HEAD INJURY

INTRODUCTION

• Traumatic brain injury is defined as damage to the brain resulting

from external mechanical force, such as rapid acceleration or

deceleration, impact, blast waves, or penetration by a projectile.

Brain function is temporarily or permanently impaired and

structural damage may or may not be detectable with current

technology. Traumatic brain injury is usually classified based on

severity, anatomical features of the injury, and the mechanism (the

causative forces).

• Mechanism-related classification divides brain injury into closed

and penetrating head injury. A closed (also called no

penetrating, or blunt) injury occurs when the brain is not

exposed. A penetrating or open, head injury occurs when an

object pierces the skull and breaches the dura mater, the

outermost brain. A large percentage of the people killed by brain

trauma do not die right away but rather days to weeks after the

event; rather than improving after being hospitalized, some 40%

of traumatic brain injury patients deteriorate.

• Primary brain injury (the damage that occurs at the moment of

trauma when tissues and blood vessels are stretched, compressed,

and torn) is not adequate to explain this deterioration; rather, it is

caused by secondary injury, a complex set of cellular processes and

biochemical cascades that occur in the minutes to days following

the trauma. These secondary processes can dramatically worsen

the damage caused by primary injury and account for the greatest

number of traumatic brain injury deaths occurring in hospitals.

• We chose this study since it deals primarily

with cognition. Our patient has had a head

injury. This caught our attention for this will

add more knowledge on how does brain injury

can cause alteration in cognition.

OBJECTIVES

• General Objectives:

• Our group aims to formulate a comprehensive

case analysis that would provide essential

knowledge and skills in delivering quality

health care to patient’s diagnosed with head

injury.

SPECIFIC OBJECTIVES:

• Present biographical information of the patient, reasons for seeking health care, history of the past and present illness including the family health history and family history.

• Discuss an overview on the anatomy and physiology of the Nervous System.

• Explain the pathophysiology of the said disease both actual and ideal.

• Enumerate and discuss the drugs and its pharmacologic effects.

SPECIFIC OBJECTIVES

• Enumerate important nursing management to improve the client’s condition.

• Identify the actual and potential prognosis of the case presented.

• Note down problems in relation to the client’s current health status base on Gordon’s typology of 11 health problems.

• Compose an effective nursing care plan to address the identified problems.

• Identify the necessary health teachings and recommendations.

DEMOGRAPHIC PROFILE

• Personal Data– Name: “Yi Jeong”– Age: 17 yrs old– Sex: Male– Civil Status: Single – Religion: Islam– Nationality: Filipino– Address: Prk. Sta. Lucia Poblacion Tupi, South

Cotabato

DEMOGRAPHIC PROFILE

• Admission impression:– Depressed Fracture

• Attending Physician: – Dr. Narciso Mirabueno Jr.

• Final diagnosis:– Open depressed fracture with dural laceration,

right parietal to occipital

DEMOGRAPHIC PROFILE

• Brief history: – NOI- Mauling– TIC- 9pm– DOI- 6/12/10– POI- Tupi South Cotabato

• Was mauled 2 days ago by known assailant thereby sustained injury.

Past Medical History:

• The patient’s usual illnesses were fever, cough, and

colds but he never consults a doctor for check up.

However, he goes to “Hilot” and uses pharmacologic

treatment such as analgesics and antipyretics to treat

fever. The patient verbalized “Wala man jud kaayo ko

gasakit bixan tong una. Kana lang ang mostly na

akung sakit”

Present Medical History:

• The patient was mauled, and through that, he sustained

a laceration on the parieto-occipital area of his head. He

stated that during the incident, he loss his consciousness

and directly admitted to a nearby hospital. Few days

after, he was rushed at General Santos Hospital for he

was experiencing severe headache and dizziness. He was

under the care of Dr. Mirabueno.

PHYSICAL AND CEPHALOCAUDAL ASSESSMENT

General survey

• A 17 year old patient, conscious and coherent.

