INTRODUCTION

Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna

NURSING CARE MANAGEMENT 104

CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RESPONSE AND
PERCEPTION AND COORDINATION

Cerebral Contusion

A Case Study presented to the faculty of the College of Nursing and Allied
Health in partial fulfillment of requirements in NCM 104

CONAH
A.Y. 2016-2017

1
INTRODUCTION

TABLE OF CONTENTS

I. INTRODUCTION.. 1

a. Overview ........1

b. Statistical Data2

c. Scope and Limitation..3

d. Background of Study..3

II. PATIENTS PROFILE..4

III. PATIENTS HISTORY..6

a. Present Health History....6

b. Past Health History..6

c. Family History.. ..7

d. Developmental History..8

e. Socioeconomics 8

f. Psychological... 8

g. Socio-cultural... 8

h. Spiritual9

i. Nutrition... 9

j. Elimination... 9

k. Exercise 9

l. Hygiene 9

m. Sleep and rest... 10

n. Tobacco Use ...10

o. Alcohol Intake ......11

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INTRODUCTION

IV. PHYSICAL ASSESSMENT..12

V. ANATOMY AND PHYSIOLOGY... 24

VI. PATHOPHYSIOLOGY.... 35

VII. DIAGNOSTIC PROCEDURE...36

VIII. MEDICAL MANAGEMENT..39

IX. NURSING MANAGEMENT.42

X. DRUG STUDY44

XI. NURSING CARE PLAN...51

XII. RECOMMENDATION.57

XIII. DISCHARGE PLAN....59

a. Medications.59

b. Environment59

c. Treatment.59

d. Health Teaching..59

e. Out-Patient..60

f. Diet.....60

g. Nursing Considerations60

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INTRODUCTION

Introduction
A. OVERVIEW OF THE DISEASE

Definition

Cerebral contusion is an ecchymosis of brain tissue and results from a severe blow to

the head. (Stanley L. 2013)

Contusion is 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 contusion 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. A contusion disrupts

normal nerve functions in the bruised area and may cause loss of consciousness, hemorrhage,

edema, coma or even death.

(Mayo Clinic 2016)

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INTRODUCTION

CAUSES

A traumatic blow to the head causes a head injury. The blow is usually sudden and

forceful such as a fall, motor vehicle accident, or punch in the head. If the blow causes an

acceleration-deceleration or coup-contrecoup injury, then a cerebral contusion results.

Road traffic accidents is the leading cause of head injury in the world, The impact of

road traffic accidents is even higher in children and young adults, Most of the victims are

from the low income or middle income countries, with pedestrians, cyclists and bus

passengers bearing most of the burden. (World Health Organization 2010)

Most common cause of traumatic brain injury:

1. Motor vehicle accidents (accounting for almost half of all traumatic brain

injuries that require hospitalization)

2. Sports or physical activity

3. Assaults

SIGNS AND SYMPTOMS

Clinical signs and symptoms depend on the size of the contusion and the amount of

associated cerebral edema.

The patient may lie motionless

With a faint pulse, shallow respirations

Cool, pale skin.

Often there is involuntary evacuation of the bowels and the bladder

The patient may be aroused with effort but soon slips back into unconsciousness.

The blood pressure and the temperature are subnormal

The patient usually complains of dizziness, nausea and severe headache

He may exhibit anterograde amnesia and retrograde amnesia

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INTRODUCTION

o In retrograde amnesia, the patient not only cannot recall what happened

immediately after events that led up to it.

o In anterograde amnesia, a loss of the ability to create new memories after the

event that caused the amnesia, leading to a partial or complete inability to

recall the recent past, while long-term memories from before the event remain

intact.

Typically, the patient repeats the same questions

A conscious patient with a cerebral contusion may become agitated and even violent

Note: If the patient has a skull fracture, he may complain of a persistent, localized headache.

Depending on the type and location of the fracture, he may appear dazed, anxious or agitated.

In the conscious patient with a cerebral contusion, vital signs will vary with his

emotional status; if he is unconscious, you may find below-normal blood pressure and

temperature, a feeble but normal pulse rate and shallow, labored respirations.

Scalp wounds

o Scalp inspection may reveal abrasions, contusions, lacerations or torn away,

you may note profuse bleeding, although seldom heavy enough to induce

hypovolemic shock from other injuries or from medullary failure if the head

injury is severe.

Tenderness or hematomas upon palpation

NEUROLOGIC SIGNS AND SYMPTOMS

Hemiraresis

Decorticate or decerebrate posturing

Unequal pupillary response

Unconscious patient can be aroused temporarily with effort

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INTRODUCTION

Note:

If the acute stage has passed, you may find that the patient has returned to a relatively

alert state, slight hemiparesis or unilateral numbness.

DIAGNOSIS OF CEREBRAL CONTUSION

1. Skull x-ray

will locate a fracture, if present unless the fracture is of the cranial vault (these

fractures are not visible or palpable)

2. Cerebral angiography

Locates vascular disruptions from internal pressure or injury that results from a

cerebral contusion or skull fracture.

3. Computed tomography (CT scan)

Will disclose intracranial hemorrhage from ruptured blood vessels, ischemis or

necrotic tissue, cerebral edema, areas of petechial hemorrhage, a shift in brain

tissue, and subdural, epidural, and intracranial hematomas that may have occurred

from the head injury

4. Magnetic resonance imaging (MRI)

Disclose intracranial hemorrhage form ruptured blood vessels in a patient with a

skull fracture.

B. STATISTICAL DATA

Each year, about 1.4 million people in the United States suffer a cerebral contusion.

Of these, about 50,000 individuals will die, 235,000 will require hospitalization, and 1.1 are

treated and then released from hospital emergency rooms. Individuals needing long-term or

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INTRODUCTION

full-time care are estimated to be about two percent of the U.S. population. (NorthShore

University HealthSystem 2014)

Data from many parts of the world consistently show a peak incidence rate in

children, young adults and elderly people. Males are injured 23 times as often as women.

(World health organization 2012)

C. SCOPE AND LIMITATION

The first group of BSN III-A had their hospital exposure last March 31, 2017, 6 AM to 2

PM shift at the surgery ward of Panlalawigang Pagamutan ng Laguna under the supervision

of their clinical instructor, Mrs. Laarni A. Bundalian. They found a case to present on their

final case study with the consent of their chosen patient.

The scope of their duty on that specific day range from basic nursing procedures

including nurse-patient interaction; vital signs taking, recording and monitoring; regulating

and monitoring IV fluids; Head to toe Physical assessment and history taking; bed making;

patient teaching; and learning a lot during their clinical duty. They were allowed to give oral

medications, documented in nurses notes, TPR sheet and I&O on the patients chart, and

performed other procedures plus, they were permitted to observe and participate on

procedures done by the staff on duty.

This study aims to assess the patients health condition, progress of the treatment given,

monitor the progress of the patients condition and what and how the condition affected the

patients lifestyle pattern after the incident.

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INTRODUCTION

D. BACKGROUND OF STUDY

This case was chosen by the group because it is timely with their present discussion

on Nursing Care Management 104 (NCM104) Care of Clients with Problems in

inflammatory and immunologic response and perception and coordination allowing the

students to identify with it. Moreover, they want to deepen their knowledge about this

traumatic brain injury, master the different and appropriate medical management, nursing

management, and all particulars associated with it; and to apply all those learnings from

lecture to become a competent nursing student.

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PATIENTS PROFILE

II. Patients Profile

Case number: 232121

Patients Name: B

Address: Duhat, Sta. Cruz, Laguna

Gender: Male

Birthday: May 7, 1987

Age: 29

Birthplace: Sta. Cruz, Laguna

Nationality: Filipino

Occupation: Road maintenance worker

Civil status: Married

Religion: Roman Catholic

Admitting date: March 30, 2017

Admitting time: 11:00 PM

Admitting Diagnosis: Multiple physical injury secondary to vehicular accident

Principal Diagnosis: Cerebral contusion

Admitting Physician: R. M, MD

Chief Complaint: Confusion, open wound on frontal area of the head

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PATIENTS PROFILE

Source of data: Patient interview, Patient Chart

Patients family member interview (mother)

Home visit

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PATIENTS HISTORY

III. Patients History

A. Present Health History

March 30, 2017 about an hour and a half prior to admission, the patient was

apparently traversing a street in Alaminos, Laguna when he was accidentally hit by a

speeding motorcycle He consequently fell on the ground sustaining abrasions on his

upper and lower extremities, and recalls of his head hitting the concrete pavement,

landing on the left side, temporal area. Because of which, he sustained a cut in that

particular area and he recalls of blood gushing from the wound. He claims of still

being able to stand up immediately after the incident. However, his companion as

well as some barangay tanod who were there at the site insisted that he be brought to

a medical institution for further evaluation. Still being able to walk, he then boarded a

barangay service which would then take him to the hospital. Along the way, he

suddenly experienced a severe headache. He eventually started vomiting. Vomitus

was described to be projectile in character consisting of previously ingested food,

curd-like in appearance amounting to about 2 cups full episode. He recalls of having

about 3-4 episodes of which, on the way to the hospital. Eventually, he had loss of

consciousness. The patient was still unconscious when he arrived at the emergency

room of Panlalawigan Pagamutan ng Laguna. He was then confined with the

admitting diagnosis of Multiple Physical Injury secondary to vehicular accident.

