West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

Crash Landing in ICU

Crash landing on ICU is derived from a hit Korean drama series, Crash Landing on You. The analogy was
made since the plot of the said movie is a good description of our case. The patient in our case was the
protagonist who encountered an ill-timed accident which placed her in a perilous place. Luckily, a savior,
clad in a long white PPE, arrived and shielded her from the claws of death. Car accidents are like destiny,
no one can ascertain when and how it will happen, but the chances of it occurring is never zero.
Moreover, to suffer from a head injury is like being in your own drama series. Climaxes and denouements
would define the plot, as the body tries to cope physically and emotionally until it reaches a decisive
ending. But just like all drama series, the protagonist has its own Captain Ri. In this case, nurses assume
this role since they are the ones who protect the patient from any grim fate that accompanies trauma
injuries.
General objective

Within 8 hours of case presentation, students must have acquired

knowledge, skills, and attitudes in presenting and delivering care
to patient with head injury and greenstick fracture while utilizing
the adult nursing process.

Specifically, the students must have:

1. Presented thoroughly the patient’s vital information, nursing
history, patterns of functioning, physical assessment,
psychosocial assessment, laboratories, drug regimen, and
nursing and medical management;
2. Discussed comprehensively the assessment findings of the
patient;
3. Provided in-depth explanation of the pathophysiology of the
condition;
4. Formulated a comprehensive nursing care plan for the
prioritized problems identified;
5. Exhibited mastery and tact in answering relevant questions
with positive attitude towards criticisms and suggestions; and,
6. Developed cooperation and teamwork among the RLE
members.
 ADULT NURSING PROCESS

I. VITAL INFORMATION
Name: A.C.C. Date of Interview: July 28, 2021, 7:20 AM
Age: 47 years old Informant: K.C.C. and few information from A.C.C.
Sex: Female Relationship to Patient: mother and patient herself
Address: Punta Buri, Banga, Aklan
Civil Status: Married
Date and Time Admitted: July 28, 2021, 6:50 AM
Chief Complaint: “Tama guid kasakit sang ulo kag mga lawas ko”, as verbalized. Rated pain as
9/10
Ward: Surgical Intensive Care Unit
Bed No.: 1
Allergies: No known allergies to food, drugs, animals, or other environmental factors
Religious Affiliation: Jehovah’s Witness
Physician’s Initial: Dr R.M. and Dr J.V.
Impression/Diagnosis: Head Injury secondary to vehicular accident

II. CLINICAL ASSESSMENT

II. A.: NURSING HISTORY

1. History of Present Illness

a. Usual Health Status
A.C.C. is an occupational health nurse who works 8 hours a day from 8:00 AM to 4:00
PM at a private company in Kalibo, Aklan. She frequently leaves home between 6:45 AM to
7:00 AM since the drive from Banga to Kalibo usually takes her 30 minutes. She currently
lives with her two children and her widowed mother in a compound at Banga, Aklan while
her husband currently works as a seafarer on an international cargo ship. She has never been
admitted to the hospital but frequently gets colds especially during the rainy season. She takes
paracetamol (Biogesic) 1 tab, 500 mg/tab, PO, prn for fever and phenylephrine HCl (Neozep)
1 tab, 500 mg/tab, PO, prn for colds. A.C.C. annually goes to the hospital for a general
check-up in compliance for the company policy. For 15 years of annual general check-up,
A.C.C.’s results have been within normal limits. She walks around their neighborhood with
her mother and children during the weekends, as their form of exercise. She has no known
allergies to food, animals, or other environmental factors. K.C.C., the mother of A.C.C.
claims that her daughter is not a picky eater and loves to drink soft drinks everyday.

b. Chronologic Story

Three days PTC, A.C.C. went to Iloilo City with her mother to attend a seminar for work. The
seminar starts on Monday and ends on Wednesday and was held in Richmonde Hotel.
They stayed at the house of A.C.C. 's aunt in Jaro while her two children were left at
Banga, Aklan. “Nag upod naman lang ako pa city kay gusto ko mabisita amon mga
paryente”, as verbalized by K.C.C., the mother of A.C.C.
 Two hours PTC, A.C.C. wakes up and prepares breakfast for the household. Afterwards, she
prepared her things to bring to the seminar.

30 minutes PTC, A.C.C. leaves the house with her car . “Naglisensya sya nga aga pa daw sya
malakat para makapwesto pa sya maayo didto sa seminar”, as verbalized by K.C.C.
Registration for the third day of the seminar starts at 7:00 AM. “Hinay man lang na sya
magpadalagan, mga 40 to 60 kph dira dira lang”. Around 6:30 AM in the morning,
K.C.C. received a call from the rescue squad, “Gitawgan ako nga nadisgrasya daw si
A.C.C., dali dali man ako nanghimos para kadtuan bata ko”. On the scene, A.C.C.’s car
has been accidentally hit by a ten-wheeler truck on the highway. She suffered head injury
and a left clavicle greenstick fracture.. Furthermore, she had cuts on her face and arms
due to glass pieces that broke upon the impact, and minor bruises on her face.

A.C.C. was immediately transported to the nearest hospital wherein she was assessed in the
ER as lethargic with GCS= 10, E2M5V3. Her vital signs are monitored through the
cardiac monitor with T= 36.3 ℃, HR= 112 bpm, RR= 22 breaths/min, BP= 90/60 mmHg,
O2 sat= 94% with sharp aching pain on left ventricle rated as 9/10 and exacerbated when
flexed. Due to the extent of her injuries and need for close monitoring, she was
transferred to the surgical ICU.

Thus, this admission.

c. Relevant Family History

None, as claimed by K.C.C.

d. Disability Assessment
Due to the accident that has occured, K.C.C. verbalized worry for the children of A.C.C.,
“Ginapangita nila si mama nila. Hindi man sila pwede kabisita kay mga minor pa kag
COVID daan subong.” K.C.C. also verbalized worry for A.C.C.’s condition and her job,
“Naluoy ako sa bata ko nga na amo sya sini”.

2. Past Health Problems/Status

a. Childhood Illness:
(+) Chicken Pox K.C.C. verbalized “Ang bal-an ko daw ginsulalob na sya sang
highschool pa sa.”
(+) Mumps K.C.C. verbalized “Kaagi sya bayuok sang una pero indi ko madumduman
kung san o gid.”
(+) Flu. K.C.C. verbalized “Sang bata pa sa sige sya ubo kag sip-o, amo na ang akon mga
apo pirme man ga trangkaso.”

b. Immunization:
K.C.C. verbalized “Napabakunahan na sa, dugay-dugay na to sang bata pa sa. Indi ko
lang gid madumduman kung ano kag sang san-o.” BCG mark noted on the right deltoid.
 c. Allergies:
K.C.C. verbalized “Wala na sa allergy sa pagkaon o kun ano man da. Wala na sa pili ano
kan-on ya, wala man sa kaagi nga nagkatol-katol or nagkarashes.”

d. Accidents and Injuries

K.C.C. verbalized “Kaagi na sya sang una natumba sa motor sang college sya, indi ko na
matandaan ano tu nga year, kay nag drive nga hubog halin sa piyesta. Mayo lang man kay
nagka pilas-pilas lang tu siya sa iya paa kag kamot, wala man nabunggo iya ulo sadto.”

e. Hospitalization for serious illnesses

None as claimed by K.C.C.

f. Medications
OTC medications
a. paracetamol (Biogesic) - 1 tab, 500 mg/tab, PO (Q4H, for fever)
b. phenylephrine HCl (Neozep Non-Drowsy) - 1 tab, 500 mg/tab, PO, (prn,
for colds)

3. Family History of Illness

(+) Heart Disease - Uncle (paternal side), grandmother (maternal side)
(+) Diabetes - father (deceased)
(+) Hypertension - mother

4. Patient’s Expectations
a. What does he/she expect to occur during this hospitalization?
Not assessed, patient is intubated.
b. What does he/she expect regarding nursing care?
Not assessed, patient is intubated.

5. Patterns of Functioning
a. Breathing Patterns
Respiratory Problems: None
Usual Remedy: N/A
Manner of Breathing: Rhythmic, quiet, relaxed and effortless
b. Circulation
Usual Blood Pressure: 100/80 mmHg- 110/90 mmHg
Any history of chest pain, palpitations, coldness of extremities, etc.: None
Usual Remedy: N/A

c. Sleep Patterns
Usual bedtime: 10:00-10:30 pm to 5:00-5:30 am
Number of pillows: 2 (1 for the head and 1 in between the legs)
Bedtime Rituals: K.C.C. verbalized “gapanibin na sa antis magtulog, dasun ga inom sang
isa ka baso sang tubig”
Problems regarding sleep: None
Usual Remedy: N/A
 d. Drinking Patterns:
Kinds of Fluid in 24 hours/Amount in mL or Number of Bottles:

Kinds of Fluid in 24 Hours Amount in mL or Number of Pattern of Drinking

Bottles

Water 6- 8 glasses 1 glass upon waking, 2 glasses

(1500- 2000 ml) every morning, 2 glasses every
afternoon, 2 glasses every
night, 1 glass before sleeping

Softdrinks 2-3 bottles Twice a day 1 bottle taken

(474-711 ml) usually at lunch, 1 bottle in the
afternoon taken with snacks
and 1bottle at dinner

Coffee 1-2 cups Drinks 1 cup at breakfast and

(250-500 ml) another taken in the afternoon
with snacks

Total 2225-3211 mL fluid intake in 24 hours

e. Eating Patterns:

Usual Food Taken Time

Breakfast 1 cup of white steamed rice, 1 serving corned beef, 1 5:30-6:00 am

boiled egg, 1 cup 3-in1 coffee

Lunch 1 cup of steamed white rice, 1 serving of sinugbang baboy, 12:30-1:00 pm

and chicken adobo, 1 bottle of softdrink

Dinner 1 cup of steamed white rice, 1 serving of lumpia , 1 7:00-8:00 pm

serving fried fish, 1 slice of cake and 1 bottle of softdrink

Snacks Bananaque and 1 bottle of softdrinks, Kakanin (suman, 9:00-10:00 am;

bibingka, puto) and 1 cup coffee 3:00-4:00 pm;

Food likes: K.C.C. verbalized “Hilig gid na sya sang softdrinks halin pana sang dalaga
sya everyday gid sa ga inom softdrinks.”
Food dislikes: K.C.C. verbalized “Wala na sa ya pili sa kaon.”

f. Elimination Patterns
1. Bowel Movement
Frequency: Twice a day (Usually upon waking and on evening)
Problems or Difficulties: None
 Usual Remedy: N/A

2. Urination
Frequency: 5-6 times
Problems: None
Usual Remedy: N/A

g. Exercise
A.C.C. walks around their neighborhood (approximately 1 km) with her mother and children
during weekends at 6:00 AM - 7:00 AM.

h. Personal Hygiene
1. Bath
Type: Full bath and half bath
Frequency: Full bath: once during morning and half bath: once before sleeping
Time of Day: Full bath: 5:00 am; Half bath: 10:00 pm

2. Oral Care
Frequency: Twice a day
Care of Dentures: N/A

3. Shaving
Frequency: Once a week
4. Use of Cosmetics: Lotion, lipstick, shampoo, soap and perfume

i. Recreation
A.C.C. is fond of taking care of her potted plants. “Gina bunyagan nya gid na kada adlaw
kag maki pag exchange bala bulak sa iban para magdamo daw iya collection”, as
verbalized by K.C.C.

j. Health Supervision:
A.C.C. goes to the hospital to have a general assessment annually in compliance with
company policy. “Sa 20 years nya dira nga ubra, kada tuig gina require sila magpa
check-up sa hospital”, as verbalized by K.C.C.