Able to cooperate during procedure. Clean

and neat, no body odor noted. The patient

appears weak and frequent yawning noted

head

• smooth contour, hair evenly distributed in the scalp, no presence of dandruff noted. Laceration at right area of the head noted.

eyes

• eyebrows and eyelashes are evenly distributed

and symmetrically aligned. Pupil is reactive to

light. Pink and moist conjunctiva. No

discharges noted. Sleepy eyes noted. Both

eyes are coordinated, moves

nose

• straight and symmetrical. Mucus membranes

are moist and pink in color. No lesion and

presence of exudates noted. Airs move freely

when the patient breathes through the nares.

No flaring noted.

mouth

• able to pursed lip. Soft, moist and pink mucosa

noted. No lesion noted. Absence of left lateral

incisor noted. Pink and moist gums noted.

ears

• symmetrical. Color same as facial skin. Auricle

aligned with outer canthus of the eye mobile,

firm and not tender; pinna recoils after it is

folded. No discharges noted. Sound is heard in

both ears

neck

• symmetrically aligned and in the midline.

Muscle equal in size; head is centered.

• neck muscles are equal in strength as patient

can flex, hyperextend and laterally rotates his

head

chest

• Symmetrical contour, skin color same with

facial skin. Skin is intact. Chest wall is intact; no

tenderness; no masses noted.

• Spinal column is straight,

• Right and left shoulder and hips are at the same

height. Full and symmetric chest expansion

abdomen

• Symmetric contour. Symmetric movements

caused by respiration. No evidence of

enlargement of liver or spleen. Flat and

rounded contour of abdomen. Unblemished

skin noted

Upper extremities

• Equal size on both sides of the body. Able to

abduct, adduct, flex and extend

Lower extremities

• Equal size on both sides of the body. Has

upright posture and steady gait with opposing

arm swing; walk unaided and can maintain

balance. Able to abduct, adduct, flex and

extend

REVIEW OF ANATOMY

NERVOUS SYSTEM

• The brain is a highly specialized organ. It serves as the control

center for functions of the body and allows us to cope with

our environment. Words, actions, thoughts, and feelings are

centered in the brain. It is so complex that some theorists

believe we will never be able to fully understand it. We do,

however, know that each part of the brain has a specific,

important function, often a profoundly important function,

and each part contributes to the healthy functioning of our

body.

• Cerebrum is the largest part of the brain and is

associated with conscious thought, movement and

sensation. It consists of two halves, each controlling

the opposite side of the body. The halves are

connected by the corpus callosum, which delivers

messages between them. Four lobes make up the

cerebrum: the frontal, temporal, parietal, and occipital

lobes.

• Frontal Lobe is one of the four lobes of the cerebral

hemisphere. It controls attention, behavior, abstract

thinking, problem solving, creative thought, emotion,

intellect, initiative, judgment, coordinated movements,

muscle movements, smell, physical reactions, and

personality.

• Occipital Lobe is one of the four lobes of the cerebral

hemisphere. It is located in the back of the head and

controls vision.

• Parietal Lobe is one of the four lobes of the cerebral

hemisphere. It controls tactile sensation, response to

internal stimuli, sensory comprehension, some

language, reading, and some visual functions.

• Temporal lobe is one of the four lobes of the cerebral

hemisphere of the cerebral hemisphere. It controls

auditory and visual memories, language, some hearing

and speech, language, plus some behavior.

• Brain Stem is located at the bottom of the brain and connects the cerebrum to the spinal cord. The brain stem controls many vitally important functions including motor and sensory pathways, cardiac and respiratory functions, and reflexes.

