CASE SHARING OF TRAUMATIC

BRAIN INJURY

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Beluan, Royce Jen Valerie V.

Cadiogan, Dianne Kate A.
Enriquez, Carmel Ray A.
Kauffman, Denise
Lagcao, Julio Nicholo
Mokhtar, Hayefah
Macmod, Ommyah
Obasa, Cristyl
Pangcoga, Aisha Ressan
Sani, Azriah II
Toling, Kaye Claudelle

SEPTEMBER 2018
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TABLE OF CONTENTS

PAGES
I. TITLE PAGE i

II. TABLE OF CONTENTS ii

III. OBJECTIVES 1

IV. INTRODUCTION OF THE CASE 2

V. NORMAL ANATOMY AND PHYSIOLOGY 5

VI. RISK FACTORS AND PATHOPHYSIOLOGY 6

VII. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM 20

VIII. DIAGNOSTIC TESTS 23

IX. PHARMACOLOGY MEDICATIONS 43

X. NURSING CARE PLAN 46

XI. MEDICAL/SURGICAL MANAGEMENT 52

XII. REFERENCES 52
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OBJECTIVES

General Objective
At the end of a one and a half - hour case presentation, the participants will be able to

distinguish the process of traumatic brain injury and its management.

Specific Objectives:
At the end of one and a half-hour case presentation, the participants will be able to:

1. Identify and explain the medical terms related to the case;

2. Summarize the pathophysiology;

3. Understand the complications of the different types of traumatic brain injuries;

4. Enumerate and describe the risk factors and manifestations of traumatic brain

injury;

5. Formulate a nursing care plan for a client with traumatic brain injuries; and

6. Apply nursing managements in the care of a client with TBI.

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INTRODUCTION

A head injury is classified to any damage to the head as a result of trauma. Trauma that

involves the central nervous system can be life threatening. Even if it that trauma is not life

threatening, brain and spinal cord injury can result in physical and psychological dysfunction.

This can alter the patient’s life completely. A head injury does not necessarily mean a brain

injury is present, but it is a contributing factor. According to Hinkle and Cheever (2018 pg.

2033), a traumatic brain injury (TBI) or craniocerebral trauma is an injury that is a result of an

external force that is enough to interfere with daily life and prompts the seeking of treatment.

Globally, TBI results in a large number of deaths and impairments leading to permanent

disabilities. Sixty-nine million individuals worldwide are estimated to sustain a TBI each year

(WHO). The Centers for Disease Control and Prevention estimates that there are 2.5 million

emergency department visits in the United States each year, the majority of which are for a mild

TBI. In the Philippinesin 2010 alone, 6,941 Filipinos died from road-related accidents and a

thousand more was said to make up the percentage that suffered from injury and disability.

Brain injury comes in different types. It could be focal, which include contusions and

several types of hematomas or diffuse which are concussions and diffuse axonal injuries.

Contusion is when the brain is bruised and damaged in a specific areadue to severe acceleration-

deceleration force or blunt trauma. Contusions may occur in any area of the brain, but they are

usually located in the anterior portions of the frontal and temporal lobes. Contusions are

characterized by loss of consciousness associated with stupor and confusion. Intracranial

Hemorrhage are collections of blood in the brain that may be epidural, subdural, or

intracerebral. Major symptoms are frequently delayed until the hematoma is large enough to
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cause distortion of the brain and increased ICP. A rapidly developing hematoma may be fatal,

while a slow developing hematoma may allow compensation for increases in ICP. Epidural

Hematoma blood collects in the epidural space and is a result from a skull fracture that causes a

rupture or lacerations of the meningeal artery. EDH accounts for 2.7% to 4% of traumatic head

injuries. EDH is characterized by a brief loss of consciousness, followed by a lucid interval in

which the patient is awake and conversant. Subdural Hematoma is a collection of blood

between the dura and the brain. SDH is more frequently venous in origin and is caused by the

rupture of small vessels that bridge the subdural space. Acute SDHapprox. 50% of brain injuries

and 60% of deaths in patients with brain injuries result from acute SDH is characterized by

changes in LOC, pupillary signs, and hemiparesis. Chronic SDH can develop from seemingly

minor head injuries and is seen most frequently in older adults who are more prone due to brain

atrophy, which is a consequence of the aging process. Intracerebral Hemorrhage and

Hematoma is bleeding into the parenchyma of the brain. Commonly seen in head injuries when

force is exerted to the head over a small area. Onset may be insidious, beginning with the

development of neurologic deficits, followed by headache. Concussion is a temporary loss of

neurologic function with no apparent structural damage to the brain. If brain tissue in the frontal

lobe is affected, the patient may exhibit bizarre irrational behavior, whereas involvement of the

temporal lobe can produce temporary amnesia or disorientation. Diffuse Axonal Injury results

from widespread shearing and rotational forces that produce damage throughout the brain-to

axons in the cerebral hemispheres, corpus callosum, and brainstem. DAI is associated with

prolonged traumatic coma; it is more serious and is associated with a poorer prognosis than a

focal lesion. Patients with DAI experiences no lucid interval, immediate coma, decorticate and

decerebrate posturing, and global cerebral edema.