B. Past Health History

The patient recalls of having experienced some of the more common illnesses

such as coughs, colds and episodes of diarrhea. Patient also denies of having

tuberculosis, bronchial asthma, diabetes nor hypertension. He also has no history of

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 PATIENTS HISTORY

seizures and denies of having had any sexually transmitted disease. He also has no

history of being involved in any other trauma or accident.

The patient has no previous hospitalization nor surgery.

C. Family Health History

Mother Father
Hypertensive

Brother

Sister Brother Brother Brother

Sister

Brother Brother
Patient Brother Brother

The patient had a family history of hypertension from his fathers side..
LEGEND:

DECEASED

FEMALE

MALE

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PATIENTS HISTORY

D. Developmental Stage
Experience Indicators of Positive Analysis
Resolution
Erik Eriksons Indication of lasting The patient achieved this
relationship and stage for the reason that he
Psychosocial commitment. values his marriage with his
wife. He knows the
(Young Adulthood 20-30 importance of commitment
old) and knows how to handle his
relationship with her. He
Intimacy vs. Isolation knows the meaning of love
and lives with it.
Masaya naman ako sa
relasyon namin ng aking
asawa. Minsan nagtatalo
kami pero normal lang
naman sa mag-asawa yon.

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PATIENTS HISTORY

Kohlbergs Stages of Moral Development

Stage Description Result Justification

Post The person lives Patient B achieved this stage

conventional: autonomously and defines because he is a very
moral values and principles independent man when it
that are distinct from comes to decision making.
personal identification with His attitude and behaviour
group values. He lives towards himself, his family
according to principles that and other people is socially
are universally agreed on acceptable and is very
and that the person appropriate with his role as
considers appropriate for a husband and a father to his
life. family.

The social rules are not the Patient B achieved this stage
sole basis for decisions and because he is open-minded
behaviour because the person and gives enough attention
believes a higher moral to his surroundings. He
1. Social
principle applies such as gives his comments and
Contract
equality, justice and due expresses himself about
Legalistic
process. politics, justice, and equality
Orientati
in a proper manner. His
on
decisions arent just based
(middle-
on what other people agree
age or
on, hence he has his own
older
reasons.
adult)

Our patient achieved this

stage because his decisions
Decisions and behaviours are and how he reacts to certain
based on internalized rules, on

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PATIENTS HISTORY

2. Universal conscience rather than social situations are not based on

Ethical laws, and on self-chosen what would satisfy other
Principle ethical and abstract principles people. He base his
Orientati that are universal, judgement and decisions on
on comprehensive and consistent. his own beliefs and
(middle conscience. Despite the
age or contrast of ideas with other
older) people sometimes, he
manages to look at things
based on how he sees it and
he still chooses to do what
he knows is right, ethical,
consistent and socially
acceptable.

Sigmund Freuds Theory of Psychosexual Development

Stage Description Result Justification

Genital At this stage, the Our patient achieved this

Stage psychosexual instincts of the stage because he directs his
(Puberty first three stages of psychosexual instincts not
to development reassert towards fantasy or his own
adulthood) themselves at puberty, but body but instead towards a
instead of being directed genuine love relationship
toward fantasy or the with his wife. He now have
persons own body, are 2 children and is very
directed outward toward a contented with his family.
genuine love relationship
focused on heterosexual
genital sex.

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PATIENTS HISTORY

E. SOCIOECONOMICS

The patients family income comes from the work of the patient. This gives them a total

earning of 1800 per week. The patients family monthly income goes to the electric bill,

water bill, rent of the house and daily food allowance.

F. PSYCHOLOGICAL

During our interview, he responded sluggishly to the questions that were asked. Some of

his answers do not match the questions asked. Patient B falls asleep in the middle of the

conversation and wakes up after 15 minutes not remembering the questions he was asked.

The patients thought process is slow and he often responds a few minutes after the questions

were asked.

G. SOCIOCULTURAL

As stated by the patients wife, whenever he or one of the family members get sick, they

treat if first as home with self-medicated over-the-counter drugs. He stated that when he

experience simple conditions such as common colds, he self-medicate with Alaxan FR

(Paracetamol 325 mg, ibuprofen 200 mg) for muscle pain. Only when serious or persistent

fever arises, that is when he or his family goes to the hospital for proper consultation.

H. SPIRITUAL

Patient is Catholic, before he does not routinely go to church every week due to too

much workload at the road widening construction site. During hospitalization, he always

prays at night and he wakes up thanking God for all the blessings and asking for fast

recovery. After hospitalization, he went to church and thank God.

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 PATIENTS HISTORY

I. ELIMINATION
B ef o r e H osp i ta l i za t i o n During Hospitalization After Hospitalization
Patient Gs bowel routine is 3 The patient voids only 1-2 times After hospitalization, the
4 times a week. Usually her a day and is pale in color. He patients elimination returned
stool is brown in color and is defecates once during to his normal number of
usually semi-formed in hospitalization. urination which is 3 5 times
appearance. He voids 3 to 5 a day with yellowish urine
times a day with yellowish and his bowel movement 3
urine. 4 times a week in a semi
formed appearance.

J. EXERCISE

Patient G exercises every day because of his work in the road widening construction site

and also he plays basketball whenever he is free.

K. Hygiene

Before Hospitalization During Hospitalization After Hospitalization

Patient B bathes himself twice
a day, first in the morning
before going to work and he
takes a bath again before
going to sleep. He shampoos
his hair with Sunsilk. He uses
Safeguard as his body soap.
He also brushes her teeth 2-3
times a day.
The patient is unable to do his
daily hygiene. His wife gives
him sponge bath only once
using a towel, soap and the
non-potable water available in
the ward and brushes her
teeth.
After being hospitalized, our
patient went back to her
normal routine wherein bathes
himself twice a day, first in
the morning before going to
work and he takes a bath
again before going to sleep.
He shampoos his hair with
Sunsilk. He uses Safeguard as
his body soap. He also
brushes her teeth 2-3 times a
day.

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 PATIENTS HISTORY

L. SLEEP AND REST

Before Hospitalization During Hospitalization After Hospitalization

According to Patient B, he During hospitalization, the After hospitalization, Patient

sleeps early at around 10 patient had a hard time taking B went back to his normal

oclock in the evening. a rest during the day and routine wherein he sleeps at

Habitually, he wakes up at 3 sleeping at night. He had around 10 oclock in the

oclock in the morning. He difficulty in resting and evening and wakes up at

can sleep without disturbance. sleeping is due to the noise, around 3o clock in the

noxious odors and the warm morning.

temperature of the

environment.

M. Nutrition

Prior to knowing his condition, patient B is fond of eating meat and vegetables during his

late adolescent, up to his mid adulthood.

Before hospitalization, she eats more meat ( 4x larger than a match box size) than

vegetables and he is also allergic with seafood. He consumes approximately two cups of rice

each meal and when cooking food he always use preservatives like magic sarap. Every

morning, he often drink one taza of black coffee and eat two to three pieces of pandesal. He

drinks 8-10 glasses of water for the whole day. He seldom drink carbonated drinks. He is 5

foot and 6 inches tall, and weighs 55 kg.

During hospitalization, he was placed on NPO. After 2 days the doctor ordered DAT

until his discharge.

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PATIENTS HISTORY

N. TOBACCO USE

The patient started smoking at the age of 15. He can consume a pack of Marlboro

cigarette a day which contains 20 sticks. When computed, he consumed 600 sticks for a

month, and 7,200 sticks for yearly consumption.

O. ALCOHOL USE

The patient confesses of starting drinking alcoholic beverages at the age of 17. At present

he claims of drinking occasionally, preferring hard drinks such as gin and brandy. He

consumes more or less 750ml per drinking session usually once or twice a week.

P. SUBSTANCE USE

The patient denies of having no history of substance use and abuse.

