory rate within normal range: 20bpm° Displayed decreasing amount of secretions
ASSESMENT
NSG Dx PLANNING INTERVENTION
RATIONALE
EVALUATION
•Humidify inspired air as indicated by treatment
•Institute respiratory treatment as needed such as CPT and nebulization.
• Give medications such as bronchodilators and mucolytic
This prevents drying of mucous membranes
A variety of respiratory treatments may be used to open constricted airways and liquefy secretions
Helps lowering the viscosity and liquefying the secretions
ASSESMENT NURSING DIAGNOSI
S
PLANNING
INTERVENTION RATIONALE EVALUATION
Subjective:Not ApplicableObjective:- confined to bed-unable to move, turn to side to side-unable to abduct and adduct extremities-medium-sized body built-back area and buttocks slightly reddened
Risk for impaired skin integrity related to immobility
° Patient’s skin will remain intact and will not develop any skin breakdown during the stay at the facility.
• Reposition the patient from side to side at least every 3hours
• Lift the patient during turning, do not drag or pull. Encourage use of lift sheets to move patient in bed
• Clean, dry, & moisturize skin, especially over bony prominences. Use powder or creams as necessary
Positioning interventions reduce pressure and shearing force to the skinFriction may cause break of skin
Moisture softens the skin &causes a break in the skin integrity. Creams or powder may help smoothen the skin
Goal met.Patient’s skin remained intact and did not developed any skin breakdown during the stay at the facility.
ASSESMENT NURSING DIAGNOSI
S
PLANNING
INTERVENTION RATIONALE EVALUATION
• Use good quality air mattress, avoid wrapped and wrinkled bed sheets
• Massage on the area of pressure avoiding reddened skin part
This helps in reducing pressure
Increase tissue perfusion by massaging around affected area
XIII. Nursing Health TeachingHealth teaching primarily focused on educating the watcher of care and management:
1. Review the signs of increased ICP or episodes of seizure with the watcher.
2. Teach the watcher with the proper techniques: therapeutic use of touch, massage and music
3. Eliminations of distractions (television, radio, crowds)
4. Provide one on one communication with the pt.5. Provide the necessary education to watcher
including proper positioning, ROM exercises and so forth.
XIV. ConclusionHead injury can be mild, moderate or severe. A mild head injury may cause confusion & headache and most people recover from it. A severe head injury may happen if the head is violently shaken without coming in contact with a hard object. When patient recover from moderate to severe head injury they may be left with long term effects such as cognitive disabilities & sensory problems & may lead to long time or maybe permanent bed confinement & sometimes in coma state. In this case, patient needs full time care & management. Comfort should always be consider, support to the back & joints when turning & lifting to prevent strain. Hygiene of the patient, bed & surroundings are also important. A daily bed bath should be given to cleanse, refresh & relax the patient. It also promotes circulation & provides a mild form of exercises. In general, nurses have a big role in assisting these patients in attending their activities of daily living while giving respect to their privacy & dignity.