I.

INTRODUCTION

A. Overview of the Study

Head injury is a general term used to describe any trauma to the head, and most specifically to the brain itself. Skull fracture: A skull
fracture is a break in the bone surrounding the brain and other structures within the skull. Linear skull fracture: A common injury, especially in
children. A linear skull fracture is a simple break in the skull that follows a relatively straight line. It can occur after seemingly minor head
injuries (falls, blows such as being struck by a rock, stick, or other object; or from motor vehicle accidents). A linear skull fracture is not a serious
injury unless there is an additional injury to the brain itself. 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. Minimally depressed fractures are less than the thickness of the bone. Other
fractures are not depressed at all. They usually do not require surgical treatment unless other injuries are noted. Basilar skull fracture: A
fracture of the bones that form the base (floor) of the skull and results from severe blunt head trauma of significant force. A basilar skull
fracture commonly connects to the sinus cavities. This connection may allow fluid or air entry into the inside of the skull and may cause
infection. Surgery is usually not necessary unless other injuries are also involved.Intracranial (inside the skull) hemorrhage (bleeding) Subdural
hematoma. Bleeding between the brain tissue and the dura mater (a tough fibrous layer of tissue between the brain and skull) is called a
subdural hematoma. The stretching and tearing of "bridging veins" between the brain and dura mater causes this type of bleeding. A subdural
hematoma may be acute, developing suddenly after the injury, or chronic, slowly accumulating after injury. Chronic subdural hematoma is
more common in the elderly whose bridging veins are often brittle and stretched and can more easily begin to slowly bleed after minor injuries.
Subdural hematomas are potentially serious and may require surgery.

B. Objective of the Study

At the end of the study, the researcher will be able to know more about head injury particularly subdural hematoma and its effects
to human and life and will be able to learn more about the necessary Medical and Nursing Interventions to be applied to Patients with
subdural hematoma.

C. Scope and Limitation

Although we have been given two days to care for our patients and dig deeper into our patients problem, it is still not enough for us
to actually find any other minor problems that our patient may be having, the lack of time also is the reason why we cannot fully assess
the extent or effectiveness of our Health Teachings and Nursing Interventions.

II. A. Patient’s Profile

Name: ?
Age: 35 years old
Sex: Female
Height: 5’2
Weight: 110 lbs
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Address: ?
Occupation: Housewife
Date of Admission: July 15, 2009
Time of Admission: 10:40 PM
Chief Complaint: Head injury
 Admitting Diagnosis: Subdural Hematoma
Physician: ?

B. Family and Personal Health

Patient is known to be hypertensive which she got genetically from her Paternal side. Her maternal side was known to have asthma and
hypertensive. Patient is occasional alcohol drinker and can consumed 5 stick/day. Patient didn’t have history of previous hospitalization but
complained hyperacidity and sometimes headache as what significant others explained.

C. History of Present Illness and Chief Complaint

A case of 35 years old which suffered head injury due to vehicular accident, 4 days prior to admission patient sustained head trauma during
vehicular accident. Patient lost consciousness few hours, after while admitted to city hospital and didn’t regain consciousness with positive
fever, Patient was taken to X, 2 days ago when city scan revealed acute subdural hematoma, patient relatives opted to transfer to X.

DIAGNOSTIC EXAM

Date Ordered Diagnostic/laboratory Exams Date Done

7-15-2009 Complete Blood Count 7-15-2009
7-16-2009 CT scan 7-15-2009

7-16-2009 X-ray for tracheostomy

Placement 7-16-2009
7-21-2009 CXR 7-21-2009

*Complete Blood Count* Normal Values

WBC: 12,300 5000-10000 mm3
RBC 3.17 9.9-5.2
Hgb: 94 120-160 g/dl
Hct: 0.28 .37- .47 g/dl
Neutrophils: .75 48-73
Lymphocytes: .12 20-45
Basophils: 0.08

*Ultrasound Chest PA*

Impression: pneumonia ,Right

Ultrasound Chest PA
Impression : Tracheostomy tube in place

CT Scan:
Impression : Subdural Hematoma
Subdural hematoma

Subdural hematoma occurs when there is tearing of the bridging vein between the cerebral cortex and a draining venous sinus. At times
they may be caused by arterial lacerations on the brain surface. Patients may have a history of loss of consciousness but they recover and do
not relapse. Clinical onset occurs over hours. A crescent shaped hemorrhage compressing the brain will be noted on CT of the head. Surgical
evacuation is the treatment. Complications include uncal herniation, focal neurologic deficits .All types of head injuries can be caused by
trauma. In adults in the United States such injuries commonly result from motor vehicle accidents, assaults, and falls. In children falls are the
most common cause followed by recreational activities such as biking, skating, or skateboarding. A small but significant number of head injuries
in children are from violence and abuse.

Causes

 Penetrating trauma: Missiles such as bullets or sharp instruments (such as knives, screwdrivers, or ice picks) may penetrate the
skull. The result is called a penetrating head injury. Penetrating injuries often require surgery to remove debris from the brain tissue.
The initial injury itself may cause immediate death, especially if from a high-energy missile such as a bullet.

 Blunt head trauma: These injuries may be from a direct blow (a club or large missile) or from a rapid deceleration force (a fall or
striking the windshield in a car accident).

Head Injury Symptoms

Signs and symptoms of head injuries vary with the type and severity of the injury.

 Minor blunt head injuries may involve only symptoms of being "dazed" or brief loss of consciousness. They may result in headaches
or blurring of vision or nausea and vomiting. There may be longer lasting subtle symptoms including, irritability, difficulty
concentrating, insomnia, and difficulty tolerating bright light and loud sounds. These post concussion symptoms may last for a
prolonged period of time.

 Severe blunt head trauma involves a loss of consciousness lasting from several minutes to many days or longer. Seizures may result.
The person may suffer from severe and sometimes permanent neurological deficits or may die. Neurological deficits from head
trauma resemble those seen in stroke and include paralysis, seizures, or difficulty with speaking, seeing, hearing, walking, or
understanding.