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The most common causes of TBIs are falls (35.2%), motor vehicle crashes (17.3), being

struck by objects (16.5%) and assaults (10%). Children 0 to 4 years, adolescents 15 to 19, and

adults 65 years and older are most likely to sustain TBI. TBI rates are higher in males than in

females. A computed tomography scan can be used to diagnose a skull fracture. If there is

suspected brain injury, an MRI scan provides better resolution and pictures of the injured area.

Nondepressed skull fractures generally do not require surgery, whereas depress skulls require

surgery.

The purpose of this case presentation is to instill knowledge to our listeners about

traumatic brain injury. With this information our listeners will be able to understand the types

and manifestations of traumatic brain injury. Furthermore, it will promote prevention of future

risks of brain injury.

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NORMAL ANATOMY AND PHYSIOLOGY OF THE BRAIN

Brain

The brain is composed of the cerebrum, cerebellum, and brainstem

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.

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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. 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.

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Lobes of the brain

The cerebral hemispheres have distinct fissures, which divide the brain into lobes.

Each hemisphere has 4 lobes: frontal, temporal, parietal, and occipital. Each lobe may be

divided, once again, into areas that serve very specific functions. It’s important to

understand that each lobe of the brain does not function alone. There are very complex

relationships between the lobes of the brain and between the right and left hemispheres.

Frontal lobe

 Personality, behavior, emotions

 Judgment, planning, problem solving

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

 Body movement (motor strip)

 Intelligence, concentration, self awareness

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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

Language

In general, the left hemisphere of the brain is responsible for language and speech

and is called the "dominant" hemisphere. The right hemisphere plays a large part in

interpreting visual information and spatial processing. In about one third of people who

are left-handed, speech function may be located on the right side of the brain. Left-

handed people may need special testing to determine if their speech center is on the left

or right side prior to any surgery in that area.

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Aphasia

Is a disturbance of language affecting speech production, comprehension, reading

or writing, due to brain injury – most commonly from stroke or trauma. The type of

aphasia depends on the brain area damaged.

Broca’s area

Lies in the left frontal lobe. If this area is damaged, one may have difficulty

moving the tongue or facial muscles to produce the sounds of speech. The person can still

read and understand spoken language but has difficulty in speaking and writing (i.e.

forming letters and words, doesn't write within lines) – called Broca's aphasia.

Wernicke's area

Lies in the left temporal lobe. Damage to this area causes Wernicke's aphasia. The

individual may speak in long sentences that have no meaning, add unnecessary words,

and even create new words. They can make speech sounds, however they have difficulty

understanding speech and are therefore unaware of their mistakes.

Cortex

The surface of the cerebrum is called the cortex. It has a folded appearance with

hills and valleys. The cortex contains 16 billion neurons (the cerebellum has 70 billion =

86 billion total) that are arranged in specific layers. The nerve cell bodies color the cortex

grey-brown giving it its name gray matter. Beneath the cortex are long nerve fibers

(axons) that connect brain areas to each other called white matter.
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The folding of the cortex increases the brain’s surface area allowing more neurons to fit

inside the skull and enabling higher functions. Each fold is called a gyrus, and each groove

between folds is called a sulcus. There are names for the folds and grooves that help define

specific brain regions.

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

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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 sellaturcica. 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 globuspallidus. These nuclei work with the cerebellum

to coordinate fine motions, such as fingertip movements.

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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).

Memory

Memory is a complex process that includes three phases: encoding (deciding what

information is important), storing, and recalling. Different areas of the brain are involved

in different types of memory (Fig. 6). Your brain has to pay attention and rehearse in

order for an event to move from short-term to long-term memory – called encoding.
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 Short-term memory, also called working memory, occurs in the prefrontal cortex. It

stores information for about one minute and its capacity is limited to about 7 items. For

example, it enables you to dial a phone number someone just told you. It also intervenes

during reading, to memorize the sentence you have just read, so that the next one makes

sense.

 Long-term memory is processed in the hippocampus of the temporal lobe and is

activated when you want to memorize something for a longer time. This memory has

unlimited content and duration capacity. It contains personal memories as well as facts

andfigures.

 Skill memory is processed in the cerebellum, which relays information to the basal

ganglia. It stores automatic learned memories like tying a shoe, playing an instrument, or

riding a bike.