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PHYSICAL ASSESSMENT

III. Physical and Neurologic Assessment

Glasgow Coma Score (March 31, 2017)

Score

Spontaneously....4
To command...3
Eyes Open 3
To pain....2
Unresponsive..1
Oriented.5
Confused....4
Best Verbal
Inappropriate..3 5
Response
Incomprehensible...2
Unresponsive.1
Obeys commands..6
Localizes pain....5
Best Motor Withdraws from pain.....4
6
Response Abnormal flexion..3
Abnormal extension..2
Unresponsive.1
Total: 14

Muscle Strength Grading Scale (date)

Right Upper Extremity 3/5 Right Lower Extremity 3/5

Left Upper Extremity 3/5 Left Lower Extremity 3/5

Level of consciousness

Lethargy A head injury can occur as a result of a direct

injury after the head hits something with force. The
brain is shaken and there is an impact on the cranial

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PHYSICAL ASSESSMENT

bones. This can result in injuries in other places

within the brain as well as the actual area where the
impact occurred. There may be injuries to the nerve
fibres which have stretched after a forceful
acceleration and deceleration and sometimes after a
twisting. It is clear that there is a lot happening in
the brain. An inflammation can occur as a result of
this trauma to the brain tissue, and also changes in
brain metabolism and disturbances to the signaling
between neurons.

Reference: University ofGothernburg, 2011

Area Findings Interpretation

Cranial nerve The patient can Normal

function identify the smell of
Olfactory an alcohol. Patient
correctly identifies
(CN I)
the scent presented
to each nostril.

Optic (CN II) Clear vision Normal

Occulomotor The patient can Normal

perform the six
(CN III)
cardinal fields of
gaze and can follow
the six ocular
movements.
Trochlear Can follow an object Normal
without moving the
(CN IV)

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PHYSICAL ASSESSMENT

head

Trigeminal Patient can smile, Normal

raise his eyebrows,
(CN V)
and puff his cheeks.

Normal
The client has the
ability to perceive
objects normally.

Abducens The patient can Normal

perform the six
(CN VI)
cardinal fields of
gaze.

The patient can

Facial (CN VII) Normal
perform facial
expression like smile
and frown.
Acoustic

(CN VIII) Able to swallow and Normal

say AH.

Glossopharyngeal
(CN IX)
Uvula and soft palate Normal
rise symmetrically
on phonation. The
patient has difficulty
to swallow.

Vagus (CN X) Intact gag reflex. Normal

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PHYSICAL ASSESSMENT

Spinal accessory Able to shrug both Normal

(XI) shoulders and turn
head on both sides
against resistance.

Hypoglossal Able to stick tongue Normal

out and move it side
(CN XII)
to side.

Area Method Findings Interpretation and

Implication
Integumentary
Skin
Inspection and Skin color is light
Normal
palpation brown, generally
uniform except in
areas exposed to the
sun. Has an equally
warm temperature
on both arms and
legs. With good
skin turgor.

With abrasions in Abrasions often result

both arms and from movement of the

bruises in left arm. skin surface over a

rough surface or vice
versa. Bruising is
caused when an

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PHYSICAL ASSESSMENT

impact damages blood

vessels so that blood
leaks into the
perivascular tissues
and is evident on the
skin surface as
discoloration.
Reference: Injury,
Assessment,
Documentation and
Interpretation

Inspection When palpated, the

Nails Normal
nail base is firm. It
And palpation
has the shape of
convex curve and
pinkish color. It is
smooth and is intact
with the epidermis.

Normal capillary
bed refill (2
seconds)

Head Inspection and Hair is black, and Normal

palpation Evenly distributed.
Absence of alopecia
and lice. Amount of
body hair is
variable.

Abnormal
Hair and Scalp The head of the

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PHYSICAL ASSESSMENT

client is rounded;
normocephalic and
symmetrical. With
an evident
contusion upon
palpation on the left
temporal area
Abnormal
There are no
Skull and Face Trauma wounds can
nodules or masses
be injuries resulting
and depressions
from accidents and
when palpated.
can worsen and
The face of the become infected
client appeared quickly if not treated
smooth and has appropriately.
uniform Reference: Wound Care
consistency. Center

Trauma wound on
the right temporal
lobe

Eyes and Vision Inspection The clients Normal

eyebrows are
symmetrically
aligned and showed
equal movement.

Eyelashes appeared
to be equally
distributed and
curled slightly
outward. There was
no presence of

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PHYSICAL ASSESSMENT

discharges, no
discoloration and
lids close
symmetrically.

Sclera appears
white.

Ears and Hearing Inspection and The Auricles are Normal

palpation symmetrical and has
the same color with
her facial skin. The
auricles are aligned
with the outer
canthus of eye.
Pinna recoils
immediately.
Normal voice tones
are audible in both
ears

Nose and Sinuses Inspection and The nose appeared Normal

palpation symmetric, straight
and uniform in
color. There was no
presence of
discharge or flaring.
Intact
glabellarPatient can
breathe normally in
both nostrils. No
discharges or
flaring. No presence

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PHYSICAL ASSESSMENT

of discharge, bumps
and tenderness; no
pain reported.reflex.

Mouth and Inspection Lips are bluish-dark Abnormal

Oropharynx in color, oral The tobacco and tar:
mucosa and gums Abundantly present in
are pale cigarettes, tar tends to
stain your lips, teeth
and gums, in turn
giving them a
blackish-blue hue.

Reference : The
Health Site (2016)

Able to purse lip. Normal

No suspected
lesions or masses on
tongue, gums, hard
and soft palate and
tonsils. Uvula in the
middle, tonsils are
pink. Tongue easily
moves in all
directions, pinkish,
moist and with gag
reflex.

Presence of dental Abnormal

carries on the upper Dental problems are

and lower molars. among the most

common health

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PHYSICAL ASSESSMENT

problems experienced
by older adults. Older
people produce less
saliva which is needed
to clean the teeth.
Gums shrink with age
exposing the tooth
decay or infection,
furthermore older
persons may difficulty
flossing and brushing
because of poor vision
or problems moving
their arms, wrist and
hands.

Reference: Health
assessment in Nursing
by Janet Weber and
Jane Kelly 2010 3rd
edition p.445

Neck
Neck Muscles Inspection and Symmetrical with Normal
palpation head in central
position.
Symmetrical
movement of neck
muscles. Movement
through full range
of motion without
complaint of
discomfort. Active

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PHYSICAL ASSESSMENT

ROM flexion,
extension, lateral
rotation and tilting.
With equal strength
upon assessing
muscle strength
(turning head and
shrugging against
resistance).

Lungs Percussion and The chest wall is Normal

palpation intact with no
tenderness and
masses. Thorax rise
and fall with
inspiration and
expiration. No
adventitious breath
sounds.Symmetrical .
with full chest
expansion.

Cardiovascular Palpation and No extra heart Normal

System auscultation sounds and no
Heart murmurs heard.
Palpable arterial
pulse and the pulses
are strong.

Digestive System Inspection, Abdomen is flat, no Normal

Abdomen Auscultation, abdominal
Percussion and distention. With

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PHYSICAL ASSESSMENT

Palpation normal bowel

sounds:
RLQ: 2 clicks/15
seconds

RUQ: 4 clicks/15
seconds

LUQ: 3 clicks/15
seconds

LLQ:3 clicks/15
seconds

Tympanic sounds
heard upon
percussion. No
presence of masses
and tenderness.

Musculoskeletal
System

Right Lower Inspection and With evident Abnormal

Extremity Palpation abrasions. No

apparent muscle
wasting contraction.
With limited range
of motion. Muscle
strength is 3/5.

With abrasions.
With limited range
of motion
Muscle strength is

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PHYSICAL ASSESSMENT

4/5.

Abnormal
Left Lower Inspection and With abrasion but
Extremity Palpation no evident masses, Abrasions often result

lesions and foreign from movement of the

bodies.. No skin surface over a

apparent muscle rough surface or vice

wasting contraction. versa.

Range of motion
and tone are within
normal limits.
Muscle strength is
4/5.

Abrasions often result

Right Upper Inspection and With abrasion and
from movement of the
Extremity Palpation bruise but no
skin surface over a
evident masses,
rough surface or vice
lesions and foreign
versa. Bruising is
bodies. No apparent
caused when an
Left Upper Inspection and muscle wasting
impact damages blood
Extremity Palpation contraction. With
vessels so that blood
limited range of
leaks into the
motion. Muscle
perivascular tissues
strength is 4/5.
and is evident on the
skin surface as
discoloration.
Reference: Injury,
Assessment,
Documentation and
Interpretation

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ANATOMY AND PHYSIOLOGY

V. Anatomy and Physiology

The Central Nervous System: Brain

The brain is divided into three major areas: the cerebrum, the brain stem, and the cerebellum.

