I.

INTRODUCTION
B .SIGNIFICANCE OF THE STUDY

NURSING EDUCATION

Similar to clinical practice, case studies are often designed to be complex and

ambiguous, offering the learner an opportunity to build critical-thinking and problem-

solving abilities. Case studies provides a body of knowledge that helps advance

nursing practice, which may help shape health policy and contribute to global

healthcare. It is used in the curriculum to provide a means for students to develop

the tools necessary to think reflectively and critically about a problem. Using clinical-

based problems encourages students to better understand thinking strategies,

develop reasoning skills, and improve critical thinking.

NURSING PRACTICE

Through this, facilitators are able to positively influence clinical practice by

actively engaging students in the process of learning about a specific disease

process. In essence, the case study allowed the instructor to build on the curriculum

to mold the scenario to fit the learning needs of the student. Case studies promotes

lifelong professional development, through helping nurses advance their field and

offering better patient care.

NURSING RESEARCH

To develop clinical judgment through critical thinking and reflective thinking

are major skills that one nurse practitioner must have in order to determine the

course of actions. Case study allows deep information about the disease/condition

thus enhancing nursing critical skills and attitude. Case studies are client centered

and it differs to every client. It is important to understand that the approach to every

client differs from each other. Additionally, clients expect to receive the most

effective care based on the best available evidence.

OBJECTIVES OF THE STUDY

General Objective:

This case study aims to identify and determine the general health problems

and needs of the patient who manifested signs and symptoms of traumatic brain

injury. This study will emphasize on providing and prioritizing an effective nursing

care plan in relation to patient’s problems with corresponding rationale for each

nursing interventions. This study also intends to help patient promote health and

medical understanding of such condition through the utilization and application of

nursing process appropriately and holistically with emphasis on curative, preventive,

rehabilitative, and health promotion. It also aims to be a tool for nursing students to

improve the quality of nursing care and interventions given to a patient.

Specific Objectives:

At the end of this case study, the researchers will be able to:

 Prioritize an effective nursing care plan in relation to patient’s problems with

corresponding rationale for each nursing interventions.

 Perform cephalocaudal physical assessment to the client thoroughly.

 Provide information and support for people with brain injuries, their relatives,

carers and concerned professional. Such as increasing awareness and

understanding of brain injury and its consequences thru initiating activities and

campaigns which may help reduce the incidence of brain injury.

 Discuss the anatomy and physiology of the central nervous system

associated with traumatic brain injury.

 Identify the most effective clinical care, and provide high quality evidence in

support of treatment recommendations and guidelines.

 Describe the typical presentation of epidural, subdural, subarachnoid, and

intraparenchymal intracranial hemorrhage.

 Summarize the evaluation of epidural, subdural, subarachnoid, and

intraparenchymal intracranial hemorrhage.

 Outline the management approaches for epidural, subdural, subarachnoid,

and intraparenchymal intracranial hemorrhage.

 Give the appropriate and sufficient health teachings on a patient with

traumatic brain injury, and to the significant others.

 Evaluate clients progress with continuous care.

C. ANATOMY AND PHYSIOLOGY

The brain is an amazing three-pound organ that controls all functions of the

body, interprets information from the outside world, and embodies the essence of the

mind and soul. Intelligence, creativity, emotion, and memory are a few of the many

things governed by the brain. Protected within the skull, the brain is composed of the

cerebrum, cerebellum, and brainstem.

The brain receives information through our five senses: sight, smell, touch,

taste, and hearing - often many at one time. It assembles the messages in a way

that has meaning for us, and can store that information in our memory. The brain

controls our thoughts, memory and speech, movement of the arms and legs, and the

function of many organs within our body.

The central nervous system (CNS) is composed of the brain and spinal cord.

The peripheral nervous system (PNS) is composed of spinal nerves that branch from

the spinal cord and cranial nerves that branch from the brain.
Cerebrum: is the largest part of the brain and is composed of right and left

hemispheres. It performs higher functions like interpreting touch, vision and hearing,

as well as speech, reasoning, emotions, learning, and fine control of movement.

Cerebellum: is located under the cerebrum. Its function is to coordinate muscle

movements, maintain posture, and balance.

Brainstem: acts as a relay center connecting the cerebrum and cerebellum to the

spinal cord. It performs many automatic functions such as breathing, heart rate, body

temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and

swallowing.

Right brain – left brain

The cerebrum is divided into two halves: the right and left hemispheres (Fig. 2) They

are joined by a bundle of fibers called the corpus callosum that transmits messages
from one side to the other. Each hemisphere controls the opposite side of the body.

If a stroke occurs on the right side of the brain, your left arm or leg may be weak or

paralyzed.

Not all functions of the hemispheres are shared. In general, the left hemisphere

controls speech, comprehension, arithmetic, and writing. The right hemisphere

controls creativity, spatial ability, artistic, and musical skills. The left hemisphere is

dominant in hand use and language in about 92% of people.

Lobes of the brain

Frontal lobe

 Personality, behavior, emotions

 Judgment, planning, problem solving

 Speech: speaking and writing (Broca’s area)

 Body movement (motor strip)

 Intelligence, concentration, self awareness

Parietal lobe

 Interprets language, words

 Sense of touch, pain, temperature (sensory strip)

 Interprets signals from vision, hearing, motor, sensory and memory

 Spatial and visual perception

Occipital lobe

 Interprets vision (color, light, movement)

Temporal lobe

 Understanding language (Wernicke’s area)

 Memory

 Hearing

 Sequencing and organization

Deep structures

Pathways called white matter tracts connect areas of the cortex to each other.

Messages can travel from one gyrus to another, from one lobe to another, from one

side of the brain to the other, and to structures deep in the brain 
Hypothalamus: is located in the floor of the third ventricle and is the master control of

the autonomic system. It plays a role in controlling behaviors such as hunger, thirst,

sleep, and sexual response. It also regulates body temperature, blood pressure,

emotions, and secretion of hormones.