 Penetrating trauma may cause immediate, severe symptoms or only minor symptoms despite a potentially life-threatening injury.
Death may follow from the initial injury. Any of the signs of serious blunt head trauma may result.

Anatomy And Physiology

MEDICAL MANAGEMENT
 Date ordered Doctor’s order Rationale

7-15-09- 11:40 pm  Pls. admit under the service of Dr.  For close monitoring
BP- 140/100 mmhg Amato.
T- 40 Celsius  Sign consent to care  For legal issue
RR-24 cpm  TPR q 4hrs.  To monitor patients temperature,
HR- 61 bpm respiration and pulse
O2 sat.- 100%  To prevent pt.from aspiration
 NPO  To determine abnormalities and
 Labs: to verify and conclude the
CBC, patient’s admitting diagnosis.
 To detect urinary tract infection
 U/A, and glucose in the urine.
 To determine the pt. blood type.
 To determine electrolyte and acid
 Blood typing base imbalance.
 To identify lung disease and heart
 serum Na+ K+ size and location.
SGPT, serum,  To determine the presence of
cardiac arrest.
 CXR: PA,  To detect structural abnormalities

 To maintain fluid and electrolyte

 ECG: 12 lead balance.

 To relieve fever

 CT scan of brain:
Pls. attached film at bedside  Decrease blood pressure.
 With on going IVF of plain PNSS IL
@20 gtts/ min.

1. Paracetamol 300 mg IV now then q  Use to manage gastrointestinal

4hrs PRN for fever disorder
 To aide the patient in breathing
2. Mannitol 150CC q and to introduce oxygen to the
4hrs. IV body to prevent hypoxia
andrespiratory acidosis
 For close monitoring.
 To monitor and relieve abdominal
distention
3. Ranitidine 50 mg q 8hrs.  For parenteral line to administer
4. O2 inhalation @ 2l/min. food and oral medication.
 To monitor pt. heart rhythm
 For baseline data
 To maintain adequate airway
patency.
 To determine effectiveness or to
5. For ICU admission keep watch for possible renal
6. With FBC F-16 attached urobag abnormalities
7. With NGT Fr- 16  To decrease Blood pressure.

 To established artificial airway

8. Attach pt. to cardiac monitor
9. Monitor V/S q 15min.
10. Suction secretion prn.
11. Monitor I&O q shift
12. Refer accordingly
 Standby intubation
 Mannitol 200cc IV. bolus now then
150cc q 3hrs
Hold to BP< 90/60mmhg
 for ET
 To replace blood loss and to avoid
blood reaction.
 To determine the adequacy of
alveolar gas exchange and
evaluate the ability of the lungs
and kidney to maintain the acid
base balance of the body fluid.
 To aide the patient in breathing
and to introduce oxygen to the
body to prevent hypoxia
andrespiratory acidosis
 To lower temperature
7-16-09- 12:45 am
 BT, protime, blood typing.
Decorticate  To relieve fever
No verbal output
No eye graving to pain  ABG
Pupil-5mm OD-2-3mm OS
(+) corneals
(+) dolls
 To lower the pressure of the
brain.
 And to preserve the skull into
 O2 inhalation to 10L/min.via homeostasis environment.
face mask

 For legality issue

 For ice bath to keep body temp < 37.5C
 
 Paracetamol 500mg/tab 1 tab q 4hrs
RTC per NGT
 Start cefuroxine 750mg (panoxim) IV q
8hrs (ANST)
 For emergency
decompressivehemicraniectomy R
expansion, duraplasty, evaluation
of hematoma of implantation of
bone fragment to hemiabdomen
7-16-09- 1am Via subcutaneous pouch
Neurosurgery note  Secure consent
Secure 1“u” FWB properly typed
GCS- 5-6 & cross matched for possible OR
Aminoscoric use.
Cranial CT Scan: R frontal
Contusion: subacute  Hold cefuroxime IV
SDH midline  Start ceftriaxone Igm IV ANST q
Shift to the L 12hrs.
 Gentamicin 80mg IV prior route to
OR
 Please inform undersign once with
consent & BO clearance
 Start cefriaxone I gm 10 ANST q 120
 IV to follow PNSS IL @ 20gtts/min
 To replace blood loss
To determine electrolyte and acid
base imbalance.
 To treat susceptible infection
 To treat short term serious
infection
 For legal issue
 To treat susceptible infection
 To maintain fluid and electrolyte
balance.
 To established artificial airway
 To help the patient breathing
pattern.
 To determine the adequacy of
alveolar gas exchange and
evaluate the ability of the lungs
and kidney to maintain the acid
base balance of the body fluid.

 For intubation

 Mechanical ventilator setting:  To identify lung disease and heart

F1O2- 100% size and location
TV- 400  For close monitoring
RR- 16  To avoid from aspiration
Mode –AC  To monitor vital sign for baseline
 For ABG 30 min. after hooking to data to determine complication
MV
 To maintain fluid and electrolyte
balance

 Use to manage gastrointestinal

7-16-09-2:10 am
 For portable CXR disorder.
 To treat pneumococci infection.
 To decrease osmotic pressure and
  To ICU intracranial pressure.
 NPO till further order  To relive mild to moderate
7-16-09- 3:30am pain,and relax muscle
HR-180-220 bpm  VS q 15min. chartpls.
7-16-09 5:50 am
 To help the patient breathing
pattern and prevent respiratory
distress
 Regulate IV F- R arm @ KVO
 Regulate IVF- L arm @ 20gtts/min.
then ft.  To determine neurologic status of
DS/R- 1 the patient
PLR- 2
DSLR- 1  To determine effectiveness or to
 Cont. ranitidine 1 gm. q 12 keep watch for possible renal
 Start cloxacillin 1 gmslow IVT abnormalities
ANST
 Mannitol to 100 cc of 40 IV bolus  To maintain adequate airway
hold if BP < 90/60 mmhg patency.
 Tramadol 50mg q 6 slow IVTT

