NAME OF CLIENT: CC SEX/AGE: F - 19 WARD/BED: 614

INITIAL DIAGNOSIS: Traumatic Brain Injury DATE/TIME OF ADMISSION: NAME OF STUDENT: Florencio, Venson

LABORATORY OR DIAGNOSTIC STUDY

NAME OF TEST OR NORMAL VALUES, RESULTS, OR ACTUAL RESULTS OR FINDINGS INTERPRETATION AND SIGNIFICANCE OF THE RESULTS OR
PROCEDURE FINDINGS FINDINGS

Creatinine 46.00 – 92.00 umol/L 74.4 umol/L

SGCT/AST 14.00 – 36.00 u/L 18 u/L
SGPT/ALT 9.00 – 52.00 u/L 10 u/L

CBC with Platelet count:

- WBC 4.00 – 10x109/L 5.5x109/L
Neutrophil 0.50 – 0.70 0.79 Neutrophil – are the most numerous circulating WBCs, and they
- Lymphocyte 0.25 – 0.35 0.16 respond more rapidly to the inflammatory and tissue injury. Increased
- Monocyte 0.03 – 0.06 0.03 level maybe due to acute infections, inflammatory diseases, tissue
- Eosinophil 0.02 – 0.04 0.02 damage,
- Basophil 0.00 – 0.01 0.00 Lymphocyte – Lymphocytes decreased in number during excess
- Hemoglobin 120.00 – 160.00/L 116.00g/L adrenocortical hormone secretion or steroid therapy.
- Hematocrit 0.37 – 0.43 0.35 Hemoglobin – a protein substance found in RBC gives blood its red
- RBC 4.00 – 5.40x1012/L 3.09x1012/L color. Hemoglobin is composed of iron, which is an oxygen carrier.
- MCV 80.00 – 90.00fl 88.00fl Low hemoglobin values are related to various clinical problems.
- MCH 28.00 – 32.00pg 29.00pg Hematocrit – Hematocrit is the volume (in ml) of packed RBCs
- MCHC 300.00 – 360.00g/L 330.00g/L found in 100mL of blood. Low hematocrits are frequently found in
- RDW 11.60 – 14.60 14.40 anemias and leukemias. Hematocrits can be an indicator of the
- Platelet Count 170.00 – 400x109/L 210.00x109/L hydration status of the patient.
EEG Abnormal Significance III RBC – RBCs contain hemoglobin which carries oxygen to your
Speech Audiometry: body tissues. The number of RBCs you have can affect how much
- BC 90 – 100 (Normal) oxygen your tissues receives.
- SF 76 – 88 (Slight Difficult)
- SF Aided 62 – 74 (Moderate Difficulty) SRT - It is a measure of the intensity level at which the listener is able
- SRT 50 – 60 (Poor Difficulty) to correctly repeat 50% of words presented.
- MCL Below 50% (Very poor understanding) MCL – This is the speech level identified by the patient as the most
CT Cranial - Minimal soft tissue swelling clear and comfortable.
noted in occipital region
NAME OF CLIENT: SEX/AGE: WARD/BED:
MEDICAL DIAGNOSIS: DATE/TIME OF ADMISSION: NAME OF STUDENT:

DRUG STUDY

DRUG ORDER DRUG CLASSIFICATION AND INDICATIONS OF CONTRAINDICATIONS TO THE SIDE/ADVERSE NURSING RESPONSIBILITIES
PHARMACOLOGIC ACTION OR THE DRUG DRUG EFFECTS OF THE
MECHANISM DRUG

Betahistine 16mg Antivertigo drugs Meniere's disease Contraindicated for patients with
pheochromocytoma. Patients with
bronchial asthma or a history of
peptic ulcer need to be closely
monitored.
Gastrointestinal Educate patient to:
disorders: Nausea, 1. Take the drug after meal
vomiting, bloating, 2. Advise relatives to support patient’s
abdominal distension or ambulation.
pain. 3. Protect medication from moisture.
Nervous system 4. Swallow tablet whole with one full glass
disorders: Headache. of water.
dizziness, convulsions, 5. Never take a double dose, if you
Psychiatric disorders: missed one medication. If you missed
confusion, hallucination. one, take medication immediately.
Respiratory disorders:
Dyspnea,
bronchospasm.
Skin and
subcutaneous tissue
disorders: Rash,
pruritus.