Pituitary gland: lies in a small pocket of bone at the skull base called the sella

turcica. The pituitary gland is connected to the hypothalamus of the brain by the

pituitary stalk. Known as the “master gland,” it controls other endocrine glands in the

body. It secretes hormones that control sexual development, promote bone and

muscle growth, and respond to stress.

Pineal gland: is located behind the third ventricle. It helps regulate the body’s internal

clock and circadian rhythms by secreting melatonin. It has some role in sexual

development.

Thalamus: serves as a relay station for almost all information that comes and goes to

the cortex. It plays a role in pain sensation, attention, alertness and memory.

Basal ganglia: includes the caudate, putamen and globus pallidus. These nuclei

work with the cerebellum to coordinate fine motions, such as fingertip movements.

Limbic system: is the center of our emotions, learning, and memory. Included in this

system are the cingulate gyri, hypothalamus, amygdala (emotional reactions) and

hippocampus (memory).
Skull

The purpose of the bony skull is to protect the brain from injury. The skull is formed

from 8 bones that fuse together along suture lines. These bones include the frontal,

parietal (2), temporal (2), sphenoid, occipital and ethmoid (Fig. 8). The face is formed

from 14 paired bones including the maxilla, zygoma, nasal, palatine, lacrimal, inferior

nasal conchae, mandible, and vomer.  

The brain is surrounded by a layer of tissue called the meninges. The skull (cranium)
helps protect the brain from injury.

Hines, T. (2018) Anatomy of the Brain. Https://mayfieldclinic.com/pe-anatbrain.htm#:~:text=The

%20brain%20has%20three%20main,and%20fine%20control%20of%20movement.

D. PATHOPHYSIOLOGY
Traumatic Brain Injury

Traumatic brain injury (TBI) can manifest itself in a variety of ways, ranging from

minor changes in consciousness to a permanent vegetative state and death. In the

most severe form of TBI, a diffuse sort of inflammation and edema affects the entire

brain. Treatment options range from regular cognitive therapy sessions to severe

surgery such as bilateral decompressive craniotomies, depending on the degree of

the injury. (Galgano et al, 2017)

Any type of traumatic brain injury can result in cerebral edema and reduced blood

supply to the brain. Because the cranial vault is set in size (limited by the skull) and

packed with non-compressible CSF and marginally compressible brain tissue, any

swelling from edema or an intracranial hemorrhage has nowhere to expand,

increasing intracranial pressure. The cerebral perfusion pressure, which is the

difference between mean arterial pressure and mean ICP, is related to cerebral

blood flow. As a result, as ICP rises, CPP falls. The brain may become ischemic if

cerebral perfusion pressure goes below 50 mmHg. Ischemia and edema can activate

a variety of secondary injury processes (e.g., release of excitatory neurotransmitters,

intracellular calcium, free radicals, and cytokines), leading to increased cell damage,

edema, and ICP. Secondary brain insults are systemic trauma consequences (e.g.,

hypotension, hypoxia) that can contribute to cerebral ischemia. Direct damage to

brain tissue (e.g., crush, laceration) can affect brain function right away. The

cascade of actions generated by the first injury may cause more damage soon after.

(Mao, 2021)
 Intreacranial pressure
Cerebral hypoxia and
TBI Pathophysiology continues to rise, brain
ischemia occur.
may herniate.

Pressure on blood
Brain suffers from vessels within the brain Cerebral blood flow
traumatic injury causes blood flow to ceases.
the brain to slow down.

Rigid cranium allows no

Brain swelling or
room for expansionof
bleeding increasing the Brain death
contents so intracranial
intracranial pressure.
pressure increases.

Primary and Secondary Traumatic Brain Injury

The term "primary brain injury" refers to a sudden and severe brain injury that is

more or less complete at the time of impact. This occurs after a car accident, a

gunshot wound, or a fall. Different mechanical assaults to the brain can result in two

kinds of primary injuries: localized and diffuse brain injuries. In patients who have

suffered from mild to severe TBI, studies have shown that both types of damage are

prevalent. (Skandsen et al., 2010)

The alterations that occur hours to days following a primary brain injury are referred

to as secondary brain damage. It refers to a sequence of biological, chemical, tissue,

or blood vascular changes in the brain that contribute to the loss of more brain

tissue. According to (Ray et al., 2002), the biochemical, molecular, and physiological

events that occur after initial injury can lead to delayed and long-term secondary
damage that can last anywhere from hours to years. Excitotoxicity, mitochondrial

malfunction, oxidative stress, lipid peroxidation, neuroinflammation, axon

degeneration, and apoptotic celiac cells are all variables that contribute to secondary

damage.

What are the symptoms?

According to the Centers for Disease and Control Prevention (CDC, 2021), the level

of symptoms is determined by the severity of the damage, which can be mild,

moderate, or severe. Symptoms include: inability to recall the cause of the injury or

events that occurred immediately before or up to 24 hours after it occurred,

confusion and disorientation, difficulty remembering new information, Headache,

dizziness, blurry vision, nausea and vomiting, ringing in the ears, trouble speaking

coherently, changes in emotions or sleep patterns.

These symptoms usually start at the time of the accident or shortly after, but they

can take days or weeks to appear. Mild traumatic brain injury symptoms are normally

transient, lasting hours, days, or weeks; however, they can sometimes linger months

or more. A moderate traumatic brain injury results in unconsciousness lasting longer

than 30 minutes but less than 24 hours, whereas a severe traumatic brain injury

results in unconsciousness lasting longer than 24 hours. Moderate and severe

traumatic brain injury symptoms are comparable to mild traumatic brain injury

symptoms, however they are more significant and last longer.

