CASE STUDY

CRANIOCEREBRAL TRAUMA
BSN 3C1-1 GROUP 81 Francia, John Mark Fuensalida, Aprilyn Fagarang, Keyzl Joven, Jeniel

SUBMITTED TO:

Ms. Rosel Estuaria, RN

INTRODUCTION: Head injury refers to trauma to the head. This may or may not include injury to the brain. However, the termstraumatic brain injury and head injury are often used interchangeably in the medical literature. The incidence (number of new cases) of head injury is 300 per 100,000 per year (0.3% of the population), with a mortality of 25 per 100,000 in North America and 9 per 100,000 in Britain. In the Philippines, there are 100,441 reported cases annually. Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull. Head injuries may be closed or open. A closed (non-missile) head injury is one in which the skull is not broken. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area. A head injury may cause a minor headache skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures. If intracranial hemorrhage occurs, a hematoma within the skull can put pressure on the brain. Types of intracranial hemorrage include subdural, subarachnoid,extradural, and intraparenchymal hematoma. Craniotomy surgeries are used in these cases to lessen the pressure by draining off blood. Brain injury can be at the site of impact, but can also be at the opposite side of the skull due to a contrecoup effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact). If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull causing additional impacts, or the brain may stay relatively still (due to inertia) but be hit by the moving skull (both are contrecoup injuries). High-risk populations Some particular segments of the populace are at increased risk of sustaining a TBI, including the following: 6 Young people Low-income individuals Unmarried individuals Members of ethnic minority groups Residents of inner cities 6 Men Individuals with a history of substance abuse Individuals who have suffered a previous TBI Sex Men are approximately twice as likely as women to sustain a TBI.7 This ratio approaches parity as age increases because of the increased likelihood of TBI caused by falls, for which males and females have similar risks in later life. The male-to-female mortality rate for TBI is 3.4:1. However, the cause-specific ratio for firearm-related injuries is 6:1, while that for injuries related to MVAs is 2.4:1. Age Injury is the leading cause of death among Americans younger than 45 years; TBI is the major cause of death related to injury. The risk of TBI peaks when individuals are aged 15-30 years. The risk is highest for individuals aged 15-24 years. Peak age is similar for males and females. Twenty percent of TBIs occur in the pediatric age group (ie, birth to 17 y).

The highest mortality rate (32.8 cases per 100,000 people) is found in persons aged 15-24 years. The mortality rate in patients who are elderly (65 y or older) is about 31.4 individuals per 100,000 people. Specific problems after head injury can include: Skull fracture Lacerations to the scalp and resulting hemorrhage of the skin Traumatic subdural hematoma, a bleeding below the dura mater which may develop slowly Traumatic extradural, or epidural hematoma, bleeding between the dura mater and the skull Traumatic subarachnoid hemorrhage Cerebral contusion, a bruise of the brain Concussion, a temporary loss of function due to trauma Dementia pugilistica, or "punch-drunk syndrome", caused by repetitive head injuries, for example in boxing or other contact sports A severe injury may lead to a coma or death Shaken Baby Syndrome - a form of child abuse DIAGNOSIS: The need for imaging in patients who have suffered a minor head injury is debated. A non-contrast CT of the head should be performed immediately in all those who have suffered a moderate or severe head injury. It can be diagnosed through CT Scan, MRI and Cerebral Angiography. Most head injuries are of a benign nature and require no treatment beyond analgesics and close monitoring for potential complications such as intracranial bleeding. If the brain has been severely damaged by trauma, neurosurgical evaluation may be useful. Treatments may involve controlling elevated intracranial pressure. This can include sedation, paralytics, cerebrospinal fluid diversion. Second line alternatives include decompressive Craniotomy, barbiturate coma, hypertonic saline and hypothermia. Although all of these methods have potential benefits, there has been no randomized study that has shown unequivocal benefit. OBJECTIVES: 1. To explain the cause and effects of a Craniocerebral Trauma. 2. To further emphasize the importance of the cranium and the central nervous system in our daily activities. 3. To elucidate facts about the incidence of this report. 4. To expound the care management for patients with Craniocerebral trauma. 5. To explain the treatment and therapy needed to achieve patients maximum level of functioning.