The cerebrum is composed of two hemispheres, the thalamus, the hypothalamus, and the

basal ganglia. Additionally, connections for the olfactory (cranial nerve I) and optic (cranial

nerve III) nerves are found in the cerebrum. The brain stem includes the midbrain, pons,

medulla, and connections for cranial nerves II and IV through XII. The cerebellum is located

under the cerebrum and behind the brain stem. The brain accounts for approximately 2% of

the total body weight; it weighs approximately 1,400 g in an average young adult (Hickey,

2003). In the elderly, the average brain weighs approximately 1,200 g.

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ANATOMY AND PHYSIOLOGY

Cerebrum

The cerebrum consists of two hemispheres that are incompletely separated by the great

longitudinal fissure. This sulcus separates the cerebrum into the right and left hemispheres.

The two hemispheres are joined at the lower portion of the fissure by the corpus callosum.

The outside surface of the hemispheres has a wrinkled appearance that is the result of many

folded layers or convolutions called gyri, which increase the surface area of the brain,

accounting for the high level of activity carried out by such a small-appearing organ. The

external or outer portion of the cerebrum (the cerebral cortex) is made up of gray matter

approximately 2 to 5 mm in depth; it contains billions of neurons/cell bodies, giving it a gray

appearance.

White matter makes up the innermost layer and is composed of nerve fibers and

neuroglia (support tissue) that form tracts or pathways connecting various parts of the brain

with one another (transverse and association pathways) and the cortex to lower portions of

the brain and spinal cord (projection fibers). The cerebral hemispheres are divided into pairs

of frontal, parietal, temporal, and occipital lobes.

Frontal

The largest lobe. The major functions of this lobe are concentration, abstract thought,

information storage or memory, and motor function. It also contains Brocas area, critical for

motor control of speech. The frontal lobe is also responsible in large part for an individuals

affect, judgment, personality, and inhibitions.

34
ANATOMY AND PHYSIOLOGY

Parietal

A predominantly sensory lobe. The primary sensory cortex, which analyzes sensory

information and relays the interpretation of this information to the thalamus and other cortical

areas, is located in the parietal lobe. It is also essential to an individuals awareness of the

body in space, as well as orientation in space and spatial relations.

Temporal

Contains the auditory receptive areas. Contains a vital area called the interpretive area

that provides integration of somatization, visual, and auditory areas and plays the most

dominant role of any area of the cortex in cerebration.

Occipital

The posterior lobe of the cerebral hemisphere is responsible for visual interpretation.

The corpus callosum (Fig. 60-3) is a thick collection of nerve fibers that connects the two

hemispheres of the brain and is responsible for the transmission of information from one side

of the brain to the other. Information transferred includes sensation, memory, and learned

discrimination. Right-handed people and some left-handed people have cerebral dominance

on the left side of the brain for verbal, linguistic, arithmetical, calculating, and analytic

functions. The nondominant hemisphere is responsible for geometric, spatial, visual, pattern,

and musical functions.

Basal ganglia

Are masses of nuclei located deep in the cerebral hemispheres that are responsible for

control of fine motor movements, including those of the hands and lower extremities.

35
ANATOMY AND PHYSIOLOGY

Thalamus

Lies on either side of the third ventricle and acts primarily as a relay station for all

sensation except smell. All memory, sensation, and pain impulses also pass through this

section of the brain. The hypothalamus is located anterior and inferior to the thalamus. The

hypothalamus lies immediately beneath and lateral to the lower portion of the wall of the

third ventricle. It includes the optic chiasm (the point at which the two optic tracts cross)

and the mamillary bodies (involved in olfactory reflexes and emotional response to odors).

The infundibulum of the hypothalamus connects it to the posterior pituitary gland. The

hypothalamus plays an important role in the endocrine system because it regulates the

pituitary secretion of hormones that influence metabolism, reproduction, stress response, and

urine production. It works with the pituitary to maintain fluid balance and maintains

temperature regulation by promoting vasoconstriction or vasodilatation. The hypothalamus is

the site of the hunger center and is involved in appetite control. It contains centers that

regulate the sleepwake cycle, blood pressure, aggressive and sexual behavior, and emotional

responses (ie, blushing, rage, depression, panic, and fear). The hypothalamus also controls

and regulates the autonomic nervous system.

Pituitary gland

Located in the sella turcica at the base of the brain and is connected to the

hypothalamus. The pituitary is a common site for brain tumors in adults; frequently they are

detected by physical signs and symptoms that can be traced to the pituitary, such as hormonal

imbalance or visual disturbances secondary to pressure on the optic chiasm. Nerve fibers

from all portions of the cortex converge in each hemisphere and exit in the form of a tight

bundle of nerve fibers known as the internal capsule. Having entered the pons and the

medulla, each bundle crosses to the corresponding bundle from the opposite side. Some of

36
ANATOMY AND PHYSIOLOGY

these axons make connections with axons from the cerebellum, basal ganglia, thalamus, and

hypothalamus; some connect with the cranial nerve cells. Other fibers from the cortex and the

subcortical centers are channeled through the pons and the medulla into the spinal cord.

Although the various cells in the cerebral cortex are quite similar in appearance, their

functions vary widely, depending on location.

The posterior portion of each hemisphere (ie, the occipital lobe) is devoted to all

aspects of visual perception. The lateral region, or temporal lobe, incorporates the auditory

center. The midcentral zone, or parietal zone, posterior to the fissure of Rolando, is concerned

with sensation; the anterior portion is concerned with voluntary muscle movements. The

large area behind the forehead (ie, the frontal lobes) contains the association pathways that

determine emotional attitudes and responses and contribute to the formation of thought

processes. Damage to the frontal lobes as a result of trauma or disease is by no means

incapacitating from the standpoint of muscular control or coordination, but it affects a

persons personality, as reflected by basic attitudes, sense of humor and propriety,

selfrestraint, and motivations. (Neurologic trauma and disease states that may result in frontal

damage are discussed in later chapters in this unit.)

Brain Stem

The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 60-2).

The midbrain connects the pons and the cerebellum with the cerebral hemispheres; it contains

sensory and motor pathways and serves as the center for auditory and visual reflexes. Cranial

nerves III and IV originate in the midbrain. The pons is situated in front of the cerebellum

between the midbrain and the medulla and is a bridge between the two halves of the

cerebellum, and between the medulla and the cerebrum. Cranial nerves V through VIII

37
ANATOMY AND PHYSIOLOGY

connect to the brain in the pons. The pons contains motor and sensory pathways. Portions of

the pons also control the heart, respiration, and blood pressure.

Medulla oblongata

Contains motor fibers from the brain to the spinal cord and sensory fibers from the

spinal cord to the brain. Most of these fibers cross, or decussate, at this level. Cranial nerves

IX through XII connect to the brain in the medulla.

Cerebellum

The cerebellum is separated from the cerebral hemispheres by a fold of dura mater,

the tentorium cerebelli. The cerebellum has both excitatory and inhibitory actions and is

largely

responsible for coordination of movement. It also controls fine movement, balance, position

sense (awareness of where each part of the body is), and integration of sensory input.

Structures protecting the brain

The brain is contained in the rigid skull, which protects it frominjury. The major

bones of the skull are the frontal, temporal,parietal, and occipital bones. These bones join at

the suture lines. The meninges (fibrous connective tissues that cover the brainand spinal cord)

provide protection, support, and nourishmentto the brain and spinal cord.

Dura mater

The outermost layer; covers the brain and the spinal cord. It is tough, thick, inelastic,

fibrous, and gray. There are four extensions of the dura: the falx cerebri, which separates the

two hemispheres in a longitudinal plane; the tentorium, which is an infolding of the dura that

38
ANATOMY AND PHYSIOLOGY

forms a tough membranous shelf; the falx cerebelli, which is between the two lateral lobes of

the cerebellum; and the diaphragm sellae, which provides a roof for the sella turcica. The

tentorium supports the hemispheres and separates them from the lower part of the brain.

When excess pressure occurs in the cranial cavity, brain tissue may be compressed against

the tentorium or displaced downward, a process called herniation. Between the dura mater

and the skull in the cranium, and between the periosteum and the dura in the vertebral

column, is the epidural space, a potential space.

Arachnoid

The middle membrane; an extremely thin, delicate membrane that closely resembles a

spider web (hence the name arachnoid). It appears white because it has no blood supply. The

arachnoid layer contains the choroid plexus, which is responsible for the production of

cerebrospinal fluid (CSF). This membrane also has unique fingerlike projections, arachnoid

villi, that absorb CSF. In the normal adult, approximately 500 mL of CSF is produced each

day; all but 125 to 150 mL is absorbed by the villi (Hickey, 2003). When blood enters the

system (from trauma or hemorrhagic stroke), the villi become obstructed and hydrocephalus

(increased size of ventricles) may result. The subdural space is between the dura and the

arachnoid layer,

and the subarachnoid space is located between the arachnoid and pia layers and contains the

CSF.

