head injury_cs

8/9/2019 Head Injury_CS

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I. INTRODUCTION

A. Overview of the Study

Head injury is a general term used to describe any trauma to the head, and most

specifically to the brain itself. Skull fracture: A skull fracture is a break in the bone surrounding

the brain and other structures within the skull. Linear skull fracture: A common injury,

especially in children. A linear skull fracture is a simple break in the skull that follows a relatively

straight line. It can occur after seemingly minor head injuries (falls, blows such as being struck

by a rock, stick, or other object; or from motor vehicle accidents). A linear skull fracture is not a

serious injury unless there is an additional injury to the brain itself. Depressed skull fractures:

These are common after forceful impact by blunt objects-most commonly, hammers, rocks, or

other heavy but fairly small objects. These injuries cause "dents" in the skull bone. If the depth

of a depressed fracture is at least equal to the thickness of the surrounding skull bone (about

1/4-1/2 inch), surgery is often required to elevate the bony pieces and to inspect the brain for

evidence of injury. Minimally depressed fractures are less than the thickness of the bone. Other

fractures are not depressed at all. They usually do not require surgical treatment unless other

injuries are noted. Basilar skull fracture: A fracture of the bones that form the base (floor) of

the skull and results from severe blunt head trauma of significant force. A basilar skull fracture

commonly connects to the sinus cavities. This connection may allow fluid or air entry into the

inside of the skull and may cause infection. Surgery is usually not necessary unless other injuries

are also involved.Intracranial (inside the skull) hemorrhage (bleeding) Subdural hematoma.

Bleeding between the brain tissue and the dura mater (a tough fibrous layer of tissue between

the brain and skull) is called a subdural hematoma. The stretching and tearing of "bridging

veins" between the brain and dura mater causes this type of bleeding. A subdural hematoma

may be acute, developing suddenly after the injury, or chronic, slowly accumulating after injury.

Chronic subdural hematoma is more common in the elderly whose bridging veins are often

brittle and stretched and can more easily begin to slowly bleed after minor injuries. Subdural

hematomas are potentially serious and may require surgery.


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B. Objective of the Study

At the end of the study, the researcher will be able to know more about head injury

particularly subdural hematoma and its effects to human and life and will be able to learn

more about the necessary Medical and Nursing Interventions to be applied to Patients with

subdural hematoma.

C. Scope and Limitation

Although we have been given two days to care for our patients and dig deeper into our

patients problem, it is still not enough for us to actually find any other minor problems that

our patient may be having, the lack of time also is the reason why we cannot fully assess the

extent or effectiveness of our Health Teachings and Nursing Interventions.

II. A. Patients Profile

Name: ?

Age: 35 years old

Sex: Female

Height: 52

Weight: 110 lbsCivil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Address: ?

Occupation: Housewife

Date of Admission: July 15, 2009

Time of Admission: 10:40 PMChief Complaint: Head injury

Admitting Diagnosis: Subdural Hematoma

Physician: ?


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B. Family and Personal Health

Patient is known to be hypertensive which she got genetically from her Paternal side. Her

maternal side was known to have asthma and hypertensive. Patient is occasional alcohol

drinker and can consumed 5 stick/day. Patient didnt have history of previous hospitalization

but complained hyperacidity and sometimes headache as what significant others explained.

C. History of Present Illness and Chief Complaint

A case of 35 years old which suffered head injury due to vehicular accident, 4 days prior to

admission patient sustained head trauma during vehicular accident. Patient lost consciousness

few hours, after while admitted to city hospital and didnt regain consciousness with positive

fever, Patient was taken to X, 2 days ago when city scan revealed acute subdural hematoma,

patient relatives opted to transfer to X.


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DIAGNOSTIC EXAM

Date Ordered Diagnostic/laboratory

Exams

Date Done

7-15-2009 Complete Blood Count 7-15-2009

7-16-2009 CT scan 7-15-2009

*Complete Blood Count* Normal Values

WBC: 12,300 5000-10000 mm3

RBC 3.17 9.9-5.2

Hgb: 94 120-160 g/dl

Hct: 0.28 .37- .47 g/dl

Neutrophils: .75 48-73

Lymphocytes: .12 20-45

Basophils: 0.08

*Ultrasound Chest PA*

Impression: pneumonia ,Right

Ultrasound Chest PA

Impression : Tracheostomy tube in place

CT Scan:

Impression : Subdural Hematoma

7-16-2009 X-ray for tracheostomy

Placement 7-16-2009

7-21-2009 CXR 7-21-2009


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Subdural hematoma

Subdural hematoma occurs when there is tearing of the bridging vein between the

cerebral cortex and a draining venous sinus. At times they may be caused by arterial lacerationson the brain surface. Patients may have a history of loss of consciousness but they recover and

do not relapse. Clinical onset occurs over hours. A crescent shaped hemorrhage compressing

the brain will be noted on CT of the head. Surgical evacuation is the treatment. Complications

include uncal herniation, focal neurologic deficits .All types of head injuries can be caused by

trauma. In adults in the United States such injuries commonly result from motor vehicle

accidents, assaults, and falls. In children falls are the most common cause followed by

recreational activities such as biking, skating, or skateboarding. A small but significant number

of head injuries in children are from violence and abuse.

