CASE

PRESENTATION
ROTATION 1

SURGICAL WARD 3B MHARS-MC

Cerebral Contusion with
Multiple Lacerations and
Abrasions Probably
Secondary to Vehicular
Accident

SURGICAL WARD 3B MHARS-MC

Objectives
General Objectives:
At the end of the case presentation, the audience and
presenters will be able to:
Trace the disease process of Cerebral contusion with multiple
lacerations and abrasions probably secondary to vehicular
accident briefly; identify its signs and symptoms, complications,
diagnostic tests, interventions effectively and present the role of
nurses as care providers in this type of patient/client efficiently.
Specific Objectives:
At the end of the case presentation, the audience and
presenters will be able to:
1.State the definition of Cerebral contusion correctly.
2.Present the anatomy and physiology of acute
gastroenteritis concisely.
3.Trace the pathophysiology of cerebral contusion with
multiple lacerations and abrasions secondary to vehicular
accident clearly leading to its manifestations.
4.Presentthe data gathered through Gordons functional
Assessment, Physical Assessment and Laboratory Findings
accurately.
5. Discuss the medications taken by the client; its
mechanism of action, indications,
contraindications, adverse effects, and the nursing
responsibilities and/or patient teachings
completely.
6. Discuss the relation of the medical interventions
performed by the physician to the patient
effectively.
7. Create an effective nursing care plan for the
underlying condition of the patient appropriately.
8. Formulate 10 nursing diagnosis in relation to the
health problems assessed correctly.
Introduction

Cerebral contusions are bruises of the brain,

usually caused by a direct, strong blow to the
head. Cerebral lacerations are tears in brain tissue,
caused by a foreign object or pushed-in bone
fragment from a skull fracture.
 Motor vehicle crashes and blows to the head are common
causes of bruises and tears of brain tissue.
Symptoms of mild or severe head injury develop.
Computed tomography is done.
The person is observed in the hospital and sometimes needs
surgery.
 Cerebral contusions and lacerations involve
structural brain damage and thus are more
serious than concussions. Contusions may be
caused by the sudden acceleration of the brain
that follows a joltas may be delivered by a
forceful blow to the heador by the sudden
deceleration that occurs when a moving head
strikes an immovable object (as when a person's
head hits the dashboard or the steering wheel in
a frontal-impact motor vehicle crash). The brain
can be damaged at the point of impact and on
the opposite side by striking the inside of the skull.
Contusions and lacerations can cause bleeding
or swelling in the brain.
 Contusions and lacerations may be very small,
causing only minimal damage to the brain, with few
symptoms or symptoms of minor head injury. However,
with larger injuries, or if swelling or bleeding from a
small injury is severe, people may have symptoms of
severe head injury (see Severe head injury). For
example, people often are unconscious for a short
time (such as a few minutes or less) or longer. When
awake, people often are drowsy, confused, restless, or
agitated. They may also have vomiting, seizures, or
impaired balance or coordination. The ability to think,
control emotions, move, feel, speak, see, hear, smell,
and remember may be impaired. A more severe injury
causes swelling within the brain, damaging brain tissue
further. Herniation of the brain may result, sometimes
leading to coma.
 Doctors do computed tomography (CT) to
diagnose a contusion or laceration. If
bleeding and swelling are minor, people are
hospitalized and observed, usually for up to a
week. If bleeding is severe, doctors treat them
as if they had a severe head injury (see Severe
head injury). Often people are admitted to an
intensive care unit. Doctors keep the blood
pressure and blood levels of oxygen and
carbon dioxide at desirable levels. They may
give supplemental oxygen, mechanical
ventilation, pain relief, and sedation. Fever
and seizures are treated.
 To measure pressure in the brain, doctors may implant a
pressure gauge inside the skull or insert a catheter into one of the
internal spaces (ventricles) within the brain. If bleeding leads to
herniation, the blood may need to be surgically removed to
prevent compression of the brain. However, if removing the
blood involves removing brain tissue, then brain function may
eventually become impaired.
ANATOMY AND
PHYSIOLOGY
The brain is a spongy organ made up of nerve and
supportive tissues. It is located in the head and is protected by a
bony covering called the skull. The base, or lower part, of the
brain is connected to the spinal cord. Together, the brain and
spinal cord are known as the central nervous system (CNS). The
spinal cord contains nerves that send information to and from
the brain.
 The CNS works with the peripheral
nervous system (PNS). The PNS is
made up of nerves that branch out
from the spinal cord to relay
messages from the brain to different
parts of the body. Together, the CNS
and PNS allow a person to walk, talk,
throw a ball and so on.
 Structure and function of the brain

The brain is the bodys control centre.

It constantly receives and interprets
nerve signals from the body and
responds based on this information.
Different parts of the brain control
movement, speech, emotions,
consciousness and internal body
functions, such as heart rate,
breathing and body temperature.

The brain has 3 main parts: cerebrum,

cerebellum and brain stem.
 Cerebrum
The cerebrum is the largest part of the brain. It is divided into 2 parts
(halves) called the left and right cerebral hemispheres. The 2
hemispheres are connected by a bridge of nerve fibres called the
corpus callosum.
The right half of the cerebrum (right hemisphere) controls the left side
of the body. The left half of the cerebrum (left hemisphere) controls
the right side of the body.
 The outer surface of the cerebrum is called the
cerebral cortex or grey matter. It is the area of the brain
where nerve cells make connections, called synapses,
that control brain activity. The inner area of the cerebrum
contains the insulated (myelinated) bodies of the nerve
cells (axons) that relay information between the brain and
spinal cord. This inner area is called the white matter
because the insulation around the axons gives it a whitish
appearance.
 The cerebrum is further divided into 4 sections called lobes.
These include the frontal (front), parietal (top), temporal (side)
and occipital (back) lobes.
Each lobe has different
functions:
The frontal lobe controls movement, speech,
behaviour, memory, emotions and
intellectual functioning, such as thought
processes, reasoning, problem solving,
decision making and planning.
The parietal lobe controls sensations, such as
touch, pressure, pain and temperature. It also
controls spatial orientation (understanding of
size, shape and direction).
The temporal lobe controls hearing, memory
and emotions. The left temporal lobe also
controls speech.
The occipital lobe controls vision.
Cerebellum

The cerebellum is the next largest part of the

brain. It is located under the cerebrum at the
back of the brain. It is divided into 2 parts or
hemispheres and has grey and white matter,
much like the cerebrum.
 The cerebellum is responsible for:
movement
posture
balance
reflexes
complex actions (walking, talking)
collecting sensory information from the body
BASELINE DATE
Biographical Data
Name of the Patient: Patient C.
Address of the Patient: P-7 Mantic Tangub City, Misamis
Occidental
Gender: Male
Birthdate: January 22,1999
Race or Ethnic Background: Pure Bisaya
Primary and Secondary Languages (Spoken and Read):
Can speak and read Filipino and Visayan
Marital Status: Single
Religious or Spiritual Practices: Roman Catholic
Educational Level: High School Grade 10
Occupation: Student
Significant Others: Mother
Reasons for Seeking Health
Care
Prior to admission, the patient complaints of pain
@ right leg, deformed right arm, and lacerated
wound in face area.
Admitting Dx: Cerebral contusion with multiple
lacerations and abrasions probably secondary to
vehicular accident.
Admission Date: July 28,2017 : 8:00 pm
Initial Assessment

Blood Pressure: 110/70 mmhg

Respiratory Rate: 23 cpm
Heart Rate: 82 bpm
Temperature: 39.3C
Intravenous Fluid and
Date of Insertion:
7-28-2017 : PLR il @ 30 gtts/miin.
History of the Present Health
Concern Using COLDSPA
Character 1. Headach 1. Pain ; 1. Periorbital 1. Lacerated
e Transvers Edema wound in
(Describe e Fracture Face area
the sign @ distal
and end of the
symptom) right arm
Onset

(When did July 28, 2017 July 28,2017 July 28,2017 July 29,2017
it begin)
Location

(Where is Head Distal of the Both Eyes Both eyebrows

it?) right arm are lacerated,
upper and lower
lips are
lacerated and
swollen,
abrasions in the
nose and in the
mandible and
also in the right
upper portion of
the face.
Duration

(How long N/A N/A N/A N/A

does it last?)

