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LICEO DE CAGAYAN UNIVERSITY

San isidro College

College of Nursing
Impalambong, Malaybalay City, Bukidnon

SUBMITTED BY:
Pasion, James Nicole

SUBMITTED TO:
Jo Anne Lalace Damasco RN, MAN

DATE SUBMITTED:
January,20 2021

Table of Contents

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I. Introduction …………………………………………………………………page 3

II. Objectives of the Study …………………………………………………..…page 4

III. Scope and Limitations of the Study ………………...……………………………

IV. Patient’s Profile …………………………………………………………………

V. Doctor’s Order …………………………………………………………………..

VI. Laboratory Results ……………………………………………………………..

VII. Nursing Assessment………………………………………………………………..

VIII. Pathophysiology…… ……………………………………………………………

IX. Nursing Care Plans …………………………………………………………….

X. Drug Study …………………………………………………………………….

XI. Referrals and Follow-up ………………………………………………………..

XII. References ……………………………………………………………………...

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I. INTRODUCTION
This case study reports a 54-year-old man who was admitted after he sustained injuries in
a motor vehicle accident. He was under the influence of alcohol during the accident. There
was no bleeding from the ear or nose. On examination, his Glasgow Coma Scale (GCS) was
9 E2V2M5. He also sustained right temporal bone fracture with underlying pneumocephalus.
No other injury was found. Skull and cervical radiographs were normal on admission. CT
brain showed a fluid level in the sphenoid sinus suggesting the presence of basal skull
fracture.

In this case study, there are also ideal and actual nursing interventions rendered in the
given duration of nursing care. This provided the opportunity for the student nurses to
develop clinical skills, expand one’s knowledge and establish an effective nurse-patient
relationship in the affective aspect. The accurate application of care guided with the nursing
care plan in the actual aspects is very important. Thereby, rendering proper interventions and
actions could certainly help the present condition of the patient.

This study deals with the care to Patient M, 54 years old, with a diagnosis of Closed
Linear Skull Fracture, Temporal Bone, Right with underlying pneumocephalus secondary to
vehicular accident 2wheel passenger non collision, BCS 9 E2V2M. He was admitted on
December 16, 2020 at 10:19 pm, with complains of a decrease sensorium. We choose the
case of Patient M to know the nature of the disease, the risk factors, its complications and
preventable measures because the complications of the disease can cause many health
problems if left untreated.

Skull fractures have plagued humankind throughout history. They occur when forces
striking the head exceed the mechanical integrity of the calvarium. Significant skull fractures
are often accompanied by moderate or severe intracranial injury and extracranial injuries
associated with high-energy trauma, such as cervical and other spine fractures and
thoracoabdominal injuries.

Pneumocephalus is defined as an intracranial gas collection. It may be caused by head

trauma, infection, barotrauma following scuba diving and surgery involving the sinuses,
orbit, nasal passages or intracranial space. It is also known as (intra) cranial aerocele that
may exist in a variety of intracranial spaces, depending upon the underlying cause. Gas
collection can occur in several compartments: extradural, subdural, subcrachnoid,
intraventricular (pneumoventricle), extradural and intracerebral pneumatocoele1. In the past,
plain radiography had an important role in making the diagnosis. Computed tomography
(CT) is currently the best modality for visualizing pneumocephalus.

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II. OBJECTIVE OF THE CASE

A. GENERAL OBJECTIVES: 

After the completion of this case study, we will be able to:

1. Identify the causes of the disease.

2. Identify the preventions of the illness and prolonged interventions by utilizing
nursing process.

B. SPECIFIC OBJECTIVES:

After the completion of this study, we will be able to:

1. Define what is Closed Linear Skull Fracture, Temporal Bone, Right with
underlying pneumocephalus.
2. Trace the pathophysiology of this disease.
3. Enumerate the different sign and symptoms of these diseases
4. Identify and determine different types of medical treatment necessary for the
treatment.

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III. Scope and Limitation of the Study

1. The range of this study is between the patient, the significant others and 3 rd year
nursing student from San Isidro College. The setting of the study is placed on the
hospital only.
2. The place enclosed with the study is NMMC (Male Nuerological Ward 1). The
study is all about neurological disease. The study is limited to the patient’s
subjective and objective data which was acquired from the patient’s chart and
consequent interviewing of the patient to allow us to expound over his condition.
We only interviewed the patient for 2 consecutive days including the assessment
day. We assessed the patient from head to toe (cephalocaudal).

