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8/9/2019 Head Injury_CS
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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.
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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. Patients Profile
Name: ?
Age: 35 years old
Sex: Female
Height: 52
Weight: 110 lbsCivil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Address: ?
Occupation: Housewife
Date of Admission: July 15, 2009
Time of Admission: 10:40 PMChief Complaint: Head injury
Admitting Diagnosis: Subdural Hematoma
Physician: ?
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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 didnt 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 didnt 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.
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DIAGNOSTIC EXAM
Date Ordered Diagnostic/laboratory
Exams
Date Done
7-15-2009 Complete Blood Count 7-15-2009
7-16-2009 CT scan 7-15-2009
*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
7-16-2009 X-ray for tracheostomy
Placement 7-16-2009
7-21-2009 CXR 7-21-2009
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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 lacerationson 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
y 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.
y 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.
y 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.
y 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 andsometimes 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.
y 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.
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Anatomy And Physiology:
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MEDICALMANAGEMENT
Date ordered Doctors order Rationale
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7-15-09- 11:40 pm
BP- 140/100 mmhg
T- 40 Celsius
RR-24 cpm
HR- 61 bpmO2 sat.- 100%
y Pls. admit under the service
of Dr. Amato.
y Sign consent to care
y TPR q 4hrs.
y NPO
y Labs:
CBC,
y U/A,
y Blood typing
y serum Na+ K+
SGPT, serum,
y CXR: PA,
y ECG: 12 lead
y CT scan of brain:
Pls. attached film at bedside
y With on going IVF of plain
PNSS IL @20 gtts/ min.
1. Paracetamol 300 mg IV now
then q 4hrs PRN for fever
2. Mannitol 150CC q
4hrs. IV
3. Ranitidine 50 mg q 8hrs.
4. O2 inhalation @ 2l/min.
y For close monitoring
y For legal issue
y To monitor patients
temperature,respiration and
pulse
y To prevent pt.from
aspiration
y To determine
abnormalities and to
verify and conclude
the patients
admitting diagnosis.
y To detect urinarytract infection and
glucose in the urine.
y To determine the pt.
blood type.
y To determine
electrolyte and acid
base imbalance.
y To identify lung
disease and heart
size and location.
y To determine the
presence of cardiac
arrest.
y To detect structural
abnormalities
y To maintain fluid
and electrolyte
balance.
y To relieve fever
y Decrease blood
pressure.
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7-16-09- 12:45 am
Decorticate
No verbal outputNo eye graving to pain
Pupil-5mm OD-2-3mm OS
(+) corneals
(+) dolls
5. For ICU admission6. With FBC F-16 attached
urobag
7. With NGT Fr- 16
8. Attach pt. to cardiac
monitor
9. Monitor V/S q 15min.
10.Suction secretion prn.
11.Monitor I&O q shift
12.Refer accordingly
y Standby intubation
y Mannitol 200cc IV. bolus now
then 150cc q 3hrs
Hold to BP< 90/60mmhg
y for ET
y BT, protime, blood typing.
y ABG
y O2 inhalation to10L/min.via face mask
y Use to manage
gastrointestinal
disorder
To aide the patientin breathing and to
introduce oxygen to
the body to prevent
hypoxia
andrespiratory
acidosis
For close
monitoring.
To monitor and
relieve abdominaldistention
For parenteral line
to administer food
and oral medication.
To monitor pt. heart
rhythm
For baseline data
To maintain
adequate airway
patency.
To determineeffectiveness or to
keep watch for
possible renal
abnormalities
To decrease Blood
pressure.
To established
artificial airway
To replace bloodloss and to avoid
blood reaction.
y To determine the
adequacy of alveolar
gas exchange and
evaluate the ability
of the lungs and
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7-16-09- 1am
Neurosurgery note
GCS- 5-6
Aminoscoric
Cranial CT Scan: R frontal
Contusion: subacuteSDH midline
Shift to the L
y For ice bath to keep body temp
< 37.5C
y
y Paracetamol 500mg/tab 1 tab q
4hrs RTC per NGT
y Start cefuroxine 750mg(panoxim) IV q 8hrs (ANST)
y For emergency
decompressivehemicraniect
omy R expansion,
duraplasty, evaluation of
hematoma of implantation
of bone fragment to
hemiabdomen Via
subcutaneous pouchy Secure consent
Secure 1u FWB properly
typed & cross matched for
possible OR use.
y Hold cefuroxime IV
y Start ceftriaxone Igm IV
ANST q 12hrs.
y Gentamicin 80mg IV prior
route to OR
y Please inform undersign
once with consent & BO
clearance
y Start cefriaxone I gm 10 ANST q
120
y IV to follow PNSS IL @
20gtts/min
y For intubation
y Mechanical ventilator setting:
F1O2- 100%
TV- 400
RR- 16
Mode AC
kidney to maintain
the acid base
balance of the body
fluid.