Severity A rate of 9 in a A rate of 9 in a Both eyes are really A rate of 9 in a pain

pain scale of 1 pain scale of 1 swollen; contusion. scale of 1 out of 10.
out of 10. out of 10. Pain scale of 8/10.

Pattern It does not make It does not make It does not make It makes better after
better according better according better according to 6 days. Its not
(What makes it to him to him him. But last August 4, painful anymore.
better or 2017 , the swollen Patient is taking
worse?) eyes got better, he Cefuroxime to avoid
can now open his infection in the
both eyes. wounds.
Associated Body Body Body weakness, Body weakness
factors/how weakness weakness and Headache,
it affects the and pain swollen distal Periorbital pain,
client end of the Swollen red eyes,
right arm cant open both
eyes
 Past Health History
Problems at birth No problems at birth.

Fever, cough, and colds

Childhood Illness

Completed all the immunizations at birth

Immunizations to date

Adult illness None

Surgeries

When he was in 3rd year high school, he had suicidal thought and cut his left
Accidents hand ; ulnar portion of the hand

N/A
Prolonged pain or pain
patterns
Allergies No allergies.

The patient does not share his problems to his parents and according to his mother, he
Physical, emotional, was bewitched.
social, or spiritual
weaknesses

N/A
Physical, emotional,
social, or spiritual
strengths
 Family Health History

Age of parents Mother: 40 -years old; living

(living or deceased Father: 60 -years old; living
date)

None
Parents Illness and
longevity

Childrens ages and

illness

Patient doesnt remember their ages but they died due to katigulangon
Grandparents Illness
and longevity
 Lifestyle and Health Practices Profile

Naa ra sa balay magtan-aw ug TV, usahay rani siya mugawas ug balay, naa
Description of Typical day rajud ni siya sa sulod, magtuon usahay, brayt maning bataa, siya galiy
manlaba sa iyang sanina as verbalized by the patients mother

Patient eat anything that is served on the table.

Nutrition and Weight
Management

Usually sleep at 8 pm and wake up at around 5:30 am.

Sleep and Rest

None
Substance use

Kuan kaning responsible bitaw sa tanan, pero dili lang jud ni siya mu-storya kung
Self-concept and Self-care unsay iyang problema sa amoa, as verbalized by the patients mother
responsibilities

Usually stays at home. Bond with his siblings.

Social Activities
Relationships He has a good relationship with her family and relatives. Hes just too shy to
share his problems.

Prays to God before he sleeps

Values and Belief

system

Hes still studying high school in Tangub City ; Grade 10.

Education and Work

Stress levels and Coping styles Patients mother did not comment

Patients mother states that the place is peaceful.

Environment
 GORDONS
ASSESSMENT
Demographic Data
Name: Patient C Age: 18 years old
Sex: Male Civil Status: Single
Address: P-7 Mantic Tangub City Misamis Occidental
Birthdate: January 22, 1999 Religion: Roman Catholic
Occupation: Student
Date of Admission: March 22, 2017

Chief Complaint(s): PTA, the patient complaints of pain @ right leg, deformed right
arm and lacerated wound in face area.
Admission Dx: Cerebral contusion with multiple lacerations and abrasions probably
secondary to vehicular accident.
Health Perception and Management
History:
A. absences from work/school, colds in past year, general health, important things you do
to keep healthy, use of cigarettes/ alcohol/drugs, self-
examination, accidents at home/work/school/driving.
None.

B. Has it been easy to find ways to carry our doctors or nurses suggestions?
Yes, as stated by the patients mother. Even though
at times its hard to easily find a way to by the
prescriptions given due to financial incapability.

C. What do you think caused current illness?

Patient does not respond. But according to her mother,
he was mistakenly accused of doing something wrong.
D. Things most important to your health.
N/A
E. Actions taken since symptoms started. Have your actions helped? How can we be
most helpful?
Intake of the medications prescribed by the physician helped him relieved
the pain he felt.

F. How often do you exercise?

N/A
History of Past Illness:
The client has experienced headache when
having fever.
History of Present Illness:
Prior to admission, patient complaints of pain
@ right leg, deformed right arm and lacerated wound
in face area.
 PTA 1St day 2nd Day INTERPRETATION