PATIENTs PROFILE Mr. JCE, a 31 year old Male, Filipino residing at Cargo Pagan Diwa, Bicutan, Taguig City and a Police Officer 2(PO2) was admitted in the hospital on May 13 2009 at 5:50 PM. He arrived in a stretcher admitted by SPO1 Laroya. Before he arrived in the Hospital, he was wounded by a gunshot in the frontotemporal area of the head in Zamboanga City. He was diagnosed of S/P Craniotomy, Debridement, Dural Repair and Repair of Cerebrospinal Fluid. Because of the trauma, his ability to speak was greatly compromised. He is with his wife; Mrs. H to help him respond to interviews, hospital procedures and interventions. He left his only son in Samar and currently on state of longing. He is currently undergoing a therapy at the Philippine Heart Center every Tuesday, Thursday and Saturday.

History of Present Illness: Pneumonia, Slight Cardiomegaly, S/P Craniotomy Debridement Dual Repair and Aspiration of Cerebrospinal Fluid leak.

PHYSICAL ASSESSMENT (September 21,2010) Vital Signs: (September 21, 2010) Temperature: 37.7 C Pulse Rate: 95 bpm Respiratory Rate: 22 cpm Blood Pressure: 110/70 mmHg Urine Output: 1 time Stool: 0 times Note: During the Physical Assessment, the Student Nurses performed and followed strict aseptic technique. In performing percussion and palpation, sterile gloves are used. The Stethoscope is cleansed with cotton ball with alcohol. General Assessment General Appearance: Conscious, Coherent, NICRD( Not in Cardio-Respiratory Distress) Posture: Abnormal( Unsteady gait and asymmetrical walking) Cranial Nerves Cranial Nerve CN I Normal Findings Ability to correctly distinguish the odor presented under the nares Able to read paper prints with adequate lightning held at a distance of 14 inches. Can follow the direction of the object hold by the examiner by eye movements only without moving the neck. Equality of muscle strength, temporal muscle when the teeth are clenched and unclenched. Symmetry of movement. Equality of Actual Findings Intact olfaction Interpretation Normal

CN II

Ability to read precisely

Normal

CN II, IV, VI

Intact EOM

Normal

CN V

Intact EOM

Normal

CN VII

Facial Assymetry.

ABNORMAL ( Assymetrical Shape of

CN VIII

CN IX, X

muscle strength when raising the eyebrows, frowning, showing both the upper and lower teeth, smiling, puffing out the cheeks and closing the eyes tightly. Ability to correctly repeat the whispered word Symmetrical rise of the soft palate and uvula when ah is said.

the face) September 21,2010

Inability to repeat words due to inability of verbal communication. Symmetrical rise of the soft palate and uvula when ah is said, but sounds does not produce. Incongruent Shoulder Shrug.

ABNORMAL(September 21,2010) ABNORMAL( Symmetrical, but AH is not produce due to inability of verbal speaking) September 21, 2010 ABNORMAL (Only left side of shoulder can be shrugged well, right side is weak) September 21, 2010 Normal

CN XI

CN XII

Symmetrical strength and contraction of the trapezius muscles as the shoulders are shrugged upward against resistance Symmetry, absence of atrophy, midline position of tongue

Tongue at midline, normal tongue movements.

Area to be examined Skin

Method of Assessment Inspection

Normal Findings Intact Skin; Absence of swelling or inflammation Rounded ( symmetrical and normocephalic) Smooth, uniform consistency. Absence of nodules or masses

Actual Findings Skin is Intact. Skin color is symmetrical Round shaped, no noticed enlargement No masses, but Edema is noticeable.

Interpretation Normal

Head

Inspection

Normal

Face

Inspection

Eyes

Inspection

Lids close symmetrically; when lids open, no visible sclera above corneas. And upper and lower borders of cornea are

The eyes are able to close and open well. No noticed eye discharge.

ABNORMAL (Slightly edematous around the eyebrows) September 21, 2010 Normal

Nose

Inspection

Ears

Inspection

slightly covered Absence of lesions. Air moves freely as the client breathes through the nares. Color same as facial skin; sound is heard in both ears.

Absence of lesions and blisters. Not tender. Intact sense of smell. Hearing is abnormal. Absence of lesions and masses. Uniform pink in color; tongue has no lesions, pink color and raised papillae. Intact gag and swallowing reflex No erosions and lesions on the neck. Pulmonic: S2 is heard louder than S1 without murmurs. Aortic: S2 is heard louder than S1 without murmurs. Resonant all over the lung fields. Bronchial sound are heard over the manubrium, bronchovesicular over the 1st and 2nd ICS and vesicular over the rest of the lung fields. Resonant all over the lung fields Bronchial sound are heard over the manubrium, bronchovesicular over the 1st and 2nd ICS and vesicular

Normal

Mouth

Inspection

Uniform pink in color; tongue has no lesions, pink color and raised papillae. Has intact gag reflex and swallowing reflex Muscles equal in size; Absence of swelling and inflammation Audible S1 and S2

