I.

INTRODUCTION

A. Overview of the Study

Head injury is a general term used to describe any trauma to the head, and most
specifically to the brain itself. Skull fracture: A skull fracture is a break in the bone surrounding
the brain and other structures within the skull. Linear skull fracture: A common injury,
especially in children. A linear skull fracture is a simple break in the skull that follows a relatively
straight line. It can occur after seemingly minor head injuries (falls, blows such as being struck
by a rock, stick, or other object; or from motor vehicle accidents). A linear skull fracture is not a
serious injury unless there is an additional injury to the brain itself. 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. Minimally depressed fractures are less than the thickness of the bone. Other
fractures are not depressed at all. They usually do not require surgical treatment unless other
injuries are noted. Basilar skull fracture: A fracture of the bones that form the base (floor) of
the skull and results from severe blunt head trauma of significant force. A basilar skull fracture
commonly connects to the sinus cavities. This connection may allow fluid or air entry into the
inside of the skull and may cause infection. Surgery is usually not necessary unless other injuries
are also involved.Intracranial (inside the skull) hemorrhage (bleeding) Subdural hematoma.
Bleeding between the brain tissue and the dura mater (a tough fibrous layer of tissue between
the brain and skull) is called a subdural hematoma. The stretching and tearing of "bridging
veins" between the brain and dura mater causes this type of bleeding. A subdural hematoma
may be acute, developing suddenly after the injury, or chronic, slowly accumulating after injury.
Chronic subdural hematoma is more common in the elderly whose bridging veins are often
brittle and stretched and can more easily begin to slowly bleed after minor injuries. Subdural
hematomas are potentially serious and may require surgery.
B. Objective of the Study
At the end of the study, the researcher will be able to know more about head injury
particularly subdural hematoma and its effects to human and life and will be able to learn
more about the necessary Medical and Nursing Interventions to be applied to Patients with
subdural hematoma.

C. Scope and Limitation

Although we have been given two days to care for our patients and dig deeper into our
patients problem, it is still not enough for us to actually find any other minor problems that
our patient may be having, the lack of time also is the reason why we cannot fully assess the
extent or effectiveness of our Health Teachings and Nursing Interventions.

II. A. Patient’s Profile

Name: ?
Age: 35 years old
Sex: Female
Height: 5’2
Weight: 110 lbs
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Address: ?
Occupation: Housewife
Date of Admission: July 15, 2009
Time of Admission: 10:40 PM
Chief Complaint: Head injury
Admitting Diagnosis: Subdural Hematoma
Physician: ?
 B. Family and Personal Health
Patient is known to be hypertensive which she got genetically from her Paternal side. Her
maternal side was known to have asthma and hypertensive. Patient is occasional alcohol
drinker and can consumed 5 stick/day. Patient didn’t have history of previous hospitalization
but complained hyperacidity and sometimes headache as what significant others explained.

C. History of Present Illness and Chief Complaint

A case of 35 years old which suffered head injury due to vehicular accident, 4 days prior to
admission patient sustained head trauma during vehicular accident. Patient lost consciousness
few hours, after while admitted to city hospital and didn’t regain consciousness with positive
fever, Patient was taken to X, 2 days ago when city scan revealed acute subdural hematoma,
patient relatives opted to transfer to X.
DIAGNOSTIC EXAM

Date Ordered Diagnostic/laboratory Date Done

Exams
7-15-2009 Complete Blood Count 7-15-2009
7-16-2009 CT scan 7-15-2009

7-16-2009 X-ray for tracheostomy

Placement 7-16-2009
7-21-2009 CXR 7-21-2009

*Complete Blood Count* Normal Values

WBC: 12,300 5000-10000 mm3
RBC 3.17 9.9-5.2
Hgb: 94 120-160 g/dl
Hct: 0.28 .37- .47 g/dl
Neutrophils: .75 48-73
Lymphocytes: .12 20-45
Basophils: 0.08

*Ultrasound Chest PA*

Impression: pneumonia ,Right

Ultrasound Chest PA
Impression : Tracheostomy tube in place

CT Scan:
Impression : Subdural Hematoma
Subdural hematoma

Subdural hematoma occurs when there is tearing of the bridging vein between the
cerebral cortex and a draining venous sinus. At times they may be caused by arterial lacerations
on the brain surface. Patients may have a history of loss of consciousness but they recover and
do not relapse. Clinical onset occurs over hours. A crescent shaped hemorrhage compressing
the brain will be noted on CT of the head. Surgical evacuation is the treatment. Complications
include uncal herniation, focal neurologic deficits .All types of head injuries can be caused by
trauma. In adults in the United States such injuries commonly result from motor vehicle
accidents, assaults, and falls. In children falls are the most common cause followed by
recreational activities such as biking, skating, or skateboarding. A small but significant number
of head injuries in children are from violence and abuse.

Causes

 Penetrating trauma: Missiles such as bullets or sharp instruments (such as knives,

screwdrivers, or ice picks) may penetrate the skull. The result is called a penetrating
head injury. Penetrating injuries often require surgery to remove debris from the brain
tissue. The initial injury itself may cause immediate death, especially if from a high-
energy missile such as a bullet.

 Blunt head trauma: These injuries may be from a direct blow (a club or large missile) or
from a rapid deceleration force (a fall or striking the windshield in a car accident).

Head Injury Symptoms

Signs and symptoms of head injuries vary with the type and severity of the injury.

 Minor blunt head injuries may involve only symptoms of being "dazed" or brief loss of
consciousness. They may result in headaches or blurring of vision or nausea and
vomiting. There may be longer lasting subtle symptoms including, irritability, difficulty
concentrating, insomnia, and difficulty tolerating bright light and loud sounds. These
post concussion symptoms may last for a prolonged period of time.

 Severe blunt head trauma involves a loss of consciousness lasting from several minutes
to many days or longer. Seizures may result. The person may suffer from severe and
sometimes permanent neurological deficits or may die. Neurological deficits from head
trauma resemble those seen in stroke and include paralysis, seizures, or difficulty with
speaking, seeing, hearing, walking, or understanding.