II.B.: CLINICAL INSPECTION

II.B.1. Vital Signs (taken from cardiac monitor):

Date and Time taken: July, 28, 2021; 7:20 AM

T = 37.9 ℃ PR = 57 bpm
BP = 130/60 mmHg RR = 18 breaths per minute

Date and Time taken: July, 28, 2021; 8:00 AM

T = 37.8 ℃ PR = 59 bpm
BP = 130/60 mmHg RR = 15 breaths per minute
 Date and Time taken: July, 28, 2021; 12:00 PM
Vital Signs:

T = 36.1 ℃ PR = 58 bpm
BP = 140/60 mmHg RR = 17 breaths per minute

Date and Time taken: July, 28, 2021; 3:00 PM

Vital Signs:
T = 36.2 C PR = 60 bpm
BP = 130/70 mmHg RR = 18 breaths per minute

II.B.2. Height: 155 cm

II.B.3. Weight: 55.8 kgs
II.B.4. BMI = 23.25 (Normal)

II.B.4. PHYSICAL ASSESSMENT

Date and Time taken: July 28, 2021; 7:30 AM
General Appearance:
appearance appropriate with age; mesomorphic body type; unconscious, appears weak and
lethargic, on semi-fowler’s position, wearing hospital gown; attached to cardiac monitor; ongoing
IVF #1 (mainline) of PLRS 1L with the level of 700 cc at KVO rate patent and infusing well with
150cc/hr via left metacarpal vein, ]no signs of infection and inflammation at IV puncture site;
IVF #2 of PLRS 1L with the level of 900 cc at KVO rate patent and infusing well via right
cephalic vein, no signs of infection and inflammation at IV puncture site; with endotracheal tube
attached to volume respirator; with 8Fr feeding tube inserted through left nostril without
difficulty; CVP reading maintained at 8 cmH2O; with indwelling catheter attached to urobag
draining to 20 ml deep amber urine for the past hour.

A. INTEGUMENTARY SYSTEM

Skin: Generally dry, with moisture in skinfolds and axillae; Uniformly light brown in color
except in areas exposed to sun; skin intact, rebounds, and does not remain indented; good skin
turgor; less than 2 seconds both dorsum of the hand; BCG mark noted on right deltoid;
calluses on the heels noted; cold clammy skin on the upper and lower extremities; 2.5 cm cut
on left parietal region; facial edema 1+; with abrasions, bruises and cuts on face and arms due
to glass breaking upon impact;

Hair: black, wavy, thin, evenly distributed smooth hair; no infestation and dandruff; body
hair evenly distributed

Nails: nails translucent, shiny and firm in texture; cleaned and well-managed; 160-degree
angle between nail base and skin noted; slightly rough and firm; nail plate colorless; uniform
thickness; nails hard and basically immobile; capillary refill of 4 secs for nails and toes;

B. NEURO-SENSORY SYSTEM
GCS= 10, E2M5V3; opens eyes to pain,localization of extremity to pain, able to respond
through inappropriate words; grade +1 (Slight response, present but diminished) DTR on left
brachioradialis, biceps, and triceps;

Fine Motor Function: able to touch index finger of right hand to each finger of the opposite
hand; able to alternately supinate and pronate right hand at rapid pace; able to touch nose and
touch nurse’s finger with coordination and rapidity using right hand; Unable to assess left
hand due to greenstick fracture;

Eyes: bulbar conjunctiva: white, transparent; capillaries evident; no swelling and lesions;
palpebral conjunctiva: pinkish, shiny; smooth; no swelling or lesions noted; lacrimal glands:
no edema, tearing or tenderness noted; sclera: white; pupils: black; 3mm in diameter; pupils
equally round and react to light;

Nose: Nasal cavities: patent; Nasal mucosa: pink, free from swelling and inflammation;
septum: intact in midline; Maxillary and frontal sinuses: present of red glow when
transilluminated; with NGT attached on left nostril, patent and intact;

Ears: auricles, symmetrical and aligned with outer canthus of eye, 10 degrees vertically,
mobile, firm, recoils after folded; cerumen dry, yellow, noted 1/3 into external canal;

Cranial Nerve Assessment Client’s Significance

Technique Response

I. Olfactory Ask the client to smell Able to identify the INTACT

and identify the smell smell of coffee with for right nostril; sense
of cologne and coffee the right nostril while of smell is functioning
with each nostril tested eyes were closed. well.
separately with eyes Unable to assess left
closed. nostril due to NGT. NOT ASSESSED
for left nostril due to
NGT

II. Optic Provide adequate Able to open eyes INTACT

lighting and ask client only as response to Cranial nerve no. 2,
to read from a reading pain. Able to read optic nerve is intact.
material held at a only the first name of The client’s sense
distance of 36 cm (14 SN on nameplate. of sight is functioning
in.). well.

III. Oculomotor REACTION TO Illuminated and NOT INTACT

LIGHT: Using a non-illuminated pupil Pupils equally round
penlight and constricted. and react to light.
approaching from the With weak pupillary
side, shine a light on accommodation to
the pupil. Observe for near objects; may
response of the possibly be
illuminated pupil. experiencing
 Shine the light on the accommodative
pupil again, and insufficiency which is
observe the response of common with mild
the other pupil. TBI (Husseindeen &
Murali, 2020).

REACTION TO Unable to focus vision

ACCOMODATION: with near objects
Ask the client to look
at a near object and
then at a distant object.
Alternate the gaze
from the near to the far
object. Next, move an
object towards the
client’s nose.

IV. Trochlear Hold a penlight 1 ft. in Unable to keep eyes INTACT

front of the client’s open for a long Cranial nerve no. 4 is
eyes. Ask the client to duration but tries to intact. The client can
follow the movements follow the movement control eye
of the penlight with the of SN’s penlight. movements on
eyes only. Move the command.
penlight upward,
downward, sideward,
and diagonally.

V. Trigeminal While the client looks Closes eyes or blinks INTACT

upward, lightly touch as cotton touches Blinking reflex is
lateral sclera of the eye lateral sclera of the present. Both motor
to elicit blink reflex. eye and sensory functions
of the facial muscles
To test light sensation, and sensory receptor
have client close eyes, Able to identify light sites are functional.
wipe a wisp of cotton sensation by tapping
over the client's finger of right hand on
forehead. To test deep SN’s hand when
sensation, use cotton is felt while
alternating blunt and eyes are closed; Able
sharp ends of an to identify blunt
object. Determine objects by raising
sensation to warm and pointing finger and
cold object by asking middle finger for
client to identify sharp objects.
warmth and coldness.

VI. Abducens Hold a penlight 1 ft. in Able to follow the INTACT

front of the client’s movement of penlight Cranial nerve no. 6 is
eyes. Ask the client to to the side but cannot intact. Client’s eyes
follow the movements keep eyes open for a move bilaterally in
 of the penlight with the long duration. both sides.
eyes only. Move the
penlight through the
six cardinal fields of
gaze.

VII. Facial Ask the client to smile, Unable to perform NOT ASSESSED
raise the eyebrows, properly since
frown, and puff out intubated.
cheeks, close eyes
tightly. Ask client to
identify various tastes
placed on the tip and
sides of the tongue.

VIII. Have the client occlude Client is unresponsive NOT INTACT

Vestibulocochlear one ear. Out of the during the watch test.
client’s sight, place a Client mumbles Vestibular deficit is
tickling watch 2-3 cm. inappropriately and common to patients
Ask what the client can cannot repeat a single with head injury as
hear and repeat with syllable word during mentioned in the study
the other ear. whisper test. of Sabini (2021),
wherein 44% of
patient’s post-TBI
experience vestibular
dysfunction.
Ask the client to Unable to assess since Furthermore, patients
walk across the client is lethargic and may experience
room and back must remain in bed. balance deficits,
and assess the vertigo, dizziness,
client’s gait. vision impairments
and/or auditory
changes.

IX. Ask the client to say Gag reflex present INTACT

Glossopharyngeal “ah” and have the during intubation The motor (movement
patient yawn to of muscle that allows
observe upward the throat to shorten
movement of the soft and widen) and
palate. Elicit gag sensory functions
response. Note ability (sense of taste at the
to swallow. back of the
tongue) are functional.
 X. Vagus Ask the patient to Unable to assess since NOT ASSESSED
swallow and speak the client is intubated.
(note hoarseness).

IX. Accessory Ask the client to shrug Unable to assess since NOT ASSESSED
shoulders against the client has a left
resistance from your greenstick clavicle
hands, and turn head to fracture.
side against resistance
from your hand (repeat
for the other side).

XII. Hypoglossal Ask the client to move Unable to assess since NOT ASSESSED
the tongue (up, down, the client is intubated.
and side-to-side) freely
and against resistance
(tongue depressor).
References:
Hussaundeen, J.R., Murali, A. (2020). Accommodative Insufficiency: Prevalence, Impact and Treatment
Options. DOVE Press Clinical Optometry. 10.2147/OPTO.S224216
Sabini, R. (2021). Vestibular Dysfunction (after brain injury). American Academy of Physical Medicine
and Rehabilitation. https://now.aapmr.org/vestibular-dysfunction-after-brain-injury/

C. RESPIRATORY SYSTEM
General: RR=18 cycles per minute; constant and regular breathing; rhythmical, quiet, and
comfortable in between breaths noted; no nasal flaring and pursed lip breathing noted;

Posterior thorax: scapulae are symmetric and non-protruding; ratio of anteroposterior to

transverse diameter is 1:2; shoulders and scapula at equal horizontal positions; temperature
bilaterally equal; equal tactile fremitus and equal chest expansion (2.5 inches) noted;
resonance elicited during percussion; negative bronchophony, “ninety-nine” was easily
muffled and not easily understood; no egophony noted, “ee-ee-ee” was muffled and still
sounded like “ee”; no whispered pectoriloquy noted, sound of “one-two-three” was muffled
and not heard distinctly; tenderness and pain noted upon palpation of right side due to
fracture;
Anterior thorax: sternum positioned midline and straight; normal, diaphragmatic breathing
noted; chest expansion (2.5 inches) noted; resonance elicited during percussion; negative
bronchophony, “ninety-nine” was easily muffled and not easily understood; no egophony
noted, “ee-ee-ee” was muffled and still sounded like “ee”; no whispered pectoriloquy noted,
sound of “one-two-three” was muffled and not heard distinctly; the ratio of anteroposterior to
transverse diameter is 1:2.