• Cerebellum is located at the lower back of the head and is connected to the brain stem. It is the second largest structure of the brain and is made up of two hemispheres. The cerebellum controls complex motor functions such as walking, balance, posture, and general motor coordination

• Dura mater or dura, is the outermost of the three

layers of the meninges surrounding the brain and

spinal cord. The other two meningeal layers are

the pia mater and the arachnoid mater. The dura

surrounds the brain and the spinal cord and is

responsible for keeping in the cerebrospinal fluid

PATHOPHYSIOLOGY

• Depressed skull fractures: These are common after

forceful impact by blunt objects-most commonly,

hammers, rocks, or other heavy but fairly small

objects. These injuries cause "dents" in the skull

bone. If the depth of a depressed fracture is at least

equal to the thickness of the surrounding skull bone

(about 1/4-1/2 inch), surgery is often required to

elevate the bony pieces and to inspect the brain for

evidence of injury

• The skull is made up of a variety of bones; the dura, the

thick membrane that wraps around the brain, attaches

at the suture lines where the bones come together. If

bleeding occurs in the enclosed space between the dura

and the bone, and a hematoma (blood clot) forms, there

is nowhere for it to accumulate and pressure within the

epidural space can build quickly. The increasing pressure

pushes the hematoma against the brain tissue and may

cause significant damage

• Presentation varies according to the injury. Some patients with head

trauma stabilize and other patients deteriorate. A patient may present

with or without neurologic deficit.

• Patients with concussion may have a history of seconds to minutes

unconsciousness, then normal arousal. Disturbance of vision and

equilibrium may also occur.

• Common symptoms of head injury include coma, confusion,

drowsiness, personality change, seizures, nausea and vomiting,

headache, during which a patient appears conscious only to

deteriorate later

LABORATORY RESULT

CT SCAN OF THE HEAD

• Multiple plain axial CT images of the head reveal a segmental, depressed

fracture in the posterior parietal occipital bones, right. This has an

aggregate width of 2.5 cm. Small pockets of air are also noted in a small

lenticular, extra axial hyperderse focus opposed to the fracture site

medially. This is immediately lateral to the posterior interhemispheric

fissure. Small hemorrhagic conclusion with mild to moderate

surrounding edema is seen in the underlying posterior parietal and

occipital lobes, right. It involves the right posterior optic tract

• Ventricles are symmetrical in size and

configuration. Midline structures and not

displaced laterally

• Posterior fossa, petromastoids and visualized

paranasal sinuses are unremarkable

Impression:

• Depressed fractures as described w/ small

pneumocephalus and epidural hematoma,

right occipito- parietal

• Hemorrhagic contusion, right posterior

parietal and occipital lobes

Skull AP/L

• A double bone density is seen in the left posterior

occipital bone. This is associated with moderate

swelling of the overlying remarkable findings

• Impression:

• Depressed fractures, Left posterior occipital bone with

soft tissue hematoma.

Complete blood count (CBC) platelet Count

Examination Result Normal Value

WBC 13.42 5x10x10 9/L x 10 9/L

Segmeters 0.74 0.55- 0.65

lymphocytes 0.12 0.25- 0.35

menocytes 0.13 0.03- 0.06

eosinophil 0.01 0.02- 0.04

hemoglobin 149 140-170g/L

hematocrit 0.42 0.40-0.50 vol % vol %

platelet count 337 150- 350 x 10 g/L x 10 g/L

RECORD OF OPERATION

• Time started: 12:25PM• Time ended: 1:43PM• Surgeon: Dr. Mirabueno• Anesthetist: Dr. B Anislag• Anesthetic: GA – intubation

• Pre- op Diagnosis:– Open deprsessed fracture Right posterior parietal;

cerebral contusion/ pneumocephalis, Right posterior Parietal lobe; Epidural hematoma Right P-O.

• Post op Diagnosis:– Same + Dural laceration 1cm

• Operation performed:– Debridement / craniotomy/elevation of depressed

skull fracture phic # 61312; evaluation of epidural hematoma; repair of plural laceration

• Surgical Technique Procedure:

– Laceration extended at both ends. Craniotomy

done to removal done to removal bone fragments.

Evacuation of EDH. Cauterization of bleed

elevation or repair of depressed fracture. Flushing

with NSS. Layer closure of skin sterile dressing

applied.