Ventricles and cerebrospinal fluid

The brain has hollow fluid-filled cavities called ventricles. Inside the ventricles is

a ribbon-like structure called the choroid plexus that makes clear colorless cerebrospinal

fluid (CSF). CSF flows within and around the brain and spinal cord to help cushion it

from injury. This circulating fluid is constantly being absorbed and replenished.
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There are two ventricles deep within the cerebral hemispheres called the lateral

ventricles. They both connect with the third ventricle through a separate opening called the

foramen of Monro. The third ventricle connects with the fourth ventricle through a long narrow

tube called the aqueduct of Sylvius. From the fourth ventricle, CSF flows into the subarachnoid

space where it bathes and cushions the brain. CSF is recycled (or absorbed) by special structures

in the superior sagittal sinus called arachnoid villi.

A balance is maintained between the amount of CSF that is absorbed and the amount that

is produced. A disruption or blockage in the system can cause a build up of CSF, which can

cause enlargement of the ventricles (hydrocephalus) or cause a collection of fluid in the spinal

cord (syringomyelia).

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,

temporal, sphenoid, occipital and ethmoid. The face is formed from 14 paired bones including

the maxilla, zygoma, nasal, palatine, lacrimal, inferior nasal conchae, mandible, and vomer.
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Inside the skull are three distinct areas: anterior fossa, middle fossa, and posterior fossa. Doctors

sometimes refer to a tumor’s location by these terms, e.g., middle fossa meningioma.

Meninges

The brain and spinal cord are covered and protected by three layers of tissue

called meninges. From the outermost layer inward they are: the dura mater, arachnoid

mater, and pia mater.

Dura mater

Is a strong, thick membrane that closely lines the inside of the skull; its two

layers, the periosteal and meningeal dura, are fused and separate only to form venous

sinuses. The dura creates little folds or compartments. There are two special dural folds,

the falx and the tentorium. The falx separates the right and left hemispheres of the brain

and the tentorium separates the cerebrum from the cerebellum.

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Arachnoid mater:

Is a thin, web-like membrane that covers the entire brain. The arachnoid is made

of elastic tissue. The space between the dura and arachnoid membranes is called the

subdural space.

Pia mater

Hugs the surface of the brain following its folds and grooves. The pia mater has

many blood vessels that reach deep into the brain. The space between the arachnoid and

pia is called the subarachnoid space. It is here where the cerebrospinal fluid bathes and

cushions the brain.

Blood supply

Blood is carried to the brain by two paired arteries, the internal carotid arteries

and the vertebral arteries. The internal carotid arteries supply most of the cerebrum.
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The vertebral arteries supply the cerebellum, brainstem, and the underside of the

cerebrum. After passing through the skull, the right and left vertebral arteries join together to

form the basilar artery. The basilar artery and the internal carotid arteries “communicate” with

each other at the base of the brain called the Circle of Willis (Fig. 11). The communication

between the internal carotid and vertebral-basilar systems is an important safety feature of the

brain. If one of the major vessels becomes blocked, it is possible for collateral blood flow to

come across the Circle of Willis and prevent brain damage.

The venous circulation of the brain is very different from that of the rest of the body.

Usually arteries and veins run together as they supply and drain specific areas of the body. So

one would think there would be a pair of vertebral veins and internal carotid veins. However, this

is not the case in the brain. The major vein collectors are integrated into the dura to form venous

sinuses — not to be confused with the air sinuses in the face and nasal region. The venous

sinuses collect the blood from the brain and pass it to the internal jugular veins. The superior and

inferior sagittal sinuses drain the cerebrum, the cavernous sinuses drains the anterior skull base.
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All sinuses eventually drain to the sigmoid sinuses, which exit the skull and form the jugular

veins. These two jugular veins are essentially the only drainage of the brain.

Cells of the brain

The brain is made up of two types of cells: nerve cells (neurons) and glia cells.

Nerve cells

There are many sizes and shapes of neurons, but all consist of a cell body,

dendrites and an axon. The neuron conveys information through electrical and chemical

signals. Try to picture electrical wiring in your home. An electrical circuit is made up of

numerous wires connected in such a way that when a light switch is turned on, a light

bulb will beam. A neuron that is excited will transmit its energy to neurons within its

vicinity. Neurons transmit their energy, or “talk”, to each other across a tiny gap called a

synapse. A neuron has many arms called dendrites, which act like antennae picking up

messages from other nerve cells. These messages are passed to the cell body, which

determines if the message should be passed along. Important messages are passed to the

end of the axon where sacs containing neurotransmitters open into the synapse. The

neurotransmitter molecules cross the synapse and fit into special receptors on the

receiving nerve cell, which stimulates that cell to pass on the message.
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Glia cells

Glia (Greek word meaning glue) are the cells of the brain that provide neurons with

nourishment, protection, and structural support. There are about 10 to 50 times more glia

than nerve cells and are the most common type of cells involved in brain tumors.