D. CARDIOVASCULAR/CIRCULATORY SYSTEM
 Neck vessels: no jugular vein distention noted

Heart: Apical pulse HR= 57 beats per minute upon auscultation, S1 and S2 heard at all sites
(aortic, pulmonic, tricuspid, apical); no heart murmurs heard.

Upper extremities: edema noted on left shoulder; capillary beds refill of 4 seconds; left
radial pulse nonpalpable, left brachial pulse 1+ (difficult to palpate, weak and easily
obliterated with pressure); Negative Allen’s test noted on left hand; sharp aching pain
radiating throughout left arm, exacerbates when flexed, pain rated as 9/10

Lower extremities: identical size and shape bilaterally, no edema noted; femoral pulses 1+
(difficult to palpate, weak and easily obliterated with pressure); dorsalis pedis pulses
bilaterally nonpalpable; bluish toned nail beds; capillary refill of 4 seconds; no sounds
auscultated over femoral arteries; popliteal pulse non-palpable; posterior tibial pulses
nonpalpable.

E. GASTROINTESTINAL/HEPATOBILIARY SYSTEM

Mouth: Lips: dry, pale, without lesions or swelling; Teeth: 14 upper teeth and 15 lower teeth
noted; first upper premolar missing and first lower molar missing, upper third molar
extracted; no cavities and dental caries noted;
Gums: color and consistency of tissues along cheeks and gums even; pale pink, moist, and
firm with tight margins to the tooth; no lesions or masses noted; Jaws: aligned with no
deviation seen with biting down; Tongue: pale pink, moist, midline, presence of white coating
at the dorsal part of the tongue; lingual frenulum midline; no lesions, ulcers, or nodules
apparent; Uvula: in midline.

Abdomen: uniform in skin color, symmetric movement during respiration; umbilicus

inverted, midline at lateral line; bowel sounds normal, RUQ= 6 cycles per minute, RLQ= 5
cycles per minute, LLQ= 6 cycles per minute, LUQ= 5 cycles per minute; bruits not heard
upon auscultation; no friction rub over liver or spleen.

F. GENITO-URINARY SYSTEM
With indwelling catheter attached to urobag draining 20 ml, deep amber urine.

G. REPRODUCTIVE SYSTEM
Breast: rounded shape, slightly unequal in size, generally symmetrical, skin uniform in color;
Areola: dark brown, round, irregular placement of sebaceous glands on the surface of the
areola; Nipples: round, everted, and equal in size, similar in color, soft and smooth, both point
downward; no tenderness, masses, and nodules upon palpation; no discharge from nipple

H. ENDOCRINE SYSTEM
Thyroid gland: not palpable and non-tender; no enlargement, no tenderness; no thyroid
masses noted

I. MUSCULOSKELETAL SYSTEM
 General: right arm and lower extremities with normal muscle mass and tone; unable to assess
gait since client is lethargic and weak.

Head: normocephalic, symmetric, and in midline; no abnormal movements noted; mouth

opens and closed fully; tenderness upon palpation on left frontal and parietal region noted;
left facial edema 1+ noted; 2.5 cm cut on left parietal region noted; cuts, bruises, and
abrasions noted prominent on the left side of the face.

Neck: symmetric, head centered and no bulging masses noted; midline, thyroid cartilage and
cricoid cartilage move upward symmetrically when swallowing; trachea is midline; thyroid
gland non-palpable; no bruits auscultated; ROM grade 3+; pain and tenderness felt upon
palpation.

Spine: concave cervical and lumbar spine, convex thoracic spine noted; nontender spinous
processes noted; well-developed, firm, and smooth, nontender paravertebral muscles noted;
no muscle spasm noted; ROM grade 3+, experiences difficulty and pain when left arm is also
moved;

Upper extremities: wrists, hands, and fingers are symmetric, no tenderness, redness,
swelling, or deformity noted; muscles fully developed, tenderness upon palpation of left
shoulder and left chest; right hand with ROM grade 3+; left arm ROM grade 1+; left clavicle
with greenstick fracture noted; with clavicle brace; left arm immobilized with arm sling.

Lower extremities: iliac crests symmetric in height; stable hips noted, non-tender and
without crepitus; knees symmetric, hollow present on both sides of patella noted; toes pointed
forward and lie flat; aligned toes and feet with the lower leg noted; firm muscles noted, no
nodules; no pain, heat, tenderness, swelling or deformities noted; no tenderness upon
palpation; ROM grade 4+ on both lower extremities, moderate resistance

J. LYMPHATIC SYSTEM
Tonsils: symmetrical, grade +2, no tenderness or swelling; tonsillar nodes palpable without
swelling, tenderness, no hardness noted.

Head and neck: superficial cervical nodes, posterior cervical nodes, deep cervical chain
nodes, and supraclavicular nodes palpable, tenderness noted upon palpation;

K. HEMATOPOIETIC SYSTEM
HR = 57 bpm (apical); pale conjunctiva; return of capillary refill on fingers and toes for 4
secs; bluish nail beds; decreased pulsation on left brachial and radial pulses; Blood type: O+;
bled moderately of approx. 1,500 ml from the parietal region of the head.
 II.B.5. PSYCHOSOCIAL NURSING ASSESSMENT

1. Lifestyle information
A.C.C. is a 47 year old woman, married with two children of 14 years old and 16 years old
respectively. She works as an occupational health nurse at a private company. She lives with her
two children and her widowed mother at Banga, Aklan. She goes on duty for 8 hours from 8:00
am-4:00 pm daily for 5 days a week. Usually she would call her husband twice a day upon
waking and before going to bed. She keeps herself busy during the weekend by tending to her
potted plants and doing household chores. She walks around the neighborhood with her mother
and children during weekends. She drinks approx 1-2 bottles of beer during special occasions, she
does not smoke or take illegal drugs.

2. Normal coping Patterns

K.C.C. verbalized, “Kung stressed na sa ga kadto na siya saiya garden kag mag tanom
sang kung ano na bulak. Kis-a ga bake na sa o kun mag luto sang mga pang snacks na makita ya
sa facebook.”

3. Understanding of Present Illness

Unable to assess since A.C.C. is intubated. with GCS= 10, E2M5V3

4. Personality Style:
K.C.C. claimed that A.C.C. is a friendly person, she likes socializing with others and can
easily make friends and open to new things and other’s opinions. She also has good relationships
with neighbors and workmates. She is not involved in any conflict within the residents of the
community.

5. History of Psychiatric Disorder

K.C.C. verbalized, “Wala man kami lahi sang mga amo na nga sakit. Pati sa iya tatay nga
side wala man.”

6. Recent Life Changes or Stressors:

K.C.C. verbalized, “Sang nag start ang Covid nga ni last year na stress gid sya,
karadlukan man dabi kag frontliner siya. Kag wala pa daan kasakay ang asawa ya sadto mga pito
ka bulan sya wala sweldo te budlay gid nga siya lang ga ubra kag sige pa sa quarantine kada duwa
ka semana.

7. Major Issues Raised by Current Illness:

Unable to assess since A.C.C. is intubated, with GCS= 10, E2M5V3

8. Mental Status Examination

APPEARANCE
Neat Clean Dishevelled Poor Grooming Erect Posture

Good eye contact Inappropriate makeup others: weak and lethargic

 Description: A.C.C.appears weak and lethargic while attached on two IV lines,
an NGT, endotracheal tube, foley catheter, and wearing hospital gown.

BEHAVIOR
Calm Appropriate Restless Agitated Compulsions

Unusual actions others: ___________

Description: Unable to assess since A.C.C. is lethargic and unresponsive to

verbal stimulation during assessment.

SPEECH
Appropriate Pressured Loose Association Loud Soft

Mute others: Inappropriate___

Description: A.C.C. is lethargic and unresponsive to verbal stimuli

however she responded earlier to localized pain by saying
inappropriate words and mumbling.

MOOD/AFFECT

Appropriate Labile Flat Depressed Worried Anxiou

s
Angry Hopeless others: _______________

Description: Unable to assess since mood/affect A.C.C. is lethargic

and unresponsive to verbal stimuli.

THOUGHTS

Appropriate Low Self-Esteem Suicidal Ideations Hallucinations

Delusions Phobias others: _______________

Description: Unable to assess thoughts since A.C.C. is lethargic and

unresponsive to verbal stimuli..

ABILITY TO ABSTRACT
Impaired: YES NO

Description: Unable to assess ability to abstract since A.C.C. is lethargic and

unresponsive to verbal stimuli.
 MEMORY
Impaired recent memory: YES NO

Impaired past memory: YES NO

Number of objects able to remember after 5 minutes: 5 objects

Description: Unable to assess memory since A.C.C. is lethargic and unresponsive

to verbal stimuli.

ESTIMATED INTELLIGENCE
Below Average Average Above Average

Description: Unable to assess intelligence since A.C.C. is lethargic and

unresponsive to verbal stimuli

CONCENTRATION
Able to focus Easily distractible

Able to subtract backwards by 7s from 100 correctly until number 72.

Description: Unable to assess concentration since A.C.C. is lethargic and

unresponsive to verbal stimuli.

ORIENTATION
Person Time Place Situation .

Description: Unable to assess orientation since A.C.C. lethargic and

unresponsive to verbal stimuli.

JUDGMENT
Realistic decision making: YES NO

Description: Unable to assess judgement since A.C.C. is lethargic and

unresponsive to verbal stimuli.

INSIGHT
Good Fair Poor

Description: Unable to assess insight since A.C.C. is lethargic and unresponsive

to verbal stimuli.
II.C. NURSING PROGRESS NOTES (On-going Appraisal) - SOAPIE

(Use SOAPIE format. Refer to example given)

07/29/2021
8:00 a.m. S- No verbalizations; Patient is intubated

O-

A - Risk for pressure ulcers r/t prolonged stationary position

8:30 a.m. P/I - Assessed the specific risk factors for pressure ulcer

Assessed the specific risk factors for pressure ulcer

Used an objective tool for pressure ulcer risk assessment

(Braden Scale Score 11)

Reposition client as tolerated every 2 hours.

Keep head of the bed at lowest safe elevation to prevent shear.

Keep skin clean and dry. Use soft paddings

Ensure nutritional intake to fulfill nutritional needs.

Examine skin for signs of sores regularly.

Monitor hemoglobin levels.

3:00 p.m E -

Source:
Bluestein, D. & Javaheri, A. (2008). Pressure Ulcers: Prevention, Evaluation and Management. American
Family Physician. https://www.aafp.org/afp/2008/1115/p1186.html

Preventing Bedsores in TBI Patients Being Cared for at home (2019). Wishart Brain and Spine Law.
https://brainandspinelaw.com/preventing-bedsores-in-tbi-patients-being-cared-for-at-home/

II.D. OTHER SOURCES OF DATA

1. HEMATOLOGY

Name of Examination: Complete Blood Count (CBC)

Definition: The CBC and differential count are a series of peripheral blood tests that provide a lot
of information about the hematologic system as well as many other organ systems. As a screening
test, these tests are inexpensive, simple, and quick.

