Chapter I Introduction

A. Background of the Study Cerebral Concussions are scattered areas of bleeding on the surface of the brain, most commonly along the under surface and poles of the frontal and temporal lobes. They occur when the brain strikes a ridge on the skull or a fold in the dura mater, the brains tough outer covering. A Cerebral Concussion can occur directly beneath the site of impact when the brain rebounds against the skull from the force of a blow or when the force of a blow drives the brain against the opposite side of the skull or when the head is hurled forward and stopped abruptly. The brain continues moving and slaps against the skull and then rebounds which may result to bruises. These bruises may occur without other types of bleeding or they may occur with acute subdural or epidural hematomas. Most patients with cerebral concussions have had a serious head injury. The signs and symptoms of a contusion include severe headache, dizziness, increased of one pupil or sudden weakness in an arm or leg. The person may seem restless, agitated or irritable. Often, the person has memory loss or seems forgetful. These symptoms may last for several hours to weeks, depending on the seriousness of the injury. Cerebral edema, or swelling typically develops around the concussion within 48 to 72 hours after injury. Any period of loss of consciousness or amnesia of the head injury should be evaluated by a health-care professional. As the brain tissue swells, the person may feel increasingly drowsy or confused. If the person is difficult to awaken, medical attention should be sought immediately. This could be a sign of more severe injury. As with other types of Intracranial Pressure hemorrhages, cerebral concussions are most rapidly and accurately diagnosed using Computed Tomography (CT) brain Scans. If pressure on the brain increases significantly or if the hemorrhages from a sizeable blood clot in the brain (an intracerebral hematoma), a craniotomy to open a section of the skull may be required to surgically remove the cerebral concussion. Recovery after the brain injury varies widely. Treatment outcomes vary according to size and location of the Cerebral concussion. Other predictors include age, the initial Glasgow coma score and the presence of other types of Brain injuries.

B. Objectives/ Significance of the Study General: To gain knowledge and attitude in the care of a patient with Cerebral Concussion Specific: To gain more knowledge To review the anatomy and physiology of the brain and circulatory systems To provide an individualized plan of care for the patient To understand the physiologic processes associated with the condition

C. Scope and Limitation This study will focus on the Cerebral Concussion and the extent of the damage occurred on his circulatory system. Also its main idea for us to learn and gain more knowledge about this case. But it will be more focusing on nursing interventions and actions and this will hind the medical management for a little.

Chapter II Health History

A. General Data Name: B, R O. Age: 50 years old Sex: Male Civil Status: Married Relgion: Roman Catholic Address: Tinajeros, Malabon City Chief Complaint: Extreme Headache Admitting Diagnosis: Cerebral Concussion Date Admitted: January 2, 2013 Time: 1:15PM

B. History of Present Illness This is a case of a 50 y/old male patient who come on due to fall. Condition started few hours ago prior to admission when patient accidentally slip, hitting his head on the floor sustaining injury. Patient was then adviced to be admitted for further monitoring. During Mr. B, R O. admission in the institution, he has episodes of uncontrolled extreme movement, so the doctors ordered him to strap up in the bed to reduced the anxiety but he find his way out to be free from the strangulation. Eventually he become more calm after the released from the strapping from his bed. He is given: Olanzapine Cefazolin Vit. B Complex

C. Past Medical History The patients present history of illness is his first admission to the institution. The patient does not regularly visits his doctor for check-up. He is also a smoker and heavy drinker. During the clients childhood years he suffered from various illnesses, he recalls that he had only few childhood illnesses like mumps, flu, colds, cough and chickenpox. The client cannot recall if he had completed his immunization, he can still perform household chores and farm work just as long as he doesnt feel any symptoms of elevated BP and he doesnt feel fatigue.