 Astrogliaor astrocytes are the caretakers — they regulate the blood brain barrier,

allowing nutrients and molecules to interact with neurons. They control homeostasis,

neuronal defense and repair, scar formation, and also affect electrical impulses.

 Oligodendroglia cells create a fatty substance called myelin that insulates axons –

allowing electrical messages to travel faster.

 Ependymal cells line the ventricles and secrete cerebrospinal fluid (CSF).

 Microglia are the brain’s immune cells, protecting it from invaders and cleaning up

debris. They also prune synapses.

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PEROS
(PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM)

Areas Assessed Objective Findings Problem Identified

General Assessment

1. Ask when, where, how the

injury occurred.

2. Does patient lose

consciousness; if so, for how
long?

3. Has been there a change in level

of consciousness. If trauma is
relate to alcohol or drug
consumption.

4. If the patient experience seizure

after the injury.
HEAD

 Inspection.  Scalp bruising (ecchymosis)

 Laceration scalp, skull and
exposure of dura of the brain. o Pain
 Hematoma o Risk for infection
 Impacted area of bone bends
inward and the area around it bends
outward.
 Bone is pressed inward into the
brain tissue
 CSF leakage from the nose and
ears.
 Abnormal head tilt

 Palpate the head. Note
consistency
EYES
1. Check for pupil size and reaction
to light (penlight).
2. Check gross vision.
If patient’s condition permits.
Have patient read any printed
materials
NEUROLOGIC
1. Assess LOC using GCS
2. Assess for signs and symptoms
ICP elevation
23
 Tenderness in the scalp
o Risk for injury
 Pinpoint and noresponsive pupils
 Pupils that fixed (nonreactive) and
dilated pupils (poor prognostic
sign)
 Ovoid pupil- midstage between
normal and dilated pupil size
 Uneven pupils
 Loss of light reaction
 Temporary cortical blindness
 Loss of consciousness o Deficient fluid volume
 Mild TBI: 15minutes w/ GCS o Ineffective cerebral
score 13-15 tissue perfusion
 Moderate TBI: 6hrs w/ GCS o Imbalanced body
score 9-12 temperature related to
 Severe TBI: longer than 6 hrs damaged temperature-
w/ GCS of 3-8. regulating mechanisms
 Disorientation or confusion in the brain
 Amnesia o Risk for injury
 Restlessness or Irritability
 Persistent Headache
 Decrease in arousal or deep
sleepiness
 Seizures (w/in 24 hrs)
 changes in temperature

RESPIRATORY
Assess patients ABC (airway,
breathing, clearance).
1. Note the respiratory pattern
(chest wall movement)
2. Note the respiratory rate.
3. Auscultate chest for breath
sound.
MUSCULOSKELETAL
1. Assess of range of motion of
joints and development of
deformities and spasticity
2. Assess for bilateral motor
responses.
CARDIOVASCULAR
1. Check BP, HR,PR
GASTROINTESTINAL
1. Inspect the abdomen for
distention
2. Auscultate bowel sounds
INTEGUMENTARY
1. Inspect the skin integrity
and character.
GENITOURINARY
1. Record Intake and output
24
 Hyperventilation o Ineffective airway
 Bradypnea clearance
 Short period of Apnea o Impaired gas exchange.
 Cheyne-stoke respirations o Decreased cerebral and
 Pulmonary edema tissue perfusion.
o Self-care deficit
 Decerebrate or decorticate o Impaired physical
posturing or flaccidity mobility
 Hemiparesis
 Immobility
 Ataxia
 Hypotension or severe
hypertension o Deficient fluid volume
 Bradycardia
 Thread, irregular and rapid pulse.
 Tachycardia
 Cardiac dysrhythmias
o Constipation
 Projectile vomiting o Imbalance nutrition
 Constipation less than body
 Bowel incontinence requirements
 Paralytic ileus
 Pressure ulcers o risk for impaired skin
integrity
 Urinary incontinence
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DIAGNOSTIC TESTS

GLASGOW COMA SCALE

The Glasgow Coma Scale is a tool for assessing a patient’s response to stimuli.
Score range from 3 (deep coma) to 15 (normal).