ABNORMAL( low hearing mechanism due to injury on the temporal area) September 21,2010 Normal

Throat Neck

Inspection Inspection

Normal Normal

Cardio Vascular Assessment

Auscultation

Normal

Anterior Chest

Percussion Auscultation

Percussion: Resonate except over scapula Vesicular and bronchovesicular breath sounds are heard

Normal Normal

Posterior Chest

Percussion Auscultation

Percussion: Resonate except over scapula Vesicular and bronchovesicular breath sounds are heard

Normal Normal

Abdomen

Inspection

Unblemished skin; uniform color Audible bowel sounds; Absence of friction rub

Auscultation

Percussion

Palpation

Lungs

Inspection Palpation

Back External Genitalia Upper Extremities

Inspection Inspection

Inspection

Tympany over the stomach and gas filled bowels; dullness especially over the liver and spleen, or a full bladder. Not tender ; relaxed abdomen with smooth, consistent tension Breathing is regular without use of accessory muscles, chest expands upon inhalation and depresses upon expiration Unblemished Skin; Uniform Color Smooth, uniform consistency; absence of nodules or masses. Uniform Consistency; Absence of Redness and Rashes Not Tender, Absence of Edema and Masses Uniform Consistency; Absence of Redness and Rashes

over the rest of the lung fields. Uniform Fair Skin on parts of the abdomen Has 6 bowel sound heard per minute in each quadrant of the abdomen RUQ: Dull LUQ: Tympanic RLQ: Tympanic LLQ: Tympanic

Normal

Normal

Normal

Absence of tenderness. Relaxed abdomen. Breathing is regular without use of accessory muscles, chest expands upon inhalation and depresses upon expiration Unblemished and Uniform Skin color No noticed lesions and nodules. No Redness and Rashes, Color same as Body color, but Flexed Right Arm. Smooth Skin No Redness and Rashes, Color same as Body color. But incongruent walking and unsteady gait. Smooth Skin

Normal

Normal

Normal Normal

ABNORMAL (Weak Right Arm) September 21, 2010 Normal ABNORMAL (Weak right leg) September 21, 2010

Palpation Lower Extremities Inspection

Palpation

Not Tender, Absence of Edema and Masses

Normal

ANATOMY of CENTRAL NERVOUS SYSTEM The central nervous system is made up of the spinal cord and brain The spinal cord conducts sensory information from the peripheral nervous system (both somatic and autonomic) to the brain conducts motor information from the brain to our various effectors o skeletal muscles o cardiac muscle o smooth muscle o glands serves as a minor reflex center The brain receives sensory input from the spinal cord as well as from its own nerves (e.g., olfactory and optic nerves) devotes most of its volume (and computational power) to processing its various sensory inputs and initiating appropriate and coordinated motor outputs. The Meninges Both the spinal cord and brain are covered in three continuous sheets of connective tissue, the meninges. From outside in, these are the dura mater pressed against the bony surface of the interior of the vertebrae and the cranium the arachnoid the pia mater The region between the arachnoid and pia mater is filled with cerebrospinal fluid (CSF). The Extracellular Fluid (ECF) of the Central Nervous System The cells of the central nervous system are bathed in a fluid that differs from that serving as the ECF of the cells in the rest of the body. The fluid that leaves the capillaries in the brain contains far less protein than "normal" because of the blood-brain barrier, a system of tight junctions between the endothelial cells of the capillaries. This barrier creates problems in medicine as it prevents many therapeutic drugs from reaching the brain. cerebrospinal fluid (CSF), a secretion of the choroid plexus. CSF flows uninterrupted throughout the central nervous system o through the central cerebrospinal canal of the spinal cord and o through an interconnected system of four ventricles in the brain. CSF returns to the blood through veins draining the brain.

The

Spinal Cord

31 pairs of spinal nerves arise along the spinal cord. These are "mixed" nerves because each contains both sensory and motor axons. However, within the spinal column, all the sensory axons pass into the dorsal root ganglion where their cell bodies are located and then on into the spinal cord itself. all the motor axons pass into the ventral roots before uniting with the sensory axons to form the mixed nerves. Crossing Over of the Spinal Tracts Impulses reaching the spinal cord from the left side of the body eventually pass over to tracts running up to the right side of the brain and vice versa. In some cases this crossing over occurs as soon as the impulses enter the cord. In other cases, it does not take place until the tracts enter the brain itself. The Brain The brain of all vertebrates develops from three swellings at the anterior end of the neural canal of the embryo. From front to back these develop into the forebrain (also known as the prosencephalon shown in light color) midbrain (mesencephalon gray) hindbrain (rhombencephalon dark color) The human brain is shown from behind so that the cerebellum can be seen. The human brain receives nerve impulses from the spinal cord and 12 pairs of cranial nerves o Some of the cranial nerves are "mixed", containing both sensory and motor axons o Some, e.g., the optic and olfactory nerves (numbers I and II) contain sensory axons only o Some, e.g. number III that controls eyeball muscles, contain motor axons only.