D. Family History No No No No No Diabetes Mellitus Hypertension Asthma Cancer Heart Disease

E. Physical Assessment Age: 50 y/o Vital Signs: Blood Pressure: 120/80 Temperature: 36.4 C Pulse Rate: 80 Respiration Rate: 25 Pain: 0 out of 10 Weight: 55kg (122lbs.) Height: 170cm BMI: 19.03

BMI= Wt (in kg)/ (Ht m^2) = 55kg/1.70m^2 = 55kg/2.89m

BMI= 19.03

Body Part Examined

Asessment Findings
Assesment from Head to Neck

Normal Findings

Interpretation/Analysis

Appearance and Mental Status

his height and weight is proporitionate to his age

Proportionate, varies with lifestyle

Normal

His posture is erect

Relaxed, erect posture; coordinated movement

Normal

Clean and neat no body odor and no breath odor present

Clean, Neat No body odor or minor body odor relative to work or exercise; no breath odor

Normal Normal

No signs of distress Healthy Theres no neglect

No distress noted Healthy appearance Cooperative, able to follow instructions

Normal Normal Normal

Appropriate to situation I can understand what his saying

Appropriate to situation Understandable, moderate pace; clear tone and inflection; exhibits thought and association

Normal Normal

Has a sense when hes answering me

Logical sequence; makes sense; has sense of reality

Normal

Skin

Brown color (kayumanggi)

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive

Normal

Uniform in skin color

Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people

Normal

Well moisturized especially on skin folds

Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature and activity)

Normal

Normal range of temperature His skin is going back to normal state when I pinched

Uniform: within normal range When pinched, skin springs back to previous state; maybe slower in elders

Normal

Normal

Nails

Convex curvature

Convex Curvature; angle of nail plate about 160degrees

Normal

Smooth fingernails His nail bed is pinkish brown because his skin color is brown

Smooth texture Highly vascular and pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal streaks

Normal Normal

Well intact The duration of his

Intact epidermis Prompt return of pink or

Normal Normal

capillary refill was 2 seconds Hair Evenly distributed hair of him Thick hair Silky and resilient hair Theres no sign of infection and infestation Skull and Face Common shape and size, theres no abnormalities

usual color (generally less than 4 seconds) Evenly distributed hair Normal

Thick hair Silky, resilient hair No infection and infestation Rounded (normocephalic and symmetric, with frontal parietal, temporal and occipital prominences); smooth skull contour

Normal Normal Normal

Normal

Theres a wound in the R parietal lobe about 1 inch because of fall Symmetric facial features

Smooth, uniform consisitency; absence of nodules or masses Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

Not normal

Normal

His facial movements was also symmetric Eye Structure and Visual Acuity Evenly distributed hair on his eyebrow, well aligned

Symmetric facial movements Hair evenly distrubuted; skin intact; eyebrows symmetrical aligned; equal movement

Normal

Normal

Curled slightly outward

Equally distributed; curled slightly outward

Normal

No discharge, his palpebral fissure was aligned symmetrically, no visible sclera when lids were open

*Skin intact; no discharge; no discoloration *Lids close symmetrically *Approximately 15 to 20

Normal

involuntary blinks per minute; bilateral blinking *When lids open, no visible sclera above comeas, and upper and lower borders of cornea and slightly covered Transparent Transparent; capillary sometimes evident; sclera appears white (darker or yellowish and with small brown macules in darkskinned clients) Smooth, shiny and pink in color no edema and no tenderness Theres no discharge Transparent, shiny and smooth Shiny, smooth and pink or red No edema or tenderness over lacrimal gland No edema or tearing Transparent, shiny and smooth; details of the iris are visible He blinked when I put the gauze to his cornea Client blinks when the cornea is touched, indicating the trigeminal nerve is intact No shadows and the depth of his iris was about 3mm His iris was black in color, normally about 3mm to 7mm in diameter his iris Transparent; no shadows of light on iris; depth of about 3mm Black in color; equal in size; normally 3 to 7mm in diameter; round smooth border; iris flat and round His eyes was Illuminated pupil Normal Normal Normal Normal Normal Normal Normal Normal

responding when the light was pass through his eyes it constricts

constricts (direct response) Non-illuminated pupil constricts (consensual response) Normal

His eyes constricts when looking in near object while looking on far objects his eyes dilate

Pupils constrict when looking at near object; pupils dilate when looking at far object; converge when near object is moved toward nose