 Penetrating trauma may cause immediate, severe symptoms or only minor symptoms
despite a potentially life-threatening injury. Death may follow from the initial injury. Any
of the signs of serious blunt head trauma may result.
Anatomy And Physiology:
MEDICAL MANAGEMENT
Date ordered Doctor’s order Rationale
7-15-09- 11:40 pm  Pls. admit under the  For close monitoring
BP- 140/100 mmhg service of Dr. Amato.
T- 40 Celsius  Sign consent to care  For legal issue
RR-24 cpm  TPR q 4hrs.  To monitor patients
HR- 61 bpm temperature,
O2 sat.- 100% respiration and pulse
 NPO  To prevent pt. from
 Labs: aspiration
CBC,  To determine
abnormalities and to
 U/A, verify and conclude
the patient’s admitting
diagnosis.
 Blood typing  To detect urinary tract
infection and glucose
 serum Na+ K+ in the urine.
SGPT, serum,  To determine the pt.
blood type.
 CXR: PA,  To determine
electrolyte and acid
base imbalance.
 ECG: 12 lead  To identify lung
disease and heart size
and location.
 To determine the
presence of cardiac
 CT scan of brain: arrest.
Pls. attached film at  To detect structural
bedside abnormalities
 With on going IVF of
plain PNSS IL @20  To maintain fluid and
gtts/ min. electrolyte balance.

1. Paracetamol 300 mg  To relieve fever

IV now then q 4hrs PRN
for fever

2. Mannitol 150CC q  Decrease blood

4hrs. IV pressure.
  Use to manage
3. Ranitidine 50 mg q gastrointestinal
8hrs. disorder
4. O2 inhalation @  To aide the patient in
2l/min. breathing and to
introduce oxygen to
the body to prevent
hypoxia and
respiratory acidosis
 For close monitoring.
5. For ICU admission  To monitor and relieve
6. With FBC F-16 abdominal distention
attached urobag  For parenteral line to
7. With NGT Fr- 16 administer food and
oral medication.
 To monitor pt. heart
8. Attach pt. to cardiac rhythm
monitor  For baseline data
9. Monitor V/S q 15min.  To maintain adequate
10.Suction secretion prn. airway patency.
 To determine
11.Monitor I&O q shift effectiveness or to
12.Refer accordingly keep watch for
7-16-09- 12:45 am possible renal
 Standby intubation abnormalities
Decorticate  To decrease Blood
No verbal output  Mannitol 200cc IV. bolus pressure.
No eye graving to pain now then 150cc q 3hrs
Pupil-5mm OD-2-3mm OS Hold to BP< 90/60mmhg  To established
(+) corneals  for ET artificial airway
(+) dolls  To replace blood loss
 BT, protime, blood typing. and to avoid blood
reaction.
 To determine the
 ABG adequacy of alveolar
gas exchange and
evaluate the ability of
the lungs and kidney
to maintain the acid
base balance of the
body fluid.
 O2 inhalation to  To aide the patient in
10L/min.via face breathing and to
mask introduce oxygen to
 the body to prevent
hypoxia and
respiratory acidosis

 To lower temperature
 For ice bath to keep body
temp < 37.5C
  To relieve fever
 Paracetamol 500mg/tab 1
7-16-09- 1am tab q 4hrs RTC per NGT
Neurosurgery note  Start cefuroxine 750mg
(panoxim) IV q 8hrs
GCS- 5-6 (ANST)
Aminoscoric  To lower the pressure
Cranial CT Scan: R frontal  For emergency of the brain.
Contusion: subacute decompressive  And to preserve the
SDH midline hemicraniectomy R skull into homeostasis
Shift to the L expansion, duraplasty, environment.
evaluation of
hematoma of
implantation of bone
fragment to
hemiabdomen Via
subcutaneous pouch  For legality issue
 Secure consent  To replace blood loss
Secure 1“u” FWB  To determine
properly typed & cross electrolyte and acid
matched for possible base imbalance.
OR use.

 Hold cefuroxime IV  To treat susceptible

 Start ceftriaxone I gm infection
IV ANST q 12hrs.  To treat short term
 Gentamicin 80mg IV serious infection
prior route to OR  For legal issue
 Please inform
undersign once with
consent & BO
clearance
 To treat susceptible
 Start cefriaxone I gm 10 infection
ANST q 120
 To maintain fluid and
7-16-09-2:10 am  IV to follow PNSS IL @ electrolyte balance.
20gtts/min
 To established
 For intubation artificial airway

 Mechanical ventilator  To help the patient

7-16-09- 3:30am setting: breathing pattern.
HR-180-220 bpm F1O2- 100%
7-16-09 5:50 am TV- 400
RR- 16  To determine the
Mode –AC adequacy of alveolar
 For ABG 30 min. after gas exchange and
hooking to MV evaluate the ability of
the lungs and kidney
to maintain the acid
base balance of the
body fluid.