The Hindbrain The main structures of the hindbrain (rhombencephalon) are the medulla oblongata pons and cerebellum

Medulla oblongata The medulla looks like a swollen tip to the spinal cord. Nerve impulses arising here rhythmically stimulate the intercostal muscles and diaphragm making breathing possible [More] regulate heartbeat regulate the diameter of arterioles thus adjusting blood flow. Pons The pons seems to serve as a relay station carrying signals from various parts of the cerebral cortex to the cerebellum. Nerve impulses coming from the eyes, ears, and touch receptors are sent on the cerebellum. The pons also participates in the reflexes that regulate breathing. Cerebellum The cerebellum consists of two deeply-convoluted hemispheres. Although it represents only 10% of the weight of the brain, it contains as many neurons as all the rest of the brain combined. Its most clearly-understood function is to coordinate body movements. People with damage to their cerebellum are able to perceive the world as before and to contract their muscles, but their motions are jerky and uncoordinated. So the cerebellum appears to be a center for learning motor skills (implicit memory). Laboratory studies have demonstrated both long-term potentiation (LTP) and long-term depression (LTD) in the cerebellum. The Midbrain The midbrain (mesencephalon) occupies only a small region in humans (it is relatively much larger in "lower" vertebrates). We shall look at only three features: the reticular formation: collects input from higher brain centers and passes it on to motor neurons. the substantia nigra: helps "smooth" out body movements; damage to the substantia nigra causes Parkinson's disease. the ventral tegmental area (VTA): packed with dopamine-releasing neurons that o are activated by nicotinic acetylcholine receptors and o whose projections synapse deep within the forebrain. The midbrain along with the medulla and pons are often referred to as the "brainstem". The Forebrain The human forebrain (prosencephalon) is made up of a pair of large cerebral hemispheres, called the telencephalon. Because of crossing over of the spinal tracts, the left hemisphere of the forebrain deals with the right side of the body and vice versa. a group of structures located deep within the cerebrum, that make up the diencephalon. Diencephalon We shall consider four of its structures: the Thalamus. o All sensory input (except for olfaction) passes through these paired structures on the way up to the somatic-sensory regions of the cerebral cortex and then returns to them from there. o signals from the cerebellum pass through them on the way to the motor areas of the cerebral cortex.

Lateral geniculate nucleus (LGN). All signals entering the brain from each optic nerve enter a LGN and undergo some processing before moving on the various visual areas of the cerebral cortex.

Hypothalamus. o The seat of the autonomic nervous system. Damage to the hypothalamus is quickly fatal as the normal homeostasis of body temperature, blood chemistry, etc. goes out of control. o The source of 8 hormones, two of which pass into the posterior lobe of the pituitary gland.

Posterior lobe of the pituitary. Receives o vasopressin and o oxytocin from the hypothalamus and releases them into the blood.

The Cerebral Hemispheres Each hemisphere of the cerebrum is subdivided into four lobes visible from the outside: frontal parietal occipital temporal

ACTIVITIES OF DAILY LIVING

BEFORE HEALTH MANAGEMENT PERCEPTION PATTERN SUBJECTIVE: The patient is healthy and seldom to get sick. DURING SUBJECTIVE: The patient take his medications on time without hesitation. INTERPRETATION The patient manifests patterns of health management which is normal for an adult.

NUTRITION METABOLIC PATTERN

SUBJECTIVE: The patient eats lots of foods. Eats on time and does not skip meal.

SUBJECTIVE: The patient remains vigorous in eating.

Remain unchanged.

ELIMINATION PATTERN

BEFORE SUBJECTIVE: The patient has a normal bowel movement and urination. BEFORE

DURING SUBJECTIVE: The patient remains normal in Elimination and Urination pattern. DURING SUBJECTIVE:

INTERPRETATION Remain unchanged.

INTERPRETATION The patient is active

ACTIVITY

SUBJECTIVE:

EXERCISE PATTERN

The patient is active on his duties and daily activities.

