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Prepared by:
Lady Diana T. Ortega
LTIM Department
I. Demographic Data
Name:
Age:
Sex:
Nationality:
Marital Status:
Date of Admission:
Patient X
19 years old
Male
Saudi
Single
December 04, 2009
II. Physical Assessment
Skin
Head
Eyes
warm, slightly moist, smooth, hair
evenly distributed
skull slightly asymmetric, no flaking
of scalp, no lesions, no tenderness,
scar noted in the craniotomy site,
left tempoparietal area
no redness, no discharges, sclera
white and clear, pupils reactive to
light and accommodation,
unable to focus
Nose and Sinuses not perforated, no discharge,
NGT is present
Mouth
no gum bleeding, tongue and
uvula in midline position,
oral cavity is pinkish in color,
buccal mucosa smooth and
moist, no ulcers, no swelling,
no palpable masses
Neck
no palpable lymph nodes,
trachea on midline position
tracheostomy tube is present
Breasts
nipples at the same level
and protrude slightly,
no palpable masses, no nipple
discharge
Thorax & Lungs
thorax is symmetric, no
retraction of the
Intercostal spaces, no
tenderness, back area slightly
reddened
Upper Extremities decorticate position, arms are
unable to extend, abduct and
adduct
Nails
convex curvature, smooth texture,
good capillary refill
Abdomen
slight abdominal distention,
positive bowel sound
Lower Extremities malpositioned tibia and fibula,
unable to flex, abduct and adduct
Genitalia
skin of the glans penis is smooth,
no ulceration, urethral meatus
located ventrally on the end of the
penis, no discharge, no palpable
masses
III. A. Past Medical History
Weaned
from
ventilation
RTA
(Dec 2003)
Craniotomy
& ORIF
Intubated
&
ventilated
CT scan &
skeletal
exam
III. A. Present Medical History
Semiconscious, unable
to speak, unresponsive
to verbal stimulus
On tracheostomy tube,
nasogastric feeding,
voiding freely on diaper
Maintained with
anticonvulsants,
levetiracetam, carbamazepine
& phenytoin
Stable vital signs, good
oxygen saturation, no
recent episodes of seizures
IV. Topic Presentation
“Head Injury”
V. Anatomy & Physiology
VI. Etiology
Head Injury
Acquired
Anoxic
Diffuse
Axonal
Traumatic
Hypoxic
Closed
Concussion
Contusion
Open
Coup
Counter
coup
Penetrating
Cerebral edema
Increased ICP
Decreased cerebral bloodflow
Cerebral Ischemia
Confusion,coma
, seizure,loss of
cognitive &
sensory
function
VII. Signs and Symptoms
Prolonged confusion, seizures, and multiple
episodes of vomiting
Inability to awaken
dilation of one or both pupils, slurred speech,
aphasia, dysarthria, weakness or numbness in
the limbs, loss of coordination, confusion,
restlessness, or agitation.
do not respond with any body movement to
pain,
do not have any speech, and
do not open their eyes.
VIII. Intervention
Maintain adequate cerebral blood
flow, control increasing ICP by:
 Proper Positioning
 Hyperventilation
 Hypertonic saline
 Diuretics
 Sedatives, analgesics & paralytics
IX. Treatment
Sedation,
paralytics,
cerebrospinal
diversion
Decompressive
craniectomy
Craniotomy
X. Complications
 Brain injury can cause prolonged or
permanent effects on consciousness (coma,
brain death, vegetative state)
 Lying still for long periods may cause many
complications
 Skull fractures & penetrating injuries may
lead to meningitis & abscesses
 Complications involving the blood vessels:
vasospasm, aneurysms and stroke
XI. Prioritization of nursing problems
Altered cerebral tissue perfusion related to
decreased cerebral blood flow secondary to
head injury
② Ineffective airway clearance related to
accumulation of secretions and decreased LOC
③ Ineffective breathing pattern related to
neurological dysfunction
④ Risk for injury related to disorientation &
restlessness
⑤ Risk for impaired skin integrity related to
immobility
①
ASSESMENT
NSG Dx
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective:
Not applicable
Ineffective
Cerebral
Tissue
Perfusion
related to
decreased
cerebral
blood
flow
secondary
to head
injury
° Maintain or
improve level
of consciousness,cognition,
& motor/
sensory
function.
° Demonstrate
stable vital
signs &
absence of
signs of
increased ICP
° Display no
further deterio
ration in
sensory,
cognitive &
motor
function
° Monitor
LOC, motor &
sensory
function
Assessment of
improvement/
deterioration of
cognitive &
sensory
function
May help
improve
cognitive brain
function &help
minimized
confusion
Reduces
arterial
pressure by
promoting
venous
drainage, hip
flexion can
reduce venous
drainage
Goal partially
met.
°Maintained
level of
consciousness,
cognition, &
motor/sensory function
°Demonstrated stable
vital sign &
absence of
signs of
increasedICP
°Displayed n
o further
deterioration
in sensory,
cognitive and
motor
function
Objective:
-semiconscious
- unresponsive
to verbal
stimulus
- unable to
follow
commands
- unable to
speak
- on a
decorticate
position
- poor motor
function
° Routinely
orient the
patient to
time, place &
surroundings
° Position
with head
slightly
elevated and
in neutral
position, and
prevent hip
flexion
ASSESMENT
NSG Dx
PLANNING
INTERVENTION
RATIONALE
°Maintain bed rest;
provide quiet
environment; Provide
structured care activities &
provide rest periods
between care activities,
limit duration of
procedures.