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IV. HEALTH HISTORY

A. Patient’s Profile

Name Pt. Z
Sex Male
Age 54 years old
Religion Roman Catholic
Civil Status Single
Income 7000/monthly
Nationality Filipino
Date of Admission Dec. 16, 2020
Time of Admission 9:30 am
Informant NA
Temperature 38
PR 119 bpm
RR 18 cpm
Blood Pressure 130/90 mm Hg
Height 5’2
Weight 57kg
Admitting Diagnosis Closed Linear Skull Fracture, Temporal Bone, Right with
underlying pneumocephalus secondary to vehicular accident
2wheel passenger non collision, BCS 9 E2V2M5
Attending Physician Lilyka P. Arceta, MD

B. Chief Complaint
On Dec. 16, 2020 both the Driver and the patient was drunk and was involved in a 2wheel
vehicular accident non collision.

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V. MEDICAL MANAGEMENT

A. Medical Orders and Rationale

Date Doctor’s Order Rationale

December 16, 2020  Please admit under  To be able to
1 AM Neurosurgery provide the patient
with the specific
care needed.
 Secure consent to care  To be able to
provide the patient
with the specific
care needed.

 NPO temporarily  To prevent

aspiration.
 IVF:
 PNSS 1L @ 50
gtts/min x 8 hours then  For fluid and
30gtts/min electrolyte
replenishment and
caloric supply.
 Lab Exams:
 CBC with PTT, BT

 To evaluate blood
components and
clotting factor.
 Na, K, Crea, BUN Also to determine
blood type.

 Measures level of
electrolytes; to
 CT Scan Brain Plain evaluate the health
of your kidneys.
 Chest X-ray

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 To assess the brain.

 Pelvis X-ray
 To assess
abnormalities of
 Cervical Spine X-ray the lungs, heart and
others.

 To check
abnormalities in
the pelvic area.

 To detect fractures
in the cervical
 Medications: vertebrae or
 Oxacillin 1 gram IVTT dislocation of the
now then q 8 hours joints between
ANST the vertebrae.

 TT 1 amp IM now
 To treat infection.

 ATS 5000 IU IM
ANST now

 Omeprazole 40 mg
IVTT now then OD  For wound
management.

 It is used for both

preventing and
 Paracetamol 600g curing Tetanus.
IVTT now then q 6
hours
 To treat conditions
 For conservative management caused by too
much acid
production in the

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stomach.

 O2 inhalation support via

nasal cannula at 4-6 LPM  For short-term
management of
pain.

 Moderate high back rest

 To preserve
function or body
parts.

 Insert FBC Fr 16 hook to

urobag
 To supply enough
oxygen the body
 Vital signs q 4 hours
needs.

 For proper lung

 Intake and output q shift
expansion and to
promote breathing;
to reduce risk for
increase ICP.
 Refer accordingly

 For immediate
drainage and
decompress
bladder.

 Tp monitor
patient’s status.

 To help evaluate
pt.'s fluid and
electrolyte balance,
any imbalance may
affect pt.'s output

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December 17, 2020
 Refer to ENT and Ortho  To be able to
provide the patient
with the specific
care needed.

 O2 inhalation @ 6LPM via

facemask  To supply enough
oxygen the body
needs.

 For the continuity

 Continue medications
of treatment.

 To replenish lost
 IVF PNSS 1L @ 30gtts/min body fluids and
electrolytes and for
caloric supply.
 Refer accordingly

December 18, 2020  DAT with SAP  To prevent

6 AM aspiration.

 Continue medications
 For the continuity
of treatment.

 Continue IVF  To replenish lost

body fluids and
electrolytes and for
caloric supply.
 Refer accordingly

8 AM

 Pt refered due to decreased

sensation

 To open airway to

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 Intubate pt using ET tube size provide oxygen.
7.5 @ level 21
 To assess electrical
activity of your
 For ECG 12 leads, CXR-AP, heart.
ABG

 Repeat CT Scan brain plain

 To assess the brain.

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VI. Laboratory Tests

HEMATOLOGY TEST:

Test Result Reference Indication

It means the patient has

White Blood Cell 14.85 5.0 – 10.0 infection.

It means that patient has

Red Blood Cell 3.98 4.2 – 5.4 bleeding or nutritional
deficiencies.

Hemoglobin 12.20 12.0 – 16.0 Normal

It means that patient has

Hematocrit 36.00 37.0 – 47.0 bleeding like trauma or
internal bleeding.