In all forms of traumatic brain injury, cognitive changes are among the most

common, disabling and long-lasting symptoms that can result directly from the injury.
The ability to learn and remember new information is often affected. Other commonly

affected cognitive skills include the capacity to pay attention, organize thoughts, plan

effective strategies for completing tasks and activities, and make sound judgments.

More severe changes in thinking skills — a hallmark characteristic of dementia —

may develop years after the injury took place and the person appears to have

recovered from its immediate effects.

REFERENCES:

Centers for Disease Control and Prevention, National Center for Injury Prevention
and Control. Report to Congress on traumatic brain injury in the United States:
Epidemiology and rehabilitationpdf icon. Atlanta (GA): Centers for Disease Control
and Prevention; 2015.

Mao (2021)
https://www.msdmanuals.com/professional/injuries-poisoning/traumatic-brain-injury-
tbi/traumatic-brain-injury-tbi?
fbclid=IwAR3uCezySo23CfSj4CqAGosTF4q9fBJgHpFHLzaWy6yua0JfnSV_fKii5RM
Galgano, M., Toshkezi, G., Qiu, X., Russell, T., Chin, L., & Zhao, L. R. (2017).
Traumatic Brain Injury: Current Treatment Strategies and Future Endeavors. Cell
transplantation, 26(7), 1118–1130. https://doi.org/10.1177/0963689717714102
Ray, S. K., Dixon, C. E., & Banik, N. L. (2002). Molecular mechanisms in the
pathogenesis of traumatic brain injury. Histology and histopathology.
https://digitum.um.es/digitum/handle/10201/20862
Skandsen, T., Kvistad, K. A., Solheim, O., Strand, I. H., Folvik, M., & Vik, A.
(2010). Prevalence and impact of diffuse axonal injury in patients with
moderate and severe head injury: a cohort study of early magnetic resonance
imaging findings and 1-year outcome, Journal of Neurosurgery JNS, 113(3),
556-563. Retrieved Aug 8, 2021, from
https://thejns.org/view/journals/j-neurosurg/113/3/article-p556.xml

II. NURSING PROCESS

A. ASSESSMENT

Biographic Data

i. Name: Patient P.

ii. Age: 40 years old

iii. Sex: Male

a. Address: Tetuan, Zamboanga City

iv. Place of Birth: Zamboanga city

v. Nationality: Filipino

vi. Religion: Roman catholic

vii. Language: Tagalog

viii. Civil Status: Married

ix. Chief Complaint: Patient was found in a semi-conscious state at the

pavement bleeding on the sidewalk with diminished breathing, open wounds

and bruises on head, face and arms accompanied by drowsiness and repeated

vomiting.

x. Final Diagnosis: Intracranial Hemorrhage at basal ganglia

xi. Date Admitted: May 21, 2021

xii. Surgical intervention: Craniotomy

xiii. Date Discharged: -----

xiv. Attending Physician: Dr. Shaun Murphy

B. Nursing History
History of Present Illness

On the 21th day of May 2021, patient was brought to the ER of Mary Johnson

hospital at 11:00 in the morning by the paramedics due to vehicular accident. Upon

arrival, he was on a semi-conscious state with GCS score of 11, open wounds and

bruises were visible on his head, face and arms. The patient was with a neck collar

and connected to an IVF. He was also experiencing dyspnea, drowsiness and

repeated vomiting. His O2 sat was down to 90%, nasal cannula and endotracheal

tube was given to the patient in the ER. Initial V/S was taken, BP=150/90, T=37c,

P=85 bpm, RR=18 bpm.

History of Past Illness

The patient has a medical history of hypertension 6 years ago. He is currently

taking Losartan and Rosuvastatin for maintenance when he’s feeling dizzy and his

blood pressure is rising.

Family history

The patient’s wife stated that his husband’s mother has a history of

hypertension and diabetes.

C. Marjorie Gordon’s Functional Health Problem

1. Health Perception and Management pattern

Prior to this condition, the patient experienced elevated blood pressure 2-3 times

a month. If he is manifesting increased in blood pressure and dizziness he takes his

maintenance, drinks a lot of fluids and doesn’t eat meat and fatty food. Her wife is

the one who takes his blood pressure using a digital blood pressure apparatus. The

patient believed that it is important to adhere to the recommendation or treatment

administered by the doctor.

2. Nutritional metabolic pattern

Prior to admission, the patient is fond of eating red meats, fried, fatty and salty

foods. He drinks beer occasionally when he is stressed and if there is an event. He

also has his own water container which he consumes 500ml-1L a day.

3. Elimination

Prior to admission, the patient usually voids three to four times a day. He has no

problems on defecating and has a bowel movement every day. The color of his urine

is usually transparent to light-yellow and the stool’s characteristic is solid and brown.

4. Activity and Exercise

Prior to admission, the patient doesn’t have a regular exercise, he sometimes go

with his friends in the road to go biking (insert moreeee)

5. Sleep and rest pattern

Prior to admission, the patient usually sleeps six hours a day. (insert moreeeee)
6. Cognitive perceptual patterns

--

7. Self-Perception and Self-concept pattern

--

8. Role and relationship pattern

The patient is married with his wife and has 3 kids. After his surgery his wife

accompanied him in the ICU.

9. Sexuality reproductive pattern

The patient practiced abstinence as their way of family planning. During

hospitalization, the wife of the patient verbalized that her husband has no plan to

conceive another child.

10. Coping stress tolerance pattern

Prior to hospitalization, the patient’s recent stress was financial constraints. He

also feels tired due to her work. He was able to cope with stress by smoking

cigarettes and eating and drinking with his colleague.

11. Value-Belief pattern

The patient is a religious person, he prays three times a day and reads the bible.

His wife said that he never loses his faith in God.