 To determine infection

2:00 pm  D/c gentamicin

 To help lung expansion
 Hook to mechanical ventilator
with setting  To avoid further complication and
P1O2= 100% pressure to the brain
TV= 400
Rate=16  Act in the brain to increase blood
Mod e AC flow and oxygen consumption.
 Cont. monitor neuro vital sign  To determine the adequacy of
pupillary size & reaction to light, level alveolar gas exchange and
of assessment evaluate the ability of the lungs
 monitor 1 & 0 q 1hr. chart and kidney to maintain the acid
base balance of the body fluid.
 To determine electrolyte and acid
base imbalance

 Suction one /ETT secretion PRN and

separate  To determine the pt.

 Repeat Hgb ,Hct, det. 4h past op &  To help loosen and to prevent
refer result bronchospasm
 Refer accordingly  To loosen secretion
 Place pt. in slight high back rest
 No pressure @ operated side of head  To help mobilization and to avoid
pressure ulcer.
 F1O2 to 50%  To maintain nutrient needed for
 Citicoline I gram IVTT q 8 body requirement

 Repeat ABG.

 To relieve constipation
 To maintain fluid and electrolyte
balance
 To avoid stomatitis and to
maintain hygiene
 To relive fever
 Repeat Na. K

 To decrease osmotic pressure and

intracranial pressure.

 F1O3 to 30%, back up 18 mu w/

rate=12mod
  Nebulize with salbutamol 1 neb.
 Do chest tappping after each
nebulization
 Turn to sides’ q 2hrs. w/ caution on
the R side of the head.
 Add 10mg KCI to present IVF
6:30 pm  Start of at 1000 kcal/day in
ABG result 1L dilution, to be given in 6
O2 sat. 100% equal feeding
 Lactulose 30cc OD at H.S
 IV FF: PNSS IL + 10KCL for SHRS X3
7-17-09- 7am cycle
 Routine oral care TID using oracare
mouthwash
 To maintain fluid and electrolyte
balance
 To maintain nutrient needed for
body requirement
 To determine abnormalities and
to verify and conclude the
patient’s admitting diagnosis. Also
to determine abnormalities in the
patient’s kidneys
 To maintain fluid and electrolyte
balance

 Revise paracetamol to 500 mg 1 tab T

tab q 4 PRN for temp.> 37.5C
 Mannitol to 100 CC  This is to practice patient normal
I>V bolus q 6hrs. w/BP precautions breathing toleration.
(hold for BP< 95/65)

 IVFTF @ L arm D5LR IL @ some

rate
7-17-09- 8;30am  Terminate IVF @ the R arm.
1st POD  OF to 1600 /day
Asleep arousable to verbal In IL dilution to be given in 6 equal
stimulation/tapping feeding.
Follow simple command  Repeat CBC, Na, K, Crea,
(+) rhonchi tomorrow AM
 To determine the adequacy of
alveolar gas exchange and
evaluate the ability of the lungs
and kidney to maintain the acid
base balance of the body fluid.
 Act in the brain to increase blood
 IVF TF. PNSS IL @ 30qtts/min. x 3 flow and oxygen consumption.
cycle  Use to manage gastrointestinal
disorder

Addendum
 Start a T-piece @10LPM of 15min,  To prevent and control incision
45 min. on mech. Vent. For 6 hrs. infection
If well tolerated increase T-piece
time to 30 min. with 30 min. MV  To identify lung disease and heart
for another 6 hrs. *** shift to size and location
continue T-piece there after if  To replace blood loss and to avoid
7-17-09- 9am blood reaction.
there are no sign of desaturation
Neurosurgery  To prophylaxis for allergic reaction
BP, PR and HR -restlessness
1st POD 
 Get ABG prior to continuous T- To relieve from bipedal edema
E4 VTM
piece (12mn)
Pupil 3mm
EBRTL L
SRTL R  For weaning the pt breathing
pattern.
 To practice patient normal
7-18-09
 Shift citicoline IV to 500mg/cap 2 breathing pattern
9:00am
cap q 12 per NGT
2nd POD
 Shift ranitidine IV to 150 mg/tab,  Towatchedpt from respiratory
7-18-09 distress
1 tab BID per NGT (Raxiole)
1:15 PM
 To detect blood in the stool and
 Wound care, change dressing. detect urinary infection
 To relive patient from
 For portable CXR-AP if possible constipation

 Secure 2 units PRBC for BT after

properly cross matched.
 Give Benadryl 50 mg IV prior to BT
  Furosemide 40 mg IV after each
bag transfused with Bp precaution
(hold to BP < 90/60)
 F1O2 to 40%
 Resume weaning
Continue T-piece for Hrs. then
back to MV SMV mode, F1O2 40%
for 2 hrs. Cycle for 24hrs.
 Watch patient for desaturation.
 For repeat U/A, stool exam with
occult blood
 bisacodel, adult suppository now
then another I @ HS if still w/o
BM.