Vit. B complex Vitamins Prevention and Contraindicated to patients Adverse neurologic • Obtain a sensitivity test history before
treatment of vitamin allergic to the product’s effects have been administration. An intradermal test dose is
b complex. components. reported following recommended in patients with possible
Supplement to help chronic administration of sensitivity.
manage high Pyridoxine doses
neuromuscular pain (e.g., 100-500 mg daily) • Protect solution from light, and refrigerate
responsive to Vit B1, and long term (i.e., 2 ampules.
B6, and B12 including months or longer)
neuralgia, neuritis, megadose (usually 2 g • Don’t mix parenteral preparations in same
neuropathies. or more daily) Pyridoxine syringe with other drugs.
use.
 • Monitor patient for hypokalemia for first 48
hours, as anemia corrects itself. Give
potassium supplement, as needed.

• Stress proper nutritional habits to prevent

recurrence of deficiency.

• Warn patient that there may be burning at the

injection site.

Levetiracetam Anticonvulsants Levetiracetam is Levetiracetam is contraindicated Blood and Lymphatic  Observe for signs of adverse effects.
indicated as in: hypersensitivity to the active System Disorders:
monotherapy in the substance or other pyrrolidone Thrombocytopenia,  Monitor fluid balance closely.
treatment of: partial derivatives or to any of the leukopenia.
onset seizures with excipients. Metabolism and  Do not administer the injection
or without secondary Nutrition Disorders: undiluted via the intravenous route.
generalization in Anorexia.
adults and Psychiatric Disorders:  Assess and document any signs of
adolescents from 16 Depression, seizure activity.
years with newly hostility/aggression,
diagnosed epilepsy. anxiety, insomnia,
nervousness/irritability.
Nervous System
Disorders: Convulsion,
balance disorder,
dizziness, lethargy,
tremor.

Levodroproprizine Antitussive Drug Cough Suppressant Contraindicated for patients with Gastrointestinal tract: - Remind pt to take the medicine on
serious renal insufficiency and nausea; vomiting; empty stomach.
patients excessive discharge of heartburn; abdominal - Watch out vomiting and signs of heart
mucus. discomfort; diarrhea. burn and abdominal discomfort.
Central nervous
system: exhaustion,
faintness.
 PATHOPHYSIOLOGY
Nonmodifiable risk factors: Modifiable risk factors:
History of brain tumor Impact on head Volleyball player
Family history of stroke
19 y/o female
Brain suffers traumatic injury
S/S by the patient:
Dizziness
Severe Headache
Brain swelling and bleeding. Confusion
Increase Intracranial volume.

Rigid cranium allows no space for expansion of content so

Increased size due
intracranial pressure increase.
to swelling.
(Monro – Kellie Hypothesis)

Decreased CSF
Pressure on the blood vessel within the brain causes blood
Decreased blood
flow to slow.

Cerebral hypoxia S/S by the book:

- Changes in level of
May result consciousness
to - Restlessness
Anaerobic metabolism Intracranial pressure continues to rise - Changes in behavior

TBI
Assessment: Diagnosis: Planning: Intervention: Evaluation:
- Risk of falling due to - Patient to not - Advice family members - After nursing
Subjective dizziness as evidenced experience any to guide the patient intervention, the
- “Medyo nahihilo pa ko by TBI fall/injury. when standing and patient/family
pag tumatayo” as walking remember did not
stated by the patient report any fall.
Objective:
- Temp: 35.2
- PR: 100
- RR: 15
- BP: 100/60