The patient loses his flexibility, unable to lift things due to immobilization of right arm. DURING SUBJECTIVE The patients sleep pattern varies. Patient is observed to have frequent awakening in the evening. DURING SUBJECTIVE: The patient does not cooperate with health practitioners.

before hospitalization but became weak due to immobilization of the right arm.

BEFORE SLEEP REST PATTERN SUBJECTIVE: The patient sleeps comfortably. He sleeps on-time when offduty.

INTERPRETATION Sleeping Pattern of the patient remain unchanged.

BEFORE COGNITIVEPERCEPTUAL SUBJECTIVE: The patient cooperates well and participates precisely on activities.

INTERPRETATION The patient is unable to perform activities.

BEFORE SELFPERCEPTION and SELF-CONCEPT SUBJECTIVE: The patient expresses his emotions. He is full of hope and with high self-esteem.

DURING SUBJECTIVE: The patient has willful refusal to speak. He has observable discomfort in social interaction. OBJECTIVE: During assessment, patient appears noncooperative. Patient do not responds to questions.

INTERPRETATION Self-perception and selfconcept of the patient was altered.

BEFORE ROLE SUBJECTIVE:

DURING SUBJECTIVE:

INTERPRETATION Hospitalization of one

RELATIONSHIP PATTERN

The patient has a good relationship with his wife, family and coworkers. He is able to interact with other people, verbalizes his feelings and thoughts.

The patient loses the ability to talk. He cannot share his feelings, do not interact with health practitioners. OBJECTIVE: Dysfunctional RoleRelationship Pattern and impaired verbal communication and social interaction.

family member may largely affect other members of the family. This will assert him of the need for interactions not only with family members but also with friends she has outside. Isolation can be seen to the patient under the age of 31.

BEFORE SEXUALREPRODUCTIVE SUBJECTIVE: Super sexually active.

DURING SUBJECTIVE: Decrease sexual activity due to hospitalization.

INTERPRETATION Hospitalization affects sexual activity. The patient prioritize more on health management.

BEFORE COPING-STRESS TOLERANCE SUBJECTIVE: He talks to his wife when there are problems. He verbalized his feelings. BEFORE VALUES-BELIEF SUBJECTIVE: The patient is attending church mass weekly.

DURING SUBJECTIVE: He cannot share his thoughts due to impaired verbal language. DURING SUBJECTIVE: The patient cannot go to church due to anguish, anxiety, hospitalization and scheduled therapy.

INTERPRETATION Impaired verbal language greatly affects CopingStress Mechanism.

INTERPRETATION When an undesirable and uncontrollable event happens to a person. One of the two things may happen. A decline in faith or a stronger belief for healing. In this case, he tends to decline his faith.

DEVELOPMENTAL TASK
Young adulthood: 18 to 35 Intimacy and Solidarity vs. Isolation Basic Strengths: Affiliation and Love In the initial stage of being an adult we seek one or more companions and love. As we try to find mutually satisfying relationships, primarily through marriage and friends, we generally also begin to start a family, though this age has been pushed back for many couples who today don't start their families until their late thirties. If negotiating this stage is successful, we can experience intimacy on a deep level. The client is experiencing isolation and distance from others occurs. And when the client does not find it easy to create satisfying relationships. The problem is heightened merely by his inability to speak and socialize with other people such as health practitioners. The clients significant relationships are with marital partners and friends.

COURSE IN THE WARD: (Upon Admission and Time of our Duty)

May 22, 2009 (Friday) The patient admitted to the hospital for debridement, dural repairing, and for repairing CSF leak due to a gunshot wound on his temporal lobe. The patient received asleep on bed and not in respiratory distress, depressed forehead on left side with condom catheter connected to urine bag, draining to yellow colored urine output. The vital signs are taken and has recorded. His oral medications like paracetamol, vitamin B complex, C and E are given and still for refferal to Dr. Orata for evaluation of management and speech therapy. He is kept comfortable and it is endorsed well. September 20,2010 At 0700H, the patient received asleep on bed and not in respiratory distress and thus afebrile. His vital signs taken and recorded and his oral medications are also given after monitoring his v/s. September 21,2010 Patient received sitting in bed with his wife, conscious and coherent, positive use of non-verbal communication and pleading eyes, positive willful refusal to speak and flexion of right arm. Vital signs was taken, negative bowel movement and positive urination 2x. Medication was given such as Vitamin C, Vitamin B Complex, and Vitamin E. September 27, 2010 The patient received on bed awake and not in respiratory distress and not febrile. His vital signs are taken but not recorded. His oral medications are well given and he is kept comfortable and endorsed.