D. Physical Assessment
 MENTAL STATUS
Note: Patient was assessed on the ER / PACU or ICU?? ************

APPEARANCE

Grooming: Attire:
Personal Hygiene:
General Body Built:

BEHAVIOR

Level of consciousness:

√ () Awake () Alert ( ) Lethargic

( ) Drowsy ( ) Stupors or unresponsive
Facial expression: Speech:
Mood:

COGNITION

Oriented: ()Person () Place () Time ( ) Confused ( ) Sedated

() Alert ( ) Restless ( ) Lethargic ( ) Comatose

Recent Memory:
Remote Memory: .

THOUGHT PROCESS

Thought Content: ( ) Logical Consistent

Client’s Perception: Reality-base ( ) Congruent with others ( ) Others:
Suicidal Thoughts/ Ideation: ( ) Present Absent
 INTEGUMENTARY SYSTEM
SKIN

INSPECTION

Color: ()Normal ( ) Flushed ( ) Pale ( ) Dusky

( ) Cyanotic ( ) Jaundiced ( ) Others:

Texture: Soft Tone: Fair color of skin all over her body
Lesions: ( ) Yes. None

PALPATION

Moisture: Temperature: 37 C Turgor:

Edema: () Absent ( ) Present, site:

( ) Mild ( ) Moderate ( ) Severe

Pruritus: ( ) Yes None

Wound incision /pressure sore site: Head, face and arms.
Dressing type:
Odor: () None ( ) Mild ( ) Foul

NAILS

INSPECTION

Color: Texture: Configuration:

Symmetry: Cleanliness:

RESPIRATORY SYSTEM
LUNGS

INSPECTION
Respiration Rate: 18 breaths per minute
Pattern: ( ) Shallow ( ) Dyspnea ( ) Tachypnea ( ) Shortness of Breath None
Chest Symmetry: Even ( ) Uneven

AUSCULTATION
Breath Sounds:
CARDIOVASCULAR SYSTEM
NECK VESSELS

PALPATION

Carotid Artery: R: Full Palpation L: Full Palpation

AUSCULTATION
Carotid Arteries: Bruits: Absent ( ) Present
Jugular Vein Distention: ( ) Yes: No

HEART

INSPECTION

Point of Maximal Impulse (PMI): Apical

Thrills:( ) Present () Absent

PALPATION

Perfusion: Capillary Refill:

Murmurs: none
PULSES

Regular ( ) Strong ( ) Irregular ( ) Weak ( ) Absent ( ) Doppler ( ) Pacemaker

Radial: R: 85 bpm L: 85 bpm
BP: R: 150/90 L: 150/90

GASTROINTESTINAL SYSTEM

Mouth:

Throat:

ABDOMEN

INSPECTION

Contour: Round and flat Symmetry: Symmetrical without masses and lesions

AUSCULTATION

Bowel sounds: High-pitched & Gurgling ( ) Hyperactive

( ) Low-pitched ( ) Hypoactive
( ) Tympany
Rate: 8 bowel sounds per minute

PALPATION

Abdomen: ( ) Tender Soft/Non-Tender ( ) Firm ( ) Rigid

Mass: No ( ) Yes
Ascites: No ( ) Yes

GENITOURINARY
INSPECTION

Serosa: Color: Amount: Odor:

 NUTRITION

General Appearance: ( ) Well Nourished () Malnourished

( ) Emaciated ( ) Other

Body Built: Weight: Height:

Diet (Pre-operation): NPO Meal Pattern (Pre-operation): NPO
Mastication/Swallowing Problem: ( ) Yes () None
Dentures: ( ) Yes No
Appetite: ( ) Increased ( ) Decreased Unusual ( ) Usual
Decreased Taste Sensation: ( ) Yes () No
Nausea: ( ) Yes None
Stool frequency: None Characteristics: None
PAIN ASSESSMENT

SELF-CARE (Post - Operation)

Need Assist With:

Ambulating Elimination
Bed Mobility Meals
Hygiene √ Dressing
B. DIAGNOSTIC TEST

Diagnostic Tests

1. CT- CT scans can detect bone and joint problems, like complex bone

fractures and tumors. CT scan spot or help doctors see any changes in the

condition like cancer, heart disease, emphysema, or liver masses. It shows

internal injuries and bleeding, such as those cause by car accident. Help

locate a tumor, blood clot, excess fluid or infection. Doctors use them to guide
 treatment plans and procedure, such as biopsies, surgeries and radiation

therapy.

2. MRI- Magnetic resonance imaging (MRI) of the body uses a powerful

magnetic field, radio waves and a computer to produce detailed pictures of

the inside of your body. It may be used to help diagnose or monitor treatment

for a variety of conditions within the chest, abdomen and pelvis. It's especially

useful for looking at soft tissues and the nervous system .Doctor can use this

test to diagnose the patient or to see how well the patient responded to

treatment. Unlike X-rays and computed tomography (CT) scans, MRIs don’t

use the damaging ionizing radiation of X-rays.

RESULT- intracranial hemorrhage (ICH) basal ganglia, Basal ganglia hemorrhage is

a common form of intracerebral hemorrhage, and usually as a result of poorly

controlled long-standing hypertension. The stigmata of chronic hypertensive

encephalopathy are often present. Other sites of hypertensive hemorrhages are the

pons and the cerebellum. Lobar hemorrhages are also encountered but are more

frequently associated with amyloid angiopathy 1

o Blood urea Nitrogen- A blood urea nitrogen (BUN) test is used to determine

how well your kidneys are working. It does this by measuring the amount of urea

nitrogen in the blood. Urea nitrogen is a waste product that's created in the liver

when the body breaks down proteins. increase BUN may be associated with poor

prognosis in patients with intracerebral hemorrhage and hematoma expansion.

o Creatinine- a chemical waste product that's produced by your muscle

metabolism and to a smaller extent by eating meat. Healthy kidneys filter

creatinine and other waste products from your blood. The filtered waste products

leave your body in your urine.Increase in creatinine may be associated with poor

prognosis in patients with intracerebral hemorrhage and hematoma expansion.

o Hematocrit- A hematocrit test is part of a complete blood count (CBC).