Preparation: There are no special preparations prior to the test and there are no food, fluid,
activity, or medication restrictions unless by medical direction.

Purpose: It is used to determine a person's overall health status, as well as to screen for, diagnose,
and monitor a variety of diseases and conditions that affect blood cells, including anemia,
infection, inflammation, polycythemia, hemolytic disease, cancer, and the effects of ABO
incompatibility, leukemia, and dehydration status.

Date: July 28, 2021; 6:00 AM

Results Normal Values Significance

Hemoglobin 9.0 12 -16 g/dl Decreased.

A decrease in hemoglobin
implies anemia, recent
hemorrhage and fluid
retention.

Anemia is a common
clinical condition in patients
suffering from traumatic
brain injury (TBI). As low
hemoglobin level may
increase the risk of poor
brain oxygen delivery and
secondary ischemic injury in
TBI, red blood cell (RBC)
transfusion is often applied
in postoperative intensive
care.
Hematocrit 0.32 0.37- 0.47 % Decreased.
A low hematocrit level
means there are too few red
blood cells in the body. In
these cases, a person may
experience symptoms that
signal anemia. This could
also be decreased with acute
massive blood loss.

Suspected anemia is the

most common reason for
hematocrit testing. The
hematocrit is calculated
from the number of red
blood cells in a sample of
blood. Anemia is common
in patients with severe TBI,
and can result in decreased
cerebral oxygen delivery
and brain injury.
RBC 4.0 4.5- 6.1 x 10^12/L Decreased.
At a biological level, anemia
develops because of an
imbalance in erythrocyte
loss relative to production;
this can be due to ineffective
or deficient erythropoiesis
(e.g., from nutritional
deficiencies, inflammation,
or genetic Hb disorders)
and/or excessive loss of
erythrocytes (due to
hemolysis, blood loss, or
both).

In major trauma, a multitude

of stress-associated changes
occur to the patient's RBCs,
including morphological
changes that increase cell
rigidity and thereby alter
blood flow hemodynamics,
particularly in the
microvascular vessels, and
reduce RBC survival.
WBC 12.3 4.4- 11.0 x 10^9/L Increased.
It has been hypothesized
that elevation of a trauma
patient's white blood cell
 (WBC) count may be a
surrogate marker of
neurohumoral activation and
be valuable in identifying
patients with major injuries.

Leukocytosis in
trauma/stress is due to
neutrophilia, caused by
neutrophil margination, and
not due to increased marrow
production or release of
immature cells or bands.
The phenomenon is
short-lived, lasting only
minutes to hours.
Neutrophils 0.57 0.54- 0.58 Within Normal Limits

Eosinophils 0.00 0.01- 0.04 Decreased.

Low eosinophil counts may
be due to the time of day.
Under normal conditions,
eosinophil counts are lowest
in the morning and highest
in the evening. Unless
alcohol abuse or Cushing's
disease is suspected, low
levels of eosinophils are not
usually of concern unless
other white cell counts are
also abnormally low.
Basophil 0.00 0.00-0.01 Within Normal Limits

Lymphocyte 0.29 0.25- 0.33 Within Normal Limits

Monocyte 0.01 0.03- 0.07 Decreased.

Astrocytes resume
proliferation specifically at
the vascular wall after brain
injury. Genetic increase of
astrocyte proliferation
reduces monocyte invasion
at the injury site, while lack
of monocyte invasion
promotes astrocyte
proliferation and reduces the
GFAP+ scar.
MCV 87.1 76.0- 96.0 FL Within Normal Limits

MCH 29.8 27.0- 32.0 pg Within Normal Limits

Platelet count 250 150- 450 x 10^9/L Within Normal Limits
(APC)

2. CLINICAL CHEMISTRY

Name of Examination: Serum Sodium

Definition: Serum sodium levels may be affected by a variety of disorders and drugs and are
evaluated in relation to other serum electrolyte and blood chemistry results.

Preparation: No special preparation is required prior to the test.

Purpose: To assess electrolyte balance related to hydration levels and disorders such as diarrhea
and vomiting and to monitor the effect of diuretic use.

Name of Examination: Serum Potassium

Definition: Potassium is an electrolyte that is required for skeletal, cardiac, and smooth muscle
function. It also helps to keep the acid–base balance in the cell and contributes to intracellular
enzyme activities. The normal concentration of K in the blood is around 4 mEq/L. Because the
serum concentration of K is so low, even slight variations in concentration have a huge effect. The
kidneys excrete K, and there is no resorption of K by the kidneys.

Preparation: There are no food, fluid, activity, or medication restrictions unless by medical
direction. Instruct the patient not to clench and unclench the fist immediately before or during
specimen collection.

Purpose: To evaluate fluid and electrolyte balance related to potassium levels toward diagnosing
disorders such as acidosis, acute kidney injury, chronic kidney disease, and dehydration and to
monitor the effectiveness of therapeutic interventions.

Date: July 28, 2021; 6:00 AM (ER)

Results Normal Values Significance

Sodium 131 135-145 meq/L Decreased.

Dysregulation of the
neuroendocrine system is
a frequent complication
after traumatic brain
injury (TBI). Symptoms
of these hormonal
abnormalities might be
subtle and thus easily
ignored. Hyponatremia is
common after head
injury due to shifts in
extracellular fluid,
electrolytes, and volume.
Potassium 5.8 3.5-5.0 meq/L Increased.
Hyperkalemia is
recognized as a general
phenomenon in trauma
patients because of the
theory that the release of
cellular contents due to
the tissue damage or
hemorrhagic shock
commonly occurs in the
severely injured patients.

Date: July 28, 2021; 3:00 PM (SICU)

Results Normal Values Significance

Sodium 133 135-145 meq/L Decreased.

Ringer’s lactate has a
sodium concentration of
128mmol/L which will
be more isotonic to the
hyponatremic patient.
Although never shown in
clinical studies,
administering Ringer’s
lactate will likely result
in a slower rise in serum
sodium than Normal
Saline, and therefore
have a lower risk of
potentiating osmotic
demyelination syndrome.
Ringer’s lactate is
therefore recommended
by our experts as the
fluid of choice for
resuscitation of the
hypovolemic/hyponatrem
ic patient.

Mannitol is freely filtered

by the glomerulus and
does not undergo tubular
reabsorption. Thus, it
acts as an osmotic
diuretic, increasing
urinary losses of both
 sodium and
electrolyte-free water.
Potassium 3.2 3.5-5.0 meq/L Decreased.
Despite containing
potassium, Lactated
Ringer’s Solution will
still decrease the serum
potassium level of a
hyperkalemic patient.
This is because the
potassium concentration
in these fluids is lower
relative to the patient’s
serum potassium level
and dramatically lower
than the patient’s
intracellular potassium
concentration.

At large doses mannitol

increases excretion of
sodium and potassium.
Initially, mannitol acutely
raises plasma and
extracellular osmolality,
which leads to an
increase in circulating
blood volume.

Name of Examination: Creatinine

Definition: This test measures the amount of creatinine in the blood. Creatinine is a catabolic
product of CPK, which is used in skeletal muscle contraction. The daily production of creatine,
and subsequently creatinine, depends on muscle mass, which fluctuates very little. The serum
creatinine test, as with BUN, is used to diagnose impaired renal function. The creatinine test is
used as an approximation of glomerular filtration rate (GFR).

Preparation: There are no food, fluid, or medication restrictions unless by medical direction.
Instruct the patient to refrain from excessive exercise for 8 hours before the test.

Purpose: To assess kidney function found in acute kidney injury and chronic kidney disease,
related to drug reaction and disease such as diabetes.

Name of Examination: Blood Urea Nitrogen (BUN)

Definition: Urea is a waste product formed in the liver when protein is metabolized into its
component parts (amino acids). This process produces ammonia, which is then converted into the
 less toxic waste product urea. This test measures the blood urea nitrogen (BUN) level in the
blood. Sometimes, a BUN to creatinine ratio is calculated to help determine the cause of elevated.

Preparation: No special preparation is needed for this test.

Purpose: The BUN test is primarily used, along with the creatinine test, to evaluate kidney
function in a wide range of circumstances, to help diagnose kidney disease, and to monitor people
with kidney dysfunction or failure. It also may be used to evaluate your general health status
when ordered as part of a renal panel, basic metabolic panel or comprehensive metabolic panel.
Blood creatinine and BUN tests may also be ordered to evaluate kidney function prior to some
procedures, such as a CT (computed tomography) scan, that may require the use of drugs that can
damage the kidneys if not cleared rapidly.

Date: July 28, 2021; 8:00 PM

Results Normal Values Significance

Serum creatinine 1.7 0.5-1.1 mg/dl Increased.

A hyperdynamic state
was found in patients
with head injury,
characterized by
increased cardiac output,
cardiac work, moderate
hypertension,
tachycardia, decreased or
normal systemic and
pulmonary vascular
resistance, increased
pulmonary shunting, and
increased oxygen
delivery and utilization.
Furthermore, according
to the study of Udy et al.
in 2017, an elevated
creatinine clearance is
directly proportional to
cardiac output changes.
An increase in cardiac
output (CO) results in a
disproportionate increase
in renal perfusion, which
consequently leads to an
elevated serum creatinine
clearance.
Blood urea nitrogen 19 10-20 mg/dl Within Normal Limits
(BUN)

3. CLINICAL MICROSCOPY

Name of Examination: Urinalysis

 Definition: A total urinalysis involves multiple routine tests on a urine specimen. A routine
urinalysis (UA) has two major components: (1) macroscopic analysis and (2) microscopic
analysis. Macroscopic analysis includes examining the urine for overall physical and chemical
characteristics. The microscopic component of a UA involves examining the sample for the
presence of crystals, casts, renal epithelial cells, transitional epithelial cells, squamous epithelial
cells, white blood cells (WBCs), red 22 blood cells (RBCs), bacteria, yeast, sperm, and any other
substances excreted in the urine that may have clinical significance.

Preparation: If urine is being tested only for a urinalysis, the patient can eat and drink normally
before the test unless by medical direction. To get the most accurate results, the sample should be
taken 30-60 minutes before the analysis and may need to be collected midstream, using a
clean-catch method. This method involves the following steps:

● Cleansing the urinary opening for both males and females to prevent contamination
● Begin to urinate into the toilet
● Pass the collection container into the urine stream
● Urinate at least 1-2 ounces into the collection container
● Finish urinating into the toilet
● Deliver the sample as directed by the doctor

Purpose: The urinary tract is composed of kidneys, ureter, bladder and urethra. Its primary role is
to filter waste and regulate the balance of water, electrolytes, proteins, acids, and other substances
in the body. If any part of this system is damaged or impaired, it will alter the chemical
composition and/or volume of urine and urinalysis is a direct means of assessing these changes.
Urinalysis can help to detect a variety of kidney and urinary tract disorders, including chronic
kidney disease, diabetes, bladder infections and kidney stones.