NUTRITIONAL /METABOLIC Prior to admission,

daily food intake the client does The clients diet is He can now eat The
(supplements, vitamins, not have any as tolerated takes rice with fish as interventions
types of snacks) problem in his IVTT drugs as a viand. Still given by the
daily fluid intake nutrition. Hes not ordered. She drinks less than 3 health care
Weight loss/gain. Height picky when it drinks less than 3 glasses of team is
loss/gain comes to foods. glasses of water a water. effective and
Appetite. Breastfeeding. He drinks more day. Has greatly
Infant feeding. than 8 glasses of lacerations and improves the
Food or eating: water per day. abrasions. He patients
Discomfort, swallowing chooses to eat condition. He
difficulties, diet soft foods does not eat
restrictions, able to because his lips that much
follow. are swollen and it because its
Healing any problems? is painful to chew painful when he
Skin problems (lesions, hard foods. chews hard
dryness) food. Yes, his
Dental problems diet is tolerated
Skin assessment, oral but he prefers
mucous membranes, eating soft food
teeth, actual to avoid pain in
weight/height, his lips.
temperature
Abdominal assessment
ELIMINATION
Bowel elimination pattern Patient defecates The client defecated The client wasnt The clients needs to
(Frequency, character, thrice a week. once with black able to defecate. increase her fluid
discomfort, problem with bowel brown stool. Voided Voided twice. intake to avoid any
control, use of laxatives) twice. further
Urinary elimination pattern complications.
(Frequency, problem with
bladder control)
Excess perspiration
Odour problems
Body cavity drainage, suction,
etc.
examine excretions or
drainage
ACTIVITY / EXERCISE
Energy for desired and/or Patient usually stays at The client The client The client doesnt
required activities home. He seldom experiences body experiences body want to take a bath
Exercise pattern (Type, goes out with friends weakness. Patient has weakness. Spends due to body
Regularity) and classmates. He headache. Can his time sleeping in weakness.
Spare time (leisure) activities prefers staying at stand with assistance the hospital bed.
Child-play activities home and study. but the posture is Has poor hygiene
Perceived ability for feeding, bad. Spends his time and does not take
grooming, bathing, general sleeping in the a bath.
mobility, toileting, home hospital bed. Has
maintenance, bed mobility, poor hygiene and
dressing and shopping does not take a bath.
Gait. Posture. Absent body
part. Range of motion (ROM)
joints.
Hand grip (can pick up pencil)
Respiration. Blood pressure.
General appearance.
Musculoskeletal, cardiac and
respiratory assessments
SLEEP / REST
Generally rested and ready for activity after sleep Usually sleeps at The client usually sleeps at The client usually sleeps Sleeping patterns doesnt
Sleep onset problems 8 pm and wakes 8 pm in the evening and at 8 pm in the evening affect him. Its just that he
Dreams, early awakening up at 5 am. wakes up at 5 am. But then and wakes up at 5 am. just wanted to take rest
Rest/relaxation periods right after eating breakfast, But then right after eating because he has
Sleep routine he chooses to sleep back breakfast, he chooses to headache all the time
Sleep apnea symptoms again because his head is sleep back again and there are
always aching. because his head is interventions done by the
always aching. health care team.
COGNITIVE-PERCEPTUAL
Hearing difficulty, hearing aid Patient has no No hearing difficulty. Cant Same thing on the 2nd The pain was alleviated
Vision problem in open his both eyes, it is day assessment. due to the prescribed
Wearing glasses (Last checked, when last hearing and in swollen. Hes restless. Can medicine by the
changed) vision. speak so softly. Has physician. The client
Change in memory (Concentration) headache. appreciated the
Important decisions easy/difficult to make interventions that were
Easiest way to learn ( any difficulties, discomfort, done to him.
pain)
COLDSPA
Orientation (Hears whispers)
Reads newsprints
Grasps ideas and questions
Language spoken
Vocabulary level
Attention span
SELF PERCEPTION/SELF CONCEPT
Describe yourself N/A The patient doesnt talk to The patient replies when I The patient realized that
Feel good (or not so good) about self me, only her mother. have questions. Im not going to harm
Changes in things you can do him. Im there to help
Problems The client has a bad The patient can now him.
Changes in the way you feel about self or body posture. Cant fully do the extend his legs slowly. Still
(generally of since illness started) ROM. has bad posture.
Things frequently make you angry, annoyed,
fearful, anxious, depressed, not able to control
things (and what helps)
Ever feel you lose hope?
Eye contact
. Attention span
Voice and speech pattern
Body posture
Client nervous (5) or relaxed (1) (rate scale 1-5)
Client assertive (5) or passive (1) (rate scale 1-5)
ROLE RELATIONSHIP According to her His mother watches Still his mother So far, they have a
Live alone/Family (Family mother, her son does him in the. hospital. watches and take good relationship.
structure) not share anything care of him. Its just that her son
Family problems you have about his problem. But doesnt want to
difficulty handling they have a good burden her.
Family or others depend on you relationship with each
for things other. Its just that she
How well are you managing thought that his son is
How families/others feel about shy or he doesnt want
your illness to burden anybody. So
Problems with children he chooses to keep
Belong to social groups, close silent. Hes close with is
friends siblings.
Feel lonely (Frequency)
income sufficient for needs
Feel part of (or isolated in) your
neighbourhood
Interaction with family members
or others
SEXUALITY / REPRODUCTIVE N/A
Sexual relationships satisfying N/A N/A N/A
(Changes, problems)
Use of contraceptives (Problems)
LMP
Menstrual problems
GTPALM
COPING / STRESS TOLERANCE The client is taking Same thing on the
Any big changes in your life in cefuroxime as a 2nd day. Due to a good
last year or two (Crisis) N/A prophylaxis or as an rapport with the
Most helpful in talking things over anti-infective because health care team,
Tense or relaxed most of the time he has a lot of patient gains trust to
(When tense, what helps) lacerated wounds and cooperate in the
Any medications, drugs, alcohol abrasions. Hes given interventions given.
to relax also mannitol for his
How do you handle big cerebral edema,
problems in your life (Are these which indicates
successful?) increased ICP. And
ketorolac for pain and
citicoline to protect his
brain for damage.
VALUES/BELIEF PATTERN
Generally get things you want Pray always and stays Unable to go to Unable to go to Religion has a big
from life positive. church due to his church due to his impact in his life. It
Important plans for future condition but the condition but the deepens the
Religion important to you (Does patient is still praying patient is still praying patients faith to
this help when difficulties arise? every night. every night. God and expresses
will being here interfere with any that God is his
religious practices? strength and savior.
 PHYSICAL
ASSESSMENT

1. Integumentary System
Assessment
Inspect general skin color
Inspect skin integrity
Inspect for skin lesion and
ulcers
Inspect for skin odor
Assess for edema
Assess skin moisture
Assess skin thickness
Assess skin texture
Assess for skin temperature
1ST DAY
The clients skin is uniform
in color with a skin color
of medium brown. Has
poor skin turgor with scars.
Lacerated and sutured
both eyebrows, abrasions
on the nose. Lacerated
both upper and lower lips.
It is also swollen.
Lacerated mandible.
Swollen right thigh and
also the right knee.
Lacerated left foot in
between 1st and 2nd
digits. Left arm has also
abrasions.
Lacerated left hand:
radius portion. Presence
of foul odor noted. Skin is
thin and dry. Periorbital
edema.
Temp.=37.6C
2ND DAY
The clients skin is uniform
in color with a skin color
of medium brown. Has
poor skin turgor with scars.
Lacerated and sutured
both eyebrows, abrasions
on the nose. Lacerated
both upper and lower lips.
It is also swollen.
Lacerated mandible.
Swollen right thigh and
also the right knee.
Lacerated left foot in
between 1st and 2nd
digits. Left arm has also
abrasions.
Lacerated left hand:
radius portion. Presence
of foul odor noted. Skin is
thin and dry. Periorbital
edema.
Temp.= 37. 4C
3rd DAY
The clients skin is uniform
in color with a skin color
of medium brown. Has
poor skin turgor with scars.
Lacerated and sutured
both eyebrows, abrasions
on the nose. Lacerated
both upper and lower lips.
It is also swollen.
Lacerated mandible.
Swollen right thigh and
also the right knee.
Lacerated left foot in
between 1st and 2nd
digits. Left arm has also
abrasions.
Lacerated left hand:
radius portion. Presence
of foul odor noted. Skin is
thin and dry. Periorbital
edema.
Temp.= 37.4C
1. Nails Assessment
Inspect nail grooming The clients nails are The clients nails are The clients nails are
and cleanliness long and not clean, long and not clean short and clean.
Inspect nail color and soiled with no nail with no nail color or No nail color or
markings color. With linear markings. Clients nail markings. Clients nail
Inspect nail shape markings. Clients nail has a shape of has a shape of
Assess nail texture and has a shape of convex curve. It is convex curve. It is
consistency, whether convex curve. It is smooth and is intact. smooth and is intact.
nail plate is attach to smooth and is intact. When nails pressed When nails pressed
nail bed When nails pressed between the fingers, between the fingers,
Test capillary refill between the fingers, the nails return to the nails return to
the nails return to usual color in less usual color in less
usual color in less than 2 second. than 2 second.
than 2 second.
1. Hair Assessment
Inspect the scalp and The hair of the client is The hair of the client is The hair of the client is
hair for general color black and is uniform black and is uniform black and is uniform
and condition. in color. It is thick with in color. It is thick with in color. It is thick with
Inspect and palpate an evenly distributed an evenly distributed an evenly distributed
the hair and the scalp amount of hair. Hair is amount of hair. Hair is amount of hair. Hair is
for cleanliness, dryness, dry and has dirty dry and has dirty dry and has dirty
oiliness, parasites and scalp, has dandruff scalp, has dandruff scalp, has dandruff
lesions because the client because the client because the client
Inspect amount and doesnt want to take doesnt want to take doesnt want to take
distribution of scalp, a bath due to body a bath. a bath.
body, axillae, and weakness.
pubic hair
1. Head and Face
Assessment The clients head is The clients head is The clients head is
Inspect for head size round and round and round and
Inspect for involuntary symmetrical with no symmetrical with no symmetrical with no
movement involuntary involuntary involuntary
Check the temporal movements. Temporal movements. Temporal movements. Temporal
artery artery is not artery is not artery is not
Check the distended. No distended. No distended. No
temporomandibular tenderness upon tenderness upon tenderness upon
joint palpation. palpation. palpation.
1. Neck Assessment
Inspect for the neck The neck is in midline The neck is in midline The neck is in midline
position, symmetry, position with no visible position with no visible position with no visible
lump and masses masses. The trachea is masses. The trachea is masses. The trachea is
Inspect movement of place in midline of the place in midline of the place in midline of the
the neck structure neck. The thyroid gland neck. The thyroid gland neck. The thyroid gland
Inspect the cervical is not visible on is not visible on is not visible on
vertebrae inspection and the inspection and the inspection and the
Inspect the range of glands ascend during glands ascend during glands ascend during
motion swallowing but are not swallowing but are not swallowing but are not
Inspect the trachea visible. Lymph nodes visible. Lymph nodes visible. Lymph nodes
Inspect the thyroid are palpable on the right are palpable on the right are palpable on the right
gland side of the neck. side of the neck. side of the neck.
Inspect for lymph nodes
1. Eyes Assessment
Inspect for the position and
alignment of the eyeball in
the eye socket
Inspect the bulbar
conjunctiva and sclera
Inspect the lacrimal
apparatus
Inspect the cornea and lens
Inspect the iris and pupil
Inspect the optic disc
Inspect the retinal vessels
Check distant visual acuity
Check for visual fields for
gross peripheral test
Inspect the eyelids and
eyelashes
1. Ears Assessment
Inspect the auricle, tragus
and mastoid process
Inspect the external auditory
canal
Inspect the tympanic
membrane
Inspect for any discharges
and discoloration
Perform Whisper test
Perform Weber test
Perform Rinne test
The clients eyes are
swollen. (Periorbital
edema). Patient cannot
open both eyes. The eyelids
are violet-red in color.
Patient has long lashes and
double eyelids.
The auricles are symmetrical
and have the same color
with the facial skin. The
auricles are aligned with the
outer canthus of the eye.
No discharges are noted.
The clients eyes are
swollen. (Periorbital
edema). Patient cannot
open both eyes. The eyelids
are violet-red in color.
Patient has long lashes and
double eyelids.
The auricles are symmetrical
and have the same color
with the facial skin. The
auricles are aligned with the
outer canthus of the eye.
No discharges are noted.
The swollen eyes subsided.
He can now open his both
eyes. The clients eyes are
aligned. The bulbar
conjunctive appeared
present with few capillaries
evident. The sclera
appeared yellowish. Patient
can shed a tear. Cornea is
transparent and details in
the iris are slightly visible.
Pupils are equally round,
reactive to light and
accommodation. Retinal
vessels are visible. Patient
cannot see clearly. Patient
has long lashes and double
eyelids.
The auricles are symmetrical
and have the same color
with the facial skin. The
auricles are aligned with the
outer canthus of the eye.
No discharges are noted.
1. Mouth, Tongue, and Teeth
Assessment Patient cant open his Patient cant open his Patient cant open his
Inspect the teeth and mouth widely. It is mouth widely. It is mouth. It is painful. Both
gums(Note the number of painful. Both upper and painful. Both upper and upper and lower lips are
teeth, color and condition) lower lips are swollen. It is lower lips are swollen. It is swollen. It is lacerated.
Inspect the buccal lacerated. Lips are lacerated. Lips are Lips are cracked with
mucosa cracked with black cracked with black black discoloration
Inspect and palpate the discoloration surrounding discoloration surrounding surrounding the lips.
tongue the lips the lips
Assess the ventral surface
of the tongue
Check the anterior
tongues ability to taste
Inspect the hard and soft
palate and uvula