7-18-09
1:30pm
E- 4VT M5-6
Pupil 3mm
ERR operative wound
healing well

7-19-09
10:30 am
MEDICAL ORDERS with RATIONALE
Medical Orders Rationale

-relieves pain
July 19 2009 -to into higher dosage
 Celecoxib 400mgmg/cap 1cap OD/NGT -supplement body fluid
 Revise tramadol to 50mg IV q12 hours
 Follow IVF with PNSS 1L and 40meq KCL @ 30gtts/min x 3 -to recheck ABG status of patient
cycles
 Repeat ABG’s in AM (9am) at the end of T piece cycle -to recheck CBC for abnormalities
 For repeat CBC at 11am
-ITC aspiration pneumonia vs. HAP
Meds: - To reduce intraocular or intracranial pressure.
 Mannitol to 100cc IV bolus q8hours -to normalize level of potassium
-supplement body fluids and to administer medication through
 Kalium Durule 1 Durule TID
tubing
 IVF PNSS 1L+20meqKCL @ 20gtts/min for 3 cycles
 Follow up 6S of ETA>refer

July 20 2009 (Neurosurgery notes) -prevent possible infection

 Wound care, open dressing done -to relieve pain
 Revise tramadol to 50mg IV q8 hours PRN for severe pain
 Shift cloxacillin in 500mg 1cap -to enhance brain function

q6hours/NGT
11:40 Am
 For referral to Dr. Gamalo for Pulmonary co-management
-text orders by Dr. Amato
 IVF TF: PNSS 1L @ 20gtts/min + 20 meq KCL for 3 cycles
 Repeat serum Na, K, AM -to supplement body fluids and to administer edication through
 for the: tubing
AO ventricular associated pneumonia -to recheck serum Na and K
P2 shift ceftriaxone IV to Imipronen500mg IV q8 hours ANST(
-)
Meds
 Start Floxel 750mg tab 1tab OD/NGT
 Fluimucil 200mg in 100ml of H2o q8 hours/NGT
 Check ET cuff BID
 F1O2 at 40% -to decrease viscosity of respiratory tract secretion
 Possibly of tracheostomy
-to check if there is dry secretions obstructed

July 21 2009 -to establish artificial patent airway

10:50 Am -improve ventilation
 Continue meds
 Daily wound care open dressing with alcohol
 Cut endotracheal tube verbal order by Dr. Gamolo
-continue treatment for patient
5th POD -prevent possible infection
 Passive flexion- extension of extremities
 Please provide foot board
 Maintain Mannitol at 100cc q8 hours

July 22 2009
 Continue meds -facilitate rehabilitation of extremities
 NPO -to promote blood circulation
 Increase citicoline to 2 caps q8 hours/NGT - To reduce intraocular or intracranial pressure.
 Decrease mannitol to 75cc IV bolus then D/C
 Repeat Chest X-ray tomorrow Am- have it compared with
-to continue treatment for the patient
previous plates -to prevent GI upset
  Prepare T pipes tomorrow AM -to enhance brain function
-to decrease intracranial pressure
July 23 2009
-to prevent drug overdose
 For early tracheostomy, OK with Dr. Gamolo
 Increase of dilution to 1600L (1:1) -to obtain accurate results
 Decrease IVF to 10gtts/min in cycles -to establish artificial airway
 IVF TF: D5NM 1L @ 10gtts/min in cycles
 Repeat serum Na, K, tomorrow
 D/C Celecoxib and Kalium durule
-to improve ventilation
3-11
 Watch patient from MV thru progressive weaning: -increase nutrition for the patient
Piece at 64minMV
15 min 20 min -supplement body fluids
30 min 30 min -to obtain accurate results, monitor status
1 HR 30 min - to determine electrolyte imbalances
-to avoid over dose
2 HR -- ABG’s MV to follow order
 Increase FiO2 to 100% perigastric (during tracheostomy)
 Refer Dr. Fernandez for anesthesia -to prevent further complication

July 24 2009
 Increase IVF to 30gtts/min
 IVF TF 1. PLR 1L x 30gtts/min
2. D5NM 1L x 30gtts/min in cycles
9:50 AM
 Increase OF to 1800 KCAL q4hours in 6 divided feedings -to prevent respiratory distress
 Fleet enema @ bedtime
11:50Am -for referrals
 May resume feeding when fully awake
 Regulate IVF at 30gtts/min
 Continue meds previously ordered -to maintain fluid and electrolyte imbalance
 Measure I&O q4hours shift
 Suction tracheostomy secretion PRN

- To maintain nutrition within body requirement

 For Chest X-ray as ordered - To clean the obstructed in the anal passage

July 25 2009
 Took to T piece at 61min - to maintain nutrition as body requirement
 May transfer to room of clinic tomorrow am -to maintain the fluid and electrolyte balance
-to reach the therapeutic effect of the medication
Meds
- To monitor pt fluid
 Fluimucil 200mg q12 hours - to prevent obstructed secretion in the tracheostomy tube.
5:00Pm -To identify lung disease and heart size and location
 May use anti embolic stocking
 Decrease IVF to KVO
 Start bladder training q12hours for 24hours then remove -to maintain oxygen passage
-to continue monitoring
Foley catheter
 Transfer IV site to Left –defer- -to decrease viscosity of respiratory tract secretion
 IVF TF: PNSS 1L @ 10gtts/min

 Pls give tramadol 500 now - To prevent hypothermia

- Use to access line for the medication
- To prevent abdominal distention
 D/C Salbutamol neb if ok with Dr. Gamolo
- To prevent phlebitis on the IV site
Neurosurgery note
 Ok for transfer to a regular room - To maintain fluid and electrolyte balance
- To relive mild to moderate pain, muscle
July 26 2009
 Shift Salbutamol neb + combivent neb q8 hours
 Continue O2 sat monitoring q shift
 1L/min to 2L/min in T piece
  Last dose Imipenem in 6Am 7/28/09 then D/C - For continuous monitoring

 Turn to sites q2 hours

- To dilate bronchus and prevent bronchospasm
 Elevate head 30 degree
- To determine O2 sat of the patient.
 Teach relatives for proper suctioning of secretions

- Treat mild to moderate tract infection,

July 27 2009 intra abdominal and gynecologic
9:35Am Neurosurgery note infection
-to prevent from bed sore and to improve
 For removal skin staples tomorrow please prepare staple
Motility
remover -To help lung expansion
Dr. Amato -to enhance proper suctioning and avoid
 Turn to side q2 hours Complication
 Please provide turning schedule at bedside
 Continue passive flexion-extension of extremities
 Pls allow and teach relatives how to feed per NGT