Measuring the proportion of red blood cells in your blood can help your doctor

make a diagnosis or monitor your response to a treatment. A lower than normal

hematocrit can indicate: An insufficient supply of healthy red blood cells (anemia)

o Red Blood cell- A red blood cell count is a blood test that your doctor uses to

find out how many red blood cells (RBCs) you have. It’s also known as an

erythrocyte count. The test is important because RBCs contain hemoglobin,

which carries oxygen to your body’s tissues. The number of RBCs you have can

affect how much oxygen your tissues receive. Your tissues need oxygen to

function.
o Hemoglobin- measures the amount of hemoglobin in your blood. Hemoglobin is

a protein in your red blood cells that carries oxygen to your body's organs and

tissues and transports carbon dioxide from your organs and tissues back to your

lungs.

o MCH- If a person is not feeling well and visited the doctor’s office or hospital, one

of the tests ordered is CBC or complete blood count. It checks various

components of the blood so as to give the doctor a general overview of the

patient’s health. The result of the test is used as a basis for diagnosing and

treating the patient’s condition.

o MCV- this is a corpuscular volume. There are three main types of corpuscles

(blood cells) in your blood–red blood cells, white blood cells, and platelets. An

MCV blood test measures the average size of your red blood cells, also known as

erythrocytes

o MCHC- The mean corpuscular hemoglobin concentration (MCHC) test is a

standard part of the complete blood count (CBC) that is done during blood

analysis, and the MCHC value is used to evaluate the severity and cause of

anemia.
o RDW- The red cell distribution width (RDW) blood test measures the amount of

red blood cell variation in volume and size. You need red blood cells to carry

oxygen from your lungs to every part of your body.

o White Blood Cell- A white blood cell (WBC) count is a test that measures the

number of white blood cells in your body. This test is often included with a

complete blood count (CBC). ... Sometimes, however, your white blood cell count

can fall or rise out of the healthy range.

o H Neutrophils- A normal (absolute) neutrophil count is between 2500 and 7500

neutrophils per microliter of blood.2 The neutrophil count may be high with

infections, due to increased production in the bone marrow as with leukemia, or

due to physical or emotional stress.

o L Lymphocyte- A blood test that counts how many lymphocytes are in a

person's blood is called a B and T cell screen. In this test, the levels of the main

types of white blood cells in the body are measured. Lymphocyte count is one

part of a larger whole blood test called a complete blood count (CBC).

o Monocytes- We are surrounded by germs in our environment that can have a

negative effect on us. They can cause us to be ill and give us harmful infections.

In severe cases, they can cost us our lives. When these germs enter our bodies,

our immune system views them as intruders that must be fought off. Our immune
 system has a key component called the white blood cells, of which there are

several different kinds.

o Eosinophil- The eosinophil count measures the number of eosinophils in your

blood. The key is for eosinophils to do their job and then go away. But if you have

too many eosinophils in your body for a long time, doctors call this eosinophilia.

o Platelet count- a test is included in a complete blood count (CBC), a panel of

tests often performed as part of a general health examination. Platelets are tiny

fragments of cells that are essential for normal blood clotting

o MPV - The MVP test is blood test measures the average size of the platelets. The

test can help diagnose bleeding disorders and diseases of the bone marrow.
C. LABORATORY RESULTS
D. DRUG STUDY

Drug Mechanism of action/Side Indication/ Nursing responsibilities

effects Contraindication

Brand name: Cozaar Selectively blocks the binding Indication:  Monitor BP at drug trough
Generic name: of angiotensin II to specific Losartan is indicated to treat hypertension (prior to a scheduled dose).
Losartan tissue receptors found in the in patients older than 6 years, reduce the  Inadequate response may
Classification: vascular smooth muscle and risk of stroke in patients with hypertension be improved by splitting the
Angiotensin II adrenal gland; this action and left ventricular hypertrophy (though daily dose into twice-daily
receptor blocker blocks the vasoconstriction this benefit may not extend to patients dose.
(ARB), effect of the renin- with African heritage), and to treat diabetic  Lab tests: Monitor CBC,
Antihypertensive angiotensin system as well nephropathy with elevated serum electrolytes, liver & kidney
Route: PO as the release of aldosterone creatinine and proteinuria in patients with function with long-term
Dosage: 100 mg leading to decreased type 2 diabetes and hypertension. therapy.
Frequency: OD blood pressure. Contraindication:
Side effects: Losartan use is contraindicated with the
CNS: Dizziness, insomnia, use of aliskiren in diabetes mellitus. It is
headache. also contraindicated in hypersensitivity to
GI: Diarrhea, dyspepsia. losartan or any of its components.
Musculoskeletal: Muscle Losartan is contraindicated in pregnancy:
cramps, myalgia, back or leg As losartan acts on the renin-angiotensin
pain. system, it causes oligohydramnios, thus
 Respiratory: Nasal resulting in fetal lung hypoplasia and
congestion, cough, upper skeletal deformities.
respiratory infection,
sinusitis.
Drug Mechanism of action/Side Indication/ Nursing responsibilities
effects Contraindication

Brand name: Crestor Atorvastatin competitively INDICATIONS: • Arrange for proper consultation
Generic name: inhibits HMG-CoA reductase, an adjunct to diet in the about need for diet and exercise
Rosuvastatin the enzyme that catalyses the treatment of elevated total changes
Classification: Anti- conversion of HMG-CoA to cholesterol, mixed • Administer drug at bed time
hyperlipi demic HMG- mevalonic acid. This results in dyslipidemia, atherosclerosis • Monitor patient closely for signs of
CoA reductase inhibitor the induction of the LDL CONTRAINDICATIONS: muscle injury, especially higher
Route: PO receptors, leading to lowered hypersensitivity, impaired doses
Dosage: 20 mg LDL-cholesterol concentration. hepatic function, alcoholism, • Provide comfort measures to deal
Frequency: OD renal impairment, advanced with headache, muscle cramps, or
SIDE EFFECTS: Nausea, age, hypothyroidism nausea
dyspepsia, diarrhea, • Offer support and encouragement
constipation, vomiting, rhinitis, to deal with disease, diet, drug
sinusitis, cough, dyspnea, therapy, and follow-up care.
pneumonia
Drug Mechanism of action/Side Indication/ Nursing responsibilities
effects Contraindication