EYE-OPENING RESPONSE Spontaneous 4

To voice 3
To pain 2
None 1
BEST VERBAL RESPONSE Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
BEST MOTOR RESPONSE Obeys command 6
Localized pain 5
Withdraws 4
Flexion 3
Extension 2
NOne 1

TOTAL: 3 TO 15
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DIAGNOSTIC NORMAL RESULT INTERPR SIGNIFICANCE NURSING

TEST/DATE VALUES ETATION RESPONSIBILITIES
CBC  If the measures in these three Used to evaluate your  Pt blood sample is being
RBC 4-6x10 12g/L areas are lower than normal, overall health and detect tested only for a complete
HEMATOCRIT 0.40-0.54 you have anemia. Anemia a wide range of blood count, Tell pt that
HEMOGLOBIN 130-160g/L causes fatigue and weakness. disorders, including he/she can eat and drink
WBC 5-10x 10 9/L Anemia has many causes, anemia, infection and normally before the test.
SEGMENTERS 0.50-0.65 including low levels of leukemia. If blood sample will be
certain vitamins or iron, used for additional tests,
LYMPHOCYTE 0.25-0.35
blood loss, or an underlying he/she may need to fast
S 0.05-0.10 To diagnose a medical
condition. for a certain amount of
STABS 0.03-0.07  A red blood cell count that's condition a complete time before the test. The
MONOCYTES 0.01-0.03 higher than normal blood count if doctor will give you
EOSINOPHILS 0-0.01 (erythrocytosis), or high ptexperiencing specific instructions.
BASOPHILS 140-450x 10 9/L hemoglobin or hematocrit weakness, fatigue, fever,
PLATELET levels, could point to an inflammation, bruising  For a complete blood
COUNT underlying medical or bleeding. A complete count, a member of your
condition, such as blood count may help health care team takes a
polycythemia vera or heart diagnose the cause of sample of blood by
disease these signs and inserting a needle into a
 A low white blood cell count symptoms. If your vein in your arm, usually
doctor suspects you at the bend in your elbow.
(leukopenia) may be caused
The blood sample is sent
by a medical condition, such have an infection, the
to a lab for analysis. Tell
test can also help
as an autoimmune disorder pt she/he can return to
confirm that diagnosis. his/her usual activities
that destroys white blood
immediately.
cells, bone marrow problems
or cancer. Certain
medications also can cause
white blood cell counts to
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drop.

 If your white blood cell

count is higher than normal,
you may have an infection or
inflammation. Or, it could
indicate that you have an
immune system disorder or a
bone marrow disease. A high
white blood cell count can
also be a reaction to
medication
 A platelet count that's lower
than normal
(thrombocytopenia) or higher
than normal
(thrombocytosis) is often a
sign of an underlying
medical condition, or it may
be a side effect from
medication..
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SERUM If you had a  blood glucose levels >149 Is used to find out if
GLUCOSE fasting blood mg/dl or above for the first your blood sugar
glucose test, a week after injury levels are in the healthy
level between 70 range. It is often used to
and 100 mg/dL help diagnose and
(3.9 and 5.6 monitor diabetes.
mmol/L) is
considered normal
.
If you had a
random blood
glucose test,
a normal result
depends on when
you last ate. Most
of the time,
the blood
glucose level will
be 125 mg/dL (6.9
mmol/L) or lower.
TOXICOLOGY Negative: No drugs POSITIVE: At least a trace of is a test that determines No special preparation is
SCREEN were found in your one or more drugs was found in the approximate amount required for a toxicology
system. This could your sample. If this happens, and type of legal or screen. However, it’s
be because you’ve another test is done to confirm illegal drugs that you’ve important to tell the
never taken the the result. This second test is taken. It may be used to appropriate person about any
types of drugs the more precise and can identify the screen for drug abuse, to prescription or over-the-
type of drug.
test was looking for monitor a substance counter medications you’re
or, if you have, abuse problem, or to taking. Certain medications
your body has evaluate drug can interfere with the test
already processed intoxication or overdose results.
them
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is most often done using

a urine or blood sample.
In some cases, a sample
of saliva or hair may be
used. The results can
show the presence of
one specific drug or a
variety of drugs at once.

The test is often ordered

to determine if someone
has taken drugs that
could endanger their
health.
ECG  RR interval:  Irregular heart rate  Prepare the Patient
0.6-1.2 The human heart typically beats While it is the physician who
seconds. at around 60–100 beats per orders the test, it is actually
 P wave: 80 minute. A heart that beats any the nurse who bears a large
milliseconds. faster or slower than this may part of the responsibility in
 PR interval: indicate an underlying issue. patient cardiac monitoring.
120-200  Irregular heart rhythm The first duty of the nurse is
milliseconds. A person may physically feel to prepare the patient to
 PR segment: changes in this rhythm, such as receive the electrodes
50-120 skipped heartbeats or feeling as attached to the monitoring
milliseconds. though the heart is fluttering. machine. The nurse must
 QRS complex:  Medication side effects: make sure that the area to
80-100 Taking certain medications can which the electrodes are to
milliseconds. impact a heart’s rate and rhythm. attach is clean and free of
 J-point: N/A. Sometimes, medications given to hair. This responsibility may
 ST segment: improve the heart’s rhythm can involve the washing and/or
80-120 have the reverse effect and shaving of the patient.