Normal

He can see on his periphery

When looking straight ahead, client can see objects in the periphery

Normal

Both eyes were coordinated

Both eyes coordinated, move in unison, with parallel alignment

Normal

Able to read newsprint 20/20 was his vision

Able to read newsprint 20/20 vision as normal person sighted can do

Normal Normal

Ears and Hearing

His ears were same as his facial skin color

Color same as facial skin; symmetrical; auricle aligned with outer canthus of the eye, about 10degrees from vertical

Normal

No tenderness present

Mobile, firm, and not tender; pinna recoils after it is folded

Normal

He can here normal voice tone Able to hear ticking of a watch He heard it in both ears

Normal voice tones audible Able to hear ticking in both ears Sound is heard in both ears or is localized at the center of the head

Normal

Normal

Normal

(Weber negative) Air conduction were greater than bone conduction Air-conducted (AC) hearing is greater than bone-conducted (BC) hearing, i.e, AC>BC (positive Rinne) Normal

Nose and Sinuses

Symmetric and well aligned, no discharge

Symmetric and straight; no discharge or flaring; uniform color

Normal

No tenderness Air moves freely when he breath to his nose

Not tender; no lesions Air moves freely as the client breathes to the nares

Normal Normal

His mucosa were pink, clear watery discharge

Mucosa pink; clear watery discharge; no lesions

Normal

His nasal septum were intact and it in midline No tenderness Mouth and oropharynx Uniform color, soft, elastic, able to purse his lips

Nasal septum intact and in midline Not tender Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips

Normal

Normal Normal

Elastic, and glistening

Uniform pink color (freckled brown pigmentation in dark skinned clients); moist, smooth, soft, glistening, and elastic texture (drier oral mucosa in elderly due to decreased salivation)

Normal

32 teeth were present on his mouth

32 adult teeth; smooth, white,shiny tooth enamel; pink gums; moist, firm texture to

Normal

gums; no retraction to gums (pulling away from the teeth) It is on central position Central position; pink color (some brown pigmentation on tongue borders in dark-skinned clients); moist; slightly rough; thin whitish coating; smooth lateral margins; no lesions; raised papillae (taste buds) No tenderness Moves freely; no tenderness Smooth tongue base Smooth tounge base with prominent veins No palpable nodules Smooth with no palpable nodules Light pink; smooth, soft palate; lighter pink hard palate, more irregular texture It is on midline of his soft palate It was smooth posterior wall Normal on size, pink and smooth Light pink; smooth, soft palate; lighter pink hard palate, more irregular texture Positioned in midline of soft palate Pink and smooth posterior wall Pink and smooth; no discharge; of normal size or not visible; Grade 1(normal)- the tonsils are behind the tonsillar pillars (the soft structures supporting the soft palate ) Neck It is equal on size Muscles equal in size; head centered Normal Normal Normal Normal Normal Normal Normal Normal Normal

Coordinated movement, no discomfort

Coordinated, smooth movements with no discomfort

Normal

Equal on strength Lymph nodes Trachea No masses Central in position

Equal strength Not palpable Central placement In midline of neck; spaces are equal on both sides

Normal Normal Normal

Thyroid gland

Gland ascends during swallowing but is not visible Not palpated

Gland ascends during swallowing but is not visible Lobes may not be palpated; if palpated, lobes are small, smooth, centrally located, painless, and rise freely, with swallowing

Normal

Normal

Body Part Examined

Posterior Thorax

Assessment Findings
*I measured it out that his AP is greater than on his TD, also his chest is symmetric *His spine is well aligned, there is no sign of abnormalities on his posture and gait *His skin is intact also his temperature is well uniformed; no tenderness after I palpate his posterior thorax *My thumbs separate about 3-5cm after I take his respiratory excursion

Normal Findings
*Anteroposterior to Transverse diameter in ratio of 1:2 *Chest Symmetric *Spine vertically aligned *Spinal Column is straight, right and left shoulders and hips are at the same height *Skin intact; uniform temperature *Chest wall intact; no tenderness; no masses *Full and symmetric chest expansion (i.e when the client takes a deep breath, your thumbs should move apart and equal distance and at the

Interpretation/ Analysis
*Normal *No signs of barrel or funnel chest on him *Normal *No presence of abnormalities because maybe his not that carrying heavy objects *Normal *His normal physical activities may affect on his skin temperature *Normal *His lungs is well functioning so that my hands especially my thumbs separate