Causes

y Penetrating trauma: Missiles such as bullets or sharp instruments (such as knives,

screwdrivers, or ice picks) may penetrate the skull. The result is called a penetrating

head injury. Penetrating injuries often require surgery to remove debris from the brain

tissue. The initial injury itself may cause immediate death, especially if from a high-

energy missile such as a bullet.

y Blunt head trauma: These injuries may be from a direct blow (a club or large missile) or

from a rapid deceleration force (a fall or striking the windshield in a car accident).

Head Injury Symptoms

Signs and symptoms of head injuries vary with the type and severity of the injury.

y Minor blunt head injuries may involve only symptoms of being "dazed" or brief loss of

consciousness. They may result in headaches or blurring of vision or nausea and

vomiting. There may be longer lasting subtle symptoms including, irritability, difficulty

concentrating, insomnia, and difficulty tolerating bright light and loud sounds. These

post concussion symptoms may last for a prolonged period of time.

y Severe blunt head trauma involves a loss of consciousness lasting from several minutes

to many days or longer. Seizures may result. The person may suffer from severe andsometimes permanent neurological deficits or may die. Neurological deficits from head

trauma resemble those seen in stroke and include paralysis, seizures, or difficulty with

speaking, seeing, hearing, walking, or understanding.

y Penetrating trauma may cause immediate, severe symptoms or only minor symptoms

despite a potentially life-threatening injury. Death may follow from the initial injury. Any

of the signs of serious blunt head trauma may result.


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Anatomy And Physiology:


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MEDICALMANAGEMENT

Date ordered Doctors order Rationale


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7-15-09- 11:40 pm

BP- 140/100 mmhg

T- 40 Celsius

RR-24 cpm

HR- 61 bpmO2 sat.- 100%

y Pls. admit under the service

of Dr. Amato.

y Sign consent to care

y TPR q 4hrs.

y NPO

y Labs:

CBC,

y U/A,

y Blood typing

y serum Na+ K+

SGPT, serum,

y CXR: PA,

y ECG: 12 lead

y CT scan of brain:

Pls. attached film at bedside

y With on going IVF of plain

PNSS IL @20 gtts/ min.

1. Paracetamol 300 mg IV now

then q 4hrs PRN for fever

2. Mannitol 150CC q

4hrs. IV

3. Ranitidine 50 mg q 8hrs.

4. O2 inhalation @ 2l/min.

y For close monitoring

y For legal issue

y To monitor patients

temperature,respiration and

pulse

y To prevent pt.from

aspiration

y To determine

abnormalities and to

verify and conclude

the patients

admitting diagnosis.

y To detect urinarytract infection and

glucose in the urine.

y To determine the pt.

blood type.

y To determine

electrolyte and acid

base imbalance.

y To identify lung

disease and heart

size and location.

y To determine the

presence of cardiac

arrest.

y To detect structural

abnormalities

y To maintain fluid

and electrolyte

balance.

y To relieve fever

y Decrease blood

pressure.


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7-16-09- 12:45 am

Decorticate

No verbal outputNo eye graving to pain

Pupil-5mm OD-2-3mm OS

(+) corneals

(+) dolls

5. For ICU admission6. With FBC F-16 attached

urobag

7. With NGT Fr- 16

8. Attach pt. to cardiac

monitor

9. Monitor V/S q 15min.

10.Suction secretion prn.

11.Monitor I&O q shift

12.Refer accordingly

y Standby intubation

y Mannitol 200cc IV. bolus now

then 150cc q 3hrs

Hold to BP< 90/60mmhg

y for ET

y BT, protime, blood typing.

y ABG

y O2 inhalation to10L/min.via face mask

y Use to manage

gastrointestinal

disorder

To aide the patientin breathing and to

introduce oxygen to

the body to prevent

hypoxia

andrespiratory

acidosis

For close

monitoring.

To monitor and

relieve abdominaldistention

For parenteral line

to administer food

and oral medication.

To monitor pt. heart

rhythm

For baseline data

To maintain

adequate airway

patency.

To determineeffectiveness or to

keep watch for

possible renal

abnormalities

To decrease Blood

pressure.