milliseconds. cause arrhythmias. Examples of
 T wave: 160 medications that affect heart
milliseconds. rhythm include beta-blockers,
sodium channel blockers,
and calcium channel
blockers. Learn more about
arrhythmia drugs.
 Electrolyte imbalances:
Electrolytes are electricity-
conducting particles in the body
that help keep the heart muscle
beating in
rhythm. Potassium, calcium,
and magnesium are electrolytes.
If your electrolytes are
imbalanced, you may have an
abnormal EKG reading.
30
 Affixing Electrodes
The nurse affixes the
electrodes to the patient. This
is a crucial step—improper
placement of the electrodes
could lead to inaccurate
results. As lives depend on
these delicate machines, it is
important that this is done
correctly. There are specific
areas of the skin on which
electrodes must be placed in
order to ensure accuracy.
These locations include the
right and left arms, right and
left legs, as well as various
locations along the rib cage.
 Monitoring
The nurse is also responsible
for observing the monitor,
ensuring that it is adjusted
correctly and reporting
accurate results. The nurse
cares for the patient while the
monitor is engaged,
intervening in case of an
emergency.

MRI (Magnetic  bruising or tearing of brain
Resonance tissue and bleeding within or
Imaging) surrounding the brain may
occur, with subsequent brain
swelling (edema)
 injury to microscopic nerve
fibers (axons), which
constitute the “wiring” that
connects nerve cells in the
brain (neurons) to each other
and to the rest of the body.
31
 Patient may be asked not to
eat or drink anything for 4 - 6
hours before the scan.
 Asked patient if they are
afraid of close spaces or
claustrophobia and inform the
doctor. Patient may be given
a medicine to help them feel
sleepy and less anxious, or
the doctor may suggest an
"open" MRI, in which the
machine is not as close to the
body.
 Explain to the patient what
she can expect during the
MRI, especially the
importance of lying still.
Warn her that the MRI
scanner will make loud
banging and clicking noises
but that earplugs or
headphones will be available.
 Before the test, asked the
patient if they have the
following:
 Artificial heart valves
 Brain aneurysm clips
 Heart defibrillator or
pacemaker
 Inner ear (cochlear)
implants
 Kidney disease or dialysis
(patient may not be able
 32

to receive contrast)
 Recently placed artificial
joints
 Vascular stents
 Worked with sheet metal
in the past (patient may
need tests to check for
metal pieces in their
eyes)
 4. Asked patients to
remove the following:
 Items such as jewelry,
watches, credit cards, and
hearing aids - may be
damaged.
 Pens, pocketknives, and
eyeglasses - may fly
across the room.
 Pins, hairpins, metal
zippers, and similar
metallic items - can
distort the images.
 Removable dental work
should be taken out just
before the scan.
 Because the MRI contains
strong magnets, metal objects
are not allowed into the room
with the MRI scanner.
 It is important to inform the
health care provider of any
pregnancy or suspected
pregnancy prior to the
 33

procedure.
b. During the procedure
 Patient will be asked to
remain perfectly still during
the time the imaging takes
place, but between sequences
some minor movement may
be allowed. The MRI
Technologist will advise
accordingly.
 When MRI procedure begins,
patient may breathe normally,
however, for certain
examinations it may be
necessary for you to hold
your breath for a short period
of time.
 Monitoring is indicated to
patients who are great
potential for change in
physiologic status (respiratory
rate, oxygen saturation,
temperature, heart rate and
blood pressure) during the
procedure or whenever a
patient requires observations
of vital physiologic
parameters due to an
underlying health problem.
 Monitoring is imperative to
patients who are using
sedative or anesthesia to
ensure patient safety
 34

c. After the procedure

 There is no recovery time,
unless you were given a
medicine to relax. After an
MRI scan, you can resume
your normal diet, activity, and
medications.
 If patient is sedated, patient is
transferred to the recovery
room for continue
monitoring. Especially
important for pediatric
patients because certain
medications have relatively
long half-lives (e.g., chloral
hydrate, pentobarbitol, etc.).