Mean Corpuscular 90.50 82.0 – 98.0 Normal

Volume (MCV)

Mean Corpuscular Normal

Hemoglobin 30.70 27.0 – 31.0

Mean Corpuscular
Hemoglobin Normal
Concentration(MCHC) 33.90 31.5 – 35.0
Red Blood Cell
Distribution 13.20 12.0 – 17.0 Normal
Width(RDW)

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Platelet Distribution
Width(PDW) 10.50 9.0 – 16.0 Normal

Mean Platelet
Volume(MPV) 9.80 8.0 – 12.0 Normal

It means that patient has

Neutrophil 87.00 43.4 – 76.2 Bacterial Infection and
Acute Inflammation.
It means that the patient
Lymphocyte 5.60 17.4 – 48.2 has ongoing medications
such as anti-immune
system medicines and
indicates patient has
infection.

Monocyte 6.10 4.5 – 10.5 Normal

It means the patient has

Eosinophil 0.90 1.0 – 3.0 excessive production of
cortisol and patient has
allergic reaction.

Basophil 0.40 0.0 – 2.0 Normal

Platelet 274 150 - 400 Normal

Laboratory Tests

Test Result Reference Indication

Blood Sugar 73.9 60 - 110 Normal

Creatinine 0.81 0.6 – 1.8 Normal

Electrolytes:

Test Result Reference Indication

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Potassium 3.68 3.5 – 5.3 Normal

Sodium 145.6 133 - 148 Normal

Arterial Blood Gases

Corrected: 37.8 Measured: 37 Reference Ranges Indication

pH 7.38 7.39 7.350-7.450 Normal

pCO 35 34 35.0-45.0 Normal

2
pO2 53 50 80-100 It means the patient
is experiencing
hypoxia

Blood Typing

Blood Type: __O__ Rh POSITIVE

Immunology

HBsAg: ____NON-REACTIVE___

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VII. NURSING ASSESSMENT

Day 1

Name of patient:Patient Z Date: December 17, 2020

NURSING SYSTEM REVIEW CHART

Temp: 37.8 PR: 119 RR:16 BP: 130/90 Height: 5’2 Weight: 57
EENT Pt, is Dizzy
[X]impaired []blind []pain Temporary impaired
vision vision due to swollen
eyes secondary to
trauma.
[]reddened []drainage []gums incomplete
[]hard []deaf []burning With yellow colored
hearing sputum
[x]edema []lesion [x]teeth Pain @R arm
Assess eyes, ears, nose, throat for any Foley Bag catheter
abnormalities []no problem connected to urobag
draining to yellowish
urine and in
moderate amount.
IV line with PNNS
1L@30gtts/min.
RESPIRATORY Dirty long Nails
[]asymmetric []tachypnea Dehydrated (dry lips)
[]rales []cough []barrel chest With 02 via nasal
cannula @5lmp

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[]bradypnea []shallow []brhonchi Temp: 37.8
[X]sputum []diminish []dyspnea Use of accessory
ed muscles (trapezius
muscle and
diaphragm)
[]orthopnea [X]labored []wheezing BP: 130/90from
brachial pulse.
[]pain []cyanotic
Assess respiration, rate, rhythm, depth, pattern,
breath sounds, comfort [x]no problem
CARDIOVASCULAR
[]arrhythmia []tachypna []numbness
[]diminished []edema []fatigue
pulses
[]irregular [X]bradyc []murmur
ardia
[]tingling []absent []pain
pulses
Assess heart sound, rate, rhythm, pulse,
blood pressure, circulation, fluid retention,
comfort
[]no problem

GASTROINTESTINAL TRACT
[]obese []distention []mass
[]dysphagia []rigidity []pain
Assess abdomen, bowel habits,
swallowing, bowel sound, comfort [X]no
problem
GENITO-URINARY & GYNE
[]pain []urine []vaginal
color bleeding
[]hematuria []discharg []nocturia
es
Assess urine frequency, control, color,
odor, comfort, gyne bleeding, discharges
[x]no problem
NEURO
[]paralysis []stuporous [X]unsteady Can’t move R arm
[]seizures []lethargic []comatose
[]vertigo []tremors []confused
[X]vision []grip
Assess motor function, sensation, Loc,
strength, grip, gait, coordination, Inability to move

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both legs
orientation, speech []no problem
MUSCULOSKELETAL & SKIN Hyperthermia 37.8
[]appliance []stiffness []itching
[]petechiae [X]hot []drainage
[]prosthesis []swelling []lesion
[]poor turgor []cool []deformity
[]wound []rash []skin color
[]flushed []atrophy [X]pain (left
arm)
[]ecchymosis []diaphoret []moist
ic
Assess mobility, motion, gait, alignment,
joint, function, skin color, texture, turgor,
integrity []no problem