Pia mater

The innermost membrane; a thin, transparent layer that hugs the brain closely and

extends into every fold of the brains surface.

39
ANATOMY AND PHYSIOLOGY

Cerebrospinal Fluid

CSF, a clear and colorless fluid with a specific gravity of 1.007, is produced in the

ventricles and is circulated around the brain and the spinal cord through the ventricular

system. There are four ventricles: the right and left lateral, and the third and fourth ventricles.

The two lateral ventricles open into the third ventricle at the interventricular foramen or the

foramen of Monro. The third and fourth ventricles connect via the aqueduct of Sylvius. The

fourth ventricle supplies CSF to the subarachnoid space and down the spinal cord on the

dorsal surface. CSF is returned to the brain and is then circulated around the brain, where it is

absorbed by the arachnoid villi. CSF is produced in the choroid plexus of the lateral, third,

and fourth ventricles. The ventricular and subarachnoid system contains approximately 125 to

150 mL of fluid, while 15 to 25 mL of CSF is located in each lateral ventricle. The

composition of CSF is similar to other extracellular fluids (such as blood plasma), but the

concentrations of the various constituents are different. The analysis and laboratory report of

CSF usually contains information on color, specific gravity, protein

count, white blood cell count, glucose, and other electrolyte levels; it may also be tested for

immunoglobulins or lactate (Hickey, 2003). Normal CSF contains a minimal number of white

blood cells and no red blood cells.

Cerebral circulation

The cerebral circulation receives approximately 15% of the cardiac output, or 750 mL

per minute. The brain does not store nutrients and has a high metabolic demand that requires

the high blood flow. The brains blood pathway is unique because it flows against gravity; its

arteries fill from below and the veins drain from above. In contrast to other organs that may

tolerate decreases in blood flow because of their adequate collateral circulation, the brain

40
ANATOMY AND PHYSIOLOGY

lacks additional collateral blood flow, which may result in irreversible tissue damage when

blood flow is occluded for even short periods of time.

Arteries

Two internal carotid arteries and two vertebral arteries and their extensive system of

branches provide the blood supply to the brain. The internal carotids arise from the

bifurcation of the common carotid and supply much of the anterior circulation of the brain.

The vertebral arteries branch from the subclavian arteries, flow back and upward on either

side of the cervical vertebrae, and enter the cranium through the foramen magnum. The

vertebral arteries join to become the basilar artery at the level of the brain stem; the basilar

artery divides to form the two branches of the posterior cerebral arteries. The vertebrobasilar

arteries supply most of the posterior circulation of the brain. At the base of the brain

surrounding the pituitary gland, a ring of arteries is formed between the vertebral and internal

carotid arterial chains. This ring is called the circle of Willis and is formed from the branches

of the internal carotid arteries, anterior and middle cerebral arteries, and anterior and

posterior communicating arteries. Functionally, the posterior portion of the circulation and

the anterior or carotid circulation usually remain separate. The arteries of the circle of Willis

can provide collateral circulation if one or more of the four vessels supplying it become

occluded or are ligated. The arterial anastomoses along the circle of Willis are frequent sites

of aneurysms. These can be formed when the pressure at a weakened arterial wall causes the

artery to balloon out. Aneurysms may be congenital or the result of degenerative changes in

the vessel wall associated with arteriosclerotic vascular disease. If an artery with an aneurysm

bursts or becomes occluded by vasospasm, an embolus, or a thrombus, the neurons distal to

the occlusion are deprived of their blood supply and the cells quickly die. The result is a

41
ANATOMY AND PHYSIOLOGY

hemorrhagic stroke (cerebrovascular accident or infarction).The effects of the occlusion

depend on which vessels areinvolved and which areas of the brain these vessels supply.

Veins

Venous drainage for the brain does not follow the arterial circulation as in other body

structures. The veins reach the brains surface, join larger veins, then cross the subarachnoid

space and empty into the dural sinuses, which are the vascular channels lying within the

tough dura mater. The network of the sinuses carries venous outflow from the brain and

empties into the internal jugular vein, returning the blood to the heart. Cerebral veins and

sinuses are unique because, unlike other veins in the body, they do not have valves to prevent

blood from flowing backward and depend on both gravity and blood pressure.

Bloodbrain barrier

The CNS is inaccessible to many substances that circulate in the blood plasma (eg,

dyes, medications, and antibiotics). After being injected into the blood, many substances

cannot reach the neu- rons of the CNS because of the bloodbrain barrier. This barrier is

formed by the endothelial cells of the brains capillaries, which form continuous tight

junctions, creating a barrier to macromolecules and many compounds. All substances

entering the CSF must filter through the capillary endothelial cells and astrocytes (Hickey,

2003). Often altered by trauma, cerebral edema, and cerebral hypoxemia, the bloodbrain

barrier has implications in the treatment and selection of medication for CNS disorders as

well as serving a protective function.

CRANIAL NERVE
There are 12 pairs of cranial nerves that emerge from the lowersurface of the brain

and pass through the foramina in the skull. Three are entirely sensory (I, II, VIII) (olfactory),

42
ANATOMY AND PHYSIOLOGY

(optic), (acoustic), five are motor (III, IV, VI, XI, and XII)(oculomotor), (trochlear),

(abducens), (spinal accessory), (hypoglossal), and four are mixed (V, VII, IX, and

X)(trigeminal), (facial), (glossopharyngeal), (vagus) as they have both sensory and motor

functions (Downey & Leigh, 1998; Hickey, 2003). The cranial nerves are numbered in the

order in which they arise from the brain. For example, cranial nerves I and II attach in the

cerebral hemispheres, whereas cranial nerves IX, X, XI, and XII attach at the medulla. Most

cranial nerves innervate the head, neck, and special sense structures. lists the names and

primary functions of the cranial.

43
ANATOMY AND PHYSIOLOGY

VI. Pathophysiology

44
DIAGNOSTIC PROCEDURE

VII. Diagnostic Procedure

A. Hematology (CBC) Results

Date: 04/30/2017

- Complete Blood Count typing identifies the number of blood cells (leukocytes, erythrocytes and platelets) as well as the hemoglobin,

hematocrit and RBC indices. Because cellular morphology is particularly important in most Hematologic disorders. In this test, a drop of blood

is spread on the glass slide, stained and examined under a microscope. The shape and size of the erythrocytes and platelets, as well as the

actual appearance of Leukocytes, provide useful information in identifying hematologic conditions.

TEST RESULT NORMAL VALUES INTERPRETATIONS IMPLICATIONS

-
Hemoglobin(g/L) 132 130-180 NORMAL

Hemorrhage
Hematocrit(%) 38.9 40-50 LOW
*This test is useful in the diagnosis of
anemia.

45
DIAGNOSTIC PROCEDURE

-
RBC 4.25 4.5-6.2 NORMAL

-
Platelet 263,000 170,000-400,000 NORMAL

Acute Infection.
WBC 23.2 4-10 HIGH
*The WBC is an indicator of Immune
function of the body. Elevation is seen
during the ongoing infection of
inflammation.

Stress and Acute infection.

SegmentedNeutroph 89.4 55-65 HIGH
ils (%) *Neutrophils are recruited to the site of
injury within the minutes following
trauma and are the hallmark at acute
inflammation.

Low lymphocytes count indicates that

Lymphocytes 7.2 25-35 LOW
the body is low on infection resistance.

-
Monocytes 3.4 3-6 NORMAL

46
DIAGNOSTIC PROCEDURE

B. CT Scan

Computed Tomography (CT Scan) provides cross-sectional images of soft tissue

and visualizes the area of volume changes to an extremity and the compartment where

changes takes place. CT Scan has a high degree of sensitivity for detecting lesions.

CLINICAL HISTORY: trauma; vomiting

Findings:

Homogenous hyperdense focuse is noted in the cortical and subcortical

region of the right temporal lobe with a volume of about 5cc. Minimal surrounding

edema is noted. No definite extra-axial fluid collection is seen.The cortical sulci and

cisterns are not effaced. The ventricles are normal in size and configuration. Density

is noted in the left sphenoid sinus. The calvarium and included base of the skull are

intact. Scalp swelling is noted in the left temporoparietal region.