 To identify lung
 For portable CXR disease and heart size
and location
 For close monitoring
 To ICU  To avoid from
 NPO till further order aspiration
 To monitor vital sign
2:00 pm  VS q 15min. chart pls. for baseline data to
determine
complication

 To maintain fluid and

 Regulate IV F- R arm @ electrolyte balance
KVO
 Regulate IVF- L arm @
20gtts/min. then ft.
DS/R- 1
PLR- 2
DSLR- 1  Use to manage
 Cont. ranitidine 1 gm. gastrointestinal
q 12 disorder.
 Start cloxacillin 1 gm  To treat pneumococci
slow IVT ANST infection.
  Mannitol to 100 cc of  To decrease osmotic
40 IV bolus hold if BP pressure and
< 90/60 mmhg intracranial pressure.
 Tramadol 50mg q 6  To relive mild to
slow IVTT moderate pain, and
relax muscle

 D/c gentamicin  To help the patient

breathing pattern and
 Hook to mechanical prevent respiratory
ventilator with setting distress
P1O2= 100%
TV= 400
Rate=16  To determine
Mod e AC neurologic status of
 Cont. monitor neuro the patient
vital sign pupillary size &
reaction to light, level of  To determine
assessment effectiveness or to
 monitor 1 & 0 q 1hr. keep watch for
chart possible renal
abnormalities

 To maintain adequate
airway patency.
 Suction one /ETT
secretion PRN and
separate  To determine infection

 Repeat Hgb ,Hct, det. 4h

past op & refer result  To help lung expansion
 Refer accordingly
 Place pt. in slight high  To avoid further
back rest complication and
6:30 pm  No pressure @ operated pressure to the brain
ABG result side of head
O2 sat. 100%  Act in the brain to
 F1O2 to 50% increase blood flow
 Citicoline I gram IVTT q 8 and oxygen
7-17-09- 7am consumption.
 To determine the
adequacy of alveolar
  Repeat ABG. gas exchange and
evaluate the ability of
the lungs and kidney
to maintain the acid
base balance of the
body fluid.
 To determine
electrolyte and acid
7-17-09- 8;30am  Repeat Na. K base imbalance
1st POD
Asleep arousable to verbal
stimulation/tapping  To determine the pt.
Follow simple command
(+) rhonchi  F1O3 to 30%, back up  To help loosen and to
18 mu w/ rate=12mod prevent bronchospasm
 Nebulize with salbutamol  To loosen secretion
1 neb.
 Do chest tappping after  To help mobilization
each nebulization and to avoid pressure
 Turn to sides’ q 2hrs. w/ ulcer.
caution on the R side of  To maintain nutrient
the head. needed for body
 Add 10mg KCI to present requirement
IVF
 Start of at 1000
kcal/day in 1L
dilution, to be
given in 6 equal
feeding  To relieve constipation
 Lactulose 30cc OD at H.S  To maintain fluid and
 IV FF: PNSS IL + 10KCL for electrolyte balance
7-17-09- 9am SHRS X3 cycle  To avoid stomatitis
Neurosurgery  Routine oral care TID and to maintain
1st POD using oracare hygiene
E4 VTM mouthwash  To relive fever
Pupil 3mm
EBRTL L  Revise paracetamol to
SRTL R 500 mg 1 tab T tab q 4  To decrease osmotic
PRN for temp.> 37.5C pressure and
 Mannitol to 100 CC intracranial pressure.
7-18-09 I>V bolus q 6hrs. w/BP
9:00am precautions (hold for
2nd POD BP< 95/65)
7-18-09  To maintain fluid and
1:15 PM  IVFTF @ L arm D5LR IL electrolyte balance
@ some rate
 Terminate IVF @ the R
arm.  To maintain nutrient
 OF to 1600 /day needed for body
In IL dilution to be requirement
given in 6 equal  To determine
feeding. abnormalities and to
 Repeat CBC, Na, K, verify and conclude
Crea, tomorrow AM the patient’s admitting
diagnosis. Also to
determine
abnormalities in the
patient’s kidneys

 To maintain fluid and

 IVF TF. PNSS IL @ electrolyte balance
30qtts/min. x 3 cycle

Addendum  This is to practice

 Start a T-piece patient normal
@10LPM of 15min, 45 breathing toleration.
min. on mech. Vent.
For 6 hrs. If well
tolerated increase T-
piece time to 30 min.
with 30 min. MV for
another 6 hrs. ***
shift to continue T-
piece there after if
there are no sign of
desaturation BP, PR
and HR -restlessness  To determine the
 Get ABG prior to adequacy of alveolar
continuous T-piece gas exchange and
(12mn) evaluate the ability of
7-18-09 the lungs and kidney
1:30pm to maintain the acid
E- 4VT M5-6 base balance of the
Pupil 3mm body fluid.
ERR operative wound  Act in the brain to
healing well
  Shift citicoline IV to increase blood flow
500mg/cap 2 cap q 12 and oxygen
per NGT consumption.
 Use to manage
7-19-09  Shift ranitidine IV to gastrointestinal
10:30 am 150 mg/tab, 1 tab BID disorder
per NGT (Raxiole)

 Wound care, change  To prevent and control

dressing. incision infection

 For portable CXR-AP if  To identify lung

possible disease and heart size
and location
 Secure 2 units PRBC  To replace blood loss
for BT after properly and to avoid blood
cross matched. reaction.
 Give Benadryl 50 mg  To prophylaxis for
IV prior to BT allergic reaction
 Furosemide 40 mg IV  To relieve from
after each bag bipedal edema
transfused with Bp
precaution (hold to BP
< 90/60)
 F1O2 to 40%  For weaning the pt
 Resume weaning breathing pattern.
Continue T-piece for  To practice patient
Hrs. then back to MV normal breathing
SMV mode, F1O2 40% pattern
for 2 hrs. Cycle for
24hrs.
 Watch patient for  Towatched pt from
desaturation. respiratory distress
 For repeat U/A, stool  To detect blood in the
exam with occult stool and detect
blood urinary infection
 bisacodel, adult  To relive patient from
suppository now then constipation
another I @ HS if still
w/o BM.
MEDICAL ORDERS with RATIONALE
Medical Orders Rationale