*His vocal fremitus is heard most clearly at the upper part of his thorax because the apex of the lungs are at the upper part

*When Im percussing his post. thorax I heard was the resonance sound * Vesicular and bronchovesicular breath sounds was I heard when Im auscultating his post. thorax *Effortless breathing and it was quiet and also rhythmic was I observed on my client *His ribs were inserted into the spine at approximately at 45 degree angle, that was I observed * His skin is intact also his temperature is well uniformed; no tenderness after I palpate his anterior thorax * its the same on his posterior thorax, my thumbs separate about 3-5cm after I take his respiratory excursion

same time; normally the thumbs separate 3 to 5cm (1 to 2in) during deep inspiration) *Bilateral symmetry of vocal fremitus *Fremitus is heard most clearly at the apex of the lungs *Low pitched voices of males are more readily palpated than higher pitched voices of females *Percussion notes resonate, except over scapula *Lowest point of resonance is at the diaphragm (i.e at the level of the eighth to tenth rib posteriorly) *Vesicular and bronchovesicular breath sounds *Quiet, rhythmic, and effortless respirations *Costal angle is less than 90degree, and the ribs insert into the spine at approximately at 45degree angle *Skin intact; uniform temperature *Chest wall intact; no tenderness; no masses

symmetrically

*Normal *Low pitched voices of males are more readily palpated than higher pitched voices of females

*Normal *Resonance sound was heard on his post. thorax because his lungs underly on that part *Normal * Vesicular and bronchovesicular breath sounds *Normal *No sign of difficulties on his breathing pattern *Normal * Costal angle is less than 90degree, and the ribs insert into the spine at approximately at 45degree angle *Normal *His normal physical activities may affect on his skin temperature

Anterior Thorax

*Full symmetric excursion; *Normal thumbs normally separate to 3 *His lungs is well to 5cm (1 to 2in) functioning so that my hands especially my thumbs separate symmetrically

*its also the same on his posterior thorax, his vocal fremitus was bilaterally heard on his anterior thorax * Percussion notes resonate down to the sixth rib at level of the diaphragm and I heard it

*Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue *Percussion notes resonate down to the sixth rib at level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach

*Normal * Fremitus is normally decreased over heart and breast tissue *Normal *Percussion notes resonate down to the sixth rib at level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach *Normal *It must be heard on both side of his neck the Bronchial and Tubular breath sounds *Normal *Must hear on both post. and ant. thorax *Normal *On inspecting on his 4 precordium it must no pulsation visible except on epigastric area, aortic pulsation is visible on that part

*I heard on his trachea was his bronchial and tubular sounds *Also the same on his post. thorax, I heard his both breath sounds *No pulsations present on his aortic, pulmonic, tricuspid and mitral and aortic pulsations was only visible on his epigastric area

*Bronchial and Tubular breath sounds

*Bronchovesicular and vesicular breath sounds *No pulsations (aortic and pulmonic) *No pulsations *No lift or heave (tricuspid) *Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL *Diameter of 1 to 2cm (1/3 to 1/2 in) *No lift or heave (mitral/ apical) *Aortic pulsations (epigastric) *S1: Usually heard at all sites, Usually louder at apical sites *S2: Usually heard at all sites, Usually louder at base of heart *Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 bpm)

Heart and Central Vessels

*Lub-dub sounds was heard on his all precordium sites

*Normal * Lub-dub sounds was heard on his all precordium sites, so that his heart was well functioning; no signs of malfunctioning of the heart

*His carotid artery was on full pulsation and also it was symmetric pulse volume

* No sound heard on auscultation of his carotid artery *His jugular veins were not visible

*Diastole: Silent interval; slightly longer duration than systole at normal heart rates *S3: In children and young adults *S4: in many other adults *Symmetric pulse volume *Full pulsations, thrusting quality *Quality remains same when client breathes, turns head, and changes from sitting to supine position *Elastic arterial wall *No sound heard on auscultation *Veins not visible (indicating right side of heart is functioning normally) *Unblemished skin *Uniform color *Silver-white striae (stretch marks) or surgical scars *Flat, rounded (convex), or scaphoid (concave) *No enlargement of liver or spleen *Symmetric contour *Symmetric movements caused by respiration *Visible peristalsis in very lean people *Aortic pulsations in thin persons at epigastric area *No visible vascular pattern *Audible bowel sounds *Absence of arterial bruits *Absence of friction rub