Impression:

- ACUTE CONTUSION HEMATOMA, RIGHT TEMPORAL LOBE

- SCALP SWELLING, LEFT TEMPOROPARIETAL REGION

- LEFT SPHENOID SINUSITIS VS HEMOANTRUM

47
MEDICAL MANAGEMENT

VIII. Medical Management

Date Doctors Order Remarks

03- Please admit to male Hospital policy designates the exact procedure that
30- surgery ward should be followed when admitting the patient to the
2017 holding are . Admission will help monitor the clients
condition. The admitting procedure is continued with
reassessment of the patient and allowance of time for
last minute question.
Reference: Lewi, Heitkemper&Dirksen., Medical-Surgical
Nursing 5th edition., chapter 17, p 380

Secure consent for Informed consent is the patients decision about

admission and whether to undergo a procedure. Before signing the
management consent, the risks and benefits of the procedure must be
explained in terms the patient could easily understand,
this is to prepare the patient psychologically and the
health care workers from battery.
(Reference: Janice L. Hinkle & Kerry H. Cheever., Brunner
and Suddarths Textbook of Medical-Surgical Nursing 13th
ed., chapter 17., p 406)

V/S every 4 hours and The recording of temperature, pulse rate and respiration
record please are part of physical examination. Acute changes and
trends overtime are documented and unexpected
changes and values that deviate significantly from a
patients normal values are brought to the attention of
the patients primary health care provider.
Monitor input and By monitoring the amount of fluids a client takes in and
output every shift and comparing this to the amount of fluid a client puts out.
record The health care team can gain valuable insights into the
client's general health as well as monitor specific
disease conditions.
nursingreviewbyozlek.blogspot.com/2010/07/intakeand-

48
MEDICAL MANAGEMENT

output.html

NPO temporarily NPO is a type of diet modification as well as a fluid

restriction. This is often prescribed before surgery and
certain diagnostic procedures, to rest the GI tract.

IVT D5LR 1 L for 16 Lactated Ringer's and 5% Dextrose Injection is a sterile,

hours nonpyrogenic solution for fluid and electrolyte
replenishment and caloric supply in a single dose
container for intravenous administration.

Diagnostic procedures:
Useful for rapid diagnosis of suspected intracranial
Skull x-ray APL
injuries and is the preferred investigation if clinical
evidence of intracranial injury.
Evaluate the extent of bone and soft tissue damage in
Plain cranial CT-
patients with facial trauma, and planning surgical
scan
reconstruction.
A complete blood count (CBC) gives important
CBC with complete information about the kinds and numbers of cells in the
platelet count blood, especially red blood cells, white blood cells
ABO typing and platelets.

Medications:

Metoclopramide Metoclopramide decreases nausea and vomiting. It also

(Plasil) 1 amp IV decreases symptoms of gastric stasis.
now then every 8
hours
Short term treatment for active benign gastric ulcer. It
Omeprazole 40mg
diminishes the accumulation of acid in the gastric lumen
IV now the once
with lessened gastro esophageal reflux.
daily
To treat skin and skin structure infections. It has a
Cefuroxime 750mg
bactericidal action against susceptible bacteria.
IV then every 8

49
MEDICAL MANAGEMENT

hours

Mannitol 500mg every Used to decrease intracranial or intraocular pressure. It

4 hours and record increases the osmotic pressure of the glomerular filtrate,
thereby inhibiting reabsorption of water and
electrolytes.
Refer accordingly This may create a collaborative treatment among the
client and the health care providers; thus it also makes a
good coordination on the treatment of the client.
3-31- Maintain NPO NPO is a type of diet modification as well as a fluid
2017 restriction. This is often prescribed before surgery and
certain diagnostic procedures, to rest the GI tract.
A CT scan can be used to visualize nearly all parts of
For CT scan the body and is used to diagnose disease or injury as
well as to plan medical, surgical or radiation treatment.
This may create a collaborative treatment among the
client and the health care providers; thus it also makes a
good coordination on thetreatment of the client.
Refer
4-1- Shift diet to soft It can help to ease difficulty in chewing and/or
2017 swallowing due to dental problems or extreme
weakness, and it is sometimes recommended to relieve
mild intestinal or stomach discomfort.
https://www.gicare.com/diets/soft-and-mechanical-soft-
diet/

For CT scan A CT scan can be used to visualize nearly all parts of

the body and is used to diagnose disease or injury as
well as to plan medical, surgical or radiation treatment.
A visit with a highly-trained specialist in the function
and malfunction of the brain, nervous system and
muscles. In most cases, the visit was arranged by your
For neuroconsultation
doctor to answer specific questions the doctor has about

50
MEDICAL MANAGEMENT

the patients neurological health.

4-2- DAT Diet as tolerated is a term that indicates that the
2017 gastrointestinal tracts is tolerating food and is ready for
advancement to the next stage.
Cinnarizine 25mg 1 tab
For vertigo
TID for vertigo
Still for neuroconsult
A visit with a highly-trained specialist in the function
and malfunction of the brain, nervous system and
muscles. In most cases, the visit was arranged by your
doctor to answer specific questions the doctor has about

Continue meds the patients neurological health.

IVF: D5LRS 1L x To promote the patients well-being

12hours Lactated Ringer's and 5% Dextrose Injection is a sterile,

nonpyrogenic solution for fluid and electrolyte
replenishment and caloric supply in a single dose
container for intravenous administration
4-3- For neuroconsultation A visit with a highly-trained specialist in the function
2017 and malfunction of the brain, nervous system and
muscles. In most cases, the visit was arranged by your
doctor to answer specific questions the doctor has about
Home meds: the patients neurological health.
Mefenamic acid 500mg
PRN
Cefuroxime 500 mg tid
7 days
MGH

51
NURSING MANAGEMENT
XI. Nursing Management
Nursing Management
Avoid use of restraints. Obtain a physicians
order if restraints are needed.
Ask family or significant others to be with the
patient to prevent him from accidentally
falling.
Assess for signs and symptoms relating to
pain.
Provide rest periods to promote relief, sleep,
and relaxation.
Review laboratory values for abnormalities
such as metabolic alkalosis, hypokalemia,
anemia, elevated ammonia levels, and signs
of infection.
Perform periodic neurological/behavioral
assessments, as indicated, and compare with
baseline.
Provide safety measures (e.g., side rails,
padding, as necessary; close
supervision, seizure precautions), as
Rationale
If patients are restrained, they can sustain
injuries, including strangulation,
asphyxiation, or head injury from leading
with their heads to get out of the bed.
This is to prevent the patient from
accidentally falling.
Some people deny the existence of pain.
Attention to associated signs may help the
nurse in evaluating pain. An increase in
BP, HR, and temperature may be present
in a patient with acute pain. The patients
skin may be pale and cool to touch.
Restlessness and inability to concentrate
are also some manifestations.
Ones experiences of pain may become
exaggerated as a result of exhaustion. Pain
may result in fatigue, which may result in
exaggerated pain. A peaceful and quiet
environment may facilitate rest.
Monitoring laboratory values aids in
identifying contributing factors.
Early recognition of changes promotes
proactive modifications to plan of care.
Protect the patient from injury according
to hhis condition. It is always necessary to
consider the safety of the patient.
52
NURSING MANAGEMENT
indicated.
Maintain a pleasant and quiet environment
and approach patient in a slow and calm
manner.
Assess and monitor nutritional status, weight,
history of weight loss, and serum albumin.
Monitor redness, swelling, increased pain,
purulent discharge from incisions, injury, and
exit sites of tubes (IV tubings), drains, or
catheters.
Monitor body temperature.
Maintain or teach asepsis for dressing
changes and wound care, peripheral IV
Initially, monitor vital signs continuously and
check for additional injuries.
Continue to check vital signs and neurologc
status, including LOC and pupil size every 15
minutes.
Observe the patient for headache, dizziness,
irritability and anxiety
Patient may respond with anxious or
aggressive behaviors if startled or over
stimulated.
Patients with poor nutritional status may
be anergic or unable to muster a cellular
immune response to pathogens making
them susceptible to infection.
These are the classic signs of infection.
Any suspicious drainage should be
cultured; antibiotic therapy is determined
by pathogens identified.
Temperature of up to 38 C (100.4 F) 48
hours post-op is usually related to
surgical stress after 48 hours,
temperature of greater than 37.7 (99.8
F) may indicate infection; very high
temperature accompanied by sweating
and chills may indicate septicemia.
Aseptic technique decreases the changes
of transmitting or spreading pathogens to
the patient. Interrupting the transmission
of infection along the chain of infection
is an effective way to prevent infection.
Abnormal respirations could indicate a
breakdown in the brains respiratory
center.
If the patients condition worsens or
fluctuates, arrange for a neurosurgical
consultation
If his condition worsens, perform a
complete neurologic evaluation and
notify the physician.
53
DRUG STUDY