-relieves pain
July 19 2009
-to into higher dosage
 Celecoxib 400mgmg/cap 1cap OD/NGT
-supplement body fluid
 Revise tramadol to 50mg IV q12 hours
 Follow IVF with PNSS 1L and 40meq KCL -to recheck ABG status of patient
@ 30gtts/min x 3 cycles
 Repeat ABG’s in AM (9am) at the end of -to recheck CBC for abnormalities
T piece cycle
 For repeat CBC at 11am
-ITC aspiration pneumonia vs. HAP - To reduce intraocular or intracranial
Meds: pressure.
 Mannitol to 100cc IV bolus q8hours -to normalize level of potassium
 Kalium Durule 1 Durule TID -supplement body fluids and to administer
 IVF PNSS 1L+20meqKCL @ 20gtts/min medication through tubing
for 3 cycles
 Follow up 6S of ETA>refer
-prevent possible infection
July 20 2009 (Neurosurgery notes) -to relieve pain
 Wound care, open dressing done
 Revise tramadol to 50mg IV q8 hours
PRN for severe pain -to enhance brain function
 Shift cloxacillin in 500mg 1cap

q6hours/NGT
11:40 Am
 For referral to Dr. Gamalo for Pulmonary
co-management
-text orders by Dr. Amato
 IVF TF: PNSS 1L @ 20gtts/min + 20 meq -to supplement body fluids and to administer
KCL for 3 cycles edication through tubing
 Repeat serum Na, K, AM -to recheck serum Na and K
 for the:
AO ventricular associated pneumonia
P2 shift ceftriaxone IV to Imipronen
500mg IV q8 hours ANST( - )
Meds
 Start Floxel 750mg tab 1tab OD/NGT
 Fluimucil 200mg in 100ml of H2o q8 -to decrease viscosity of respiratory tract
secretion
hours/NGT
 Check ET cuff BID -to check if there is dry secretions obstructed
 F1O2 at 40%
 Possibly of tracheostomy -to establish artificial patent airway
-improve ventilation
July 21 2009
10:50 Am
 Continue meds
 Daily wound care open dressing with -continue treatment for patient
alcohol -prevent possible infection
 Cut endotracheal tube verbal order by
Dr. Gamolo

5th POD
 Passive flexion- extension of extremities
 Please provide foot board -facilitate rehabilitation of extremities
 Maintain Mannitol at 100cc q8 hours -to promote blood circulation
- To reduce intraocular or intracranial
pressure.
July 22 2009
 Continue meds
 NPO -to continue treatment for the patient
 Increase citicoline to 2 caps q8 -to prevent GI upset
hours/NGT -to enhance brain function
 Decrease mannitol to 75cc IV bolus then -to decrease intracranial pressure
D/C
-to prevent drug overdose
 Repeat Chest X-ray tomorrow Am- have
it compared with previous plates -to obtain accurate results
 Prepare T pipes tomorrow AM -to establish artificial airway

July 23 2009
 For early tracheostomy, OK with Dr.
-to improve ventilation
Gamolo
 Increase of dilution to 1600L (1:1) -increase nutrition for the patient
 Decrease IVF to 10gtts/min in cycles
 IVF TF: D5NM 1L @ 10gtts/min in cycles -supplement body fluids
  Repeat serum Na, K, tomorrow -to obtain accurate results, monitor status
 D/C Celecoxib and Kalium durule - to determine electrolyte imbalances
3-11 -to avoid over dose
 Watch patient from MV thru progressive
weaning: -to prevent further complication
Piece at 64min MV
15 min 20 min
30 min 30 min
1 HR 30 min
2 HR -- ABG’s MV to follow order
 Increase FiO2 to 100% perigastric
(during tracheostomy) -to prevent respiratory distress
 Refer Dr. Fernandez for anesthesia
-for referrals
July 24 2009
 Increase IVF to 30gtts/min
 IVF TF 1. PLR 1L x 30gtts/min
-to maintain fluid and electrolyte imbalance
2. D5NM 1L x 30gtts/min in cycles
9:50 AM
 Increase OF to 1800 KCAL q4hours in 6
divided feedings - To maintain nutrition within body
 Fleet enema @ bedtime requirement
- To clean the obstructed in the anal passage
11:50Am
 May resume feeding when fully awake
 Regulate IVF at 30gtts/min - to maintain nutrition as body requirement
 Continue meds previously ordered -to maintain the fluid and electrolyte balance
 Measure I&O q4hours shift -to reach the therapeutic effect of the
medication
 Suction tracheostomy secretion PRN
- To monitor pt fluid
- to prevent obstructed secretion in the
 For Chest X-ray as ordered tracheostomy tube.
-To identify lung disease and heart size and
July 25 2009 location
 Took to T piece at 61min
 May transfer to room of clinic tomorrow
-to maintain oxygen passage
am
-to continue monitoring
Meds
 Fluimucil 200mg q12 hours -to decrease viscosity of respiratory tract
5:00Pm secretion
  May use anti embolic stocking
 Decrease IVF to KVO
 Start bladder training q12hours for - To prevent hypothermia
- Use to access line for the medication
24hours then remove Foley catheter
- To prevent abdominal distention
 Transfer IV site to Left –defer-
 IVF TF: PNSS 1L @ 10gtts/min - To prevent phlebitis on the IV site

 Pls give tramadol 500 now - To maintain fluid and electrolyte

balance
- To relive mild to moderate pain,
muscle
 D/C Salbutamol neb if ok with Dr.
Gamolo
Neurosurgery note
 Ok for transfer to a regular room

July 26 2009 - For continuous monitoring

 Shift Salbutamol neb + combivent neb
q8 hours - To dilate bronchus and prevent
 Continue O2 sat monitoring q shift bronchospasm
 1L/min to 2L/min in T piece - To determine O2 sat of the patient.
 Last dose Imipenem in 6Am 7/28/09
then D/C
- Treat mild to moderate tract infection,
intra abdominal and gynecologic
 Turn to sites q2 hours infection
 Elevate head 30 degree -to prevent from bed sore and to improve
 Teach relatives for proper suctioning of Motility
secretions -To help lung expansion
-to enhance proper suctioning and avoid
Complication
July 27 2009
9:35Am Neurosurgery note
 For removal skin staples tomorrow
please prepare staple remover
Dr. Amato - To enhance and facilitates healing
 Turn to side q2 hours
 Please provide turning schedule at
bedside - to prevent bedsore and promote circulation
 Continue passive flexion-extension of - so that significant other will able to follow
 extremities schedule.
 Pls allow and teach relatives how to feed
per NGT - To promote