July 28 2009 - To enhance and facilitates healing

 Give tramadol 50mg IV if in pain
-text order by Dr. Amato
 May D/C O2 tomorrow Am change O2 sat 1 hour after.
- to prevent bedsore and promote circulation
 Prepare the following at home
- so that significant other will able to follow
1. Nebulizer schedule.
2. Suction materials
- To promote
Neurosurgery Notes
 D/C ranitidine -for proper home feeding
 Start amlopidine 10mg 1tab OD/NGT

July 29 2009 -To relieve mild and moderate pain

 D/C IVF once consumed
 Increase oral feed to 2000 Kcal/24 hour 1:1 dilution (2liters) -To change new O2 sat
in 6 divided feeding including H2o & oral feeding
-For progress of ventilation at home
4:20 Pm
 Auscultate lungs and refers O2 sat 95%
 Tracheal mask regulated O2 @ 4pm
 During feeding placed patient on HBR
 Flush 50cc of H2o instead of 150 cc during feeding
-To stop for further health condition
4:30 Pm
-To decrease blood prepare
 Repeat Chest X-ray today
Call order by Dr. Amato
 Nebulizer with combivent neb now

-To avoid excess of fluid

-To maintain nutrition within the body requirements
July 30 2009
9:00Pm
 Na, K now
-To assess lung sounds
July 31 2009 -To prevent patient from respiratory acidosis
7:30 am
-To prevent aspiration
 Increase head & trunk elevation to 40-60 degree during the
-To prevent obstruction in feeding
day time
 Provide foot board
 Do not put a pillow underneath both knees when in supine - To identify lung disease and heart size and location
position
7:55 Pm -Relaxes smooth muscle thus preventing bronchospasm
 Reinsert IVF; start PNSS 1L + 30 meq Kcl regulated @
20gtts/min for 3 cycles
 Text order by Dr. Amato

-to determine electrolyte imbalances

August 1 2009
1:30 Pm Rehab -prevent ICP
 Continue PT program
 Maintain both feet in neutral position (90 degree) when -To enhance circulation
patient in supine -To promote comfort and unnecessary flexes
 Repeat serum Na, K
Meds
 Diazepam 5mg IV now -To maintain fluid and electrolyte balance
 Start Clonazepam 20mg 1tab ¼ tab OD at HS
 Fluxetine 20mg/cap 1cap OD at 9am daily

August 2 2009
 Maintain on moderate HBR up elevation
-during the daytime
-will progress rehab to short sitting starting tomorrow
 May have wheel chair rides x 30-45 minutes BID -for rehabilitation of joint and extremities
 Consumed IV then terminate -to promote circulation and avoid flexes

August 3 2009 -to determine electrolyte imbalances

 Do wound dressing
 Pls teach relatives to feed -Promote calmness and sleep
- Prevents or stop seizure activity
August 3 2009
 Pls refer to dietary department for Oral feeding instructions
-To inhibit CNS neuronal uptake of serotonin
prior to possible discharge
 Do not fleet enema
 Monitor patient able to urinate spontaneously after 4 hours
of straight catheter
August 4 2009 -to promote lung expansion
 Insert Foley catheter attached to uro bag
 Start diflucan 100mg 1tab OD
2:55pm -to promote mobilization
 Continue PT progress

-to avoid further fluid excess

-to maintain aseptic technique

-for health teaching

-for home food preparation

-to prevent complication

-to determine output

-to promote drainage

-to decrease osmotic and intracranial pressure

-for rehabilitation of joint and extremities

 Name of drugs Date ordered classification Dose/ frequency Mechanism of Specific indication Contraindication Side effects Nursing Precaution
action

Clonazepam 8-2-09 Anticonvulsant 2mg ¼ tab OD Prevents or stop Panic disorder Use cautiously in Confusion Be alert of adverse
seizure activity Restless leg patients with mixed drowsiness slurred effects reaction and
syndrome type of seizures tonic speech abnormal drug interaction
clonic seizures eye movement
Dalacin 8-2-09 Antibiotic 15mg 1 cap tID/NGT Inhibits bacterial Bacrtericidalvaginosi Contraindicated in Head ache Before giving first
protein wall s acne vulgaris patient thrombophlebitis dose obtain
synthesis thus hypersensitive to specimen for culture
causing cell death drug or orlincomycin and sensitivity test.
Begin therapy
pending results
Diflucan 8-4-09 Antifungal 100mg 1tab OD/NGT Inhibits fungal CYP, Cryptococcal Contraindicated in Headache nausea If patient develop
(fluconazole) and enzyme meningitis systemic patients vomiting abdominal mild rash, monitor
responsible for candidias hypersensitivity to pain him closely. If lesions
fungal sterol drug or any of its Diarrhea progress stop drug
synthesis and component and notify precriber
weakens fungal cell
walls
 Name of drugs Date ordered classification Dose/ frequency Mechanism of Specific indication Contraindication Side effects Nursing Precaution
action