DISCHARGE PLANNING:

G-ive his medications related to his case. U-se his energy for exercises. N-utritional needs : increase Vitamins in his diet like vitamin C, B complex and E. S-pecial activities : like in mental exercise and physical exercise (walking, sitting and standing) H-ealth teaching : about his daily activities and lifestyle O-ccluding or preventing his wrong lifestyles like drinking beverages or smoking. T-o practice his speech exercise

NCP- September 21,2010

Other Nursing Diagnosis: Impaired Social Interaction related to Communication barrier secondary to inability to talk. Impaired Physical Mobility related to Neuromuscular Impairment secondary to Craniocerebral trauma. ASSESSMENT Subjective: The patient loses the ability to talk. He cannot share his feelings, do not interact with health practitioners. Objective: Vital Signs are as follows: T: PR: BP: RR: (+) use of nonverbal communication and cues (+) pleading eyes (+) willful refusal to speak DIAGNOSIS Impaired Verbal Communication related to Anatomical deficit secondary to Craniocerebral trauma on Frontotemporal Area. NURSING ANALYSIS PLANNING Short-term goal: After 2 hours of Nursing Intervention, the client indicates an understanding of communication difficulty and plans for ways of handling. The next two hours, the patient establishes method of communication in which needs can be expressed. Long-term Goal: Within our shift, the patient demonstrates congruent verbal and non-verbal communication. INTERVENTION To assist client to establish a means of communication to express needs, wants, ideas and questions. Determine meaning of words use by the client (non-verbal message). Plan for alternative method of communicatio n (e.g letter board). To promote wellness Use and assist client and teach family to learn therapeutic communication skills of management (Active listening and I message) RATIONALE To help him express ideas and promote social interaction. EVALUATION The goal was met. He response to interventions and teachings and actions performed. He practice nonverbal communication and I message.

Improves general communication skills, enhances participation and commitment to plans.

The goal was partially met.

DRUG STUDY
Name/ classification Paracetamol Analgesic Dosage/ Route Oral 500 mg tab. Action Blocks pain impulses, proably by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting in hypothalamic heatregulating center. Indication The preparation is indicated in diseases manifesting with pain and fever: headache, toothache, mild and moderate postoperative and injury pain, high temperature, infectious diseases and chills (acute catarrhal inflammations of the upper respiratory tract, flu, small-pox, parotitis, etc.). Indication For the treatment of hypertension, chronic stable angina and confirmed or suspected vasospastic angina. Contraindication Paracetamol should not be used in hypersensitivity to the preparation and in severe liver diseases. Side effect Paracetamol only rarely causes gastrointestinal problems or allergic skin reactions. Blood dyscrasia (e.g. thrombocytopenia), methaemoglobinemia, and hemolytic anemia are very rare. A minority of the subjects with socalled aspirin intolerance responds to paracetamol with bronchospasms. It is not safely established if paracetamol can cause a nephropathy, like drug combinations containing phenacetin. Side effect - dizziness; - dizziness or lightheadedness; - drowsiness; - excessive tiredness; - fainting; - fainting; - flushing (feeling of warmth); - headache; - more frequent or more severe chest pain; - rapid heartbeat; - rapid, pounding, or irregular heartbeat; - stomach pain; - swelling of the hands, feet, ankles, or lower legs; - upset stomach; Nursing intervention - Tell patient that drug is for shortterm use. - Warn patient that high doses or unsupervised longterm use can cause liver damage.

Name/ classification Amlodipine

Dosage/ Route 5 mg cap/ oral

Action Calcium is needed by the body for muscle contraction. The heart is a muscle that is constantly contracting to pump blood through out the body. Calcium channel blockers like amlodipine work by blocking the flow of calcium into the muscles of the heart and smooth muscles of blood vessels. The blood vessels relax and become wider plus the pumping action of the heart is reduced.

Contraindication mlodipine is contraindicated in patients with known sensitivity to amlodipine.

Nursing intervention Monitor patient carefully (BP, cardiac rhythm, and output) while adjusting drug to therapeutic dose; use special caution if patient has CHF. Monitor BP very carefully if patient is also on nitrates. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. Administer drug without regard to meals.

Name/ classification Piracetam

Dosage/ Route 1.2 tab./ oral

Action Piracetam protects the cerebral cortex against hypoxia. It also inhibits platelet aggregation and reduces blood viscosity.

Indication Piracetam, solution for injection is used in cases of severe brain diseases: cerebro-cranial trauma in acute stage, comatose states, ischemic stroke, acute psychic disturbances due to intoxications, alcohol delirium. Piracetam tablets are used in cerebro-vascular disease; degenerative cortical dementia (Alzheimers disease); senile psychoorganic syndrome (aging brain); cortical myoclonia; dyslexia of vascular and other origin; vestibulopathies; protection of the nervous tissue in a brain hypoxia; postoperative deliriums.