-for proper home feeding

July 28 2009
 Give tramadol 50mg IV if in pain
-text order by Dr. Amato
 May D/C O2 tomorrow Am change O2
sat 1 hour after. -To relieve mild and moderate pain
 Prepare the following at home
-To change new O2 sat
1. Nebulizer
2. Suction materials -For progress of ventilation at home

Neurosurgery Notes
 D/C ranitidine
 Start amlopidine 10mg 1tab OD/NGT
-To stop for further health condition
-To decrease blood prepare
July 29 2009
 D/C IVF once consumed
 Increase oral feed to 2000 Kcal/24 hour
1:1 dilution (2liters) in 6 divided feeding
-To avoid excess of fluid
including H2o & oral feeding
-To maintain nutrition within the body
4:20 Pm requirements
 Auscultate lungs and refers O2 sat 95%
 Tracheal mask regulated O2 @ 4pm
 During feeding placed patient on HBR
 Flush 50cc of H2o instead of 150 cc -To assess lung sounds
-To prevent patient from respiratory acidosis
during feeding
4:30 Pm -To prevent aspiration
 Repeat Chest X-ray today -To prevent obstruction in feeding
Call order by Dr. Amato
 Nebulizer with combivent neb now
- To identify lung disease and heart size and
location
July 30 2009 -Relaxes smooth muscle thus preventing
9:00Pm bronchospasm
 Na, K now
July 31 2009
7:30 am
 Increase head & trunk elevation to 40-
-to determine electrolyte imbalances
60 degree during the day time
 Provide foot board
 Do not put a pillow underneath both
knees when in supine position -prevent ICP
7:55 Pm
-To enhance circulation
 Reinsert IVF; start PNSS 1L + 30 meq Kcl
-To promote comfort and unnecessary flexes
regulated @ 20gtts/min for 3 cycles
Text order by Dr. Amato

-To maintain fluid and electrolyte balance

August 1 2009
1:30 Pm Rehab
 Continue PT program
 Maintain both feet in neutral position
(90 degree) when patient in supine
 Repeat serum Na, K
Meds -for rehabilitation of joint and extremities
-to promote circulation and avoid flexes
 Diazepam 5mg IV now
 Start Clonazepam 20mg 1tab ¼ tab OD
at HS -to determine electrolyte imbalances
 Fluxetine 20mg/cap 1cap OD at 9am
daily - Promote calmness and sleep
- Prevents or stop seizure activity
August 2 2009
 Maintain on moderate HBR up elevation
- To inhibit CNS neuronal uptake of serotonin
-during the daytime
-will progress rehab to short sitting
starting tomorrow
 May have wheel chair rides x 30-45
minutes BID -to promote lung expansion
 Consumed IV then terminate

August 3 2009 -to promote mobilization

  Do wound dressing
 Pls teach relatives to feed
-to avoid further fluid excess
August 3 2009
 Pls refer to dietary department for Oral -to maintain aseptic technique
feeding instructions prior to possible -for health teaching
discharge
 Do not fleet enema
 Monitor patient able to urinate
spontaneously after 4 hours of straight
-for home food preparation
catheter
August 4 2009
 Insert Foley catheter attached to uro bag -to prevent complication
 Start diflucan 100mg 1tab OD -to determine output
2:55pm
 Continue PT progress