Fluoxitine 8-2-09 Antidepressant 20mg 1cap OD/NGT May inhibit CNS Depression, Use cautiously in Fever, nervousness, Tell patient not to
neuronal uptake of obsessive patient at high risk anxiety, insomnia, take drug in
serotonin compulsive disorder for suicide and in palpitation, nasal afternoon or in
those with history of congestion, nausea, evening because
mania, seizures, diarrhea fluoxetine common
diabetes mellitus, causes nervousness
hepatic renal or CV and insomnia
disease
Valproic acid 7-30-09 Anticonvulsant 5ml q8 hours/NGT Prevent and treat Prevent migraine Contraindicated to Headache, dizziness, Tell patient or
certain types of headache, mania, patient sensitive to depression, muscle relative that drug
seizure activity complex partial drugs or any of its weakness, nausea, may be taken with
seizure component and in vomiting, ingestion, food or milk adverse
patient with hepatic diarrhea GI effect, tell patient
dysfunction or urea and parents that
cycle disorder syrups shouldn’t be
mixed with
carbonated
beverage
Amlodipine 7-22-09 Antihypertensive 10mg 1tab OD/NGT Reduces blood Hypertension, Contraindicated to Headache, fatigue, Be alert of adverse
(NorVAsc) Antianginal pressure seizure and chronic stable angina patients somnolence, edema, reaction. Assess
prevent angina hypersensitive to dizziness, flushing, patient’s blood
drugs palpitation pressure or angina
before therapy and
regularly thereafter
Cefuroxime 7-24-09 Antibiotic 750mg IV q8 hours Hinders or kills Kills serious infection Contraindicated to Dizziness, headache, Assess patient
ANST (-) susceptible bacteria of lower respiratory patient malaise, GI infection before
including many gram and urinary tract skin hypersensitive to abdominal cramps, therapy ang
positive organisms and skin structure drug or other anal pruritus, regularly thereafter
an enteric gram infections bone and cephalosporins diarrhea, nausea,
bacilli joint infection, vomiting, genital
septicemia, pruritus
meningitis,
gonorrhea and
perioperative
prophylaxis
Lactulose 7-24-09 Laxatives 30cc OD @ HS/NGT Relieves Constipation to Contraindicated in Abdominal cramps, Advise patient to
constipation, restore bowel patients on low belching, diarrhea, dilute drug with juice
decrease blood movement after galactose diet distention, nausea, or water or to take
ammonia hemorrhoidectomy vomiting with food to improve
concentration taste
Salbutamol 7-24-09 bronchodilator 1 neb q6 hours Relaxes bronchial To prevent exercise Contraindicated to Tremor, Be alert for adverse
and uterine smooth induced patient nervousness, reaction and drug
muscle by acting on bronchospasm hypersensitive to dizziness, insomnia, interaction, obtain
beta 2 adrenergic drug or its headache, baseline assessment
receptors component tachycardia, of patient
 palpitation respiratory status
Ranitidine 7-24-09 antiulcerative 150mg/tab 1tab Relieves GI Duodenal and gastric Contraindicated in Vertigo, malaise, Assess patient GI
BID/NGT discomfort ulcer maintenance patient blurred vision, condition before
therapy for duodenal hypersensitive to jaundice starting therapy and
ulcer drug and its to monitor drug
component effectiveness
Cloxacillin 7-20-09 500mg 1cap q8/NGT

Imipenem 7-20-09 antibiotic 500mg IV q8 Kill susceptible Treat mild to Contraindicated to Seizure, dizziness, Assess patien’s
ANST( - ) organism including moderate tract patient somnolence, fever, infection before
many gram positive infection, intra hypersensitive to HPN, nausea starting therapy and
gram negative and abdominal and drug and its vomiting, diarrhea, regularly thereafter.
anaerobic bacteria gynecologic infection component rashes, urticaria Be alert for adverse
pruritus reaction and drug
infection
Fluimucil 7-20-09 200mg in 100ml of
H2o q8 hours/NGT

Celecoxib 7-19-09 Anti-inflammatory 400mg/ cap 1cap Relieves pain and Relieves of signs and Contraindicated in Dizziness, headache, Assess patient for
OD/NGT inflammation in symptoms of patients insomnia, stroke, appropriateness of
joints and smooth osteoarthritis hypersensitive to HPN, peripheral therapy drug must
muscle tissue relieves signs and drug sulfonamides or edema, abdominal be cautiously in
symptom of aspirine or other pain, diarrhea, patient with history
rheumatoid arthritis NSAID’s and in nausea of ulcers or GI
patient with severe bleeding, heart
hepatic or renal failure or asthma
impairment
Tramadol 7-19-09 Analgesics 50g IV q12 hours Relieves pain Moderate to Contraindicated in Dizziness, vertigo, Assess patient’s pain
moderate severe patient headache, before starting
pain hypersensitive to somnolence, therapy and
drug or any of its stimulations, regularly thereafter
component and in anxiety, confusion, to monitor drugs
those with acute malaise effectiveness
intoxications from
alcohol, centrally
acting analgesics
opioids or
psychotropic drug
Kalium Durule + 7-20-09 Potassium salt NGT TID Replaces potassium Prevention of Use cautiously in Weakness, heaviness teach patient how to
durule and maintains hypokalemia patient with cardiac of limbs, prepare powder and
potassium level disease or renal hypotension, nausea how to prepare drug
impairment vomiting tell patient to take
with or after meal
with full glass water
or fruit juices to
lessen GI distress
Mannitol 7-20-09 Osmotic diuretics 75cc IV bolus q12 Increases osmotic To reduce Contraindicated in Seizure, dizziness, Monitor vital signs
 hours pressure of intraocular or patient headache, fever, including central
glumerular filtrate intracranial pressure. hypersensitive to edema, hypotension, venous pressure and
inhibiting tubular To prevent oliguria drugs hypertension, fluid intake and
reabsorption of or acute renal failure blurred vision, tears, output hourly
water and nausea vomiting
electrolytes diarrhea
Floxel 7-20-09 750mg tab 1 tab
OD/NGT

Citicoline 7-22-09 Brain enhancer 500mg/cap 2caps Improve blood flow Stroke, head injury Contraindicated in Headache, insomnia, Tell patient to notify
q8/NGT and oxygen supply to patient dizziness, fever, physician if any
the brain hypersensitive to nausea, vomiting, abnormalities occur
drugs or any drug tremor
component
Paracetamol 7-24-09 Antipyretic 500mg 1tab q4hours Prevent the moderate to severe Contraindicated in Headache, dizziness, Drug should be
Analgesic synthesis of pain, fever, patient nausea vomiting taken with foods if
NSAID’s prostaglandin which inflammation hypersensitive to diarrhea, tremors, GI upset occurs
stimulates drug, pregnancy, malaise May experience
hypothalamus for lactation adverse effects
temperature
regulation thus
reducing body
temperature
 Nursing System Review Chart