X. Drug Study

Name of drug Dosage Classification Indication and Mechanism of Adverse Effect Nursing
and Contraindication Acton Consideration
frequency

METOCLOP 1amp now GI stimulant; Indication: Potent central CNS: mild sedation, Be aware
RAMIDE then every prokinetic agent dopamine receptor fatigue, restlessness, that fatal
To prevent nausea
HYDROCHL 8 hours antagonist that agitation, headache, hypersensitivity
Therapeutic and vomiting
ORIDE increases resting insomnia, disorientation, reactions have
Class: GI
Contraindication: tone of extrapyramidal occurred with
stimulant,
Route: esophagealsphinct symptoms (acute meropenem use.
antiemetic Hypersensitivity or
Brand name: TIV er, and tone and dystonic type), tardive Determine
intolerance to
Emex, amplitude of dyskinesia, neurologic whether patiennt
Onset:1-3 metochlopramide;
Maxeran, upper GI malignant syndrome with has had previous
mins uncontrolled
Metozolv, contractions. Thus injection reactions to
seizures; allergy to
ODT, Peak:1-2
sulfiting agents; gastric emptying anntibiotics or
hours CV: shock
Octamide and intestinal other allergens.
pheochromocytoma;
PFS, Reglan Duration: transit are EENT: Epistaxis, Monitor
mechanical GI
1-3 hours accelerated. glossitis, oral candidiasis patient closely
obstruction or
perforation; lactation Antiemetic action GI: Anorexia, and stop during
results from drug- constipation, diarrhea, immeditely if
Date induced elevation signs and
elevated liver function
54
DRUG STUDY

ordered: of CTZ threshold test results, nausea, symptoms of

03-30- and enhanced pseudomembranous anaphylaxis
2017 gastric emptying. colitis, vomiting occur.
Notify
GU: Elevated BUN and
prescriber, and
serum creatinine levels,
expect to provide
hematuria, renal failure
supportive
HEME: emergency care
Agranulocytosis, that may include
hemolyticanemia, epinephrine and
leukopenia, neutropenia, IV steroid
positive Coombs test administration,

RESP: Apnea, dyspnea oxygen, and

airway
SKIN: Erythema
management
multiforme, pruritus,
Monitor
rash, Stevens-Johnson
patient closely for
syndrome, toxic
diarrhea
epidermal necrolysis

Other: Anaphylaxis;
angioedema; injection

55
DRUG STUDY

site inflammation, pain,

phlebitis, or
thrombophlebitis; sepsis

OMEPRAZO 40 mg IV Chemical Indication: to Reduces gastric CNS: Agitation, Encourage

LE PTOR Class: suppress gastric acid acid secretion and asthenia, dizziness, patient to avoid
Substituted ssecretion. increases gastric drowsiness, fatigue, alcohol, aspirin
benzimidazole mucus and headache, psychic products,
Contraindication:
Brand Name: Date bicarbonate disturbance, somnolence ibupropen, and
Therapeutic
Omeplus Hypersensitivity to production, CV: Chest pain, foods that may
Ordered: Class: Antiulcer
omeprazole creating protective hypertension, peripheral increase gastric
9-27-16
coating on gastric edema secretions during
mucosa and therapy.
EENT: Anterior
easing discomfort Notify the
ischemic optic
from excess prescribers about
neuropathy, optic atrophy
gastric acid. prescription drug
or neuritis, stomatitis
use.
ENDO: Advise
HypoglycemiaGI: patient to notify

56
DRUG STUDY

Abdominal pain, prescriber

constipation, diarrhea, immediately
Clostridium difficile- about abdominal
associated pain and diarrhea
Because drug can
diarrhea, dyspepsia,
interfere with
elevated liver function
absorption of
tests, flatulence, hepatic
vitamin B12,
dysfunction or failure,
monitor patient
indigestion, nausea,
for macrocytic
pancreatitis, vomiting
anemia.
GU: Interstitial nephritis
HEME: If
Agranulocytosis, anemia, omeprazole is
hemolytic given with
antibiotics, watch
anemia, leukopenia,
for diarrhea from
leukocytosis, neutroA
Clostridium
penia, pancytopenia, difficile. If
thrombocytopenia diarrhea occurs,

MS: Back pain, bone notify prescriber

and expect to

57
DRUG STUDY

fracture withhold drug and

treat with fluids,
RESP: Cough
electrolytes,
SKIN: Erythema protein, and an
multiforme, photo A antibiotic

sensitivity, pruritus, rash, effective against

Stevens-Johnson C. difficile.
Monitor
syndrome, toxic
the patient,
epidermal necrolysis,
especially the
Urticaria patienton long-
term therapy,
Other: Anaphylaxis,
forhypomagnese
angioedema,
mia. If patient is
hypomagnesemia,
to remainon
hyponatremia omeprazole long-
term, expect
tomonitor the
patients serum
magnesiumlevel,
as ordered, and if

58
DRUG STUDY

level becomes
low,anticipate
magnesium
replacementthera
py and
omeprazole to
bediscontinued
CEFUROXI 750mg IV Antibiotic; Indication: Semisynthetic Body as a whole: Determine hx
ME every 8 second infections caused by second-generation thrombophlebitis (IV of
hours (-) generation susceptible cephalosporin site), pain, burning, hypersensitivi
ANST cephalosporin organisms in the beta-lactam superinfections ty to reactions
Brand Name: lower respiratory antibiotic. to
GI: diarrhea, nausea
Zinacef tract, urinary tract, Preferentially cephalosporin
Therapeutic skin and skin binds to one or Skin: rash, pruritus, s, penicillins
Class: structures moe of the urticaria and history of
Date
ordered: antibiotic penicillin-binding allergies
Contraindication:
03-30- proteins (PBP) particularly to
Hypersensitivity to located on cell drugs, before
2017
cephalosporin and walls of therapy is
related antibiotics; susceptible initiated
viral infections organisms. This Monitor

59
DRUG STUDY

inhibits 3rd and periodically

final stage of the BUN and
bacterial cell wall creatinine
synthesis, thus Report onset
killing the of loose stools
bacterium. or diarrhea

CO- 1g every Indication: Semisynthetic Hypersensitivity May be taken

AMOXICLA 12 hours (- infections caused by second-generation reactions & GI with or
Therapeutic
V ) ANST susceptible cephalosporin disturbances. without food:
Class:
organisms beta-lactam May be given
Body as a whole:
Analgesics, antibiotic. w/o regard to
Contraindication: Reversible leukopenia &
Date Antipyretic, Preferentially meals. Best
thrombocytopenia,
ordered: Anti- Hypersensitivity to binds to one or taken at the
thrombocytopenic
03-31- inflammatory penicillins. Cross- moe of the start of meals
purpura, agranulocytosis,
2017 sensitivity w/ other penicillin-binding for better
anemia, slight
-lactam antibiotics. proteins (PBP) absorption &
thrombocytosis,
located on cell to reduce GI
eosinophilia, abnormal
walls of discomfort.
platelet aggregation,
susceptible
prolonged bleeding
organisms. This
&prothrombin time.
inhibits 3rd and

60
DRUG STUDY

final stage of CNS: Dizziness,

bacterial cell wall headache, reversible
synthesis, thus hyperactivity &
killing the convulsions, agitation,
bacterium. anxiety, behavioral
changes, confusion,
insomnia.

Increased AST & ALT,

serum bilirubin &
alkaline phosphatase;
hepatitis, cholestatic
jaundice, acute hepatic
dysfunction.

Skin: Acute interstitial

nephritis, crystalluria,
vag itching, soreness &
discharge.

Others: Superficial tooth

discoloration

61
DRUG STUDY

Cinnarizine 25mg 1 antivertigo Indications:vertigo, Cinnarizine is a Somnolence, wt gain, Instruct

tab TID motion sickness, non-competitive nausea, vomiting, patient that
for vertigo peripheral vascular antagonist of dyspepsia, lethargy, the drug
Brand names: disease, smooth muscle upper abdominal pain, should be
Cinnabloc, cerebrovascular contractions hyperhidrosis, lichenoid taken with
Gorizine, Date disease caused by various keratosis (e.g. lichen food.
Vertisin, ordered: vasoactive agents planus), fatigue. Rarely,
Contraindication:
Dizzinon 04-02- (e.g. histamine). It extrapyramidal
2017 Hypotension selectively symptoms.
inhibits Ca influx
into depolarised
cells, thereby
reducing free Ca
ions available for
the induction and
maintenance of
contraction.