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SUBJECTIVE DATA OBJECTIVE DATA
COMMUNICATI Comments: []Glasses []Languages 18
ON
[]Hearing Loss LICEO DE CAGAYAN UNIVERSITY
“Dili man Maam []Contact Lens []Hearing Aide
sakit ra ibuka and R L
[x]Visual Changes mata”- as Pupil size:
verbalized by the []Speech difficulties
[] Denied significant patient. Reaction: swelling

OXYGENATION Comments: Respiration []Regular [x]Irregular

[] Dyspnea “naay plemas”- as Describe: with adventitious sounds in both lung
[x]Smoking History verbalized by the field heard and use of accessory muscle noted,
Started when his 16 patient. with respiratory rate of 16 cpm.
yo
[]Cough
[x]Sputum R: Symmetrical to left lung
[] Denied L: Symmetrical to right lung
CIRCULATION Comments: Heart Rhythm [X] Regular []Irregular
[]Chest Pain Ankle Edema: None
“dili nako malihok Pulse Car Rad AP Fem*
[x]Numbness of akong lawas kay R 119 + + + +
extremities sakit.” As L 119 + + + +
[] Denied Verbalized by the Comments: All pulse are palpable, regular and
patient. symmetrical

NUTRITION Comments: []Dentures [X]None

Diet: NPO “gutom na kayo Complete Incomplete
[]N[]V maam sakit na
[]Recent change in akong tiyan”- as Upper [] [X]
weightand appetite verbalized by the Lower [] [X]
patient.
[]Swallowing Comments:
Difficulty No dentures patient is
under NPO and no
difficulty swallowing.
[x] Denied

Comments: Foley bag

ELIMINATION Urinary frequency catheter in placed with Bowel Sounds:
Usual bowel pattern urobag draining to yellow Client’s bowel sound
urine with moderate is normoactive
[]Urgency amount. Abdominal Distention
Constipation []Dysuria []Yes [x]No
Remedy:
[]Hematuria Urine color,
Date of last BM: []Incontinence consistency, odor:
not able to Urine is yellow in 18
remember color.
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Day 2

Name of patient: Patient Z Date: December 18, 2020

NURSING SYSTEM REVIEW CHART

Temp: 38 PR: 102 RR: 15 BP: 70/40 Height: 5’2 Weight: 57
EENT Temporary impaired
vision due to swollen
eyes secondary to
trauma.
[X]impaired []blind []pain incomplete
vision
[]reddened []drainage []gums With yellow colored
sputum
[]hard []deaf []burning Pain @R arm
hearing
[X]edema []lesion [x]teeth With adventitious
breath sound in both
lung field (rhonci)
Assess eyes, ears, nose, throat for any IV line with PNNS
abnormalities []no problem 1L@30gtts/min.
Foley Bag catheter
connected to urobag
draining to yellowish
urine and in
moderate amount.
RESPIRATORY
[]asymmetric []tachypnea With 02 via face
mask @5lmp
[]rales []cough []barrel chest Respiratory arrest
[X]bradypnea []shallow []brhonchi - Ambubaging
- suctioning

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[]sputum []diminish []dyspnea O2 Sat 76%
ed Respi 15

[x]labored []wheezing BP:70/40from

brachial pulse.
[]pain []cyanotic Temp: 38C
Assess respiration, rate, rhythm, depth, pattern, Use of accessory
breath sounds, comfort []no problem muscles (trapezius
muscle and
diaphragm)

CARDIOVASCULAR
[]arrhythmia []tachypna []numbness
[]diminished []edema [X]fatigue
pulses
[]irregular [X]bradyc []murmur
ardia
[]tingling []absent []pain
pulses
Assess heart sound, rate, rhythm, pulse,
blood pressure, circulation, fluid retention,
comfort Can’t move R arm
[]no problem

GASTROINTESTINAL TRACT
[]obese []distention []mass
[]dysphagia []rigidity []pain
Assess abdomen, bowel habits, Inability to move
swallowing, bowel sound, comfort [x]no both legs
problem
GENITO-URINARY & GYNE
[]pain []urine []vaginal
color bleeding
[]hematuria []discharg []nocturia
es
Assess urine frequency, control, color,
odor, comfort, gyne bleeding, discharges
[x]no problem
NEURO
[]paralysis []stuporous [X]unsteady
[]seizures [X]lethargic []comatose
[]vertigo []tremors []confused
[X]vision []grip
Assess motor function, sensation, Loc,