*Normal * Quality remains same when client breathes, turns head, and changes from sitting to supine position *Normal *It must not have heard on auscultating the carotid artery *Normal * Veins not visible (indicating right side of heart is functioning normally) *Normal *Uniformity in color of abdomen must be present *Normal *Eating well balanced diet prevents him from enlargement of his liver *Normal * Visible peristalsis in very lean people

Abdomen

*His abdomen was unblemished and in uniform in color *His abdomen was flat, and scaphoid because he was thin; no signs of enlargement of liver or spleen; symmetric contour of his abdomen *Symmetric movements caused by respiration was I observed on his abdomen *His vascular pattern was not visible *His bowel sounds was audible; absence of arterial bruits also

*Normal * No visible vascular pattern *Normal *Bowel sounds were more audilble after

absence of friction rub was I heard on his abdomen after I auscultate *Tympanic sound was I heard on his stomach LUQ and dull sound on his liver site RRQ

eating

*Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

*Approximately his liver size was 6 to 12cm (2 to 3 ) in the Midclavicular line; 4 to 8 cm (1 to 3in.) at the midsternal line *His abdomen was smooth and relaxed and there is no sign of tenderness on his abdomen *His pubic symphisis is not palpable Upper and Lower Extremities *I observed that his body is equal on both side

*Normal *Percussing abdomen must be heard right percussion sounds like on stomach it must be tympany while on the liver and spleen must be dull sound *6 to 12cm (2 to 3 ) in the *Normal Midclavicular line; 4 to 8 cm (1 *The liver size must be to 3in.) at the midsternal approximately 6 to line 12cm (2 to 3 ) in the Midclavicular line; 4 to 8 cm (1 to 3in.) at the midsternal line *No tenderness; relaxed *Normal abdomen w/ smooth, constant *Abdomen must be tension relaxed and smooth *Not palpable *Equal size on both side of body *Normal *Pubic symphisis must not be palpated *Normal *It varies among his physical activity so that his muscle was equal bilaterally *Normal *No signs of tremors and contracture must a normal person have *Normal *Athletic person normally has firm and toned muscles *Normal *Does not have any difficulty on muscle and joint movement *Normal *Passed all the muscle

*No signs of tremors when I told to him that hold his arm straight *Firm muscles on his both part of his body *No difficulty on the simple exercise Ive tell to him *Bilaterally and symmetrically was equal

*No contracture *No tremors *Normally firm

*Smooth coordinated movements *Equal strength on each body side

strength on each of his body side *No swelling or tenderness on his joints * Varies to some degree in accordance w/ persons genetic make up and degree of physical activity

strength test *No deformities *No swelling or tenderness *Joints more smoothly *Varies to some degree in accordance w/ persons genetic make up and degree of physical activity *Normal *No deformities on the joints *Normal * Varies to some degree in accordance w/ persons genetic make up and degree of physical activity

Reference: Pg. 572-609 Fundamentals of Nursing, 8th edition, volume one, by Kozier & Erb

F. Gordons Functional Pattern

Health Perception/ Health Management

Ayun kapag nagwawalis walis ako, ayun na ang isa sa nagiging ehersisyo para sa akin para bumuti ang aking kalusugan as verbalized by the client. Client's perceived pattern of health hand well-being and how health is managed. Nutritional-Metabolic

Gulay at isda ang kalimitan naming kinakain mag-anak at palagi din akong umiinom ng tubig as verbalized by the client. It is evident on his height and weight it proportion and the BMI also is normal for him. Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply.

Elimination

Normal naman ang aking pagdumi at pag-ihi, kapag akoy nadudumi o naiihi hindi ko pinipigilan nilalabas ko na ito agad sa palikuran as verbalized by the client. He does the right job to eliminate wastes from his body. Patterns of excretory function (bowel, bladder, and skin). Includes client's perception of normal" function. Activity- Exercise

Ayun kapag nagwawalis walis ako, ayun na ang isa sa nagiging ehersisyo para sa akin para bumuti ang aking kalusugan as verbalized by the client. Patterns of exercise, activity, leisure, and recreation.