1. Nose and Sinuses

Assessment
Check the external
structure
Check the patency of
airflow through the nostrils
Check the internal
structure
Inspect the frontal and
maxillary sinuses
Check for nasal
discharges
The nose appeared
symmetric, straight and
uniform in color. No nasal
flaring and discharges.
No tenderness noted. It
only has abrasions on the
external surface.
The nose appeared
symmetric, straight and
uniform in color. No nasal
flaring and discharges.
No tenderness noted. It
only has abrasions on the
external surface.
The nose appeared
symmetric, straight and
uniform in color. No nasal
flaring and discharges.
No tenderness noted . It
only has abrasions on the
external surface.
1. Throat Assessment
Inspect the tonsils I wasnt able to assess I wasnt able to assess I wasnt able to assess
appearance because the client says because the client says because the client says
Inspect the posterior it hurts when I open it it hurts when I open it it hurts when I open it
pharyngeal wall widely. widely . widely
Check the patency of the
airflow
Note the odor

1. Thoracic and Lungs

Assessment The clients face is round
Inspect the face, lips and and lips are cracked with
chest black discoloration
Assess for breath sounds surrounding the lips. A
Inspect for shape of the small abrasion in the
sternum upper right portion near in
Inspect slope of the ribs the clavicle. The chest
Observe quality and wall is intact with
pattern of respiration symmetrical expansion.
Check for tenderness and The client does not exert
masses effort in inspiration. The
Check anterior chest sternum is midline. No
expansion tenderness and masses
upon palpation.
RR= 22 cpm
Lips are cracked with The chest wall is intact
black discoloration with symmetrical
surrounding the lips. A expansion. The client
small abrasion in the exerts effort in inspiration.
upper right portion near in The sternum is midline. No
the clavicle. The chest tenderness and masses
wall is intact with upon palpation.
symmetrical expansion. RR= 24 cpm
The client exerts effort in
inspiration. The sternum is
midline. No tenderness
and masses upon
palpation.
RR= 18 cpm
1. Breast and
LymphaticAssessment
Inspect size and symmetry
Inspect color and texture
Inspect superficial venous
pattern
Inspect the areola
Inspect the nipples
Check for tenderness and
masses
Inspect and palpate the
axillae
1. Abdominal Assessment
Observe the color of the
skin
Inspect for scars and striae
Assess for lesions and
rashes
Inspect the umbilicus, its
appearance and location
Assess abdominal
symmetry
Inspect abdominal
movement
Check bowel sounds
Check internal organs
Check for masses and
abdominal tenderness
Breast is symmetric with Breast is symmetric with Breast is symmetric with
no masses upon no masses upon no masses upon
palpation. Nipples are palpation. Nipples are palpation. Nipples are
firm with brownish color firm with brownish color firm with brownish color
of the areola. No of the areola. No of the areola. No
discharges noted. discharges noted. discharges noted..
The skin color is lighter The skin color is lighter The skin color is lighter
than the skin color. No than the skin color. No than the skin color. No
scars and striae noted. scars and striae noted. scars and striae noted.
No lesions and rashes No lesions and rashes The umbilicus is located
noted. Umbilicus is noted. Umbilicus is midline. No lesions and
located in the left lower located in the left lower rashes noted. Client
quadrant due to quadrant due to defecates only once
abdominal enlargement. abdominal enlargement. with black brown in
The client was able to Client wasnt able to color. No masses and
able to defecate once, defecate. No masses tenderness upon
black brown in color. No and tenderness upon palpation.
masses and tenderness palpation.
upon palpation.
1. Heart and neck vessels
Observe and evaluate
jugular venous pulse
Check the carotid arteries
Check the apical pulse
Check for the extra heart
sounds
Check blood pressure
1. Peripheral vascular
Assessment
Inspect the fingers, hands,
arms, and temperature
Inspect the capillary refill
time
Check the brachial pulses,
femoral pulses, popliteal
pulse, posterior tibial pulse
and dorsalis pedis pulse
Perform Allen test
Inspect the superficial
inguinal lymph nodes
Inspect for varicosities and
thrombophlebitits
Jugular vein is not
distended. No extra heart
sound. No visible
pulsations in the aortic
and pulmonic areas. A
blood pressure of -
110/70mmHg.
The clients hands, finger
and arms are cold to
touch. Inability to do ROM
and his right arm has
transverse fracture. The
capillary refill time is within
2 second. No varicosities
noted.
Jugular vein is not
distended. No extra heart
sound. No visible
pulsations in the aortic
and pulmonic areas. A
blood pressure of -
110/70mmHg.
The clients hands, finger
and arms are cold to
touch. Inability to do ROM
and his right arm has
transverse fracture. The
capillary refill time is within
1 second. No varicosities
noted.
Jugular vein is not
distended. No extra heart
sound. No visible
pulsations in the aortic
and pulmonic areas. A
blood pressure of
110/60mmHg.
The clients hands, finger
and arms are warm to
touch. Can now extend
his both legs. But still his
right arm has transverse
fracture.
The capillary refill time is
within 1 second. No
varicosities noted.
1. Male/Female Genitalia
Male:
Inspect the base of the penis N/A N/A N/A
and pubic hair
Inspect the skin of the shaft
Inspect the foreskin
Inspect the size, shape an
position of the scrotum
Check urethral discharges
Check for inguinal lymph nodes
and hernia
Female:
Inspect for mons pubis
Observe and palpate inguinal
nodes
Inspect the labia majora and
perineum
Inspect the labia minora, clitoris,
urethral meatus and vaginal
opening inspect the size of the
vaginal opening of the angle of
the vagina
Inspect the cervix
Inspect the vaginal wall
1. Anus and rectum Assessment
Inspect for the peri-anal No masses in the peri-anal No masses in the peri-anal No masses in the peri-anal
area(Note for lumps, ulcers, area. Defecate once with area. Wasnt able to area. Defecate once. No
lesions, rashes and redness) black brown in color. No other defecate. No other other discharges noted.
Check the rectum discharges noted. discharges noted.
Inspect for the stool
characteristic
Inspect for any other discharges
1. Musculoskeletal
Assessment
Inspect size, shape, color
and symmetry
Check for edema, heat,
tenderness, pain and
nodules
Check for ROM
Observe and assess gait
Observe the cervical,
thoracic and lumbar
curves from the side, then
from behind
Check ROM of cervical
spine, thoracic and lumbar
spine
Check ROM of elbows,
wrist, hands, fingers, hips,
ankles and feet
1. Neurologic Assessment
Assess GCS
Check 12 cranial nerves
Assess movement,
balance, coordination,
sensation and reflexes
Check involuntary
movements
Evaluate gait and balance
Assess for sensory system
The extremities are not
symmetrical in color and
size. Edema noted in right
posterior thigh (violet red
in color), tenderness or
pain upon palpation. Also
in the right knee, it is
painful to touch. Has a
bad good posture.
Patient can stand with
assistance but feel dizzy
when standing, can sit
and cannot walk on his
own. Transverse fracture
in the right hand with
bandage on it.
A GCS scoring of 14.
Having an inadequate
sense of balance,
incoordination and
reflexes with no
involuntary movements.
Patient felt restlessness
sometimes. Hes still sometimes. Hes still
oriented. Patient always
sleeps.
The extremities are not The extremities are not
symmetrical in color and symmetrical in color and
size. Edema noted in right size. Edema noted in right
posterior thigh (violet red posterior thigh (violet red
in color), tenderness or in color), tenderness or
pain upon palpation. Also pain upon palpation. Also
in the right knee, it is in the right knee, it is
painful to touch. Has a painful to touch. Has a
bad good posture. bad good posture.
Patient can stand with Patient can stand with
assistance but feel dizzy assistance but feel dizzy
when standing, can sit when standing, can sit
and cannot walk on his and cannot walk on his
own. Transverse fracture own. Transverse fracture
in the right hand with in the right hand with
bandage on it. bandage on it.
A GCS scoring of 14. A GCS scoring of 14.
Having an inadequate Having an inadequate
sense of balance, sense of balance,
incoordination and incoordination and
reflexes with no reflexes with no
involuntary movements. involuntary movements.
Patient felt restlessness Patient felt restlessness
sometimes. Hes still
oriented. Patient is oriented. Patient is
awake. awake.
 Laboratory Results
Name of lab Result Normal value Interpretation Impression / analysis
Hematocrit 40.1 % 42.0 52. 0 % Below the normal Indicates bleeding
range
Hemoglobin 13.6 g/dl 13.5 18.0 g/dl Within normal -
range
WBC 18.1 10^ 9/L 5.0 10.0 10^9/L Above the normal Indicates inflammation
range
RBC 4.52 10 ^12/L 4.7 6.1 10^12/L Below the normal Indicates bleeding
range
Platelet count 258 10^g/L 150-450 10^g/L Within normal -
range
MCV 89 fl 80 94 fl Within normal -
range
MCH 30 pg 27- 31 pg Within normal -
range
MCHC 33.8 g/L 33- 36 g/L Within normal -
range
Differential -
count:

Neutrophils 82.8 50 70 % Above the Indicates infection

normal range

Lymphocytes 5.6 25 - 40% Below normal Indicates infection

range

Monocytes 10.3 3- 11 % Within normal -

range

Eosinophils 1.2 0-10 % Within normal -

range

Basophils 0.1 0- 2 % Within normal -

range
CT Scan- Brain Plain ; July 31, 2017

Impressions:

1. Multifocal Contusion Hemorrhage, left occipital and bilateral posterior parietal

cortical area.
2. Minimal subarachnoid hemorrhage.
3. Mild cerebral edema.
4. Pneumocephalus
5. Linear fractures left side of nasal bone, superior wall of the left orbit.
6. Frontal, ethmoid, maxillary sinuses hemoantra.
7. Adjacent soft tissue swelling along the frontal scalp area.
CXR PA View

Impression:

X-ray of right knee for APL views negative for fracture-dislocation as far as visualized.

X-RAY Wrist

Impression:

Reveals transverse fracture involving the distal end of the right radius.
Pathophysiology
Predisposing Factors: Precipitating Factors:
Age 18 Attempting suicide
Vehicular accident

Multifocal contusion Inflammation

hemorrhage: left occipital
subcortical area (3.0 cc) & WBC- 18.10 10^9/L- I
bilateral posterior parietal Head Injury/ Fractures
Neutrophils- 82. 8 %-I
cortical area (6.0 cc) Lymphocytes- 56.6 %-D

Blood clotting Cefuroxime 750 mg

Minimal Subarachnoid IVTT q8h
Hemorrhage in the
cerebral sulci Linear fracture left
Disruption of nerves side nasal bone,
in the brain superior wall of left
Cerebral sulci are HCT- 40.1 % orbit
Headache slightly effaced RBC-4.52 Adjacent soft tissue
Fatigue 10^12/L swelling along the
Cerebral Hypoxia frontal scalp
Dizziness
Pain Mild cerebral
Loss of edema
function
ISCHEMIA Pneumocephalus

Increased ICP

Mannitol 100 cc IV (by

Decreased Citicoline 1 gm IV the virtue of osmosis;
Ketorolac 30 mg Cerebral q12H (Protects decreased the ICP) q4H
IVTT q6h for pain Perfusion the penumbra
region of the
brain)
IF COMPLICATION OCCURS:
Cerebral Vasoconstriction

Severe Cerebral
Ischemia Cerebral Ischemia

Increased Systemic
Vasoconstriction
COMPENSTORY MECHANISMS

Brain Herniation and

Necrosis Increased ICP

Decreased CPP

DEATH
DOCTORS ORDER
DATE DOCTORS ORDER
07/28/17 Please admit
Secure consent to care
Diet: NPO-Temporarily
IVF- PLD 1 liter @30 gtts/min; 08:05 pm.
Labs:
CBC with BT
X-Ray for right wrist APO
CT Scan: Brain Plain
Meds
1. Mannitol 150 cc IV q8H ;8:10 pm now then 100 cc q4H
2. Ketorolac 30 mg IVTT q6H PRN for pain
3. Tetanus toxoid 0.5 ml IM
4. Tetanus Immune Globulin 250 ml IM
5. Cefuroxime 750 mg IVTT q8H ANST(-)
Monitor v/s every 4h
I&O every shift
Refer accordingly
07/29/17 DAT
CXR-PA
07/30/17 X-RAY RIGHT KNEE APL
07/31/17 Follow up for CT Scan
08/01/17 Follow up for referral to Dr. Bombeo
08/02/17 Citicoline 1 gm IV q12H
Please refer to Dr. Bombeo for collaborative management
08/03/17 Follow up referral to Dr. Bombeo
08/04/17 Follow up referral to Dr. Bombeo
08/05/17 Please follow up Dr. Bombeo
Refer to ortho. Dept. regarding fracture of distal end of the right radius
08/06/17 For referral ortho.
08/07/17 Still for follow up ortho. Dept.
Please follow up referral CT Scan result to Dr. Bombeo
08/08/17 Still for ortho. Dept.
Continue meds.
Please refer CT Scan result to Dr. Bombeo
08/09/17 CT Scan noted
Plan: Non-surgical
Medical management
Management Date General Description Indication Clients Response
Ordered
PLR 07-28-2017 1 liter 30 gtts/mmin Fluid & Electrolyte Rehydrated
replenishment
MOA: restores fluid and electrolyte balances,
produces diuresis, and acts as alkalizing agent

CBC 07-28-17 A complete blood count (CBC) gives important Bleeding and HCT: 40.1 %
information about the kinds and numbers of cells in Inflammation RBC: 4.52 10^12/L
the blood, especially red blood cells , white blood WBC: 18.1 10^9/L
Neutrophils: 82.8 %
cells , and platelets.
Lymphocytes: 5.6 %

Mannitol 07-28-2017 150 cc IV Soln Adjunct in the Edema subsided and the
treatment of edema intraocular pressure
Therapeutic Class: Osmotic Diuretic and intraocular decreases.
pressure.