To aide the patient
in breathing and tointroduce oxygen to
the body to prevent
hypoxia
andrespiratory
acidosis
To lower
temperature
To relieve fever
y To lower the
pressure of the
brain.
y And to preserve the
skull into
homeostasis
environment.
y For legality issue
y To replace blood
lossy To determine
electrolyte and acid
base imbalance.
y To treat susceptible
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7-16-09-2:10 am
7-16-09- 3:30am
HR-180-220 bpm
7-16-09 5:50 am
2:00 pm
y For ABG 30 min. after
hooking to MV
y For portable CXR
y To ICU
y NPO till further order
y VS q 15min. chartpls.
y Regulate IV F- R arm @ KVO
y Regulate IVF- L arm @
20gtts/min. then ft.
DS/R- 1
PLR- 2
DSLR- 1
y Cont. ranitidine 1 gm. q 12
y Start cloxacillin 1 gmslow
IVT ANST
y Mannitol to 100 cc of 40 IV
bolus hold if BP < 90/60
mmhg
y Tramadol 50mg q 6 slow
IVTT
y D/c gentamicin
y Hook to mechanical
ventilator with setting
P1O2= 100%
infection
y To treat short term
serious infection
y For legal issue
y To treat susceptible
infection
y To maintain fluid
and electrolyte
balance.
y
To establishedartificial airway
y To help the patient
breathing pattern.
y To determine the
adequacy of alveolar
gas exchange and
evaluate the ability
of the lungs andkidney to maintain
the acid base
balance of the body
fluid.
y To identify lung
disease and heart
size and locationy For close monitoring
y To avoid from
aspiration
y To monitor vital sign
for baseline data to
determine
complication
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6:30 pm
ABG resultO2 sat. 100%
7-17-09- 7am
TV= 400
Rate=16
Mod e AC
y Cont. monitor neuro vital sign
pupillary size & reaction to
light, level of assessmenty monitor 1 & 0 q 1hr. chart
y Suction one /ETT secretion
PRN and separate
y Repeat Hgb ,Hct, det. 4h past
op & refer resulty Refer accordingly
y Place pt. in slight high back
rest
y No pressure @ operated side
of head
y F1O2 to 50%
y Citicoline I gram IVTT q 8
y Repeat ABG.
y Repeat Na. K
y F1O3 to 30%, back up 18 mu
w/ rate=12mod
y Nebulize with salbutamol 1
y To maintain fluid
and electrolyte
balance
y Use to manage
gastrointestinal
disorder.
y To treat
pneumococci
infection.
y
To decrease osmoticpressure and
intracranial
pressure.
y To relive mild to
moderate pain,and
relax muscle
y To help the patient
breathing pattern
and prevent
respiratory distress
y To determine
neurologic status of
the patient
To determine
effectiveness or to
keep watch forpossible renal
abnormalities
To maintain
adequate airway
patency.
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7-17-09- 8;30am
1st
POD
Asleep arousable to verbal
stimulation/tapping
Follow simple command
(+) rhonchi
7-17-09- 9am
Neurosurgery
1st
POD
E4 VTM
Pupil 3mm
EBRTL L
SRTL R
7-18-09
9:00am
2nd
POD
neb.
y Do chest tappping after each
nebulization
y Turn to sides q 2hrs. w/
caution on the R side of the
head.y Add 10mg KCI to present IVF
Start of at 1000
kcal/day in 1L dilution,
to be given in 6 equal
feeding
y Lactulose 30cc OD at H.S
y IV FF: PNSS IL + 10KCL for SHRS
X3 cycle
y Routine oral care TID using
oracare mouthwash
y Revise paracetamol to 500 mg
1 tab T tab q 4 PRN for temp.>
37.5C
y Mannitol to 100 CC
I>V bolus q 6hrs. w/BP
precautions (hold for BP