Continual
stimulation can
increase ICP.
Absolute rest and
quiet may be
needed to prevent
stimulation
Provides cerebral
° Maintain a patent airway, oxygenation
administer supplemental
oxygen as indicated.
Valsalva
maneuver
° Prevent straining at
increases ICP and
stool, may administer
risk of cerebral
stool softener or laxatives hemorrhage
as ordered
to improve
° Administer medications cerebral blood
as ordered including
flow and prevent
anticonvulsants,
clotting, embolus
enoxaparin Na,
and episode of
carbamazepine, phenytoin seizures
EVALUATION
ASSESMENT
NSG Dx
PLANNING
NTERVENTION
Subjective:
Not
Applicable
Objective:
+cough
-frequent
sneezing
-secretions
characterized
as; yellowish
in color, thick
in
consistency
- respiratory
rate: 24bpm
Ineffective
Airway
Clearance
related to
accumulations of
secretions
and
decreased
LOC
° Maintain a
patent
airway &
will demonstrate
signs of
reduction in
respiratory
congestion
°Respiratory
rate within
normal
range: 16 to
20bpm
° Display
decreasing
amount of
secretions
• Auscultate lung
sounds before &
after tx noting
areas of decreased ventilation & presence
of adventitious
breath sounds
RATIONALE
Assist in
evaluating
prescribed
treatments
and client
outcomes
EVALUATION
Goal met.
° Patient
maintained a
patent
airway &
demonstrate
d signs of
reduction in
respiratory
• Position the
allows good
congestion
patient on semi
lung
° Respiratory
fowler’s position expansion and rate within
maximum
normal
ventilation
range:
• Clear secretions To prevent
20bpm
from the mouth obstruction/
° Displayed
and trache.
aspiration.
decreasing
Suction as
amount of
necessary
secretions
ASSESMENT
NSG Dx
PLANNING
INTERVENTION
RATIONALE EVALUATION
•Humidify
inspired air as
indicated by
treatment
This prevents
drying of
mucous
membranes
•Institute
respiratory
treatment as
needed such
as CPT and
nebulization.
A variety of
respiratory
treatments
may be used to
open
constricted
airways and
liquefy
secretions
• Give
medications
such as
bronchodilato
rs and
mucolytic
Helps
lowering the
viscosity and
liquefying the
secretions
ASSESMENT
Subjective:
Not
Applicable
Objective:
- confined to
bed
-unable to
move, turn to
side to side
-unable to
abduct and
adduct
extremities
-mediumsized body
built
-back area and
buttocks
slightly
reddened
NURSING
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Risk for
impaired
skin
integrity
related to
immobility
° Patient’s
skin will
remain
intact and
will not
develop
any skin
breakdown
during the
stay at the
facility.
• Reposition the
patient from side to
side at least every
3hours
Positioning
interventions
reduce pressure
and shearing
force to the skin
Friction may
cause break of
skin
Goal met.
Patient’s skin
remained
intact and
did not
developed
any skin
breakdown
during the
stay at the
facility.
• Lift the patient
during turning, do
not drag or pull.
Encourage use of lift
sheets to move
patient in bed
• Clean, dry, &
moisturize skin,
especially over bony
prominences. Use
powder or creams as
necessary
Moisture softens
the skin &causes
a break in the
skin integrity.
Creams or
powder may
help smoothen
the skin
ASSESMENT
NURSING
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
• Use good quality
air mattress, avoid
wrapped and
wrinkled bed
sheets
This helps in
reducing
pressure
• Massage on the
area of pressure
avoiding reddened
skin part
Increase tissue
perfusion by
massaging
around
affected area
EVALUATION
XIII. Nursing Health Teaching
Health teaching primarily focused on educating the
watcher of care and management:
1. Review the signs of increased ICP or episodes of
seizure with the watcher.
2. Teach the watcher with the proper techniques:
therapeutic use of touch, massage and music
3. Eliminations of distractions (television, radio,
crowds)
4. Provide one on one communication with the pt.
5. Provide the necessary education to watcher
including proper positioning, ROM exercises and
so forth.
XIV. Conclusion
Head injury can be mild, moderate or severe. A mild head
injury may cause confusion & headache and most people
recover from it. A severe head injury may happen if the head is
violently shaken without coming in contact with a hard object.
When patient recover from moderate to severe head injury they
may be left with long term effects such as cognitive disabilities
& sensory problems & may lead to long time or maybe
permanent bed confinement & sometimes in coma state. In
this case, patient needs full time care & management. Comfort
should always be consider, support to the back & joints when
turning & lifting to prevent strain. Hygiene of the patient, bed
& surroundings are also important. A daily bed bath should be
given to cleanse, refresh & relax the patient. It also promotes
circulation & provides a mild form of exercises. In general,
nurses have a big role in assisting these patients in attending
their activities of daily living while giving respect to their
privacy & dignity.