Contraindication First trimester of pregnancy; severe parenchymal liver or kidney diseases; agitated depression, particularly in the elderly.

Side effect Rarely in susceptible patients can be observed the following symptoms: increased aggressiveness, headache, sleep disturbance, gastrointestinal problems, blood pressure instability.

Nursing intervention Prior to: Wash hands thoroughly. Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO.. After: Record the drug after its administration (charting). Observe the patients for possible untoward reaction. Instruct to take the medication exactly as directed.

Name/ classification Mefenamic acid /NSAID

Dosage/ Route oral 500 mg tab.

Action Anti-inflammatory, analgesic and antipyretic activities related to inhibition of prostaglandin synthesis; exact mechanisms of action are not known.

Indication Like other antiinflammatory drugs, mefenamic acid can impair the effect of antihypertensive agents and it can increase the toxicity of lithium and methotrexate. Mefenamic acid increases only marginally (but still more than e.g. ibuprofen) the risk of bleeding under oral anticoagulants.

Contraindication Inflammatory intestinal diseases. Active peptic ulcers. Hypersensitivity to aspirin (acetylsalicylic acid) or other nonsteroidal antiinflammatory agents. Renal failure.

Side effect Dependent on the dose and the duration of treatment, mefenamic acid frequently causes diarrhea. Long-term treatment can lead to enteritis or colitis (sometimes with steatorrhea). The drug can also cause nausea, vomiting and upper abdominal pain. Like other antiinflammatory agents, it occasionally is the cause of peptic ulcers or even of bleeding or perforations.

Nursing intervention BEFORE: Assess the physical for skin color and lesions; orientation, reflexes, opthalmolgic, and andiometric evaluation, peripheral sensation; P, edema R, adventitious sounds,; renal function tests, serum electrolytes, stool guaiac Rs AFTER: Take drug with food; take only the prescribed dosage and teach not to take the drug longer than 1 week Discontinue drug and consult health care provider if rash, diarrhea, or digestive problems occur. Dizziness or drowsiness can occur ( so avoid driving and using dangerous machinery )

Name/ classification Gloclav CO-AMOXICLAV

Dosage/ Route 625mg/ cap..

Action Amoxicillin inhibits transpeptidase, preventing crosslinking of bacterial cell wall and leading to cell death. Addition of clavulanate (a betalactam) increases drug's resistance to beta-lactamase (an enzyme produced by bacteria that may inactivate amoxicillin).

Indication Co-amoxiclav is indicated for treatment of the following bacterial infections due to susceptible organisms: -Upper respiratory tract infection. -Genitourinary tract infections. -Skin and soft tissue infections, e.g. boils, abscesses, cellulitis, animal bites, wound infections. Bone and joint infections, e.g. osteomyelitis. -Dental infections, e.g. dentoalveolar abscess. -Other infections, e.g. puerperal sepsis, septic abortion, intraabdominal sepsis.

Contraindication Co-amoxiclav is contraindicated in patients with a history of allergic reactions to any penicillin. It is also contraindicated in patients with a previous history of amoxicillin-potassium clavulanate-associated cholestatic jaundice/ hepatic dysfunction.

Side effect Co-amoxiclav is well tolerated. Side effects, as with amoxicillin, are uncommon and mainly of mild and transitory nature. The reported adverse effects include diarrhea, nausea, vomiting, antibiotic-associated colitis (including pseudomembranous colitis), and candidiasis have been reported. Hepatitis and cholestatic jaundice have been reported rarely. Uriticarial and erythematous rashes sometimes occur. Rarely erythema multiforme (including StevensJohnson syndrome), toxic epidermal necrolysis, exfoliative dermatitis and vasculitis have been reported.

Nursing intervention Assess for infection Obtain specimens for culture and sensitivity prior to therapy. First dose may be given before receiving the result Monitor bow function Instruct the patient to take the medication around the cock and to finish the drug completely as directed. Review use and preparation of tablets for oral suspension

Name/ classification Citicoline CNS stimulant.

Dosage/ route

Action Citicoline increases blood flow and O2 consumption in the brain. It is also involved in the biosynthesis of lecithin.

Indication Cardiac stroke, Head trauma, Ischaemic heart disease, Paralysis of lower extremities, and can also be given in adjunctive therapy as an alternative drug of choice in Parkinson's disease.

Contraindication Unconciousness, Brain surgery, Pregnancy, Breast feeding.