Date:August 03, 2009

Vital Signs:
Temp:37.5ºCPulse:135bpmradialBP:130/90 mmHgRespiration:35 cpm

Sunken part of
With O2 the head due to
inhalation decompression
at 2-3 and craniotomy
LPM
- Nasogastric procedure
Tube

Tracheostomy -Generalized
tubing body
Weakness
-Dry Skin

IVF insertion
site
Scar

Irregular fast
35 cpm
 NURSING SYSTEM REVIEW CHART

Date:August 04, 2008

Vital Signs:
Temp:38.5 CPulse: 132 bpmBP:140/100 mmHgRespiration:32 cpm

Suture and
Tracheostomy slight
with O2 Deform head
inhalation at 2
L/min Productive
cough with
whitish
- phlegm
Nasogastric
Tube

Pulse fast
Scar and irregular

-Generalized
body
Irregular fast Weakness
32 cpm.

IVF insertion
site
Nursing diagnosis: Ineffective cerebral Tissue Perfusion related to head injury

Objectives: at the end 2 days intervention, patient will demonstrate improve level of consciousness, cognition, motor and sensory function

“Subjective”
Makamatana siya peromurag wala sa iyangpamuot, dili ganigatingog, as verbalized by significant
Others.

Objectives
Unconscious
Weak in appearance
With O2 nasal cannula
Intervention Rationale
Monitor/document neurologic status frequently and compare with Assesses trends in level of consciousness (LOC) and potential for
baseline. increased ICP and is useful in determining location, extent, and
progression/resolution of CNS damage.

To monitor condition of the patient

Monitor vital signs
Monitor neurologic status of the patient
Monitor Glasgow Coma scale and SPERM

Reduces arterial pressure by promoting venous drainage and may

Position with head slightly elevated and in neutral position. improve cerebral circulation/perfusion.

Continual stimulation/activity can increase ICP. Absolute rest and

Maintain bed rest, provide quiet environment, restrict visitors quiet may be needed to prevent rebleeding in the case of
hemorrhage.

Administer supplemental oxygen as indicated. Reduces hypoxemia, which can cause cerebral vasodilation and
increase pressure/edema formation.

Evaluation: at the end of 2 days intervention to the patient, patient did not demonstrate improvedin level of consciousness, cognition, motor and
sensory function.
Nursing Diagnosis: self care deficit related to neuromuscular impairment secondary to head injury

Objectives: at the end of 8 hours, patient will meet self care needs.

“subjectives”
Dili gyudniya ma-atimaniyanglawas kay wala pa gani siya pamuot as verbalzed by significant others.
Objectives
Weak
Unconscious
Intervention Rationale
Provided morning care Enhances patient daily hygiene

Provided mouth care Eliminate bacteria that may cause infection

Suction secretion from tracheostomy to remove secretions

Elevated head part every 2 hours to provide comfort to patient

Administer suppositories and stool softeners. to aid in establishing regular bowel function.
To prevent constipation
Evaluation: at the end of 8 hours, patient meet self care needs.
Nursing Diagnosis: Impaired physical mobility related to loss consciousness secondary head injury

Objectives: at the end 2 days, patient will maintain skin integrity

Objective Cues
Unconscious
Weakness
immobile
Intervention Rationale
Change positions at least every 2 hr Reduces risk of tissue ischemia/injury.

Position in prone position once or twice a day. Helps maintain functional hip extension.

Inspect skin regularly, particularly over bony prominences.
Get client up in wheel chair as soon as vital signs are stable.
Consult with physical therapist regarding active, resistive exercises
and client ambulation.
Pressure points over bony prominences are most at risk for decreased
perfusion/ischemia.
promotes maintenance of extremities in a functional position and
emptying of bladder
Individualized program can be developed to meet particular
needs/deal with deficits in balance, coordination, strength.

Evaluation: at the end 2 days, patient had maintained skin integrity

 Nursing Diagnosis: Risk for infection related to lacerated wound secondary to head injury

Objectives: at the end of 8 hours, patient will be kept safe from possible infection

Objectives: at the end

Intervention Rationale
Stress proper hand washing techniques to all care givers and relatives To prevent nosocomial infection.

Perform wound dressing daily as indicated.

To promote faster wound healing and prevent from infection.

Maintain sterile technique for invasive procedures like IVF, urinary To prevent contamination/transmission of microorganisms from one area to
catheter, and pulmonary suctioning. another and to reduce risk factors of infections.

Instruct significant others in techniques to protect the integrity of the To promote client wellness or to prevent cross-contamination.
skin, care of lesions, and prevention of spread of infection

Monitor temperature. Note presence of chills and tachycardia with/ Reflective of inflammatory process/ infection, requiring evaluation.
without fever.

Collaborative
Shifts in differential and changes in WBC count indicate infectious process.
Monitor laboratory studies e.g. Complete Blood Count (CBC)
To treat and prevent the infection
Administer prophylactic antibiotics and immunizations as indicated.

Evaluation: at the end of 8 hours duty, patient was successfully kept away from getting infection
ACTUAL NURSING MANAGEMENT

Nursing Diagnosis:

Ineffective airway clearance and impaired gas exchange related to brain injury and increase secretion production.
Objective :
“Gihangus na cyaatong wala cyaoxygenugkanang dili cya ma suction” as significant others verbalized
Subjective:
-O2 inhalation attached to tracheostomy tube
-RR- 35-36
-increase accumulation of secretion
-restlessness

Intervention Rationale

1. Checked for aspiration and respiratory 1. To assess patient states of maintaining airway
insufficiency 2. To check vital signs, to assess patient active airway, and for
2. Respiratory rate checked every 15 minutes. documentation purposes
3. Elevate the head of the bed as prescribed. 3. To allow secretions drain from patient mouth.
4. To support patient maintenance of air
4. Provide oxygenation, prescribed by the
physician 5. To maintain patent airway

5. Suction patient PRN limit 5-10 second per

suction

At the end of 15-30 mins.The client’s restlessness was alleviated and remained calmed.