– EST blood loss 150cc

NURSING CARE PLAN

Self Care Deficit r/t uncomfortable bathing

environment

Self Care Deficit r/t uncomfortable bathing environment

Subjective Cues

• “Gusto nako maligo pero dili ko ganahan kay daghan ug samok” as verbalized by the pt.

Objective Cues

• Dry skin noted• Diaphoresis noted• Clothes was not

changed for two days

• Unorganized bathroom noted

Self Care Deficit r/t uncomfortable bathing environment

NEED• PHYSIOLOGIC

Desired Outcome

• within 8° span of care, pt. will be able to:

• perform self care activities (bathing)

Self Care Deficit r/t uncomfortable bathing environment

NURSING INTERVENTION• establish rapport

• encourage verbalization of feelings

• assess the clients ability to participate in bathing

RATIONALE• establishing rapport gains

trust and cooperation through out the procedure

• discovers barriers to participate on intervention

• underlying conditions dictates level of deficit in choice of intervention

NURSING INTERVENTION

• assess barriers to participation in self care

• identify or plan for environmental modifications (maintain bathroom clean and organized)

• provide pts. privacy

RATIONALE

• assessing pts. participation can contribute on motivating pt. to observe hygiene

• prepares for increased independence, which enhances self esteem and can motivate pt. do bathing

• providing privacy increases motivation to do task

NURSING INTERVENTION

• provide positive feedback for efforts and accomplishments

• give information about other self care options (TSB)

• obtain bath supplies (soap, towel)

RATIONALE

• enhances sense of self worth, promotes independence

• provides other alternatives on self care activities

• encourages pt. to do bathing

goals met as evidenced by:

>able to perform self care

EVALUATION

Sleep Deprivation related to Uncomfortable Sleeping

Environment

Sleep Deprivation related to Uncomfortable Sleeping Environment

Subjective Cues

• “dili kayo ko makatulog” as verbalized by the pt.

Objective Cues

• restless• weakness noted• Lethargic• frequent yawning

noted• diaphoresis noted• disorganized bed

noted

Sleep Deprivation related to Uncomfortable Sleeping Environment

NEED

• PHYSIOLOGIC

DESIRED OUTCOME

• within 8° span of care, pt. will be able to:

• rest and sleep comfortably

Sleep Deprivation related to Uncomfortable Sleeping Environment

NURSING INTERVENTION• establish rapport

• encourage verbalization of feelings

• encourage walking and instructed to return to bed until feeling sleepy

RATIONALE• establishing rapport gains

trust and cooperation through out the procedure

• discovers barriers to participate on intervention

• enhances expenditure of energy so that client feels ready for sleep or rest

NURSING INTERVENTION

• provide with calm and quiet environment conducive for rest

• assist pt. on arranging his bed linens

• provide comfort measures such as touch therapy

RATIONALE

• reduces stimulation and promotes relaxation

• promotes relaxation

• reduces tension thereby promotes relaxation

NURSING INTERVENTION

• recommend quiet activities such as reading

• encourage to use relaxation techniques such as touch therapy

RATIONALE

• reduce stimulation so pt. can relax

• reduces tension thereby promotes relaxation

goals met as evidence by:

>able to rest and sleep comfortably

EVALUATION

DRUG STUDY

Nalbuphine HCL (Nubain)

INDICATION• This is indicated for

relief of moderate to severe pain.

MODE OF ACTION• Acts as an agonist at

specific opioid receptors in the CNS to produce analgesia and sedation but also acts to cause hallucination

ADVERSE EFFECTS• CNS: sedation, clamminess, sweating,

headache, confusion, hallucination• CV: hypotension, hypertension, bradycardia,

tachycardia• Dermatologic: pruritus, urticaria• GI: nausea and vomiting, dyspepsia, dry

mouth• GU: urinary urgency• Respiratory: dyspnea, respiratory depression

NURSING RESPONSIBILITIES• Observe for the 10 rights before giving the drug.• Educate the patient about the side effects of the

drug.• Taper dosage when discontinuing after prolonged

use to avoid withdrawal symptoms.• Keep opiod antagonist and facilities for assisted o

controlled respiratory depression.• Reassure patient about addiction liability; most

patients who received opiates for medical reasons do not develop dependence syndrome.