62
NURSING CARE PLAN

XI. Nursing Care Plan

PRIORITIZATION

Increased Intracarnial Pressure

Altered level of consiousness

Acute Pain related to decreased cerebral blood flow secondary to physical trauma as

manifested by guarding behavior ,facial grimace

Impaired physical mobility

Impaired social interaction

63
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Increased Intracarnial Assess respiratory

Pressure Acute and neurological
confusion status
Vital Signs
Monitor and
recorded
To stabilized
keep the patient in
increased
semi-Fowlers
intracranial
positions
pressure

promote healthy
and comfortable
environmental
assist with turning,
coughing, and
deep breathing
Maintain seizure
precautions
Maintain fluid

64
NURSING CARE PLAN

restrictions as
ordered
Administer the
following
medications if
ordered to reduce
cerebral edema
(osmotic diuretics,
loop diuretics,
corticosteroids)
maintain fluid
restrictions as
ordered
Keep head and
neck in neutral, these conditions

midline position; cause an increase

avoid flexion, in intrathoracic

extension, and pressure, which

rotation of head subsequently

and neck impedes venous

return from the

65
NURSING CARE PLAN

brain

Administer a To prevent
laxative, anti straining to have a
tussive, and bowel movement,
antiemetic if coughing, and
ordered vomiting
observe for and To prevent
control conditions excessive cerebral
that can cause blood flow and/or
agitation dilation of cerebral
initiate seizure vessels. to prevent
precautions an increase in
blood pressure

66
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Altered level

of

consiousness

67
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain r/t After 8 hours of 1.perform a 1.to determine After 8 hours of
decreased cerebral nursing interventions, comprehensive etiology/precipitating nursing interventions,
Sumasakit pa din
blood flow secondary the patient will be assessment of pain to contributory factors patient was able to
ang ulo ko kahit sa
to physical trauma as able to; include location, verbalize that he felt
konting galaw lang.
manifested by characteristics, better after the
Rated pain as 7 guarded behaviour onset/duration, interventions were
out of 10 (using and narrowed focus Become relieved of frequency, quality done. Patient rated
the pain rating signs and symptoms and severity (using pain as 4 out of 10
scale) of pain experienced the pain rating scale) (using the pain rating
as evidenced by: and precipitating or scale). Patient was

Objective: aggravating factors able to relax. No any

untoward
Facial grimace Verbalize pain is 2. determine possible
2. To implement complication noted.
Guarded relieved (rate pain pathophysiologic
proper and adequate
from 4 out of 10) causes of pain
behavior (clutches interventions in order
head) 3. Assess clients to treat the problem
with scattered perceptions, along
3. to determine
movements with behavioural and
etiology/precipitating
with narrowed physiologic
contributory factors
focus (with responses. Note the

68
NURSING CARE PLAN

impaired thought clients attitude

process, with towards pain and
reduced specific pain
interaction with medications
people and 4. to rule out
4. perform pain
environment) worsening of
assessment each time
pain occurs underlying condition/

T: 37.2 development of
complications
P; 86 bpm
5. accept the clients
5.pain is a subjective
R: 22 cpm description of pain
experience and cannot
BP: 130/90 mmHg be felt by others

6. monitor vital signs 6. These are usually

altered in acute pain

7. support head with

7. Identify ways of
pillow and assist
avoiding/ minimizing
patient when turning
pain
or sitting in an upright
position
8. Encourage rest 8. To help minimize

69
NURSING CARE PLAN

periods and decrease

frequency of pain

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:
masakit pag tinataas
ko yung kamay at Impaired physical After series of nursing Note factors Identifies potential After series of
braso ko mobility related to intervention the affecting current impairments and nursing intervention
As verbalized pain patient will be able to situation (eg. determines type of the patient is able to
verbalize Serious trauma interventions verbalize
Objective: understanding of requiring long needed to provide understanding of
situation and term bed rest) for clients safety situation and
Limited range of individual treatment To determine individual treatment
motion regimen and safety presence of regimen and safety
Limited ability to measures. characteristics of measures.
perform gross or Assess clients clients unique
fine motor skills developmental impairment and to
Difficulty turning level, motor skills, guide choice of
Slowed movement ease and capability intervention.
of movement, Impairments
posture and gait. related to trauma
require alternative
interventions or
changes in care

70
NURSING CARE PLAN

plan.
Determine degree Feelings of
of perceptual or frustration or
cognitive powerlessness
impairment and may impede
ability to follow attainment of
directions goals.
For position
changes

Note
emotional/behavio
ral responses to
problems of
immobility

Instruct in use of
siderails

Provide safety
measures as
indicated by
individual
situation including
environmental
management and
fall prevention.

71
NURSING CARE PLAN

Asessment Diagnosis Planning Intervention Rationale Evaluation

Suibjective : Impaired Social After series of Determine Affects ability After series of nursing
Interaction related nursing intervention clients use of to be involve intervention the patient
to Head Injury as the patient will : coping skills in social verbalizes awareness of
Objective: manifested by use and defense situation factors causing or promoting
of unsuccessful Verbalize mechanisms social interaction.
Use of social interaction awareness of
unsuccessful factors
social causing or Have client Once
interaction promoting list behaviors recognized,
behavior social that cause client can
Lethargic interaction discomfort choose to
Sluggish in change as he
response learns to
Delayed in listen and
response communicate
Falls asleep and socially
in between Provide acceptable
conversation positive
reinforcement
for Encourage
improvement continuation
in social of desired
behaviors and behavior and
interaction effort for
change

72
NURSING CARE PLAN

Provide for
occasional For
follow up as reinforcement
appropriate of positive
behaviors
after
professional
relationship
ended.

73
RECOMMENDATION

XII. Recommendation
To the Patient:

The student researchers would like to advise the patient to comply with the ordered home

medications for continued and progressive healing. It is also recommended for him to

avoid lifting and too much work including household chores for the mean time and to rest

sufficiently. Patient also advised toeat well balanced meals, adequate rest and

He must be instructed to not to take anything stronger than acetaminophen for a

headache. Warn him not to take aspirin because it may heighten the risk of bleeding.

Patient must know not to cough, sneeze or blow his nose because these activities can rise

intracranial pressure.

Also, he must be instructed to return to the hospital immediately if he experiences a

persistent or worsening headache, forceful or constant vomiting, blurred vision, any

change in personality, abnormal eye movements, a staggering gait or twitching. We also

emphasize the need to return for suture removal and follow-up evaluation.

To the Family:

It is recommended to the family to provide continuous care and support for the patient. It

is also important to instruct the family member to awaken the patient every 2 hours

throughout the night and whether he can identify the person. It is also important to

instruct the family to return the patient to the hospital if he is difficult to arouse, is

disoriented or has seizure. The family is also advised to provide a quiet and clean

environment, provide the patient with the emotional and spiritual needs. And lastly family

should must know how to care and clean his scalp would.

To the Student Nurses:

The students must provide adequate information about cerebral contusion to the patient.

They must give appropriate information about his prescribed medications; and they

74
RECOMMENDATION

should deliver physical, emotional and social support for the patient. Provide adequate

Health Education about the significance of proper hygiene and wound care,

environmental sanitation, and adequate nutrition.

75
DISCHARGE PLAN

XIII. Discharge Plan

A. MEDICATION

Continue prescribed home medication:

Mefenamic acid500mg PRN

Cefuroxime 500mg TID for 7 days

B. ENVIRONMENT

Advise the client to maintain a clean environment and dust-free environment

to reduce the risk of infection

C. TREATMENT

Continue prescribed medication

A balanced meal rich in vitamins and minerals

Increasing oral fluid intake

Vitamin supplements as prescribed

Follow-up check up

D. HEALTH TEACHINGS

Advise to continue taking home medications as prescribed

Advise client to have well-balanced diet rich in vitamins and minerals to help

boost immunity

Provide proper education about clients medication

Emphasize proper wound care.

Tell the patient to return to the hospital immediately if he experiences a

persistent or worsening headache, forceful or constant vomiting, blurred

vision, any change in personality, abnormal eye movements, a staggering gait,

or twitching.

Explain that mild cognitive changes do not resolve immediately.

76
DISCHARGE PLAN

Stress the importance of follow-up visits to the physician.

E. OUTPATIENT

Instruct the patient to have a checkup to consult the physician to monitor the

patients condition and for detection of recurrences and other complication

that may rise to it.

Glasgow coma scale should be determined.

Enough rest and proper nutrition should be needed for outpatient care.

F. DIET

Adviceto increase oral fluid intake

Advice patient to eat foods rich in vitamin C to boost immune system.

G. NURSING CONSIDERATIONS

A neurologist should be consulted if the patient is believed at risk for

complications.

Special care is taken in the positioning of the head of the patient to avoid

flexion of the neck which might impair circulation to the brain.

Emotional supports are required to keep the person comfortable and calm.

Watch the patient closely for any change in level of consciousness.

77