Date: July 28, 2021; 8:00 AM

Results Normal Values Significance

RBC 0-2 0-11 u/L Within Normal Limits

Pus Cells 5 0-22 u/L Within Normal Limits

Epithelial cells 4 0-28 u/L Within Normal Limits

Cast 0.00 0.0- 0.03 u/L Within Normal Limits

Color deep amber Pale yellow to deep Within Normal Limits

amber
Transparency Hazy Transparent Altered.
An increase in turbidity
and cloudiness of the
urine may indicate that
there are particles with
the urine. These could
possibly be blood
components, proteins,
and bacteria.
 It could also be caused
by dehydration from loss
of body fluids right after
experiencing trauma or
accidents.
pH Acidic 6.9 6.5-8.0 Within Normal Limits

Specific Gravity 1.035 1.010-1.020 Increased.

Elevated specific gravity
is due to the presence of
more solid materials in
the urine. This could be
caused by dehydration in
patients with blood loss.
When there is less fluid
in the body, the kidney
will make urine with less
water in it, thus
increasing the specific
gravity.
Glucose (-) Negative Within Normal Limits

Protein (-) Negative Within Normal Limits

4. RADIOLOGY

Name of Examination: Computed Tomography Scan (Cranial)

Definition: A computerized tomography (CT) scan combines a series of X-ray images taken from
different angles around the body and uses computer processing to create cross-sectional images
(slices) of the bones, blood vessels and soft tissues inside the body. CT scan images provide
more-detailed information than plain X-rays do.

Preparation: There are no food, fluid, activity, or medication restrictions unless the CT scan
involves contrast (a special dye that aids in highlighting the body area that is needed to be
examined). Instruct the patient to fast and restrict fluids, as ordered, for 2 to 4 hrs prior to the
procedure. Patients should be instructed to avoid taking natural products and medications with
known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered,
prior to the procedure. (Bladh & Van Leeuwen, 2019 p. 378)

Purpose: To visualize and assess internal organs/structures for abnormal or absent anatomical
features, abscess, aneurysm, cancer or other masses, infection, or presence of disease. Used as an
evaluation tool for surgical, radiation, and medical therapeutic interventions.

Date: July 30, 2021; 7:10 PM

Results:
Diffuse axonal injury
 CT Findings:
- Early imaging may be subtle
- Foci of decreased density
- May show some degrees of cerebral swelling
- May show small focal hemorrhage or small petechial haemorrhage particularly at gray-white
junction and corpus callosum.
- May show extensive injury

Note: Left scan Patient’s CT; Right Normal CT

Impression:

DIFFUSE AXONAL INJURY

Diffuse axonal injury is a form of traumatic brain injury that happens when the brain rapidly shifts
inside the skull caused by an injury or an accident.The axons of the brain are torn as the brain
rapidly accelerates and decelerates inside the skull. Patients usually experience a lower level of
consciousness and in severe cases, coma. The microscopic and tiny damages to the brain can be
seen using CT or MRI scans.

Significance:

Diffuse axonal injury does not damage the brain directly, but the brain cells are the ones who are
damaged or impaired, which may cause neurological problems. The most prevalent symptom is
loss of consciousness which lasts up to six hours. Mild cases may allow the client to be conscious
but may display other signs of brain damage.

The damage to the brain cells results in them not functioning and swelling may also occur, which
may cause more damage. The client may experience disorientation, loss of balance, nausea,
vomiting, and headaches. It is one of the most dangerous types of head injuries, but has different
severities having concussion as one of the milder types. It can lead to permanent brain damage
and even death (Young, 2018).

Name of Examination: X- ray

Definition: X-rays are a type of radiation called electromagnetic waves. X-ray imaging creates
pictures of the inside of the body. The images show the parts of the body in different shades of
black and white. This is because different tissues absorb different amounts of radiation. Calcium
in bones absorbs x-rays the most, so bones look white. Fat and other soft tissues absorb less and
look gray. Air absorbs the least, so lungs look black.

Preparation: Wear a gown given by the technician; remove jewelry, eyeglasses and any metal
objects because they can show up on an X-ray

Purpose: Standard X-rays are performed for many reasons, including diagnosing tumors or bone
injuries. X-rays are made by using external radiation to produce images of the body, its organs,
and other internal structures for diagnostic purposes.

Date: July 30, 2021; 7:15 PM

Results:

Clavicular fracture, left arm

Impression:

A direct blow to the shoulder is the most common cause of clavicle fractures. This can occur as a
result of a fall onto the shoulder or a car accident. A clavicle fracture can also be caused by a fall
onto an outstretched arm. A clavicle fracture can be excruciatingly painful, making it difficult to
move the affected arm. Sagging of the shoulder downward and forward, inability to lift the arm
due to pain, a grinding sensation when trying to raise the arm, presence of a deformity over the
break, and bruising, swelling, and tenderness over the collarbone are all signs and symptoms of a
fracture.

Significance:

Broken bones are one of the most common car side effects, with clavicular fractures accounting
for 5% of all adult fractures. The clavicle, also known as the collarbone, is a delicate bone that is
easily broken. Many people's clavicles are also close to their seatbelts, which can cause pressure
and breakage. A clavicle, unlike other extremities, cannot be cast neatly. To avoid movement, the
arm may be placed in a cast, and physical therapy will be an important part of the recovery
process (AICA Orthopedics, 2020).

REFERENCES:

AACC Lab Tests Online. (2019, October 25). Blood Urea Nitrogen (BUN) - Understand the Test.
Retrieved from https://labtestsonline.org/tests/blood-urea-nitrogen-bun

AACC Lab Tests Online. (2020, February 19). Complete Blood Count (CBC) - Understand the
Test & Your Results. Retrieved from https://labtestsonline.org/tests/complete-blood-
countcbc#:~:text=The%20complete%20blood%20count%20(CBC,as%20infections%2C
%20anemia%20and%20leukemia.

AACC Lab Tests Online. (2019, October 24). Creatinine. Retrieved from https://labtestsonline
.org/tests/creatinine

AACC Lab Tests Online. (2015). Hematocrit. Retrieved from

https://labtestsonline.org/tests/hematocrit.

AACC Lab Tests Online. (2015). Hemoglobin. Retrieved from

https://labtestsonline.org/tests/hemoglobin.

AICA Orthopedics. (2020, February 17). What You Need To Know About Clavicle Fractures.
https://aica.com/need-know-clavicle-fractures/

Baimel, M. & Etchells, E. (2015). Emergency Management of Hyponatremia.

https://emergencymedicinecases.com/episode-60-emergency-management-hyponatremia/

Carey, R. (2018). Red Cell Indices.Retrieved from

https://labtestsonline.org/tests/red-cellindices?fbclid=IwAR1W151tDwtXOYSOgUJJ6Uwu8SSu
UKmCoS7Cy9RxilpMsevxPzU7Fs3FYyg

Fischbach, F.T., & Fischbach, M.A. (2018). A Manual of Laboratory and Diagnostic Tests. 10th
ed. Philadelphia, PA: Wolters Kluwer.

Frik, J. et al. (2018). Cross-talk between monocyte invasion and astrocyte proliferation regulates
scarring in brain injury. EMBO Rep. 2018 May;19(5):e45294. doi: 10.15252/embr.201745294.

Gürkanlar, D. et al. (2009). Predictive value of leucocytosis in head trauma. Turk Neurosurg.
 19(3):211-5. https://pubmed.ncbi.nlm.nih.gov/19621283/

Hayes, B. & O’Brien, M. (2021). Is Lactated Ringer’s Solution Safe for Hyperkalemia Patients?
https://www.aliem.com/lactated-ringers-solution-safe-hyperkalemia-patients/

Healthwise. (2020, September 23). Urine Test. Https://Myhealth.Alberta.Ca/.

https://conditions.aspx

Husney, A. (2018). Sodium (Na) in Blood.Retrieved from https://wa.kaiserpermanente.org/

kbase/topic.jhtml?docId=hw203476

Kuramatsu, J.B. et al. (2013). Advances in the management of intracerebral hemorrhage. J Neural
Transm (Vienna). 120 Suppl 1:S35-41. doi: 10.1007/s00702-013-1040-y.

MedLine. (2018). Hematocrit Test. Retrieved from

https://medlineplus.gov/labtests/hematocrit-test/

Open Anesthesia. (2014). Mannitol – Hemodynamic effects. Openanesthesia.org.

https://www.openanesthesia.org/aba_mannitol_-_hemodynamic_effects/

Osborn, C. O. (2019, March 8). Why Is My Urine Cloudy? Healthline.

https://www.healthline.com/health/cloudy-urine#TOC_TITLE_HDR_1

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Young, B. (2018, September 29). Diffuse Axonal Injury. Healthline.

https://www.healthline.com/health/diffuse-axonal-injury

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s13054-019-2498-2

III. DRUG STUDY

VI. TEXTBOOK DISCUSSION AND PATHOPHYSIOLOGY

A.Definition:

Head Injury
A head injury is a broad term that describes a vast array of injuries that occur to the scalp, skull, brain,
and underlying tissue and blood vessels in the head. Head injuries are also commonly referred to as brain
injury, or traumatic brain injury (TBI), depending on the extent of the head trauma.

Traumatic Brain Injury (TBI) is a traumatically induced structural injury or physiological disruption in the
normal function of the brain as a result of an external force, specifically by a blow, bump or jolt to the
head, the head suddenly and violently hitting an object or when an object pierces the skull and enters
brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of damage to
the brain. Mild cases may result in a brief change in mental state or consciousness.

According to the unique physical mechanisms of insult, TBI can be divided into three categories: (i)
closed head; (ii) penetrating; and (iii) explosive blast TBI.

● Closed head TBI is typically caused by blunt impact incurred mainly from motor vehicle
accidents, falls and sports activities. The incidence rate of this form of TBI is the highest amongst
the civilian population.
● Penetrating TBI results when a foreign body penetrates the skull and traverses through the dura
into brain parenchyma. Similar to closed head TBI, laceration of brain tissues primarily causes
focal damages, intracranial hemorrhage, cerebral edema and ischemia. Due to exposure of brain
tissue to the harsh environment, the chance of infection is relatively high in this form of TBI.
With the invasive nature of this type of injury, penetrating TBI is associated with acute medical
complications such as respiratory failure, pneumonitis, hypotonia and cerebrospinal leakage in
comparison to closed head TBI.
● With the high prevalence of casualties suffering from war-related TBI in the 20th century mainly
in Afghanistan and Iraq, explosive blast TBI has recently been considered as a new category. In
addition, post-traumatic stress disorder is frequently associated with explosive blast TBI, and
research has shown a high occurrence rate in TBI survivors.