Cognitive- Perceptual

The client is on normal state of thinking and he answers consistent among the questions Ive asked. Sensory-perceptual and cognitive patterns.

Sleep- Rest

Nakakatulog ako sa tamang oras at sa tamang haba ng oras, para sa umaga pagkagising ko makapagtrabaho ako as verbalized by the client. Client's perception of quality and quantity of sleep and energy, sleep aids, routines client uses.

Self- Perception/ Self Concept

The clients possess body comfort, body image, feeling state, attitudes about self, perception of abilities, objective data such as body posture, eye contact, voice tone.

Role- Relationship

Ako ang nagtataguyod ng aking pamilya bilang kanilang ama at asawa ng aking misis as verbalized by the client. Perception of current major roles and responsibilities (e.g., father, husband, salesman); satisfaction with family, work, or social relationships.

Sexuality- Reproductivity

Wala ng oras para sa mga ganyang bagay sa edad naming ito as verbalized by the client. Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern.

Coping/ Stress Tolerance

Kapag may problema agad naming nireresolba sa aming pamilya ito as verbalized by the client. Client's usual manner of handling stress, available support systems, perceived ability to control or manage situations.

Value- Belief

Tuwing linggo kami pa naman ay nagsisimba ng aking pamilya, pero kapag may trabaho di na namin ito nagagawa as verbalized by the client. Religious affiliation, what client perceives as important in life, value-belief conflicts related to health, special religious practices.

Chapter III DISCUSSION OF THE DISEASE PROCESS

A. Anatomy and Physiology The Brain The brain, when fully developed, is a large organ which fills the cranial cavity. Early in its development the brain becomes divided into three parts known as the forebrain, the midbrain and the hindbrain. The forebrain is the largest part and is called the cerebrum; it is divided into the right and left hemispheres by a deep longitudinal fissure. The separation is complete to the front and back but in the center, the hemispheres are joined by a broad band of nerve fibers called the corpus callosum. The outer layer of the cerebrum is called the cerebral cortex and is composed of grey matter (cell bodies) thrown into numerous folds or convolutions called gyri, separated by fissures called sulci. This enables the surface area of the brain, and therefore the number of cell bodies, to be increased greatly. The general pattern of the gyri and sulci is the same in all humans; three main sulci divide each hemisphere into four lobes, each named after the skull bone under which it lies. The central sulcus runs downwards and forwards from the top of the hemisphere to a point just above the lateral sulcus; the lateral sulcus runs backwards from the lower part of the front of the brain and the parieto-occipital sulcus runs downwards and forwards for a short way from the upper posterior part of the hemisphere. The lobes of the hemispheres are the frontal lobe, lying in front of the central sulcus and above the lateral sulcus; the parietal lobe lying between the central sulcus and the parietooccipital sulcus and above the line of the lateral sulcus; the occipital lobe, which forms the back of the hemisphere and the temporal lobe lying below the lateral sulcus and extending back to the occipital lobe. The area lying immediately in front of the central sulcus between is known as the pre-central gyrus and is the motor area from which arise many of the motor fibers of the central nervous system. Immediately behind the central sulcus lies the sensory area, called the post-central gyrus, in the cells of which several kinds of sensation are interpreted. Longitudinal section of a hemisphere shows grey matter (cell bodies) on the outside and white matter (nerve fibers) forming the interior. The nerve fibers connect one part of the brain with the other parts and with the spinal cord, but within the white matter groups of nerve cells can be seen forming areas of grey matter. These areas of grey matter are called cerebral nuclei.