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strength, grip, gait, coordination,
orientation, speech []no problem
MUSCULOSKELETAL & SKIN
[]appliance [x]stiffnes []itching
s
[]petechiae [x]hot []drainage
[]prosthesis []swelling []lesion
[]poor turgor []cool []deformity
[x]wound []rash []skin color
[]flushed []atrophy [x]pain (left
arm)
[]ecchymosis []diaphoret []moist
ic
Assess mobility, motion, gait, alignment,
joint, function, skin color, texture, turgor,
integrity []no problem

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SUBJECTIVE DATA OBJECTIVE DATA
COMMUNICATI Comments: []Glasses []Languages 22
ON
[]Hearing Loss LICEO DE CAGAYAN UNIVERSITY
“sakit gihapon.” – []Contact Lens []Hearing Aide
as verbalized by R L
[x]Visual Changes the pt. Pupil size:
3mm []Speech difficulties
[] Denied Reaction: - PERRLA

OXYGENATION Comments: Respiration []Regular [x]Irregular

[] Dyspnea “dili nako Describe: with adventitious sounds in both lung
[x]Smoking History magawas akoang field heard and use of accessory muscle noted,
Smoker since 16yo plemas maam.” – with respiratory rate of 16cpm
as verbalized by
[x]Cough the patient.
[x]Sputum R: Symmetrical to left lung
[] Denied L: Symmetrical to right lung
CIRCULATION Comments: Heart Rhythm [X] Regular []Irregular
[]Chest Pain Ankle Edema: None
“sakit gihapon Pulse Car Rad AP Fem*
[x]Numbness of akoang kamot R 102 + + + +
extremities maam, dili nako L 102 + + + +
[] Denied malihok akoang Comments: All pulse are palpable, regular and
lawas kay sakit”- symmetrical with pulse rate of 102bpm.
as verbalized by
the patient.

NUTRITION Comments: “ []Dentures [X]None

Diet: NPO Wala pako nag Complete Incomplete
[]N[]V kaon mam As
[]Recent change in verbalized by the Upper [] [X]
weightand appetite patient. Lower [] [X]

[]Swallowing Comments:
Difficulty No dentures patient is
under NPO and no
difficulty swallowing.
[x] Denied

Comments: Foley bag

ELIMINATION Urinary frequency catheter in placed with Bowel Sounds:
Usual bowel pattern urobag draining to yellow normoactive
color urine.
[]Urgency Abdominal Distention
Constipation []Dysuria []Yes [x]No
Remedy:
[]Hematuria Urine color,
Date of last BM: []Incontinence consistency, odor:
not able to Urine is yellow in 22
remember color.
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VIII. PATHOPHYSIOLOGY WITH ANATOMY AND

PHYSIOLOGY

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Admitting Diagnosis: Closed Linear Skull Fracture, Temporal Bone, Right with underlying
pneumocephalus secondary to vehicular accident 2wheel passenger non collision, BCS 9
E2V2M5

Predisposing Precipitating factor:

Factor: >> Hitting the ground
>>Vehicular Accident
2 wheel

Brain suffers
traumatic injury s/s: pain
Affecting temporal
bone

Brain swelling or bleeding s/s: temp. 37.8

increases intracranial (12/17/18)
volume. Hemorrhage

Pneumocephalus
(presence of air or gas
within the cranial
cavity.)

Rigid cranium allows no s/s: increase

room for expansion of blood pressure
contents so intracranial of 130/90
pressure increases. (12/18/18)

Pressure on the blood

vessels within the brain
causes blood flow to the
brain to slow

Cerebral hypoxia and s/s: restlessness

ischemia occur

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Intracranial pressure s/s: still

continues to rise. increase in
blood
pressure of
130/80
(12/18/18)

IX. NURSING MANAGEMENT

CUES NURSING OBJECTIV INTERVENTI RATIONALE EVALUATI

DIAGNOSI ES ON ON
S
Objective: Independent
Hyperther At the end : At the end
Temperatu mia of 30 Enhances of 30
re: 38 via minutes Do tepid heat loss by minutes
axilla patient’s sponge bath evaporation. patient’s
temperatur temperature
Chilling e will be lowered to
lowered, at To reduce 37.5
Warm Skin least below Promote bed body heat degrees
38 degrees rest production by Celsius
Diaphoreti closer to decreasing closer to
c Skin normal metabolism normal
values. values.
Flushed To monitor
skin Monitor vital any changes
signs and evaluate

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Restlessne constantly effectiveness
ss specifically of nursing
patients interventions
temperature
Decrease
warmth and
Provide cool increases
circulating air cooling by
and remove evaporation
extra
blankets
according to
clients
comfort IV fluid
Replenish
fluid losses
Monitor and during
regulate hyperthermia
Intravenous
fluid