Diffuse Axonal Injury

Diffuse axonal injury (DAI) is a type of traumatic brain injury (TBI) that results from a blunt injury to the
brain. Diffuse axonal injury (DAI) primarily affects the white matter tracts in the brain. Clinically,
patients with DAI can present in a spectrum of neurological dysfunction. This can range from clinically
insignificant to a comatose state. However, most patients with DAI are identified to be severe and
commonly have a GCS of less than 8. A diffuse axonal injury is a clinical diagnosis. The primary insults
of diffuse axonal injury lead to disconnection or malfunction of neuron's interconnection. This affects
numerous functional areas of the brain. Usually, patients with diffuse axonal injury present with bilateral
neurological examination deficits frequently affecting the frontal and temporal white matter, corpus
callosum, and brainstem. The Adams classification of diffuse axonal injury utilizes pathophysiological
lesions in the white matter tracts and clinical presentation.
The Adams Diffuse Axonal Injury Classification

● Grade 1: A mild diffuse axonal injury with microscopic white matter changes in the cerebral
cortex, corpus callosum, and brainstem
● Grade 2: A moderate diffuse axonal injury with gross focal lesions in the corpus callosum
● Grade 3: A severe diffuse axonal injury with finding as Grade 2 and additional focal lesions in the
brainstem

Axonal portions of neurons have a mechanical disruption of cytoskeletons resulting in proteolysis,

swelling, and other microscopic and molecular changes to the neuronal structure.

Greenstick Fracture

A greenstick fracture is a partial thickness fracture where only cortex and periosteum are interrupted on
one side of the bone, while they remain uninterrupted on the other side. Greenstick fractures occur most
commonly after a fall on an outstretched arm (FOOSH); however, they can also occur due to other types
of trauma including motor vehicle collisions, sports injuries, or non-accidental trauma where the
individual is hit with an object.

They occur most often in long bones, including the fibula, tibia, ulna, radius, humerus, and clavicle. Most
commonly, they occur in the forearm and arm involving either the ulna, radius or humerus. This is
because people brace falls with an outstretched arm, resulting in fractures to the upper extremities.
Greenstick fractures can also occur in the face, chest, scapula and virtually every bone in the body, but
with much less frequency than long bones.
B.Signs and Symptoms:

Head Injury
SIGNS AND SYMPTOMS ACCORDING TO SIGNS AND SYMPTOMS MANIFESTED
TEXTBOOK

● Confusion (-)
● Dizziness or balance problems (+) 07/28/2021
● Double or fuzzy vision (-)
● Fatigue (+) 07/28/2021
● Headache (+) 07/28/2021
● Memory loss (-)
● Nausea (-)
● Sensitivity to light or noise (-)
● Changes in size of pupils (-)
● Bleeding (+) 07/28/2021
● Convulsions (-)
● Impaired hearing, smell, taste, or vision (+) 07/28/2021
● Irritability
● Lightheadedness (-)
● Loss of consciousness (+) 07/28/2021
● Low breathing rate (-)
● Restlessness (-)
● Slurred speech (-)
● Stiff neck (+) 07/28/2021
● Vomiting (-)
● Swelling at the site of the injury (-)
(+) 07/28/2021

Greenstick Fracture
SIGNS AND SYMPTOMS ACCORDING TO SIGNS AND SYMPTOMS AS MANIFESTED
TEXTBOOK
● Pain (+) 07/28/2021
● Bruising (+) 07/28/2021
● Swelling (+) 07/28/2021
● Deformity of the affected body part (+) 07/28/2021
● Abrasion or laceration (+) 07/28/2021
C.Pathophysiology (Separate File)
D. Management

Medical Management:

Head Injury

● ICP Medications:
An increase in ICP can be prevented by administering sedation. The foremost therapies
after pain and agitation are mannitol or hypertonic sodium chloride solution.
■ Propofol, I.V dexmedetomidine, and fentanyl are commonly used in
mechanically ventilated patients. Steroids are not recommended in TBI.
■ Barbiturates are commonly used to treat ICP. There is no affirmation that
barbiturates reduce mortality; it also causes low BP.
■ Mannitol can be used to reduce ICPand it also helps in improving CBF.
■ Phenytoin is recommended to reduce posttraumatic seizures.
■ Levetiracetam can be used as an alternative. Sympathetic storming which
includes posturing, dystonia, hypertension, tachycardia, dilatation of the pupils,
sweating, hyperthermia, and tachypnea can occur within the first 24 h after injury
till several weeks. This can be caused after the cessation of sedatives and
narcotics in the ICUs and should be treated based on their signs and symptoms by
initiating planned medications to reduce the activities of the sympathetic nervous
system.
■ The patients who receive erythropoietin show lower mortality and better
neurological outcome and limit neuronal damage induced by TBI.
■ Naloxone effectively reduce mortality and controls ICP in TBI.

● Headache Management
○ Treatment can include analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs).
○ Warn patients against overusing NSAIDs and other over-the-counter (OTC) remedies:
○ Advise them to report severe or persistent headaches to the healthcare provider, who may
prescribe an alternate analgesic or, in some cases, refer the patient to a pain clinic or
headache specialist.

● Brain tissue oxygen-directed management

Patients who receive brain tissue oxygen therapy to maintain brain tissue oxygen tension
≥20 mmHg and treated with ICP- or CPP-guided therapy to keep ICP <20 mmHg and
CPP > 60 mmHg are recognized to have a better outcome and decreased mortality. These
patients should be resuscitated and managed by the following methods such as
■ earlier recognition and removal of hematomas;
■ intubation and ventilation with FiO2 and minute ventilation adjusted to set
SaO2>93% and to evade PaO2<60 mmHg;
■ PaCO2 set at 35–45 mmHg unless ICP is increased when PaCO2 is maintained
between 30 and 40 mmHg;
 ■ normothermia (~35°C–37°C);
■ sedation by administering propofol during the initial 24 h, succeeded by sedation
and analgesia with lorazepam, morphine, or fentanyl;
■ head end elevated to 15°–30° and knee elevated;
■ if seizures are present, administer anticonvulsants (phenytoin) for 1 week or
more; and
■ euvolemia by administering a crystalloid infusion (0.9% normal saline, 20 mEq/L
KCl; 80–100 ml/h).
The use of both an ICP and a brain tissue PO2 monitor and therapy directed at brain
oxygen reduces the mortality rate after STBI.

● Stress ulcer prophylaxis

Stress ulcers (Cushing's ulcer) are a very common risk factor of patients in the Intensive
Care Unit (ICU). Early enteral feeding, H2-blockers, proton-pump inhibitors, and
sucralfate are recommended for the prophylaxis of stress ulcers.

● Hemostatic therapy
Patients with STBI develop coagulopathies. Prothrombin complex concentrate, fresh
frozen plasma, and/or Vitamin K should be given for patients with warfarin-associated
intracerebral hemorrhage (ICH). Platelet count should be maintained >75,000 with
platelet transfusions if necessary for patients with thrombocytopenia.

● Glucose management
Extremes of very high or low blood glucose levels should be managed accordingly. A
target range of up to 140 mg/dL or possibly even 180 mg/dL may be appropriate. Patients
with hyperglycemia should be administered insulin protocol in cases with value >200
mg/dl for improving the outcome.

● Tracheostomy
In patients with severe isolated TBI, tracheostomy might be favorable if it is performed
in the 2nd or 3rd week after admission.

● Fluid therapy
Fluid therapy helps in restoring vascular capacity, tissue perfusion, and cardiac flow rate.
Hypertonic saline can be used for patients with complications of STBI and systemic
shock. Euvolemia can be maintained using isotonic fluids such as normal saline.

● Hyperventilation
Hyperventilation reduces PaCO2, CBF, and ICP by the cerebral autoregulation. It can be
used only if ICP >30 mmHg and CPP <70 mmHg; CPP >70 mmHg but higher ICP >40
mmHg.
Greenstick Fracture:

● Immobilization
If the degree of angulation is significant, then the healthcare provider needs to perform a closed
reduction and immobilization. All greenstick fractures require immobilization, and casting several
days after the initial injury decreases the risk of the need to recast due to increasing edema post
fracture.
● Fracture reduction refers to the restoration of the fracture fragments to anatomic
alignment and positioning and can be open or closed depending on the type of fracture.
● Orthopedic referral at the initial visit is generally recommended, but depends on the
degree of angulation and age.
● Adequate splinting is essential to prevent the movement of fracture fragments. The most
common way to treat the fractures in the middle is with immobilization with either a sling
or a special bandage called a figure-of-8 splint.

● Wound Dressing
In an open fracture, the wound should be covered with a sterile dressing to prevent contamination
of the deeper tissues.

● Cold Therapy and Pain Management

The second thing that helps in the treatment of clavicle fractures is pain relief with cold therapy
and pain medication.
● It is recommended that ice is applied to the fractured area for 15 to 20 minutes every two
hours for as long as necessary to decrease the pain and swelling.
● Heat is not recommended.
● Pain medication in the form of narcotics is the best for relief of pain from a fractured
clavicle, and the patient may need it for several weeks, especially to help him/her sleep.
● Many patients with this injury have to sleep sitting up to be comfortable.
● Other pain-relieving medications such as acetaminophen or nonsteroidal medications
may be used, but they generally will not be adequate by themselves until the pain and
swelling start to subside.

Surgical Management:

Head Injury

● Decompressive Craniectomy
○ Decompressive craniectomy is a surgical procedure that involves removal of a large
section of the skull. Craniectomy reduces ICP by giving extra space to the swollen brain,
and it may quickly prevent brainstem herniation.
○ A surgical evacuation is done on patients having GCS score ≤8 with a huge lesion on
noncontrast head CT scan. Depressed skull fractures those are open or complicated need
surgical repair. Decompressive craniectomy helps in positive patient outcome.
 ○ An epidural hematoma larger than 30 mL in volume despite a patient's GCS score should
be evacuated immediately.
○ Acute subdural hematomas greater than 10 mm in thickness or associated with midline
shift greater than 5 mm on CT also should be surgically evacuated.
○ If there is an evident mass effect, then a surgical evacuation is recommended in traumatic
ICH.
○ Superficial debridement and dural closure are indicated in a penetrating injury to
prevent CSF leak. For depressed skull fractures, elevation and debridement are
recommended.

Greenstick Fracture

● Some fractures can take six to nine months to heal. If the fracture does not heal, surgery may be
necessary.
○ Some fractures of the clavicle that do not heal completely are not painful and may not
need surgery.
○ Many factors determine whether a clavicle fracture will need surgery, and they should be
discussed with the attending doctor.
○ Generally, if surgery is necessary it is done with an incision followed by implanting a
plate and screws. Sometimes a bone graft may be needed to help stimulate healing.
○ Treatment after surgery depends upon many factors, such as how fast the fracture heals.
Fortunately surgery is needed in few cases and is successful in cases where it is needed.
○ Surgery can reduce a visible deformity of the fracture but results in a scar.