MOA: Increases the osmotic pressure of the

glomerular filtrate, thereby inhibiting re-absorption of
water and electrolyte, causing excretion of water,
sodium, potassium, chloride, calcium, phosphorus
and magnesium.

Ketorolac 07-28-2017 30 mg IVTT q6H for pain Short term Patient reports no pain.
management for
Therapeutic class: NSAIDs pain.

MOA: Inhibits prostaglandin synthesis.

Tetanus Immuno 07-28- 250 ml IM For transient Patient reports no
Globulin 2017 protection infection of tetanus.
Therapeutic Class: Vaccine against tetanus
in any person
that may be
MOA: Directly neutralizes toxins excreted contaminated
by Clostridium tetanae, causing tetanus. with tetanus
spores when
patients history
or immunization
is unknown.
Tetanus Toxoid 07-28- 0.5 ml IM Prevention Reports no infection of
2017 against tetanus. tetanus.
Therapeutic Class: Anti-tetanus

MOA: Absorped inducers active immunity to

tetanus antigen by activating the immune
system to produce specific anti-toxins

Cefuroxime 07-28- 750 mn IVTT q8h ANST Skin structures/ Reports no skin infection.
2017 infections
Therapeutic Class: Anti-infective

MOA: Bind to bacterial cell wall membrane

causing cell death.

X-RAY WRIST 07-28- Diagnostic x rays are useful in detecting To identify Reveals transverse
2017 abnormalities within the body. They are a fracture.
fracture involving the distal
painless, non-invasive way to help diagnose
problems such as broken bones, tumors, end of the right radius.
dental decay, and the presence of foreign
bodies.
CXR RIGHT KNEE 07-29-2017 The purpose of knee radiographs is to assess the To identify fracture. X-ray of right knee for APL
APL bony structure of the knee and specifically to define
views negative for fracture-
the presence of fractures and also to assess for
degenerative disease within the joint. dislocation as far as
visualized.

CT SCAN: Brain 07-31-2017 A computerized tomography (CT) scan combines a To identify head injury 1. Multifocal Contusion
Plain series of X-ray images taken from different angles and and bleeding.
Hemorrhage, left occipital
uses computer processing to create cross-sectional
images, or slices, of the bones, blood vessels and soft and bilateral posterior
tissues inside your body. CT scan images provide more parietal cortical area.
detailed information than plain X-rays do.
2. Minimal subarachnoid
hemorrhage.
3. Mild cerebral edema.
4. Pneumocephalus
5. Linear fractures left side of
nasal bone, superior wall
of the left orbit.
6. Frontal, ethmoid, maxillary
sinuses hemoantra.
7. Adjacent soft tissue
swelling along the frontal
scalp area

Citicoline 08-2-2017 1 gm IVTT q12h Head trauma Reports no further complications

in the brain.
Therapeutic Class: Central Nervous System stimulant

MOA: Promotes brain metabolism by restoring

phospholipid content in the bran and regulation of
neuronal membrane excitability.
 MEDICATION DOSE TIMING MECHANISM OF ACTION
Mannitol (Osmitrol) 100 cc IV Bolus Every 8 hours Increases the osmotic pressure of the glomerular
filtrate, thereby inhibiting re-absorption of the water
and electrolytes, causing excretion of water, sodium,
potassium, chloride and calcium, phosphorus and
magnesium.

Tetanus Immuno 250 ml IM Directly neutralized toxins excreted by Clostridium

Globulin (Baytet) tetanae, causing tetanus.
Tetanus Toxoid 0.5 ml IM Tetanus toxoid absorbed induces active immunity of
tetanus antigen by activating the immune system to
produce specific anti-toxin.

Citicoline (Cholinerv) 1g IV Every 12 hours Promotes brain metabolism by restoring phospholipid

content in the brain and regulation of neuronal
membrane excitability.

Cefuroxime (Zinacef) 750 mg IVTT Every 8 hours Bind to bacterial cell wall membrane causing cell
ANST death.

Ketorolac (Toradol) 30 mg IVTT for Every 6 hours Inhibits prostaglandin synthesis.