 Prior to allowing the patient

to leave the MRI facility, the
patient should be alert,
oriented, and have stable vital
signs. A responsible adult
should accompany the patient
home. Written instructions
that include an emergency
telephone number should be
provided to the patient.
 35

CT (Computed  Before the procedure

Tomography)  Informed Consent. Obtain an
Scan informed consent properly
signed.
 Look for allergies. Assess for
any history of allergies to
iodinated dye or shellfish if
contrast media is to be used.
 Get health history. Ask the
patient about any recent
illnesses or other medical
conditions and current
medications being taken. The
specific type of CT scan
determines the need for an
oral or I.V. contrast medium
 Check for NPO
status. Instruct the patient to
not to eat or drink for a period
amount of time especially if a
contrast material will be used.
 Get dressed up. Instruct the
patient to wear comfortable,
loose-fitting clothing during
the exam.
 Provide information about the
contrast medium. Tell the
patient that a mild transient
pain from the needle puncture
and a flushed sensation from
an I.V. contrast medium will
be experienced.
 Instruct the patient to remain
 36

still. During the examination,

tell the patient to remain still
and to immediately report
symptoms of itching,
difficulty breathing or
swallowing, nausea,
vomiting, dizziness, and
headache.
 Inform about the duration of
the procedure. Inform the
patient that the procedure
takes from five (5) minutes to
one (1) hour depending on the
type of CT scan and his
ability to relax and remain
still.
 After the procedure
 The nurse should be aware of
these post-procedure nursing
interventions after computed
tomography (CT) scan:
 Diet as usual. Instruct the
patient to resume the usual
diet and activities unless
otherwise ordered.
 Encourage the patient to
increase fluid intake (if
a contrast is given). This is so
to promote excretion of the
dye.
 37

PET scan (-) hematoma (+)hematoma (blood clot), 

Positron (-)bleeding bleeding, and/or low perfusion
emission Normal blood and (blood and oxygen flow) of the
tomography oxygen flow of the brain tissue
brain tissue

Intracranial  Low and stable ICP (below
pressure (ICP) 20 mm Hg)—for example,
monitoring. seen in patients following
uncomplicated head injury.
Such a pattern is also
commonly seen in the initial
period after brain trauma
before the brain swelling
evolves.
 High and stable ICP (above
20 mm Hg)—the most
common picture to follow
head injury
 Vasogenic waves—“B”
waves (fig 1C) and plateau
waves
 ICP waves related to changes
in arterial pressure and
hyperaemic events
 Refractory intracranial
hypertension (fig 1H). This
usually leads to death unless
To determine if high or  Sometimes, swelling of
low cerebrospinal fluid
(CSF) pressure is
causing your symptoms.
The test measures the
pressure in your head
directly using a small
pressure-sensitive probe
that is inserted through
the skull.
the brain from a TBI can
increase pressure inside
the skull. The pressure
can cause additional
damage to the brain. A
health care provider may
insert a probe through the
skull to monitor this
swelling.On some cases, a
shunt or drain is placed
into the skull to relieve
ICP.
 38

radical measures—for
example, surgical
decompression, are applied.

Evoked If the test indicates To help  sign a consent form

potential diagnose multiple  tell their doctor about any
that MS might be sclerosis (MS) and other health issues, allergies,
present, a doctor conditions that can and medications they are
cause a person's using
will usually do  bring their glasses if they
reactions to slow. The
further tests to are doing a visual test
test can detect unusual
 They are unlikely to need
confirm the responses to stimulation. to fast or stop using
diagnosis and rule medications before the
To confirm a diagnosis test.
out other possible
or monitor the nervous  The healthcare
causes of system, rather than to professional conducting
symptoms. determine the cause of a the test will use a special
slow reaction. paste, jelly, or tape to
attach the electrodes.
If the results of all  The location of the
the tests indicate electrodes will depend on
the type of test. Then, the
MS, a doctor will test can begin
work with the

individual to
provide
appropriate
treatment and
monitoring.
Blood no narrowing or Abnormal blood flow patterns,
Flow/Doppler blockages in your including narrowing or closing
arteries. It also of the arteries, can indicate:
means that the  blockage in the arteries,
blood pressure in which may be due to a
your arteries is buildup of cholesterol
normal  blood clots in a vein or artery
 poor circulation, which can
be caused by damaged blood
vessels
 venous occlusion, or closing
of a vein
 spastic arterial disease, a
condition in which the
arteries contract due to stress
or exposure to cold weather
 blockage or clots in an
artificial bypass graft
39
To detect abnormal flow Remove clothing, jewelry,
within an artery or blood and any other objects from
vessel. This can help to the area that will be studied.
diagnose and treat a However, there’s no need to
variety of conditions, remove your glasses, contact
including blood lenses, dentures, or hearing
clots and poor aids. You may be asked to
circulation. A Doppler wear a hospital gown.
ultrasound can be used After the procedure
as part of a blood flow In general, there are no
study. special instructions following
a Doppler ultrasound. You
may resume your usual
To show signs of activities right away, unless
decreased blood flow in your doctor tells you
the arteries or veins of otherwise
your legs, arms, or neck. In general, there’s no
A reduced amount of preparation required for this
blood flow may be due test. If you’re a smoker, your
to a blockage in the doctor may ask you to stop
 40

artery, a blood clot smoking for several hours

inside a blood vessel, or before the
an injury to a blood test. Smoking causes your
vessel. blood vessels to narrow,
which can affect the results of
your test.
 41