Nursing Management:

Traumatic Brain Injury

● Neurologic Assessment
○ Observe spontaneous movement; ask patient to raise and lower extremities; compare
strength of hand grasp at periodic intervals
○ Note presence or absence of spontaneous movement of each extremity.
○ Assess responses to painful stimuli in absence of spontaneous movement; abnormal
responses carries a poorer prognosis
○ Determine patient's ability to speak; note quality of speech.
○ Evaluate spontaneous eye opening
○ Evaluate size of pupils and reaction to light (unilaterally dilated and poorly responding
pupils may indicate developing hematoma). If both pupils are fixed and dilated, it usually
indicates overwhelming injury and poor prognosis

● Monitoring for Complications

○ Deterioration in condition may be due to expanding intracranial hematoma, progressive
brain damage, and herniation of the brain.
 ○ Peak swelling occurs about 72 hours after injury, with resulting elevation of ICP.
○ Assess for systemic infections or neurosurgical infections: wound infection,
osteomyelitis, or meningitis.
○ After injury some patients develop focal nerve palsies, such as anosmias or eye
movement abnormalities and focal neurologic deficits, such as aphasia, memory deficits,
and posttraumatic seizures or epilepsy.
○ Patients may be left with organic psychosocial deficits and may lack insight into their
emotional responses.

● Monitor Vital Signs

○ Monitor patient at frequent intervals to assess intracranial or neurologic status
○ Assess for increasing ICP, including slowing of pulse, increasing systolic pressure, and
widening pulse pressure. As brain compression increases, vital signs are reversed, pulse
and respirations become rapid, and BP may decrease.
○ Monitor for rapid rise in body temperature; keep temperature below 38°C (100.4°F) to
avoid increased metabolic demands on the brain.
○ Keep in mind that tachycardia and hypotension may indicate bleeding elsewhere in the
body

● Maintaining Airway
○ Position the unconscious patient to facilitate drainage of secretions; elevate the head of
the bed 30 degrees to decrease intracranial venous pressure.
○ Establish effective suctioning procedures.
○ Guard against aspiration and respiratory insufficiency.
○ Monitor ABGs to assess adequacy of ventilation
○ Monitor patient on mechanical ventilation

● Maintaining Fluid and Electrolyte Balance

○ Monitor serum and urine electrolyte levels, osmolality, and intake and output to evaluate
endocrine function.
○ Record daily weights (which may indicate fluid loss).

● Providing Adequate Nutrition

○ Start enteral feedings or nasogastric feedings as soon as condition stabilizes (or within 72
hours) unless there is discharge of CSF from the nose; oral feeding tubes may be used.
Food intake may resume when swallowing reflex returns and patients can meet caloric
requirements orally.
○ By day 7 of postinjury, these patients should be given full caloric replacement. After TBI,
early initiation of nutrition is recommended.
○ Give small, frequent feedings to lessen the possibility of vomiting and diarrhea
(continuous drip infusion or trolling pump to regulate feeding); elevate head of the bed,
check residual feeding before feedings.
● Positioning
○ The patient should be positioned properly with the neck in neutral position and the head
end of the bed elevated to 30°. This facilitates cerebral venous drainage.
○ Head end of the bed should be elevated for patients with CSF, rhinorrhea, and otorrhea.

● Preventing Injury
○ Observe restlessness, which may be due to hypoxia, fever, pain, or a full bladder.
Restlessness may also be a sign that an unconscious patient is regaining consciousness.
○ Avoid bladder distention.
○ Protect patients from injury (padded side rails, hands wrapped in mitts).
○ Keep environmental stimuli to a minimum.
○ Provide adequate lighting to prevent visual hallucinations.
○ Do not disrupt sleep/wake cycles.

● Maintaining Skin Integrity

○ Assess all body surfaces, and document skin integrity every 8 hours.
○ Turn patient and reposition every 2 to 4 hours.
○ Provide skin care every 4 hours; use skin lubricant to prevent irritation due to rubbing
against the sheet.
○ Assist patients to get out of bed three times a day (when appropriate).

● Improve Cognitive Functioning

○ Develop a patient's ability to devise problem-solving strategies through cognitive
rehabilitation over time, use multidisciplinary approach.
○ Be aware that there are fluctuations in the orientation and memory and that these patients
are easily distracted.
○ Do not push to a level greater than the patient's impaired cortical functioning allows
because fatigue, headache, stress may occur.

● Supporting Family Coping

○ Provide family with accurate and honest information.
○ Encourage family to continue to set well defined, mutual, short-term goals.
○ Encourage family counseling to deal with feeling of loss and helplessness, and provide
guidance in the management of inappropriate behaviors.
○ Refer family to support groups that provide a forum for networking, sharing problems,
and gaining assistance in maintaining realistic expectations and hope.

● Transport of patients
○ These patients should be transported with caution and care with suitable protection. It
should be done by trained and suitably equipped personnel with careful supervision,
support to the vital organs, continuous monitoring, prevention of damage to the spine,
and complete documentation.
● Dizziness
○ For patients complaining of dizziness, nurses should determine if it’s associated with
nausea or motion.
○ Advise these patients to rest for 3 to 5 days and then gradually resume both physical and
cognitive activity and to avoid activities that could result in additional head trauma during
the recovery period.
○ Reassure them that dizziness typically resolves spontaneously over time.

● Sleep management
○ Educate patients complaining of sleep disturbances about sleep hygiene practices such as
avoiding stimulants and alcohol and restricting exposure to TV or any type of illuminated
screens such as computer monitors or phones for at least 1 hour before bedtime because
the light wavelengths from these screens can suppress melatonin.
○ Advise them to go to bed at the same time every night and to avoid napping during the
day.
○ Performing light exercise approved by the healthcare provider, such as walking or
stationary bicycling before bedtime, can be beneficial.
○ Teach patients about any medications such as melatonin that may be prescribed to
manage sleep disturbances. Warn them that most OTC sleep aids contain an antihistamine
(commonly diphenhydramine) and aren’t recommended for people with TBI because they
may cause disturbances in memory and new learning.

● Psychosocial Support
○ Advise patients to avoid alcohol during recovery. Attention, memory, problem solving,
and reaction times are all affected while someone is under the influence of alcohol.
○ Although these problems should all improve with time and appropriate treatment, referral
to a neuropsychologist or cognitive therapy program may be indicated if symptoms
persist.

● Sexual dysfunction management

○ Because the injury and recovery period will likely disrupt the patient’s personal and
family life, a holistic and collaborative plan should be developed to address all concerns
and issues.

● Rest and Activity

○ Following mTBI, both physical and cognitive rest for 3 to 5 days is indicated to promote
recovery. Although challenging, cognitive rest includes avoiding reading, texting, playing
video games, and using computers.
○ Advise them to return gradually to work or school rather than attempting to immediately
return to their preinjury level.
○ If symptoms worsen with activity, tell them to decrease their activity to a level where
symptoms are no longer present and wait several days before attempting to increase
activity.
 ○ Gradual progression from light physical activity such as walking or stationary bicycling
to more vigorous aerobic activity followed by resistance activities will promote recovery.
○ Warn patients about the danger of second-impact syndrome and tell them to avoid
activities that might lead to any new head impact, especially during the recovery period.
○ Make sure they understand that although helmets help protect against scalp injuries and
skull fractures, they don’t prevent brain injuries resulting from whiplash type or rotational
head motions.

● Patient Education
○ Teach patients and families that mTBI and concussion are terms that are used
interchangeably, and that a concussion is a brain injury. Tell them that mTBI is defined as
a self-limiting phenomenon and that recovery occurs within 3 months of the inciting
event in most patients who follow all treatment recommendations.

Greenstick Fracture

● Relieving Pain
○ Assess type, degree (pain scale), and location of pain.
○ Inform patient of available analgesics.
○ Handle extremity gently, supporting it with hands or pillows.
○ Use pain modifying strategies (e.g., modify the environment, administer analgesics,
evaluate response to medications).
○ Position for comfort and function, assist with frequent changes in position.

● Physical Activity
○ It is important to teach exercises to maintain the health of the unaffected muscles and to
increase the strength of muscles needed for transferring and for using assistive devices.
○ Encourage patient to exercise elbow, wrist, and fingers as soon as possible and, when
prescribed, to perform shoulder exercises.
○ Tell the patient that vigorous activity is limited for 3 months.
○ Caution the patient not to elevate the arm above shoulder level until the ends of the bones
have united (about 6 weeks).

● Wound management
○ Monitor vital signs.
○ Perform aseptic dressing changes.
○ Assess wound appearance and character of drainage.
○ Assess for complaints of pain.
○ Administer prescribed prophylactic antibiotic agents.
○ Wound irrigation and debridement are initiated as soon as possible.
○ The patient must be assessed for presence of signs and symptoms of infection.

● Maintaining Skin Integrity

○ Apply elastic tape in vertical fashion to reduce the incidence of tape blisters.
 ○ Provide proper skin care.
○ Obtain and use high-density foam, static air , or other special mattress to provide
protection and distribute pressure more evenly.

● Promoting Effective Coping Mechanisms

○ Encourage patient to express concerns and to discuss the possible impact of fractured
clavicle.
○ Support use of coping mechanisms. Involve significant others and support services as
needed.
○ Contact social services, if needed.
○ Encourage patient to participate in planning.
○ Explain anticipated treatment regimen and routines to facilitate positive attitude in
relation to rehabilitation.

● Safety
○ Plans are made to help the patients modify the home environment to promote safety such
as removing any obstruction in the walking paths around the house.

References:

Atanelov Z, Bentley TP. (2021). Greenstick Fracture. In: StatPearls [Internet]. StatPearls Publishing;
https://www.ncbi.nlm.nih.gov/books/NBK513279/

Dash, H. H., & Chavali, S. (2018). Management of traumatic brain injury patients. Korean Journal of
Anesthesiology, 71(1), 12. https://doi.org/10.4097/kjae.2018.71.1.12

Fong. R., Konakondla, S., Schirmer, C., LaCroix, M. (2017) Surgical interventions for severe traumatic
brain Injury. Journal of Emergency and Critical Care Medicine. doi: 10.21037/jeccm.2017.09.03

John Hopkins Medicine. (n.d.). Clavicle Fractures. Retrieved September 28, 2021, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/clavicle-fractures

John Hopkins Medicine. (n.d.). Head Injury. Retrieved September 12, 2021, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/head-injury

Menon, G., Varghese, R., & Chakrabarty, J. (2017). Nursing management of adults with severe traumatic
brain injury: A narrative review. Indian Journal of Critical Care Medicine, 21(10), 684–697.
https://doi.org/10.4103/ijccm.ijccm_233_17

Mesfin FB, Gupta N, Hays Shapshak A, & Taylor R. (2021). Diffuse Axonal Injury. In: StatPearls
[Internet]. StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK448102/
Saling, J. (2010b, January 8). Head Injury. WebMD.
https://www.webmd.com/fitness-exercise/guide/head-injuries-causes-and-treatments

Vacca, V. M. (2018). Managing mild TBI in adults. Nursing, 48(8), 30–37.