Brand name: Cardene Calcium entry blocker that INDICATIONS: Either alone  Establish baseline data before
IV inhibits the transmembrane or with beta blockers for treatment is started including BP,
Generic name: influx of calcium ions into chronic, stable (effort- pulse, and lab values of liver and
Nicardipine cardiac muscle and smooth associated) angina; either
kidney function.
Classification: muscle, thus affecting alone or with other
cardiovascular contractility. More selectively antihypertensives for
agent; calcium channel affects vascular smooth essential hypertension.  Monitor BP during initiation and
blocker; antihypertensi muscle than cardiac muscle; CONTRAINDICATIONS: titration of dosage carefully.
ve agent relaxes coronary vascular Hypersensitivity to Hypotension with or without an
Route: via soluset smooth muscle with little or no nicardipine; advanced aortic increase in heart rate may occur,
titrated accordingly negative inotropic effect. stenosis; lactation
especially in patients who are
Dosage: 100cc PNSS SIDE EFFECTS:
CNS: Dizziness or headache, hypertensive or who are already
fatigue, anxiety, depression, taking antihypertensive medication.
parerethesias, insomnia,
somnolence, nervousness.
CV: Pedal edema,  Avoid too rapid reduction in either
hypotension, flushing,
systolic or diastolic pressure during
palpitations, tachycardia,
increased angina. parenteral administration.
GI: Anorexia, nausea,
vomiting, dry mouth,  Discontinue IV infusion if
constipation, dyspepsia. hypotension or tachycardia develop.
Skin: Rash, pruritus.

 Observe for large peak and trough

differences in BP. Initially, measure
BP at peak effect (1–2 h after dosing)
and at trough effect (8 h after
dosing).
Drug Mechanism of action/Side Indication/ Nursing responsibilities
effects Contraindication

Brand name: Osmitrol Mannitol is a naturally INDICATIONS:  Take care to avoid extravasation.
Generic name: occurring substance that Cerebral edema, Reduction Observe injection site for signs of
Mannitol causes the body to lose water of raised intracranial inflammation or edema.
Classification: (diuresis) through osmosis. pressure, Reduction of raised  Lab tests: Monitor closely serum and
Diuretics, Osmotic Mannitol promotes diuresis in intraocular pressure urine electrolytes and kidney function
Agents. kidneys by increasing the during therapy.
Route: IV infusion concentration of filtrates in the CONTRAINDICATIONS:  Measure I&O accurately and record
Dosage: 150 cc kidney and blocking Pulmonary congestion or to achieve proper fluid balance.
Frequency: q6 reabsorption of water by edema; intracranial bleeding;  Monitor vital signs closely. Report
kidney tubules. The FDA CHF; metabolic edema with significant changes in BP and signs
approved mannitol in June abnormal capillary fragility; of CHF.
1964. anuria due to severe renal  Monitor for possible indications of
SIDE EFFECTS: disease; severe dehydration. fluid and electrolyte imbalance (e.g.,
  pulmonary congestion thirst, muscle cramps or weakness,
 Fluid and electrolyte paresthesias, and signs of CHF).
imbalance  Be alert to the possibility that a
 dry mouth rebound increase in ICP sometimes
 thirst occurs about 12 h after drug
 headache administration. Patient may complain
 blurred vision of headache or confusion.
 dizziness  Take accurate daily weight.
 chest pain, dizziness
Drug Mechanism of action/Side Indication/ Nursing responsibilities
effects Contraindication

Brand name: Tylenol Produces analgesia by INDICATIONS:  Monitor for S&S of: hepatotoxicity,
Generic name: unknown mechanism, perhaps Fever reduction. Temporary even with moderate acetaminophen
Acetaminophen by action on peripheral relief of mild to moderate doses, especially in individuals with
Classification: Central nervous system. Reduces pain. Generally as substitute poor nutrition or who have ingested
nervous system fever by direct action on for aspirin when the latter is alcohol over prolonged periods.
agent; nonnarcotic hypothalamus heat-regulating not tolerated or is  Do not take other medications (e.g.,
analgesic, antipyretic center with consequent contraindicated. cold preparations) containing
Route: PO peripheral vasodilation, acetaminophen without medical
Dosage: 325 mg sweating, and dissipation of CONTRAINDICATIONS: advice; overdosing and chronic use
Frequency: q4, PRN heat. Unlike aspirin, Hypersensitivity to can cause liver damage and other
acetaminophen has little effect acetaminophen or toxic effects.
on platelet aggregation, does phenacetin; use with alcohol.  Do not self-medicate adults for pain
not affect bleeding time, and more than 10 d without consulting a
generally produces no gastric physician.
bleeding.  Do not use this medication without
SIDE EFFECTS: medical direction for: fever persisting
Body as a Whole: Negligible longer than 3 d, fever over 39.5° C
with recommended dosage; (103° F), or recurrent fever.
rash.
Acute poisoning: Anorexia,
nausea, vomiting, dizziness,
lethargy, diaphoresis, chills,
epigastric or abdominal pain,
diarrhea
Drug Mechanism of action/Side Indication/ Nursing responsibilities
effects Contraindication

Brand name: Rosephin Ceftriaxone works by inhibiting INDICATIONS: BEFORE:

Generic name: the mucopeptide synthesis in Susceptible bacterial  Do Skin Testing into the intradermal
Cefriaxone the bacterial cell wall. The infections of the lower area
Classification: beta-lactam moiety of respiratory tract, skin and  Protect Drug from light
cephalosporin ceftriaxone binds to skin structure, bone and joint,
antibiotics carboxypeptidases, acute otitis media, UTIs,  Do not mix ceftriaxone with other
Route: IV infusion endopeptidases, and septicemia, pelvic antimicrobial drug
Dosage: 1 grm transpeptidases in the inflammatory disease (PID),
Frequency: q12 bacterial cytoplasmic intraabdominal infections, DURING:
membrane. These enzymes meningitis, uncomplicated  Use a separate syringewhen giving
are involved in cell-wall gonorrhea. Surgical this drug
synthesis and cell division. prophylaxis.  Have Vitamin K available in case
Binding of ceftriaxone to these CONTRAINDICATIONS: of hypoprothrombinemia occurs
enzymes causes the enzyme Hyperbilirubinemic or
to lose activity; therefore, the premature neonates. AFTER:
bacteria produce defective cell Concomitant calcium-
 Discontinue if hypersensitivity occurs
walls, causing cell death. containing IV solutions or
SIDE EFFECTS: products in neonates.  Monitor Blood levels in patients
 rash, Ceftriaxone solutions taking this drug
 diarrhea, containing lidocaine for IV
 nausea,vomiting, administration.
 upset stomach,
 blood clots,
 dizziness, headache
Drug Mechanism of action/Side Indication/ Nursing responsibilities
effects Contraindication

Brand name: Valium Diazepam is a benzodiazepine INDICATIONS:  Assess blood pressure, pulse and
Generic name: tranquilliser with Benzodiazepines have respiration if IV administration.
Diazepam anticonvulsant, sedative, largely replaced barbiturates
Classification: muscle relaxant and amnesic in the treatment of anxiety
 Provide frequent sips of water for
Antianxiety Agents; properties Benzodiazepines, and sleep disorders because
Anxiolytics, such as diazepam, bind to of their improved safety dry mouth.
Benzodiazepines; Skel receptors in various regions of profile, fewer side effects,
etal Muscle Relaxants; the brain and spinal cord. This and the availability of the
Anticonvulsants, binding increases the inhibitory antagonist flumazenil to  Provide fluids and fibre for
Benzodiazepine. effects of gamma-aminobutyric reverse oversedation and constipation.
Route: IV acid (GABA). GABAs functions benzodiazepine intoxication.
Dosage: 10 mg include CNS involvement in
Frequency: PRN sleep induction. Also involved CONTRAINDICATIONS:  Evaluate therapeutic response,
in the control of hypnosis, Other contraindications to mental state and physical
memory, anxiety, epilepsy and diazepam include patients dependency after long-term use.
neuronal excitability with severe respiratory
SIDE EFFECTS: insufficiency, myasthenia
 Drowsiness, dizziness gravis, sleep apnea
 tiredness. syndrome, and severe
 muscle weakness. hepatic insufficiency. It is
 headache. permissible in patients with
 dry mouth. open-angle glaucoma who
 Nausea, constipation are receiving appropriate
therapy but is contraindicated
in acute narrow-angle
glaucoma.
Drug Mechanism of action/Side Indication/ Nursing responsibilities
effects Contraindication

Brand name: KCl Potassium ions participate in a INDICATIONS:  Monitor I&O ratio and pattern in
Generic name: number of essential Potassium chloride is used patients receiving the parenteral
Potassium Chloride physiological processes, to prevent or to treat low drug. If oliguria occurs, stop infusion
Classification: Minerals including the maintenance of blood levels of potassium promptly and notify physician.
and Electrolytes intracellular tonicity; the (hypokalemia). Potassium  Lab test: Frequent serum electrolytes
Route: Incorporated to transmission of nerve levels can be low as a result are warranted.
mainline IVF of PNSS impulses; the contraction of of a disease or from taking  Monitor for and report signs of GI
Dosage: 40 mEq cardiac, skeletal, and smooth certain medicines, or after a ulceration (esophageal or epigastric
Frequency: every 8 muscle; and the maintenance prolonged illness with pain or hematemesis).
hours of normal renal function diarrhea or vomiting.  Monitor patients receiving parenteral
SIDE EFFECTS: CONTRAINDICATIONS: potassium closely with cardiac
 Nausea, vomiting, Potassium supplements are monitor. Irregular heartbeat is usually
diarrhea; contraindicated in patients the earliest clinical indication of
 gas, stomach pain; or with hyperkalemia since a hyperkalemia.
 the appearance of a further increase in serum  Be alert for potassium intoxication
potassium chloride potassium concentration in
tablet in your stool. such patients can produce
cardiac arrest.
E. NURSING CARE PLAN

CUES NURSING GOALS AND DESIRED NURSING RATIONALE

DIAGNOSIS OUTCOME INTERVENTION
Subjective Decreased After 8 hours nursing Monitor the patient’s - Subtle changes such as irritability,
Cues: Intracranial intervention, the patient neurological status, increased confusion, and restlessness can
Adaptive will have an optimal meaning the LOC, pupils, indicate a deterioration in status. A change in
Capacity r/t cerebral tissue perfusion and Glasgow coma scale LOC may be a sign of an increased ICP
increased as evidenced by stable scores continuously (intracranial pressure).
Objective intracranial ICP and LOC secondary
Cues: pressure to vehicular accident. Monitor vital signs -Changes in vital signs may be a sign of
continuously or at least increased pressure in the brain. An increased
Semi- every hour. ICP causes bradycardia, a widening pulse
conscious pressure, and irregular respirations
state, with (Cushing’s triad).
open wounds Avoid any activities and -Position changes (keep head straight),
bruises on symptoms that increase Endotracheal suctioning, Coughing,
her face ICP. vomiting,Bending at the waist. Valsalva
head and maneuvers Pain, Fever, Shivering These
arms, drowsy factors can increase cerebrospinal fluid and,
with therefore, intracranial pressure. Elevation of
repeated the head of the bed and maintaining a neutral
vomiting alignment help reduce venous pressure and
thus decrease ICP. Limiting suctioning and
hyperoxygenation before suctioning helps
keep ICP at bay. Treating pain, fever and
shivering helps lower ICP as well.
Administer medication as
ordered to decrease ICP. -Medications such as Mannitol are used to
draw fluid from interstitial spaces into the
intravascular space reducing cerebral edema.
Steroids help reduce brain swelling.
F. HEALTH TEACHINGS AND TEACHING PLAN