-to promote drainage

-to decrease osmotic and intracranial

pressure

-for rehabilitation of joint and extremities

 Name of Date classification Dose/ Mechanism Specific Contraindicatio Side effects Nursing
drugs ordered frequency of action indication n Precaution
Clonazepam 8-2-09 Anticonvulsan 2mg ¼ tab Prevents or Panic Use cautiously Confusion Be alert of
t OD stop seizure disorder in patients with drowsiness adverse
activity Restless leg mixed type of slurred speech effects
syndrome seizures tonic abnormal eye reaction and
clonic seizures movement drug
interaction
Dalacin 8-2-09 Antibiotic 15mg 1 cap Inhibits Bacrtericidal Contraindicated Head ache Before giving
tID/NGT bacterial vaginosis in patient thrombophlebiti first dose
protein wall acne vulgaris hypersensitive s obtain
synthesis to drug or or specimen for
thus causing lincomycin culture and
cell death sensitivity
test. Begin
therapy
pending
results
Diflucan 8-4-09 Antifungal 100mg 1tab Inhibits Cryptococcal Contraindicated Headache If patient
(fluconazole) OD/NGT fungal CYP, meningitis in patients nausea vomiting develop mild
and enzyme systemic hypersensitivity abdominal pain rash,
responsible candidias to drug or any of Diarrhea monitor him
for fungal its component closely. If
sterol lesions
synthesis progress
and weakens stop drug
fungal cell and notify
walls precriber
 Name of Date classification Dose/ Mechanism Specific indication Contraindicatio Side effects Nursing
drugs ordere frequency of action n Precaution
d
Fluoxitine 8-2-09 Antidepressant 20mg 1cap May inhibit Depression, Use cautiously Fever, Tell patient not
OD/NGT CNS neuronal obsessive in patient at nervousness, to take drug in
uptake of compulsive high risk for anxiety, afternoon or in
serotonin disorder suicide and in insomnia, evening
those with palpitation, because
history of nasal fluoxetine
mania, seizures, congestion, common
diabetes nausea, causes
mellitus, hepatic diarrhea nervousness
renal or CV and insomnia
disease
Valproic 7-30-09 Anticonvulsant 5ml q8 Prevent and Prevent migraine Contraindicated Headache, Tell patient or
acid hours/NGT treat certain headache, mania, to patient dizziness, relative that
types of complex partial sensitive to depression, drug may be
seizure seizure drugs or any of muscle taken with food
activity its component weakness, or milk adverse
and in patient nausea, GI effect, tell
with hepatic vomiting, patient and
dysfunction or ingestion, parents that
urea cycle diarrhea syrups
disorder shouldn’t be
mixed with
carbonated
beverage
Amlodipine 7-22-09 Antihypertensiv 10mg 1tab Reduces Hypertension, Contraindicated Headache, Be alert of
(NorVAsc) e OD/NGT blood chronic stable to patients fatigue, adverse
Antianginal pressure angina hypersensitive somnolence, reaction. Assess
seizure and to drugs edema, patient’s blood
prevent dizziness, pressure or
 angina flushing, angina before
palpitation therapy and
regularly
thereafter
Cefuroxime 7-24-09 Antibiotic 750mg IV Hinders or Kills serious Contraindicated Dizziness, Assess patient
q8 hours kills infection of lower to patient headache, infection before
ANST (-) susceptible respiratory and hypersensitive malaise, GI therapy ang
bacteria urinary tract skin to drug or other abdominal regularly
including and skin structure cephalosporins cramps, anal thereafter
many gram infections bone pruritus,
positive and joint infection, diarrhea,
organisms an septicemia, nausea,
enteric gram meningitis, vomiting,
bacilli gonorrhea and genital
perioperative pruritus
prophylaxis
Lactulose 7-24-09 Laxatives 30cc OD @ Relieves Constipation to Contraindicated Abdominal Advise patient
HS/NGT constipation, restore bowel in patients on cramps, to dilute drug
decrease movement after low galactose belching, with juice or
blood hemorrhoidectom diet diarrhea, water or to
ammonia y distention, take with food
concentratio nausea, to improve
n vomiting taste
Salbutamol 7-24-09 bronchodilator 1 neb q6 Relaxes To prevent Contraindicated Tremor, Be alert for
hours bronchial and exercise induced to patient nervousness, adverse
uterine bronchospasm hypersensitive dizziness, reaction and
smooth to drug or its insomnia, drug
muscle by component headache, interaction,
acting on tachycardia, obtain baseline
beta 2 palpitation assessment of
adrenergic patient
receptors respiratory
 status
Ranitidine 7-24-09 antiulcerative 150mg/ta Relieves GI Duodenal and Contraindicated Vertigo, Assess patient
b 1tab discomfort gastric ulcer in patient malaise, GI condition
BID/NGT maintenance hypersensitive blurred before starting
therapy for to drug and its vision, therapy and to
duodenal ulcer component jaundice monitor drug
effectiveness
Cloxacillin 7-20-09 500mg
1cap
q8/NGT
Imipenem 7-20-09 antibiotic 500mg IV Kill Treat mild to Contraindicated Seizure, Assess patien’s
q8 susceptible moderate tract to patient dizziness, infection before
ANST( - ) organism infection, intra hypersensitive somnolence, starting therapy
including abdominal and to drug and its fever, HPN, and regularly
many gram gynecologic component nausea thereafter. Be
positive gram infection vomiting, alert for
negative and diarrhea, adverse
anaerobic rashes, reaction and
bacteria urticaria drug infection
pruritus
Fluimucil 7-20-09 200mg in
100ml of
H2o q8
hours/NGT
Celecoxib 7-19-09 Anti- 400mg/ Relieves pain Relieves of signs Contraindicated Dizziness, Assess patient
inflammatory cap 1cap and and symptoms of in patients headache, for
OD/NGT inflammation osteoarthritis hypersensitive insomnia, appropriatenes
in joints and relieves signs and to drug stroke, HPN, s of therapy
smooth symptom of sulfonamides or peripheral drug must be
muscle tissue rheumatoid aspirine or other edema, cautiously in
arthritis NSAID’s and in abdominal patient with
patient with pain, history of ulcers
 severe hepatic diarrhea, or GI bleeding,
or renal nausea heart failure or
impairment asthma
Tramadol 7-19-09 Analgesics 50g IV q12 Relieves pain Moderate to Contraindicated Dizziness, Assess patient’s
hours moderate severe in patient vertigo, pain before
pain hypersensitive headache, starting therapy
to drug or any of somnolence, and regularly
its component stimulations, thereafter to
and in those anxiety, monitor drugs
with acute confusion, effectiveness
intoxications malaise
from alcohol,
centrally acting
analgesics
opioids or
psychotropic
drug
Kalium 7-20-09 Potassium salt NGT TID Replaces Prevention of Use cautiously Weakness, teach patient
Durule + potassium hypokalemia in patient with heaviness of how to prepare
durule and cardiac disease limbs, powder and
maintains or renal hypotension, how to prepare
potassium impairment nausea drug tell
level vomiting patient to take
with or after
meal with full
glass water or
fruit juices to
lessen GI
distress
Mannitol 7-20-09 Osmotic 75cc IV Increases To reduce Contraindicated Seizure, Monitor vital
diuretics bolus q12 osmotic intraocular or in patient dizziness, signs including
hours pressure of intracranial hypersensitive headache, central venous
 glumerular pressure. To to drugs fever, pressure and
filtrate prevent oliguria or edema, fluid intake and
inhibiting acute renal failure hypotension, output hourly
tubular hypertension
reabsorption , blurred
of water and vision, tears,
electrolytes nausea
vomiting
diarrhea
Floxel 7-20-09 750mg tab
1 tab
OD/NGT
Citicoline 7-22-09 Brain enhancer 500mg/ca Improve Stroke, head injury Contraindicated Headache, Tell patient to
p 2caps blood flow in patient insomnia, notify physician
q8/NGT and oxygen hypersensitive dizziness, if any
supply to the to drugs or any fever, abnormalities
brain drug component nausea, occur
vomiting,
tremor
Paracetamo 7-24-09 Antipyretic 500mg Prevent the moderate to Contraindicated Headache, Drug should be
l Analgesic 1tab synthesis of severe pain, fever, in patient dizziness, taken with
NSAID’s q4hours prostaglandin inflammation hypersensitive nausea foods if GI
which to drug, vomiting upset occurs
stimulates pregnancy, diarrhea, May experience
hypothalamu lactation tremors, adverse effects
s for malaise
temperature
regulation
thus reducing
body
temperature
 Nursing System Review Chart