https://doi.org/10.1097/01.nurse.0000541383.21610.5a

V. PROBLEM LIST

1. Ineffective breathing pattern r/t head trauma aeb presence of endotracheal tube attached to a
volume respirator; respiratory rate = 18 breaths/min with signs of hyperventilations; O2
saturation=93%; bluish discoloration of the nail beds, capillary refill of 4 seconds
2. Ineffective cerebral tissue perfusion r/t interruption of blood flow/cerebral edema aeb GCS: 10/15
(Eye opening - 2; Verbal response - 3; Motor response - 5); altered mental state- appears weak
and lethargic, responded to localized pain with inappropriate words; blood pressure = 130/60
mmHg at right arm; heart rate = 57 beats / min
3. Ineffective peripheral tissue perfusion r/t trauma/interruption of blood flow aeb bluish
discoloration of the nail beds, capillary refill of 4 seconds, and decreased pulsation on the injured
extremities.
4. Deficient fluid volume r/t bleeding and edema aeb altered mental state; bluish discoloration of the
nail beds, capillary refill of 4 seconds, and decreased pulsation on the injured extremities;
decreased hemoglobin = 9 g/dL, decreased hematocrit = 0.32%; decreased serum sodium = 131
meq/L, increased serum potassium = 5.8 meq/L; decreased urine output of 20ml/hr; blood
pressure = 130/60 mmHg at right arm; heart rate = 57 beats / min; and respiratory rate = 18
breaths/min; temperature= 37.9°C and with signs of hyperventilations
5. Acute Pain r/t head trauma from vehicular accident aeb pain scale of 9/10
6. Impaired Skin Integrity r/t trauma and injury aeb minor bruises and cuts on face and upper
extremities; right upper extremity with ROM = 3; left arm greenstick clavicular fracture; left
upper extremity with ROM=1; bluish discoloration of the nail beds, capillary refill of 4 seconds,
and decreased pulsation on the injured extremities
7. Electrolyte imbalance r/t deficient fluid volume aeb decreased urine output of 20ml/hr; bluish
discoloration of the nail beds, capillary refill of 4 seconds, and decreased pulsation on the injured
extremities; blood pressure = 130/60 mmHg at right arm; heart rate = 57 beats / min; and
respiratory rate = 18 breaths/min; temperature= 37.9°C and with signs of hyperventilations;
sodium= 133 meq/L, potassium=3.2 meq/L
8. Acute Confusion r/t brain injury aeb GCS: 10/15 (Eye opening - 2; Verbal response - 3; Motor
response - 5); altered mental state- appears weak and lethargic, responded to localized pain with
inappropriate words; blood pressure = 130/60 mmHg at right arm; heart rate = 57 beats / min
9. Impaired Physical mobility r/t altered cognition and prescribed movement restriction aeb GCS:
10/15 (Eye opening - 2; Verbal response - 3; Motor response - 5); altered mental state- appears
weak and lethargic, responded to localized pain with inappropriate words; blood pressure =
130/60 mmHg at right arm; heart rate = 57 beats / min; right upper extremity with ROM = 3; left
 arm greenstick clavicular fracture; left upper extremity with ROM=1; bluish discoloration of the
nail beds, capillary refill of 4 seconds, and decreased pulsation on the injured extremities
10. Risk for pressure ulcers r/t prolonged stationary position
11. Risk for seizures r/t intracranial bleeding, hypoxia, hyponatremiaRisk for imbalanced nutrition,
less than body requirements r/t impaired LOC, restriction to intake
12. Risk for Infection r/t inadequate primary defenses or traumatized tissue
13. Risk for shock r/t deficient fluid volume, non-compliance to blood transfusion
14. Risk for powerlessness r/t complex treatment regimen

VI. NURSING CARE PLAN

‌ UESTIONS:
Q
1. Briefly describe the extent of damage seen in a patient post-vehicular accident. At
SICU what is her GCS?
A.C.C. was driving her car when she was accidentally hit by a ten wheeler truck on the highway.
By the time the rescue squad arrived, she had suffered head injury and clavicle greenstick
fracture. In the Emergency Room, A.C.C. was lethargic GCS (Glasgow Coma Scale) 10/15.

2. What are the signs and symptoms present that may be suggestive of increased
intracranial pressure (ICP)?

These are the most common symptoms of increased ICP:

● Headache
● Blurred vision
● Confusion
● High blood pressure
● Shallow breathing
● Vomiting
● Changes in your behavior
● Weakness or problems with moving or talking
● Lack of energy or sleepiness

3. What is the reason for the hyperventilation of the patient? What possible irregular
respiratory rate to expect for traumatic brain injury with increased ICP?

Hyperventilation lowers PaCO2 levels, which induces arterial vasoconstriction and lowers
Cerebral Blood Flow, Cerebral Blood Volume, and Intracranial Pressure. pH fluctuations in the
extracellular fluid elicit cerebral vasoconstriction or vasodilation, depending on the pH. Every 1
mmHg decrease in PaCO2 levels results in a 2% decrease in CBF. Although the effects of
hyperventilation are virtually immediate, the effects on CBF fade over 6-24 hours as the brain
adapts by adjusting bicarbonate levels in the extracellular fluid to bring the pH back to normal.
Additionally, if prolonged hyperventilation is suddenly discontinued and normocapnia is restored
too quickly, there is a resultant rebound increase in CBF and thus ICP which can be deleterious.

A patient experiencing increased ICP would also manifest Cheyne-Stokes Respiration as part of
the Cushing's Triad. These respirations consist of periods of slow, deep breaths followed by
periods of apnea, when breathing comes to a complete stop. Individuals also often experience
hypertension, or increased blood pressure as well.

4. Explain why this patient's systolic blood pressure was so high and her heart rate so
slow upon arrival at the emergency room.

Cushing's triad is caused by an increase in ICP, which stimulates the Cushing reflex, a
neurological system response. As the ICP rises, it eventually surpasses the mean arterial
pressure, which must be higher than the ICP for the brain tissue to get appropriate oxygenation.
The cerebral perfusion pressure (CPP), or the amount of blood and oxygen delivered to the
brain, is reduced as a result of the pressure difference, resulting in the brain obtaining
insufficient oxygen (also known as a brain ischemia). The sympathetic nervous system is
triggered to compensate for the lack of oxygen, resulting in an increase in systemic blood
pressure and an initial increase in heart rate. When blood pressure rises, the carotid and aortic
baroreceptors activate the parasympathetic nervous system, which causes the heart rhythm to
slow down. The brain stem may begin to malfunction as the pressure in the brain rises, leading
to erratic breathing followed by intervals when breathing stops completely. This progression
indicates that the prognosis is deteriorating.

5. What is Mannitol? How does it decrease intracranial pressure?

Mannitol then constitutes a new solute in the plasma, which increases the tonicity of the
plasma. Since mannitol cannot cross the intact blood-brain barrier, the increased tonicity from
the mannitol draws water out of the brain parenchyma and into the intravascular space. The
water then travels with the mannitol to the kidneys, where it gets excreted in the urine. It is
indicated to reduce intracranial pressure

6. Why was it important to immediately administer intravenous fluids to this patient?

The immediate rapid infusion of large volumes of crystalloids to restore blood volume and blood
pressure is now the standard treatment of patients with combined traumatic brain injury (TBI)
and hemorrhagic shock (HS). The choice of the ideal crystalloid fluid in TBI should be made
based on tonicity, type of buffer used and volume status. Hypotonic fluids buffered with
substances altering blood coagulation should be avoided in clinical practice.

7. What is a "broad-spectrum" antibiotic, and why did she need it?

A broad-spectrum antibiotic is an antibiotic that acts on the two major bacterial groups,
Gram-positive and Gram-negative, or any antibiotic that acts against a wide range of
disease-causing bacteria. Because of their broad spectrum of activity, cephalosporins are the
drugs of choice in cases of orthopaedic trauma. In this case, the patient was prescribed
cefuroxime.

8. Why is paracetamol given to the patient?

Paracetamol exhibits analgesic and antipyretic activity by inhibiting prostaglandin synthesis. It
produces analgesia by elevating the pain threshold and antipyresis through action on the
hypothalamic heat-regulating center. For patients with head injury, it is used for the treatment of
mild to moderate pain and reduction of fever

9. Why is it important to monitor the fluid status of the patient?

Intravenous fluid management of trauma patients is fraught with complex decisions that are
often complicated by coagulopathy and blood loss. Fluid balance disorders are a relevant risk
factor for morbidity and mortality in critically ill patients. Volume assessment in the intensive care
unit (ICU) is thus of great importance.

10. Why is the patient maintained at a 30-35 degree angle position on bed?
Special interventions in the intensive care unit are required to minimise factors contributing to
secondary brain injury after trauma. This includes proper positioning of the patient. The optimum
angle of the head‐of‐bed elevation needs to be decided individually after an analysis of the
response of intracranial pressure, cerebral perfusion pressure and cerebral blood flow in each
backrest position. In this case, It is indicated that head‐of‐bed elevation of at least 30°
decreases ICP according to a study by Alarcon et al., in 2017.

11. What other laboratories are needed for this client?

Magnetic Resonance Imaging (MRI), and an intracranial pressure monitor scan are all feasible
diagnostic tests for this patient.

● Magnetic resonance imaging (MRI) creates a detailed image of the brain by using powerful
radio waves and magnets. This test may be utilized when the person's condition has
stabilized or if the symptoms have not improved within a few days of the injury.
● Doctors may use an intracranial pressure monitor to put a probe through the skull and
monitor a rise in pressure inside the skull that could lead to more brain damage.

References:

Ainsworth, C. R. (2021). Head trauma Workup: Laboratory studies, imaging Studies, other tests.
https://emedicine.medscape.com/article/433855-workup#c6.

Alarcon, J. D., Rubiano, A. M., Okonkwo, D. O., Alarcón, J., Martinez-Zapata, M. J., Urrútia, G.,
& Bonfill Cosp, X. (2017). Elevation of the head during intensive care management in
 people with severe traumatic brain injury. Cochrane Database of Systematic Reviews.
https://doi.org/10.1002/14651858.cd009986.pub2
Alvis-Miranda, H. R., Castellar-Leones, S. M., & Moscote-Salazar, L. R. (2014). Intravenous
Fluid Therapy in Traumatic Brain Injury and Decompressive Craniectomy. Bulletin of
Emergency and Trauma, 2(1), 3–14.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4771253/

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‌Basso, F., Berdin, G., Virzì, G. M., Mason, G., Piccinni, P., Day, S., Cruz, D. N., Wjewodzka, M.,
Giuliani, A., Brendolan, A., & Ronco, C. (2013). Fluid Management in the Intensive Care
Unit: Bioelectrical Impedance Vector Analysis as a Tool to Assess Hydration Status and
Optimal Fluid Balance in Critically Ill Patients. Blood Purification, 36(3-4), 192–199.
https://doi.org/10.1159/000356366

Enam, S., Kazim, S., Tahir, M., Waheed, S., & Shamim, M. (2011). Management of penetrating
brain injury. Journal of Emergencies, Trauma, and Shock, 4(3), 395.
https://doi.org/10.4103/0974-2700.83871
Zornow MH, Prough DS. Fluid management in patients with traumatic brain injury. New Horiz.
1995 Aug;3(3):488-98. PMID: 7496759.

Ciattei, J. (2018). ICP Monitoring: Direct: Department of Neurology and Neurosurgery. In Johns
Hopkins Medicine.
https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/cerebral-fluid/
procedures/icp-monitoring-direct.html