pain
 DATE SOLUTION GTTS INDICATION

07-28-17 PLR 30 gtts/min - Fluid and electrolyte

replenishment
07-29-17 PLR 30 gtts/min

07-30-17 PLR 30 gtts/min

07-31-17 PLR 30 gtts/min

08-01-17 PLR 30 gtts/min

08-02-17 PLR 30 gtts/min

08-03-17 PLR 30 gtts/min

08-04-17 PLR 30 gtts/min

08-05-17 PLR 30 gtts/min

08-06-17 PLR 30 gtts/min

08-07-17 PLR 30 gtts/min

08-08-17 PLR 30 gtts/min

08-09-17 PLR 30 gtts/min

10 Nursing Diagnosis
1.Impaired skin integrity related to multiple lacerations and abrasions secondary
to vehicular accident.
2.Impaired physical mobility related to pain; decreased muscle strength, loss if
integrity of bone structures and musculoskeletal impairment secondary to
vehicular accident.
3.Acute pain related to physical injury secondary to vehicular accident.
4.Imbalanced nutrition: less than body requirements related to inability to ingest
foods as evidenced by swollen lips with abrasions.
5.Impaired verbal communications related to low self-esteem.
6. Spiritual distress related refuses interactions with significant others.
7. Risk for suicide related to history of prior suicide attempt.
8. Dysfunctional gastrointestinal motility related to pharmaceutical
agents (Cefuroxime) and also immobilization.
9. Fatigue related to poor physical condition as evidenced by lack of
energy.
10.Impaired walking related to insufficient muscle strength and pain.
NURSING CARE PLAN
 ASSESSMENT NURSING DESIRED OUTCOME INTEVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Impaired skin At the end of 8 hours 1. Identify underlying 1. To assess At the end of 8 hours
Gikulata man gud ni integrity related to nursing interventions, the condition or pathology causative/contributi nursing intervention, the
siya ug gitabangan ug multiple lacerations client will be able to; involved. ng factor. client was able to;
upat ka tawo dayun wala and abrasions 2. Determine nutritional 2. To assess the
pd siya kaila, hasta pud secondary to 1.Maintain optimal status and potential for factors. 1.Partially maintained
mi wala kaila. Nakit-an vehicular accident nutrition for healing delayed healing or tissue 3. To help in healing optimal nutrition for
rana siya sa bukid sa promotion injury exacerbated by process. healing promotion.
Tangub sa among 2.Participate in malnutrition. 4. To provide 2.Participate in prevention
kapitan didto as prevention and treatment 3. Assess and evaluate skin comparative and treatment program.
verbalized by the program care. baseline and 3.Displayed timely healing
patients mother. 3.Display timely healing 4. Assess vital signs and opportunity for of skin lesions and
of skin lesions and sensation of skin surfaces timely intervention wounds without
Objective: wounds without and affected area on when problems are complications.
Lacerated wound in complications. regular basis. noted.
the face area 5. Note presence of 5. That may impact
Periorbital edema compromised mobility, clients self-care as
Abrasions in both sensation, vision, hearing relates to skin care.
upper and lower lips or speech. 6. To assess also the
Abrasions in the 6. Review Lab results healing process.
mandible pertinent to causative 7. To determine
Lacerations in both factors. appropriate
eyebrows 7. Obtain specimen from therapy.
Bruises at right thigh draining wounds when 8. To determine the
Swollen right knee appropriate for culture and healing progress.
sensitivities. 9. To fight for
8. Perform routine skin bacterial infection.
inspections describing 10. For the patients
observed changes. participation.
9. Administer medications as 11. To assist with
prescribed by the developing plan of
physician (Cefuroxime- care for
antibacterial) problematic or
10. Obtain psychological potentially serious
assessment of the clients wounds.
emotional status.
11. Consult with wound
specialist.
 ASSESSMENT NURSING DIAGNOSIS DESIRED OUTCOME INTEVENTION RATIONALE EVALUATION
Subjective: Impaired physical At the end of 8 hours 1. Assess degree of 1. To assess At the end of 8 hours
Nabali man gud na mobility related to pain; nursing intervention, pain. causative/ nursing intervention, the
iyang kamot, tapos decreased muscle the patient will be able 2. Determine history contributing factors. patient was able to;
nilagom ug nihubag strength, loss of to; of falls and 2. To assess
ang tuo nga bagtak integrity of bone related to current causative/ 1.Verbalized
hasta tuhod as structures and 1.Verbalize situation. contributing factors. understanding of
verbalized by the musculoskeletal understanding of 3. Assess for vital 3. Identify deviation situation and individual
patients mother. impairment secondary situation and individual signs and any from the normal and regimen and safety
to vehicular accident. treatment regimen and complications. to establish baseline measures.
Objective: safety measures. 4. Asses nutritional parameters. 2.Partially position of
Swollen right thigh 2.Maintain position of intake. 4. To promote energy. function and skin
and knee with bruises. function and skin 5. Encourage to turn 5. To promote comfort integrity.
Transverse fracture integrity. to side every 2 and circulation. 3.Maintain or increase
distal end of the 3.Maintain or increase hours. 6. To assess strength and function of
radius of the right strength and function 6. Determine degree functional ability. affected or
hand of affected or of immobility in 7. To promote optimal compensatory body
Lacerated and compensatory body relation to level of function and part.
sutured wound part. previously prevent
between the 1st and suggested scale. complications
2nd digit of the left 7. Assist with the 8. To promote faster
foot. treatment of healing progress.
underlying 9. For faster recovery.
condition 10. To develop
8. Administer individual exercise
medications as and mobility
prescribed by the program.
physician
9. Encourage
adequate intake
of fluids and
nutritious foods.
10. Collaborate with
physical medicine
specialist
involving range of
motion.
 ASSESSMENT NURSING DESIRED OUTCOME INTEVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain related to At the end of 8 hours 1. Identify presence 1. To assess At the end of 8 hours
Sakit ang iyang ulo, physical injury nursing intervention, of physical causative/contrib duty, the client was
naa daw murag secondary to vehicular the client will be able condition. uting factors. able to:
gatusok-tusok tapos accident. to; 2. Note diagnosis 2. To assess 1.Regained her energy.
kada mutindog siyay 1.Regain energy. or possibility of causative/contrib 2.Partially met; still
mangihi, malipong 2.Report no pain. acute pain uting factors. reports pain.
siya as verbalized by 3.Perform activities of 3. Assess vital 3. To evaluate fluid 3.Partially performed
the patients mother. daily living and signs. status and activities of daily living
participate in desired 4. Assess for pain. cardiopulmonary and participated in
Objective: activities at level of 5. Establish response to desired activities at
Facial grimace ability. realistic activity activity. level of ability.
Irritability 4.Participate in goals with client 4. To provide 4.Participated in
Restlessness recommended and encourage appropriate care. recommended
treatment program. forward 5. To promote program.
movement. optimal outcome.
6. Provide nutrition. 6. To regain energy
7. Administer and metabolism.
medications as 7. To promote
prescribe by the comfort and
physician. regain energy.
8. Review 8. Combinations of
medication drugs are known
regimen. to cause fatigue.
9. Refer to 9. To improve
comprehensive stamina, strength
rehabilitation and muscle tone
program, and to enhance
physical and sense of well-
occupational being.
therapy for
programmed
daily exercises
and activities.
Drug Study
DRUG NAME ROUTE/DOS INDICATI MECHANISM CONTRAINDICAT SIDE EFFECTS NURSING RESPONSIBILTY/ PT TEACHING
AGE/FREQU ON OF ACTION ION
ENCY
GENERIC 100 cc IV Adjunct in Increases the Hypersensiti 1. Confusion Monitor vital signs, urine output and the
NAME: Bolus the osmotic
Mannitol treatment pressure of vity 2. Headache IVF.
of edema the Anuria 3. Blurred vision
and glomerular Assess for dehydration.
BRAND intraocular filtrate, Dehydration 4. Rhinitis
NAME: pressure. thereby Active 5. Transient Monitor electrolyte imbalance.
Osmitrol inhibiting re-
intracranial volume
absorption of Assess for edema.
PHARMACOL the water and bleeding expansion
OGIC CLASS: electrolytes,
6. Chest pain Monitor neurological status.
Osmotic causing Use cautiously in:
diuretic excretion of 7. CHF
water, Monitor for persistent eye pain.
Pregnancy 8. Pulmonary
THERAPEUTI sodium,
C CLASS: potassium, Lactation edema Observe infusion site frequently for
Diuretic chloride and 9. Tachycardia infiltration.
calcium,
phosphorus 10. NV
Assess for physical examination, muscle
and 11. Thirst
magnesium. tingling, paresthesia, confusion, excessive
12. Renal failure
thirst.
13. Urinary retention

14. Dehydration Report to physician for any complications

15. Hyperkalemia
Renal functions should be monitored.
16. Hypernatremia

17. Hyponatremia

18. Hypokalemia

19. Phlebitis @ IV

site.
 DRUG NAME ROUTE/DOSAGE INDICATION MECHANISM OF CONTRAINDICA SIDE EFFECTS NURSING
/FREQUENCY ACTION TION RESPONSIBILTY
/ PT TEACHING
GENERIC NAME: 250 ml IM Transient Directly Hypersensiti 1. Difficulty of Assess
Tetanus Immuno protection against neutralized toxins vity breathing previous
Globulin tetanus in any excreted by Caution: 2. Hives immunizatio
person that may Clostridium Bleeding 3. Itching n history.
BRAND NAME: be contaminated tetanae, causing 4. Swelling Inform
Baytet with tetanus tetanus. 5. Tiredness patient of
spores when 6. Weakness potential and
patients history of 7. Convulsion reportable
PHARMACOLOG immunization is side effect of
IC CLASS: unknown. the TIG.
Immune Globulin

THERAPEUTIC
CLASS:
Vaccine
DRUG NAME ROUTE/D INDICATIO MECHANI CONTRAIN SIDE EFFECTS NURSING
OSAGE/F N SM OF DICATION RESPONSIBILTY/
REQUEN ACTION PT TEACHING
CY
GENERIC 0.5 ml IM Prevention Tetanus Hyperse 1. Redness Monitor vital
NAME: against toxoid nsitivity 2. Swelling signs.
Tetanus tetanus. absorbed Patient 3. Lymphadenop Educated patient
Toxoid induces with low athy to increase fluid
active immune 4. Tachycardia intake.
BRAND immunity system 5. Hypotension Educate patient
NAME: of tetanus 6. Flushing that pain and
Tetanus antigen by 7. Muscle pain tenderness in the
Toxoid activating 8. Thrombocytop injection site may
the enia occur.
immune Monitor patient
PHARMACO system to for complication.
LOGIC produce
CLASS: specific
EPI Vaccine anti-toxin.

