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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.