Dependent: Antipyretics
lowers body
Give temperature
antipyretic by blocking
medications the synthesis
as ordered by of
the physician prostaglandin
s which acts
in the
hypothalamu
s causing
abnormal
thermoregulat
ion

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CUES NURSING OBJECTIV INTERVENTI RATIONA EVALUATI

DIAGNOS ES ON LE ON
IS
Subjective
: Ineffective At the end Independent: At the end of
Airway of 15 15 minutes
“Mam, Clearance minutes Position client Promotes patient had
tabangi ko patient will in semi proper lung clear, patent
ga lisod ko have clear, fowlers expansion airways as
ug ginhawa patent position evidenced
mam.”- as airways as by improved
verbalized evidenced RR: 18 and
by the by improved Perform To O2
patient RR and O2 suctioning as eliminate saturation:
saturation needed not secretions 94 percent
and without exceeding 15 obstructing and without
Objective: dyspnea seconds. airways. dyspnea,
and SOB. Suction SOB and
SOB less than dizziness.
15 minutes
Dyspnea to avoid
increasing
RR: 21 Intracranial

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pressure
O2 Provide since
Saturation: humidified patient had
85 percent Supplemental head
oxygen @ 5L injury.
Restlessne or more as
ss ordered by the To support
physician. patient’s
Productive oxygen
Cough needs and
Monitor to reduce
(+) patient’s viscosity of
Moderate respiratory secretions.
amount of rate, Oxygen
yellowish saturation and
secretions type of
respiration. To know
Dizziness patient’s
respiratory
(+) crackles Auscultate status,
at both and note any evaluate
lung fields Adventitious effectivene
breath sounds ss of
Interventio
ns and
Dependent: note any
changes
Do
nebulization To note the
as ordered by cause and
the physician the area of
the lung
severely
affected
Assist
physician in
Endotracheal
Tube
Placement. Helps
expand
airways
and
decrease
the
viscosity of

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secretions

Serves as
passage
through
upper
airway,
permits air
to pass
freely into
and from
the lungs,
to aid
ventilation

CUES NURSING OBJECTIV INTERVENTI RATIONA EVALUATI

DIAGNOS ES ON LE ON
IS
Subjective
: Risk for At the end Independent: At the end of
Increase of 15 15 minutes
“Dili ko Intracrania minutes Lower patients Helps patient will
magpa l Pressure patient will temperature lower has
oxygen have by TSB temperatur decrease
mam, mam decrease e by risk to have
mag uli risk to have evaporatio Increase
nako.” –as Increase n. Intracranial
verbalized Intracranial Lowering Pressure as
by the Pressure as temperatur evidenced
patient evidenced e by absence
by absence decreases of
Objective: of body’s restlessness
restlessnes metabolis and
Restlessne s and m, with agitation,
ss agitation, decreased blood
decreased Elevate head need for pressure of :
Agitation blood of bed 30-35 oxygen 120/90 and
pressure degrees, and and blood temperature
BP: 130/90 and keep the head supply. of: 37.5 And
temperature in the midline Thus verbalization
Temperatur . And decreasing of
e: 38 verbalizatio intracranial appropriate
degrees n of Do glassgow blood responses.

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Celsius appropriate coma scale pressure.
responses. and note
Headache results To improve
cerebral
venous
drainage,
Decrease lower
external cerebral
stimuli such blood
as noises volume
and lower
ICP
Provide
supplemental To
oxygen evaluate
neurologic
Raise side functioning
rails and and take
guard patient note any
from fall changes

Can make
Measure CPP patient
more
agitated
and
restless
increasing
ICP
Dependent:
To help
Administer oxygenate
osmotic cerebral
diuretics as tissues
ordered by the
physician Falls may
cause
further
injury
causing
increase in
ICP

Consistentl
y measure

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cerebral
blood
perfusion
and
pressure
which
could
affect ICP

Promotes
elimination
of fluid
from
cerebral
tissue by
the
process of
osmosis.