Date: August 03, 2009

Vital Signs:
Temp: 37.5ºC Pulse: 135bpm radial BP:130/90 mmHg Respiration: 35 cpm

Sunken part of
With O2 the head due to
inhalation decompression
at 2-3 and craniotomy
LPM procedure
- Nasogastric
Tube

Tracheostomy -Generalized
tubing body
Weakness
-Dry Skin

IVF insertion
site
Scar

Irregular fast
35 cpm
 NURSING SYSTEM REVIEW CHART

Date: August 04, 2008

Vital Signs:
Temp: 38.5 C Pulse: 132 bpm BP: 140/100 mmHg Respiration: 32 cpm

Suture and
Tracheostomy slight
with O2 Deform head
inhalation at 2
L/min Productive
cough with
whitish
- phlegm
Nasogastric
Tube

Pulse fast
Scar and irregular

-Generalized
body
Irregular fast Weakness
32 cpm.

IVF insertion
site
Nursing diagnosis: Ineffective cerebral Tissue Perfusion related to head injury

Objectives: at the end 2 days intervention, patient will demonstrate improve level of consciousness,
cognition, motor and sensory function

“Subjective”
Maka mata na siya pero murag wala sa iyang pamuot, dili gani gatingog, as verbalized by significant
Others.

Objectives
Unconscious
Weak in appearance
With O2 nasal cannula
Intervention Rationale
Monitor/document neurologic status Assesses trends in level of consciousness (LOC)
frequently and compare with baseline. and potential for increased ICP and is useful in
determining location, extent, and
progression/resolution of CNS damage.

Monitor vital signs To monitor condition of the patient

Monitor Glasgow Coma scale and SPERM

Monitor neurologic status of the patient

Position with head slightly elevated and in Reduces arterial pressure by promoting
neutral position. venous drainage and may improve cerebral
circulation/perfusion.

Maintain bed rest, provide quiet environment, Continual stimulation/activity can increase
restrict visitors ICP. Absolute rest and quiet may be needed to
prevent rebleeding in the case of hemorrhage.

Administer supplemental oxygen as indicated. Reduces hypoxemia, which can cause cerebral
vasodilation and increase pressure/edema
formation.

Evaluation: at the end of 2 days intervention to the patient, patient did not demonstrate improved
in level of consciousness, cognition, motor and sensory function.
Nursing Diagnosis: self care deficit related to neuromuscular impairment secondary to head injury

Objectives: at the end of 8 hours, patient will meet self care needs.

“subjectives”
Dili gyud niya ma-atiman iyang lawas kay wala pa gani siya pamuot as verbalzed by significant
others.
Objectives
Weak
Unconscious
Intervention Rationale
Provided morning care Enhances patient daily hygiene

Provided mouth care Eliminate bacteria that may cause infection

Suction secretion from tracheostomy to remove secretions

Elevated head part every 2 hours to provide comfort to patient

Administer suppositories and stool softeners. to aid in establishing regular bowel function.
To prevent constipation
Evaluation: at the end of 8 hours, patient meet self care needs.
Nursing Diagnosis: Impaired physical mobility related to loss consciousness secondary head injury

Objectives: at the end 2 days, patient will maintain skin integrity

Objective Cues
Unconscious
Weakness
immobile
Intervention Rationale
Change positions at least every 2 hr Reduces risk of tissue ischemia/injury.

Position in prone position once or twice a day. Helps maintain functional hip extension.

Inspect skin regularly, particularly over bony Pressure points over bony prominences are
prominences. most at risk for decreased perfusion/ischemia.

Get client up in wheel chair as soon as vital promotes maintenance of extremities in a

signs are stable. functional position and emptying of bladder

Consult with physical therapist regarding Individualized program can be developed to

active, resistive exercises and client meet particular needs/deal with deficits in
ambulation. balance, coordination, strength.

Evaluation: at the end 2 days, patient had maintained skin integrity

 Nursing Diagnosis: Risk for infection related to lacerated wound secondary to head injury

Objectives: at the end of 8 hours, patient will be kept safe from possible infection

Objectives: at the end

Intervention Rationale
Stress proper hand washing techniques to all To prevent nosocomial infection.
care givers and relatives

Perform wound dressing daily as indicated. To promote faster wound healing and prevent from
infection.

Maintain sterile technique for invasive To prevent contamination/transmission of

procedures like IVF, urinary catheter, and microorganisms from one area to another and to
pulmonary suctioning. reduce risk factors of infections.

Instruct significant others in techniques to To promote client wellness or to prevent cross-

protect the integrity of the skin, care of contamination.
lesions, and prevention of spread of infection

Monitor temperature. Note presence of chills Reflective of inflammatory process/ infection,

and tachycardia with/ without fever. requiring evaluation.

Collaborative

Monitor laboratory studies e.g. Complete Shifts in differential and changes in WBC count
Blood Count (CBC) indicate infectious process.

Administer prophylactic antibiotics and To treat and prevent the infection

immunizations as indicated.