The main function of these areas is coordination of movement and posture of the body: disorders affecting these areas cause jerky movements and unsteadiness. The cavities within the brain are called ventricles. There are two lateral ventricles, a central third ventricle and a fourth ventricle between the cerebellum and the pons. All are filled with cerebrospinal fluid. The midbrain lies between the forebrain and the hindbrain. It is about 2cm in length and consists of two stalk-like bands of white matter called the cerebral peduncles, which convey impulses passing to and from the brain and spinal cord, and four small prominences called the quadrigeminal bodies, which are concerned with sight and hearing reflexes. The pineal body lies between the two upper quadrigeminal bodies. The hindbrain has three parts: 1. The pons, which lies between the midbrain above and the medulla oblongata below. It contains fibres which carry impulses upwards and downwards and some which communicate with the cerebellum. 2. The medulla oblongata lies between the pons above and the spinal cord below. It contains the cardiac and respiratory centres which are also known as the vital centres and which control the heart and respiration. 3. The cerebellum projects backwards beneath the occipital lobes of the cerebrum. It is connected to the midbrain, the pons and the medulla oblongata by three bands of fibres called the superior, middle and inferior cerebellar peduncles respectively. The cerebellum is responsible for the coordination of muscular activity, control of muscle tone and maintenance of posture. It is continuously receiving sensory impulses concerning the degree of stretch in muscles, the position of joints and information from the cerebral cortex. It sends information to the thalamus and the cerebral cortex. The midbrain, the pons and the medulla have many functions in common and together re often known as the brain stem. This area also contains the nuclei from which originate the cranial nerves.

B. Pathophysiology
Fall

Direct and Indirect Head Trauma

Brain strikes the skull

Brain movement inside the cranial vault causes injury to the brain and blood vessels

Vascular injury

Acute traumatic damage to the brain

Parenchymal bruises on the surfaces of the brain

Blood extend bidirectionally to white matter, subdural and subarachnoid spaces

Multiple shearing injury

Multiple microhemorrhages Brain Herniation Neuronal Injury

Edematous lesions

Multifocal Hemorrhagic Contusion Tissue Injury Tearing and Bleeding of arteries Vascular Response Decreased Blood Circulation Edema Decreased Oxygenation Increased Intracranial Pressure Ischemia Change in Vital Signs Crushing of Brain Tissue Mortality Burst Lobe Subdural Hematoma

Rising of blood pressure or widening Pulse pressure between systole or diastole

Headache

Pulse changes- bradycardia to tachycardia as Intracranial pressure rises.

Change in level of responsiveness Lethargy, slowing of speech, quietness To restlessness, orientation to confusion, Stupor, increasing drowsiness, coma and Progressive deterioration.

Constant/ increasing intensity aggravated By movement.

C. Drug Study (Another File)

D. Diagnostics and Laboratory Examinations

Lab Results Hematology

Sodium Potassium Erythrocytes NUMC Hemoglobin Hemoglobin SUBSTC Erythrocytes VOLFR Leukocytes NUMC Segmenters Eosinophiles Lymphocytes Monocytes Thrombocytes NUMC MCV MCH MCHC

Results
126.9 mmol/L 3.75 mmol/L 4.07 x 10^12/L 13.80 g/dl 2.139 mmol/dl 0.41 5.4 x 10^g/L 0.16 0.02 0.20 0.02 REDUCED 99.7 fl 34 pg 0.34

Normal
135-148 mmol/L 3.5-5.3 mmol/L 4.6-6.20 10^12/L 13.5-18.0 g/dl 2.09-2.79 mmol/dl 0.42-0.50 4.5-11 x 10^g/L 0.56 0.027 0.34 0.04 150-400 x 10^g/L 80-96 fl 27-31 pg 0.32-0.36

Chapter IV Nursing Management

A. Long-term Objectives Wound Healing Back to previous activity/work Readiness for safety environment Annual Check-up

B. Problem List 1. Impaired Skin Integrity 2. Risk for infection 3. Risk for falls 4. Risk for trauma 5. Impaired home maintenance 6. Readiness for safety environment

C. NCP (Another File)

D. Discharge Planning Nursing Considerations: for complications. to avoid flexion of

the neck which might impair circulation to the brain. self help capabilities. level of consciousness.

and calm. alled on to assist the patient in developing closely for any change in

Further Outpatient Care: Glasgow coma scale level should be determined It is important to keep in mind that recovery from a traumatic brain injury can be slow It is best to ask the health-care providers if any change have occurred Enough rest and nutrition should be needed for outpatient care Patient Education: mouths widely to prevent recurrent dislocation contusion and to lower increase intracranial pressure consciousness