Cues Nursing Objectives Interventi Rationale Evaluation

Diagnosis ons
Subjecti Impaired At the end of 15 Independe Independen After 15
ve: gas minutes of nt: t: minutes of
“Maam, exchange intervention, the - Position -For proper intervention
galisod patient will be client 30- lung , the
ko ug able to 35 degrees expansion patient was
pagawa demonstrate a able to
s sa normal depth, - Provide -Assist demonstrat
akong rate and pattern O2 oxygenation e a normal
plema.” of respirations. -to depth, rate
Objectiv - expe and pattern
e: Emphasise ctora of
RR- deep te respirations
21cpm breathing and .
O2- 85% and for
SOB coughing prop
Nasal exercise er
flaring Dependent lung
: expa
nsion

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X. DRUG STUDY
DRUG MECHANI SPECIFI CONTRAINDICA SIDE EFFECTS NURSI
ORDER SMS C TIONS NG
OF INDICATI RESPO
ACTION ON NSIBILI
TIES/
PRECA
UTION
S
Generic Gastric Short- Contraindicated Headache, Assess
name: acid-pump term with dizziness, Rash, Vital
Omeprazole inhibitor: treatment hypersensitivity dry skin, Signs
Suppress of active to omeprazole or alopecia,
Brand es gastric duodenal its components; Diarrhea, -Check
name: acid ulcer; abdominal pain, for
Prilosec secretion Treatmen nausea abdomi
by specific t of Back pain, fever nal
Classificatio inhibition heartburn Pain,
n: of the or s/s of emesis,
proton hydrogen- GERD Diarrhe

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pumpinhibito potassium a or
rs (PPI) ATPase constip
enzyme ation.
Dose/Frequ system at
ency/Route: the -
40mg/ OD/ secretory Evaluat
IVTT surface of e fluid
the gastric and
parietal intake
cells;
blocks the -Tell
final step patient
of acid to take
production 30-60
minutes
before
a meal,
prefera
bly in
mornin
g.

DRUG MECANISM INDICATION CONTRAINDI SIDE NURSING

ORDER OF CATION EFFECTS RESPONSIBILI
ACTION TIES/
PRECAUTIONS

Interferes Severe Concentration CNS: Lethargy, Before

Generic with infections s hallucinations, - Observe 15
Name: bacterial caused by - Allergies to seizures rights of drug

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cell wall sensitive penicillins, administration.
Penicillin G synthesis organisms cephalosporins GI: Glossitis, - Reduce
Benzathine during (streptococci) , or other stomatitis, dosage with
active - URTI allergens gastritis, sore hepatic or renal
multiplicatio caused by mouth, furry failure.
Brand n, causing sensitive Precaution tongue, black - Assess for
Name: cell wall streptococci - Renal “hairy” tongue, hypersensitivity
death and - Treatment disorders nausea, to drug.
(Penadur) resultant of syphilis, - Pregnancy vomiting, - Assess for any
bactericidal bejel, - Lactation diarrhea, contraindications
Clasificatio activity congenital abdominal to the drug.
n: against syphilis, Drug pain, bloody - Educate about
susceptible pinta, yaws interaction diarrhea, side effects of
Anti- bacteria. - Prophylaxis Drug to drug enterocolitis, drug.
infective, of rheumatic - Decreased pseudomembra During
Antibiotic fever and effectiveness nous colitis, - Drug is not for
chorea with nonspecific IV use. Do not
Dosage/Fre tetracyclines hepatitis inject or mix with
quency/Ro - Inactivation of GU: Nephritis other IV
ute: parenteral Hematologic: solutions.
aminoglycoside Anemia, - Give IM
5 million IU/ s (amikacin, thrombocytope injection in
q6h/ IVTT gentamicin, nia, upper outer
kanamycin, leukopenia, quadrant of the
neomycin, neutropenia, buttock.
tobramycin) prolonged - Avoid contact
bleeding itme with the needle.
Drug to food Hypersensitivi - Withdraw
- none reported ty: Rash, fever, needle as
wheezing, quickly as
anaphylaxis possible to avoid
Local: Pain, discomfort.
phlebitis, - Stay with
thrombosis at patient
injection site, throughout
Jarisch- whole duration
Herxheimer of
reaction when administration.
used to treat After
syphilis - Monitor client
for at least 30
minutes.
- Arrange for
regular follow-
up, including