Evaluation: at the end of 8 hours duty, patient was successfully kept away from getting infection
ACTUAL NURSING MANAGEMENT

Nursing Diagnosis:

Ineffective airway clearance and impaired gas exchange related to brain injury and increase
secretion production.
Objective :
“Gihangus na cya atong wala cya oxygenug kanang dili cya ma suction” as significant others
verbalized
Subjective:
-O2 inhalation attached to tracheostomy tube
-RR- 35-36
-increase accumulation of secretion
-restlessness

Intervention Rationale

1. Checked for aspiration and 1. To assess patient states of maintaining

respiratory insufficiency airway
2. Respiratory rate checked every 2. To check vital signs, to assess patient
15 minutes. active airway, and for documentation
3. Elevate the head of the bed as purposes
prescribed. 3. To allow secretions drain from patient
mouth.
4. Provide oxygenation, 4. To support patient maintenance of air
prescribed by the physician
5. To maintain patent airway
5. Suction patient PRN limit 5-10
second per suction

At the end of 15-30 mins. The client’s restlessness was alleviated and remained calmed.
Nursing Diagnosis:

Risk for injury related to brain damage due to vehicular accident

Goal:
At the end 8 hours of intervention, patient safety was established
Objective cues:
-decrease neurologic function
- decorticate posturing
-decrease level of consciousness

Intervention Rationale
1. Keep bed side rails raise 1. To provide safety
2. Position and place patient at the middle of 2. To monitor patients activity
the bed and level of safety
3. Watch patient for the entire shift. measures
4. Secure patient hands and feet on the bed 3. To prevent patient from
5. Assess level of consciousness, orientation injury
and ability to move extremities 4. These parameters provide a
baseline and help identify
signs and symptoms of
neurologic complication
6. Position patient to enhance comfort, 5. This promotes safety and
safety and lung expansion reduces risk of complication
6. To help patient breathing
7. Provide bed rest pattern

8. Watch patient all the time and assess 7. To avoid patient from stress
patient needs and conserve energy
8. To assure patient safety

At the end of 8 hours of nursing interventionpatient safety was prevented and minimized.
Nursing Diagnosis:

Risk for infection related to wound. Located at right front to parietal area of the brain due to
decompression and craniotomy.
Plan:
At the end of 8 hours of nursing intervention patient
Objective:
-wound on the right side of head
- wound puss is visible
- elevated temp. 38 degrees
Intervention Rationale

1. Wound dressing done with proper 1. To clean and eliminate the number
sterile technique after operation of microorganisms located at the
2. Keep wound force of dressing wound area.
threads. 2. Foreign bodies retard healing
3. Surgical site and wound drainage
assisted. 3. Assessment provides baseline and
help identify signs and symptoms
4. Monitor patient closed drainage of hemorrhage early.
system; check for secretions, color 4. For documentation purposes and
and amount accumulated hiding process
5. To get baseline date related to
5. Monitor TPR infection
6. Administer antibiotic medication as
prescribed. 6. To eliminate microorganisms.

At the end of 8 hours of nursing our objectives was partially met since, we able to control
further infection related to craniotomy and decompression incision
 Nursing Diagnosis:
Disturbed in sensory perception related to brain trauma
Plan: At the end of 2 days intervention patient able to demonstrate the presence of residual
involvement.

Subjective cues:
Dili cya motubag ug storyahon igo ra cya mo tan aw dayon mo piyong dayun as verbalized by
the niece.

Objective:
] -motor incoordination
] -alteration in posture
] - altered communication pattern
] - poor concentration-
Intervention Rationale
1. Continual monitor in changes in 1. Damage may may occur at time of
orientation, ability to speak, initial injury
mood, affect and sensorium.
2. to determine the ability to perceive
2. Assess sensory awareness.
and respond appropriately to stimuli
3. Eliminate extraneous stimuli as
3. to reduce anxiety
necessary
4. Client have limited attention span,
4. Speak calm, quite voice,use
and understanding, these measures
short, simple sentences,
can help client attend communication.
maintain eye contact
5.to assist patient to differentiate
5. Reorient client to environment,
reality in the presence of altered
and procedure
perception
6. to progress toward independence,
6. Allow adequate time for
enhancing, sense of control while
communication and
compensating for neurologic deficits.
performance.

At the end of 2 day of intervention my goal was not met because patient was demonstrate of
deterioration of neurologic status.
HEALTH TEACHINGS

Health teachings imparted to the significant others:

Medications  Stress out to the patients the

importance of compliance to home
medication regimen
 Discuss the action of the
medication ordered
 Emphasize the significance of the
following the right timing when
administering
Exercise  Demonstrate passive range of
motion exercises and explain why is
it necessary for the patient
Treatment  Emphasize the importance of good
rest
Out patient  Emphasized the significance of
follow-up checkup
Diet  The importance is increased fluid
intake
 Intake of vitamin C rich foods

. REFERRAL AND FOLLOW-UP

 Advice the patient to follow scheduled check-ups to the physician after discharge, constant
monitoring and checking of the patient’s condition is really important to ensure that the patient is
given adequate and continuous care and medication. If the patient or the significant others are not
satisfied with the findings of the current doctor, it is advisable to recommend another doctor
whose specialization is on the head injury aspect for a second opinion. Since Mrs. X is already
weak, keeping watch and acknowledging the risk for aspiration when the patient goes home is
also very important because it is a big factor which can contribute to the patient’s breathing
pattern.

X. EVALUATION AND IMPLICATION

Having a patient with head injury with brain trauma is challenging and at the same time
very educational, we able to exercise our interventions and we developed the skills on how to
think critically so that we can improve my patient’s condition. I can use this experience for my
future patient who has the same problems as Mrs. X and the interventions that I have learned will
also be applicable to them. The experience in taking care of subdural hematoma patients can
really be so challenging, the patient could have moods and affect and the need to constantly
explain everything that you do and to constantly remind the patient is very important. The 2 day
care of my patient was fulfilling and challenging but the most important thing is we have learned
something from our patient and in turn we can say that we have done our best to give utmost care
to our patient.

BIBLIOGRAPHY
 Medical-Surgical Nursing 11th  Edition. Suzanne Smeltzer, Brenda Bare, Janice
Hinkle, Kerry Cheever. Volume 1. Pp. 1204 – 1207

 Nurse’s Pocket Guide (Diagnoses. Prioritized Interventions, and Rationales) 11 th

Edition. Mrilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

 PPD’s Nursing Drug Guide 2007 Edition

 Ms. Manilyn Cabiles (patient) and mother Purificacion Cabiles

 http://www.emedicine.com/MED/topic850.htm