To established

artificial airway

To replace bloodloss and to avoid

blood reaction.

y To determine the

adequacy of alveolar

gas exchange and

evaluate the ability

of the lungs and


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7-16-09- 1am

Neurosurgery note

GCS- 5-6

Aminoscoric

Cranial CT Scan: R frontal

Contusion: subacuteSDH midline

Shift to the L

y For ice bath to keep body temp

< 37.5C

y

y Paracetamol 500mg/tab 1 tab q

4hrs RTC per NGT

y Start cefuroxine 750mg(panoxim) IV q 8hrs (ANST)

y For emergency

decompressivehemicraniect

omy R expansion,

duraplasty, evaluation of

hematoma of implantation

of bone fragment to

hemiabdomen Via

subcutaneous pouchy Secure consent

Secure 1u FWB properly

typed & cross matched for

possible OR use.

y Hold cefuroxime IV

y Start ceftriaxone Igm IV

ANST q 12hrs.

y Gentamicin 80mg IV prior

route to OR

y Please inform undersign

once with consent & BO

clearance

y Start cefriaxone I gm 10 ANST q

120

y IV to follow PNSS IL @

20gtts/min

y For intubation

y Mechanical ventilator setting:

F1O2- 100%

TV- 400

RR- 16

Mode AC

kidney to maintain

the acid base

balance of the body

fluid.

To aide the patient

in breathing and tointroduce oxygen to

the body to prevent

hypoxia

andrespiratory

acidosis

To lower

temperature

To relieve fever

y To lower the

pressure of the

brain.

y And to preserve the

skull into

homeostasis

environment.

y For legality issue

y To replace blood

lossy To determine

electrolyte and acid

base imbalance.

y To treat susceptible


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7-16-09-2:10 am

7-16-09- 3:30am

HR-180-220 bpm

7-16-09 5:50 am

2:00 pm

y For ABG 30 min. after

hooking to MV

y For portable CXR

y To ICU

y NPO till further order

y VS q 15min. chartpls.

y Regulate IV F- R arm @ KVO

y Regulate IVF- L arm @

20gtts/min. then ft.

DS/R- 1

PLR- 2

DSLR- 1

y Cont. ranitidine 1 gm. q 12

y Start cloxacillin 1 gmslow

IVT ANST

y Mannitol to 100 cc of 40 IV

bolus hold if BP < 90/60

mmhg

y Tramadol 50mg q 6 slow

IVTT

y D/c gentamicin

y Hook to mechanical

ventilator with setting

P1O2= 100%

infection

y To treat short term

serious infection

y For legal issue

y To treat susceptible

infection

y To maintain fluid

and electrolyte

balance.

y

To establishedartificial airway

y To help the patient

breathing pattern.

y To determine the

adequacy of alveolar

gas exchange and

evaluate the ability

of the lungs andkidney to maintain

the acid base

balance of the body

fluid.

y To identify lung

disease and heart

size and locationy For close monitoring

y To avoid from

aspiration

y To monitor vital sign

for baseline data to

determine

complication


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6:30 pm

ABG resultO2 sat. 100%

7-17-09- 7am

TV= 400

Rate=16

Mod e AC

y Cont. monitor neuro vital sign

pupillary size & reaction to

light, level of assessmenty monitor 1 & 0 q 1hr. chart

y Suction one /ETT secretion

PRN and separate

y Repeat Hgb ,Hct, det. 4h past

op & refer resulty Refer accordingly

y Place pt. in slight high back

rest

y No pressure @ operated side

of head

y F1O2 to 50%

y Citicoline I gram IVTT q 8

y Repeat ABG.

y Repeat Na. K

y F1O3 to 30%, back up 18 mu

w/ rate=12mod

y Nebulize with salbutamol 1

y To maintain fluid

and electrolyte

balance

y Use to manage

gastrointestinal

disorder.

y To treat

pneumococci

infection.

y

To decrease osmoticpressure and

intracranial

pressure.

y To relive mild to

moderate pain,and

relax muscle

y To help the patient

breathing pattern

and prevent

respiratory distress

y To determine

neurologic status of

the patient

To determine

effectiveness or to

keep watch forpossible renal

abnormalities

To maintain

adequate airway

patency.


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7-17-09- 8;30am

1st

POD

Asleep arousable to verbal

stimulation/tapping

Follow simple command

(+) rhonchi

7-17-09- 9am

Neurosurgery

1st

POD

E4 VTM

Pupil 3mm

EBRTL L

SRTL R

7-18-09

9:00am

2nd

POD

neb.

y Do chest tappping after each

nebulization

y Turn to sides q 2hrs. w/

caution on the R side of the

head.y Add 10mg KCI to present IVF

Start of at 1000

kcal/day in 1L dilution,

to be given in 6 equal

feeding

y Lactulose 30cc OD at H.S

y IV FF: PNSS IL + 10KCL for SHRS

X3 cycle

y Routine oral care TID using

oracare mouthwash

y Revise paracetamol to 500 mg

1 tab T tab q 4 PRN for temp.>

37.5C

y Mannitol to 100 CC

I>V bolus q 6hrs. w/BP

precautions (hold for BP

head injury_cs

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