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blood tests, to
DRUG MECH INDICA CONTRAIN SIDE NURSING
ORDE ANIS TIONS DICATIONS EFFECTS RESPONSIBILITI
evaluate effects.
R M OF ES/ - Instruct to
ACTI PRECAUTIONS report difficulty
ON breathing,
rashes, severe
Generi Blocks Mild to Hypersensiti CNS: Tell patient that pain at injection
c pain moderat vity to headache, tablets may be site, mouth
Name: impulse e pain, acetaminop dizziness, crushed or sores, unusual
Parace s by hen or any somnolence, swallowed whole. bleeding or
tamol inhibiti of its insomnia, Advise patient to bruising.
ng components fatigue, contact prescriber - Instruct to take
Brand synthe . dizziness before taking
medication as
Name: sis of tinnitus, other prescription
Bioges prosta ophthalmologic or OTC drugs; directed for the
ic glandi effects they may contain full course of
ns. It acetaminophen therapy, even if
Classi relieves and lead to feeling better.
ficatio fever by toxicity.
n: central Teach patient
Anti- action signs of
pyretic in the hepatotoxicity;
Analge hypoth such as bleeding,
sics alamic easy bruising and
heat- malaise.
regulati Should not be
Dosag ng used for self-
e/Freq center. medication of
uency/ marked fever.
Route: This drug should
600 not be used for
mg / medicating fever
q6h/ persisting for 3
IVTT days.

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Drug Name Mechanism Indication Contraindicat Side Nursing

of Action ion Effects/ Responsibiliti
Adverse es
Effects
Generic Name: A penicillinase Systemic Contraindicate  fev  Use
Oxacillin – resistant infections d to patients er, sore cautiously in
penicillin that caused by hypersensitive throat,
Classification: inhibits cell- penicillinase- to drug and its patients with
and he
Penicillin wall synthesis producing contents other drug
adache 
during staphylococci allergy,
with a
Dosage/Freque microorganism specifically eye especially to
ncy/Route: multiplication; infections severe
blisterin cephalospori
bacteria
1gm q8h ANST resists g, ns.
IVTT penicillins by peeling  Obtain
producing , and specimen for
penicilllinase – red culture and
enzymes that skinras sensitivity
convert h;diarrh

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penicillins to ea that tests before
inactivate is first dose.
penecillic watery  Give 1-2
acids. or
Oxacillin hours before
bloody;
resists these or 2-3 hours
fever,
enzymes. after meals
chills,
body to prevent
aches, gastric
flu irritation.
sympto
ms;eas
y
bruisin
g or
bleedin
g,
unusua
l
weakne
ss;
urinatin
g less
than
usual
or not
at all;
severe
skin
rash,
itching,
or
peeling
;
agitatio
n,
confusi
on,
unusua
l
thought

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s or
behavi
or; or
seizure
.

XI. REFERRALS AND FOLLOW-UP

Upon admission patient was referred to neuro ward. This is to treat patient’s disease and
symptoms. The most recent doctor’s order was patient is for ECG 12 leads which revealed
that patient is bradycardic, ABG, CT scan (brain) and CXR-AP.
During the duration of care we haven’t seen the results of the CT scan and CXR-AP.
Other than that, the group suggested the following to the family;

(1) What are the signs of infection like swelling, purulent discharge or presence of pain
from wounds, catheters or drains.

(2) The Importance of washing hands, especially before meals, toileting, and before and
after administering self-care to prevent spread of infection from one part of the body
to another reduces these risks.

(3) Limiting visitors which reduce the transmission of pathogens. We Instructed

significant others to refer to the nurse if any abnormalities were noted.

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(4) We told the significant others that patient is on NPO as ordered by the doctor but may
have sips of water.

(5) We emphasized the importance of proper hygiene to the SO and Teaching them on
how to bath patient on bed.

(6) Since there’s no side rails, pt. is at risk of falling from the bed so we instructed SO to
always sit at the side of the pt.’s bed.

Following the regular check-up after discharge and follow regimen of the drugs prescribed

XII. EVALUATION AND IMPLICATIONS

As a student nurse of San Isidro College, aim to develop essential as well as skillful
neurologic nursing care which is based on the better and effective approach that will serve as
a catalyst to promote health, reduce illness and/or completely eliminate such diseases. We are
also up to in knowing the nature of the disease and on how to manage it in such a way that it
would be therapeutic to the client and the SO.
By the end of this whole rotation, as a student nurse of San Isidro College I were be able to:
1. Enhance our ability to manage the said disease in regards to their cultural beliefs and
lifestyle.
2. Develop an independent and collaborative work together with the medical health team
members.
3.Prioritize things which are essential in assessing and developing proper interventions in
treating or alleviating the illness

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. 4.Improve the use of the nursing process that would include assessment, diagnosis,
planning, implementation and evaluation into a more useful and more effective in doing the
patient’s care.
5.Apply the core and fundamental systematic approach of the nursing profession in
promoting health unto the client

XIII. REFERENCE

http://brainmind.com/SkullFractures.html

Brunner & Suddart: Textboook of Medical Surgical nursing Vol.2 11th Edition
Pages 2207-2243

Elsiever; Clinical Nuerology Textbook

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