Side effect The severe or irreversible adverse effects of Citicoline, which give rise to further complications include Hypotension. The symptomatic adverse reactions produced by Citicoline are more or less tolerable and if they become severe, they can be treated symptomatically, these include Excitement, Insomnia.

Nursing intervention Somazine must not be administered along with medicaments containing meclophenoxate

tab. Oral

Name/ classification LACTULOSE

Dosage/ route 30 cc

Action Inhibits bacterial DNA gyrase thus preventin greplication in susceptibe bacteria

Indication Constipatio n, salmonello sis. Treatment of hepatic encephalo pathy

Contraindication Pt who require a low lactose diet. Galactosemia deficiency. Intestinal obstruction

Side effect Lactose intolerance, diabetes Adverse Rxn: Abdominal discomfort associated with flatulence and intestinal cramps. Nausea, vomiting, diarrhea on prolonged use

Nursing intervention >Assess condition before therapy and reassess regularly thereafter to monitor drugs effectiveness >Monitor pt for any adverse GI reactions, nausea,vomiting,diarr hea, >Assess for adverse reactions >for pt. with hepatic encelopathy: regularly assess mental condition >monitor I & O >monitor for Inc. glucose level in diabetic pts

Name/ classification AMLODIPINE BESYLATE

Dosage/ route 5 mg cap/ oral

Action Antianginal Antihyperte nsive Calcium channel blocker

Indication Angina pectoris due to coronary artery spasm (Prinzmetals variant angina) Chronic stable angina, alone or in combination with other drugs Essential hypertension, alone or in combination with other antihypertensives

Contraindication Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), and lactation. Use cautiously with heart failure, pregnancy

Side effect CNS: Dizziness, lightheadedness, headache, asthenia, fatigue, lethargy CV: Peripheral edema, arrhymias Dermatologic: Flushing, rash jaundice (yellowing of the skin or eyes). GI: Nausea, abdominal discomfort Urinating more or less than usual, or not at all; Fever, chills, body aches,

Nursing intervention Monitor BP carefully if patient is also on nitrates. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long term therapy. Administer drug without regard to meals. Always remember and follow the 10 Rs of drug administration.

flu symptoms; Tired feeling, muscle weakness, and pounding or uneven heartbeats;
chest pain; swelling, rapid weight gain

Name/ classification Moriamin Forte/multivita mins and minerals

Dosage/ route 1 cap/oral

Action multivitamins and minerals

Indication malnutrition, protein and vitamin deficiencies, anemia, convalescence,restor

Contraindication contraindicated for patients with malabsorption syndrome Form: cap 100s

Side effect hypervitaminosis (large doses)

Nursing intervention contraindicated for patients with malabsorption syndrome Form: cap 100s

ation and maintenance of body resistance, pregnancy and lactation, adjuvant in the therapy of peptic ulcer and TB

LABORATORY RESULTS May 22, 2010

Hemoglobin Hematocrit Result 148 0.44 Normal 140-180 g/L 0.42-0.54 Interpretation Within the normal range but it is near to abnormal. The level is just normal but it falls near the boundary. So Hct level should be monitored well. Within Normal Range but needs continous monitoring due to close to abnormal level. The result is low and abnormal. The result is very high, and requires continous monitoring. The result is very low.

WBC

5.2

5.0x10x10 g/L

DIFFERENTIAL COUNT Segmenters 0.47 Lymphocytes 0.46 Eosinophil 0.07

0.50-0.65 0.25-0.40 1.3

CONCLUSION:
**We therefore conclude that the Differential Counts of the patient such as Segementers, Lymphocytes and Eosinophil should be monitored regularly since it shows abnormal results.

PATHOPHYSIOLOGY
Gunshot Skull Penetration Skull Fractures

CSF Leak
RISK FOR INFECTION RISK FOR INFECTION

Open brain injury on frontotemporal area Tissue Inflammation and Bleeding Increase Intracranial Volume Increase ICP Slow Blood Flow to the Brain Tissue Perfusion Cell Death or Cell Damage Neurologic Dysfunction

Muscle Weakness on the Right Extremities opoosite to the affected area, Hemiplagia SEPTEMBER 21,2010

Altered Behaviour (frontal area is affected) SEPTEMBER 21,2010

Aphasia Difficulty expressing speaking(temporal area is affected) SEPTEMBER 21,1010

REFERENCES:
http://www.wikipedia.org (For Anatomy and Physiology, and Introduction) http://www.scribd.com (For Drug Study) http://www.nursingcrib.com (For Drug Study) Anatomy and Physiology book by Ellen Marieb