Nursing Diagnosis:

Risk for injury related to brain damage due to vehicular accident

Goal:
At the end 8 hours of intervention, patient safety was established
Objective cues:
-decrease neurologic function
- decorticate posturing
-decrease level of consciousness

Intervention Rationale
1. Keep bed side rails raise 1. To provide safety
 2. Position and place patient at the middle of the bed 2. To monitor patients activity and level of
3. Watch patient for the entire shift. safety measures
4. Secure patient hands and feet on the bed 3. To prevent patient from injury
5. Assess level of consciousness, orientation and ability to move 4. These parameters provide a baseline and
extremities help identify signs and symptoms of
neurologiccomplication
5. This promotes safety and reduces risk of
complication
6. Position patient to enhance comfort, safety and lung expansion 6. To help patient breathing pattern

7. Provide bed rest 7. To avoid patient from stress and conserve

energy
8. Watch patient all the time and assess patient needs 8. To assure patient safety

At the end of 8 hours of nursing interventionpatient safety was prevented and minimized.

Nursing Diagnosis:

Risk for infection related to wound. Located at right front to parietal area of the brain due to decompression and craniotomy.
Plan:
At the end of 8 hours of nursing intervention patient
Objective:
-wound on the right side of head
- wound puss is visible
- elevated temp. 38 degrees
Intervention Rationale

1. Wound dressing done with proper sterile technique 1. To clean and eliminate the number of
after operation microorganisms located at the wound area.
2. Keep wound force of dressing threads. 2. Foreign bodies retard healing
3. Surgical site and wound drainage assisted.
3. Assessment provides baseline and help identify signs
4. Monitor patient closed drainage system; check for and symptoms of hemorrhage early.
secretions, color and amount 4. For documentation purposes and accumulated hiding
process
5. Monitor TPR 5. To get baseline date related to infection
6. Administer antibiotic medication as prescribed.
6. To eliminate microorganisms.

At the end of 8 hours of nursing our objectives was partially met since, we able to control further infection related to craniotomy and
decompression incision

Nursing Diagnosis:
Disturbed in sensory perceptionrelated to brain trauma
Plan: At the end of 2 days intervention patient able to demonstrate the presence of residual involvement.
 Subjective cues:
Dili cyamotubag ug storyahonigo ra cyamo tan aw dayon mopiyongdayun as verbalized by the niece.

Objective:
] -motor incoordination
] -alteration in posture
] - altered communication pattern
] - poor concentration-
Intervention Rationale
1. Continual monitor in changes in orientation, 1.Damage may may occur at time of initial injury
ability to speak, mood, affect and sensorium.
2.to determine the ability to perceive and respond
2. Assess sensory awareness.
appropriately to stimuli
3. Eliminate extraneous stimuli as necessary
3. to reduce anxiety
4. Speak calm, quite voice,use short, simple
4. Client have limited attention span, and understanding,
sentences, maintain eye contact
these measures can help client attend communication.
5. Reorient client to environment, and procedure
5.to assist patient to differentiate reality in the presence of
altered perception
6. Allow adequate time for communication and
6. to progress toward independence, enhancing, sense of
performance.
control while compensating for neurologic deficits.

At the end of 2 day of intervention my goal was not met because patient was demonstrate of deterioration of neurologic status.

HEALTH TEACHINGS

Health teachings imparted to the significant others:

Medications  Stress out to the patients the importance of

compliance to home medication regimen
 Discuss the action of the medication ordered
 Emphasize the significance of the following the right
timing when administering
Exercise  Demonstrate passive range of motion exercises and
explain why is it necessary for the patient
Treatment  Emphasize the importance of good rest
Out patient  Emphasized the significance of follow-up checkup
Diet  The importance is increased fluid intake
 Intake of vitamin C rich foods
. REFERRAL AND FOLLOW-UP

Advice the patient to follow scheduled check-ups to the physician after discharge, constant monitoring and checking of the patient’s
condition is really important to ensure that the patient is given adequate and continuous care and medication. If the patient or the significant
others are not satisfied with the findings of the current doctor, it is advisable to recommend another doctor whose specialization is on the head
injury aspect for a second opinion. Since Mrs. X is already weak, keeping watch and acknowledging the risk for aspiration when the patient goes
home is also very important because it is a big factor which can contribute to the patient’s breathing pattern.

X. EVALUATION AND IMPLICATION

Having a patient with head injury with brain trauma is challenging and at the same time very educational, we able to exercise our
interventions and we developed the skills on how to think critically so that we can improve my patient’s condition. I can use this experience for
my future patient who has the same problems as Mrs. X and the interventions that I have learned will also be applicable to them. The experience
in taking care of subdural hematoma patients can really be so challenging, the patient could have moods and affect and the need to constantly
explain everything that you do and to constantly remind the patient is very important. The 2 day care of my patient was fulfilling and challenging
but the most important thing is we have learned something from our patient and in turn we can say that we have done our best to give utmost care
to our patient.

BIBLIOGRAPHY

 Medical-Surgical Nursing 11th  Edition. Suzanne Smeltzer, Brenda Bare, Janice Hinkle, Kerry Cheever. Volume 1. Pp.
1204 – 1207

 Nurse’s Pocket Guide (Diagnoses. Prioritized Interventions, and Rationales) 11th Edition. Mrilynn E. Doenges, Mary
Frances Moorhouse, Alice C. Murr

 PPD’s Nursing Drug Guide 2007 Edition

 Ms. ManilynCabiles (patient) and mother PurificacionCabiles

 http://www.emedicine.com/MED/topic850.htm