Diphenhydramine HCL (Allerdryl)

INDICATION

• It is indicated for relief of symptoms associated with seasonal allergic rhinitis.

MODE OF ACTION

• Competitively blocks the effects of histamine h1-receptor site, has atropine like, anti-pruritic and sedative effects.

SIDE EFFECTS

• CNS: drowsiness, sedation, fatigue, confusion, tremor

• CV: hypotension, palpitation, bradycardia• GI: epigastric distress, increased appetite and

weight gain, diarrhea and constipation• Respiratory: thickening of bronchial

secretions, chest tightness, wheezing, stuffiness

NURSING RESPONSIBILITIES• Observe for the 10 rights before giving the drug.• Educate the patient as well as the significant

others with the side effects of the drugs.• Administer with food to avoid GI upset.• Monitor patient’s response and arrange for

adjustment of dosage to lowest possible effective dose.

• Instruct patient to avoid alcohol to prevent serious sedation.

Cefuroxime axetil (Zinnat)

INDICATION

• Lower and upper respiratory tract infections, GUT infections, skin and soft tissue infections, gonorrhoea including acute uncomplicated gonococcal urethritis and cervicitis

MODE OF ACTION

• Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs)

ADVERSE REACTION• GI disturbances, occasionally

pseudomembranous colitis; hypersensitivity reactions.

• Eosinophilia; headache, superinfection, eryrhema multiforme.

• Steven’s-Johnson syndrome

NURSING RESPONSIBILITIES• Observe for the 10 rights before giving the

medication• Assess bowel function• Monitor for allergic reaction• Monitor urine output• Assess for opportunistic infection (fever,

malaise, rash)

Mefenamic acid(Dolfenal)

INDICATION

• Relief of mild to moderately severe somatic and neurotic pain

MODE OF ACTION

• Anti-inflammatory, Analgesic and Antipyretic activities related inhibition of prostaglandin synthesis; exact mechanism of action are not known.

ADVERSE REACTION

• GI disturbance• GI hemorrhage• Drowsiness• Dizziness• Headache• Visual disturbances

NURSING RESPONSIBILITIES

• Observe for the 10 rights before giving the medication

• Instruct patient that swallow it whole do not chew or break the capsule

• Instruct patient to take drug with food for good absorption

• Maintain hydration• Instruct patient to report promptly if adverse

reaction occurs

PROGNOSIS

• In some cases, transient neurological disturbances may occur, lasting

minutes to hours. Recovery in patients with neurologic deficits will

vary. Patients with neurologic deficits who improve daily are more

likely to recover, while those who are vegetative for months are less

likely to improve. Most patients without deficits have full recovery.

However, persons who sustain head trauma resulting in

unconsciousness for an hour or more have twice the risk of

developing Alzheimer's disease later in life.

CONCLUSION

• You cannot hold yourself if unavoidable circumstances strikes. In this case, patient knows the assailant (a friend). The assailant was drunk and has altered on his level of consciousness. With this, he was mauled by a rock.

RECOMMENDATION

• Bed rest, fluids, and a mild pain reliever, for example, acetaminophen (Tylenol) may be prescribed. Ice may be applied to the scalp for pain relief and to decrease swelling.

• Eat a balanced diet.• Proper exercise. Exercise is very vital to the

body’s normal functioning.• Have a regular check-up.

RECOMMENDATION

• Have adequate rest and sleep periods. Avoid too much straining or performing strenuous activities especially during the few days after operation.

• Maintain a close relationship among family members and neighbours. Social interaction is vital for well-being. Spirituality must also be taken in consideration.