HEALTH TEACHING

 Explain to the patient’s watcher how the medications given work and how it is

administered and its importance

 Advice the patient’s watcher to do simple exercise that the patient can do

while he is still on the bed.

 Explain to the patient or his watcher the procedures of the therapies that were

ordered by the doctor

 Teach the patient and his watcher how to maintain good hygiene to prevent

infections and advice the patient’s watcher how they can avoid accidents.

 Instruct the patient and his watcher to report any signs and symptoms that he

might experience and immediately contact his physician.

 Instruct the patient and his watcher what foods he should take to maintain

healthy life style

 TEACHING PLAN

Topic/s: TBI
Venue: WARD
General Objectives: Care for patient with TBI

Learning Content Time Strategies/Methodology References Evaluation

Objectives Allotment

General: At the end of the discussion the patient’s

watcher was able to identify what is
After 4 days of 5 Discussion Uptodate. (n.d.). traumatic brain injury and its signs and
student nurse-patient https://www.upto symptoms as well as TBI preventions
interaction, the minutes date.com/conten
patient will be able to ts/head-injury-in-
gain knowledge, skills children-and-
and attitude in adolescents-
dealing with the beyond-the-
condition traumatic basics/print.
brain injury.

Specific:

After 4 hours of
student nurse-patient
interaction, the
5 minutes
patient/ patient’s
watcher will be able Traumatic Brain Injury
to;
Also known as intracranial
injury and/or TBI.
1. Define Traumatic Is a substantial head injury that
Brain Injury results in damage to the brain.
 This damage can cause a wide
spectrum of possible health
outcomes

The brain is launched into a

collision course with the inside
of the skull, resulting in
possible bruising of the brain,
tearing of the nerve fibers and
bleeding.

Signs And Symptoms

2. determine  Headache that gets

symptoms of brain worse and does not go
traumatic injury that away. 5
needs to be reported  Weakness, numbness
or decreased minutes
immediately
coordination.
 Repeated vomiting or
nausea
 Confusion
 Fatigue (tiredness and
lethargy)
 Becoming more easily
distracted
 Loss of sense of smell
and taste
 Moodiness
 Persistent pain in the
back
 Light headedness
 Dizziness
  Tinnitus

Preventions

 Always wear a seatbelt

in a motor vehicle
3. Identify preventive  Never drive under the
measures to avoid influence of alcohol or
further brain drugs
traumatic injury  Always wear a helmet
when on bicycle,
motorcycle, scooter,
and other open
unrestrained vehicles.
 Use the rails on
stairways
 Provide adequate
lightning, especially on
stairs for people with
poor vision or who
have difficulty walking
 keep firearms
unloaded in a locked
cabinet or safe
III. EVALUATION

The researchers were able to conduct a case study about neuro patient with

Traumatic Brain Injury (TBI) thorough assessment through GCS, CT Scan and MRI.

It reveals that the patient has a Decreased Intracranial Adaptive Capacity related to

increased intracranial pressure that shows the etiology of a patient being in a semi-

conscious state, with open wounds bruises on her face head and arms, drowsy with

repeated vomiting and the Initial Vital signs of the patient was BP= 150/90, T=37,

P=85, RR=18, GCS=11 and O2 sat. of 90% at room air. Patient was intubated at the

Emergency Room. Craniotomy was performed to the patient in OR for 8 hours and

after surgery the patient was wheeled at the PACU immediately and the researchers

performed an assessment by taking the patients vital signs every 15 mins. for one

hour then every 30 mins.for two hours, and every hour thereafter until vital signs

become stable. The patient was admitted and stayed in the ICU after 2 hours in the

PACU. Post-op Patient was with ETT connected to mechanical ventilator, with NGT

on free flow, with retained urinary catheter, and NPO till further order. 3rd. post-op

day, during rounds, 40meq of KCL was added to present medications every 8hrs to

be incorporated to mainline ivf of PNSS 1/L at 30gtts/min. The patient’s wedding ring

becomes tightened on his finger and the nurse has to remove it. On her 5th post-op

day, upon assessment during rounds, Mr. Peter V/S was T=40C’ for the last 16hrs,

BP monitoring gradually decreased from 180/110 to 140/90, GCS of 3, and with a

coffee ground output from NGT. The patient laboratory result was …..
With his diagnosis, the researchers provide health teaching on the patient towards

the nature of disease, the risk factors and treatment and health teaching on the

medication given, contraindication, indication and do’s and don’ts when given the

medication. By explain to the patient about TBI risk factors, prevention, and

treatment. With the rationale of to lessen worry and provide client the capability to

contribute in the treatment. And also by explaining the medication and its indication

to the body. Through their engagement with health education, patient develops the

confidence toward the medication treatment, and for them to manage their own well-

being; make health-enhancing choices, and plan. The patient was able to have an

optimal cerebral tissue perfusion as evidenced by the stable ICP and LOC. Through

this case study, the researchers gain more knowledge about this kind of state in

which the researchers gathered information by the source of medical books and

internet such us diagnostic procedures, clinical manifestation of the given disease

and the nursing management and intervention that has been done.
IV. RECOMMENDATIONS

V. REFERENCES/BIBLIOGRAPHY