THERAPEUT
IC CLASS:
Anti-tetanus
 DRUG ROUTE/D INDICATION MECHANIS CONTRAINDI SIDE EFFECTS NURSING RESPONSIBILTY/ PT
NAME OSAGE/F M OF CATION TEACHING
REQUENC ACTION
Y
GENERIC 1g IV Head trauma Promotes Hypersen 1. Fleeting and Instruct patient to take
NAME: brain sitivity discrete medications as directed.
Citicoline metabolism Patient hypotension Assess vital signs especially
by restoring with effect the blood pressure.
BRAND phospholipid hypertoni 2. Increase Monitor adverse effects.
NAME: content in the c of the parasympathe Report directly if the patient
Cholinerv brain and parasymp tic effect experience chest tightness,
regulation of athetic 3. Hypotension headache, tingling
PHARMAC neuronal Cautions: 4. Itching sensation, and blurring of
OLOGIC membrane pregnanc 5. Hives vision.
CLASS: excitability. y and 6. Swelling in the Monitor neurologic function.
Nootropics lactation face and Advise to report any
hands complications.
THERAPE 7. Chest
UTIC tightness
CLASS: 8. Tingling in the
Central mouth and
nervous throat
system 9. Headache
stimulant 10. NV
11. Diarrhea
12. Blurred vision
DRUG NAME ROUTE/DOS INDICATION MECHANISM CONTRAINDICAT SIDE EFFECTS NURSING RESPONSIBILTY/ PT
AGE/FREQU OF ACTION ION TEACHING
ENCY

Bind to bacterial
GENERIC 750 mg IVTT Skin structure Hypersensiti 1. Seizure Arrange for culture and sensitivity
NAME: q8H infections. vity. 2. Pseudomembr tests before beginning therapy.
Cefuroxime ANST cell wall Cross- anous colitis
Assess for skin infections.
membrane sensitivity 3. Diarrhea
among 4. Cramps Assess for vital signs.
BRAND causing cell agents within 5. NV
Continue therapy for 2 days after
NAME: death. class may 6. Rashes
signs and symptoms of infection are
Zinacef occur. 7. Urticarial gone.
8. Bleeding
PHARMACOL 9. Hemolytic Ensure that patient is well hydrated.
OGIC CLASS: Cautions anemia
Give antacids at least 2 hr after
2nd Pregnancy 10. Phlebitis @ IV
dosing.
generation Lactation site
Cephalospori Renal 11. Pain @ IM site Monitor clinical response; if no
ns impairment 12. anaphylaxis improvement is seen or a relapse
occurs, repeat culture and sensitivity.
THERAPEUTI Encourage patient to complete full
C CLASS: course of therapy.
Anti-infective
Drink plenty of fluids while you are
taking this drug.

You may experience these side

effects: Nausea, vomiting,
abdominal pain (eat frequent small
meals); diarrhea or constipation;
drowsiness, blurring of vision,
dizziness (observe caution if driving
or using dangerous equipment).

Report rash, visual changes, severe

GI problems, weakness, tremors.
 DRUG ROUTE/D INDICATIO MECHANIS CONTRAINDI SIDE EFFECTS NURSING RESPONSIBILTY/ PT
NAME OSAGE/FR N M OF CATION TEACHING
EQUENCY ACTION
GENERIC 30 mg IVTT Short term Inhibits Hypersen 1. Drowsiness Assess for asthma, aspirin-
NAME: q6H for manageme prostaglandin sitivity. 2. ABN induced allergy and nasal
Ketorolac pain nt for pain. thinking
synthesis polyps.
3. Dizziness
Cautions 4. Headache
Assess for pain.
BRAND Pregnanc 5. Asthma
NAME: y 6. Dyspnea Evaluate liver function test.
Toradol Lactation 7. Edema
8. Pallor Assess for bleeding.
PHARMAC 9. Vasodilation
OLOGIC 10. Diarrhea Monitor increased BUN and
CLASS: 11. Bleeding creatinine.
Pyrroziline 12. NV
Carboxylic 13. Oliguria Take medications as
Acid 14. Exfoliate prescribed by the physician.
dermatitis
THERAPE 15. Pruritus Advise patient to avoid
UTIC 16. Sweating alcohol, aspirin, NSAIDs
CLASS: 17. Urticarial without consulting the
NSAIDs, 18. Paresthesia
physicians.
non-opioid 19. Anaphylaxis
analgesics Advise to report any
complications.
Discharge Summary

DATE ADMITTED: 07-28 17; 8:00 pm DATE OF DISCHARGE: Still On-admission

ATTENDING PHYSICIAN: Dr. Damiles

ADMITTING DIAGNOSIS: Cerebral contusion with multiple lacerations and abrasions probably
secondary to vehicular accident.

FINAL DIAGNOSIS:

CHIEF COMPLAINT Prior to admission, the patient complaints of pain @ right leg, deformed right arm,
and lacerated wound in face area.
Discharge Planning

Medicine:

Continue medication

Treatment

Medication as prescribed:

Health Teaching

1. Eat healthy foods to promote faster healing.

2. Take the medication prescribed by the doctor religiously.
3. Do not scratch the cast or splint with sharp objects if there is a cast or splint used.
4. Make sure that there is no drainage from the cast or splint, if present ask for the nurse to prepare
wound dressing.
5. Do not scratch the scabbing wound.
6. Do not put any harsh ointment on the lacerated skin.
7. Put an icepack on the area that is swelling
Out patient Follow-up:

Prognosis
The prognosis of the patient is getting better because there are visible signs
that the swelling, bruises and lacerations are healing.
Recommendation:
The students recommend the following for the patient:
WOUND CARE/ LACERATION
1) If you have stitches, do not wet the area for the first 24 hours. After 24
hours, you can wash the area with mild soap and water and pat dry. Do
not scrub the wound.
2) If you have a bandage, do not touch it for the first 24 hours. If it becomes
stained with blood, make the bandage thicker by adding more gauze. You
can remove the bandage after 24 hours.
3) Do not pick at the sutures, tape or glue. It may cause the wound to open
or get infected.
4) Do not wet the area for the first 24 hours.
5) Have the stitches or sutures removed when instructed. Do not remove
them yourself. They will be removed at different times depending on the
type and location on your body. If they are removed too late, they can
cause scars or lead to an infection. If you have absorbable sutures, they
do not have to be removed and will break down on their own. If the
injury is over a joint, avoid stretching the joint so the wound does not
open.
BROKEN ARM
1. If the doctor gave you a sedative:
o For 24 hours, don't do anything that requires attention to detail. It takes time for
the medicine's effects to completely wear off.
o For your safety, do not drive or operate any machinery that could be dangerous.
Wait until the medicine wears off and you can think clearly and react easily.
2. Put ice or a cold pack on your arm for 10 to 20 minutes at a time. Try to do this every
1 to 2 hours for the next 3 days (when you are awake). Put a thin cloth between the
ice and your cast or splint. Keep the cast or splint dry.
3. Follow the cast care instructions your doctor gives you. If you have a splint, do not
take it off unless your doctor tells you to.
4. Be safe with medicines. Take pain medicines exactly as directed.
o If the doctor gave you a prescription medicine for pain, take it as prescribed.
o If you are not taking a prescription pain medicine, ask your doctor if you can
take an over-the-counter medicine.
5. Prop up your arm on pillows when you sit or lie down in the first few days after the
injury. Keep the arm higher than the level of your heart. This will help reduce
swelling.
6. Follow instructions for exercises to keep your arm strong.
7. Wiggle your fingers and wrist often to reduce swelling and stiffness
QUESTIONS ?
 THANK YOU
FOR LISTENING
!!!