Pharmacology/Medications

DRUG MECHANISM SIDE USE AND CONTRAINDICATION NURSING

OF ACTION EFFECTS DOSAGE RESPONSIBILITIES
Benzodiazepines Enhances the  Anticholinergi Relieve pain DO NOT USE Watch for CNS effect
effect of the c (dry mouth) and discomfort  Compromised
 Minor neurotransmitter  Blurred vision from pulmonary Monitor CBC, WBC
Traquillizers gamma-  Constipation musculoskeletal function with differentiation
 Anticonvulsant aminobutyric  Drowsiness disorders,  Hepatic disease
 Anxiolytic acid (GABA)  Cardiovascula manage anxiety  Impaired Notify physician if BP
r collapse myocardial drop of 20 mmHg
resulting in and manage
sedative, acute alcohol function
 Acute alcohol Assess for allergic
 Absorbed from GI hypnotic (sleep Adverse withdrawal
intoxication reaction including
metabolize in liver inducing), Effect/Toxicit
 Narrow angle idiosyncratic reaction,
anxiolytic (anti- y: Maximum anaphylaxis, rash,
Onset: 30 minutes IM, 60  Erythema glaucoma, open
anxiety), effect will be fever respiratory
PO, 15 IV, works quickly  Angioedema angle glaucoma
anticonvulsant seen in 1-2 distress
Peak: 1-2hr PO and muscle  Anaphylaxis weeks
Duration: 15 minutes to relaxant  Dysrhythmia Do not stop abruptly-
1hr IV; up to 3 hrs PO properties, often  Seizure Dosage: withdrawal symptoms
Half-life: 20-50 minutes leads to The initial dose will occur (insomnia,
improve is 2 mg two to nausea, spasticity,
tachycardia)
physical and four times a
mental health day; the dose
No alcohol (will
can be increase CNS
increased by 1- depression)
2mg daily; the
usual Suicide prevention
therapeutic precautions
dose is 15-30
 42

mg total/day,
with twice daily
or three times a
day dosing. An
IM dose of 10
mg can be
administered
every 4 hours if
needed for
alcohol
withdrawal
 43

DRUG MECHANISM SIDE USE AND CONTRAINDICATION NURSING

OF ACTION EFFECTS DOSAGE RESPONSIBILITIES
Lorazepam (Antivan) Act on the  Fatigue Management of DO NOT USE In patients with
brain and  Drowsiness anxiety  Hypersensitivity to depression, a possibility
 Antianxiety nerves (CNS)  Amnesia disorders benzodiazepines or for suicide should be
agent to produce a  Memory Short-term to any components borne in mind;
calming effect, impairment relief of the of the formulation benzodiazepines should
this drug works  Confusion symptoms of  Acute narrow-angle not be used such patients
 Disorientation glaucoma without adequate
by enhancing anxiety with
antidepressant therapy
the effects of a  Depression depressive
certain natural  Suicidal symptoms Should be used with
chemical in the ideation
caution in patients with
body (GABA)  Seizures The usual range compromised respiratory
 Tremors is 2 to 6 mg/day function (COPD, sleep
 Vertigo given in divided apnea syndrome)
 Visual doses, the
disturbance largest dose Elderly or debilitated
 Slurred being taken patients should be
speech monitored frequently
before bedtime,
 Nausea and have their dosage
but daily dosage
 Constipation adjusted
may vary from
1 to 10 mg/day
Should be used with
caution in pateints with
For anxiety, problem with renal
most patient lorazepam may worsen
require an initial hepatic encephalopathy
dose of 2 to 3
mg/day given
BID or TID
 44

For insomnia
due to anxiety
or transient
situational
stress, a single
daily dose of 2
to 4 mg may be
given usually
bedtime

For elderly or
debilitated
patients, an
initial dosage of
1 to 2 mg/day in
divided doses is
recommended
to be adjusted as
needed and
tolerated
 45

PHARMACOLOGY/MEDICATION
DRUG MECHANISM SIDE USE CONTRAINDICATION NURSING
OF ACTION EFFECTS AND RESPONSIBILITIES
DOSAGE
Midazolam (Versed) Physiologic:  Nausea Dosage: DO NOT USE Assess level of sedation
 Short-term  Vomiting IV: inject  Hypersensitivity to and level of
 Anti-anxiety agents sedation  Headache 2.5 mg for benzodiazepines or consciousness
 Sedatives/hypnotics  Postoperative  Laryngospas 2 minutes to any components throughout for 2-6 hr
amnesia m (never as of the formulation following
 Dyspnea bolus)  Chronic respiratory administration
Pharmacologic  Hallucination IM: 0.07- insufficiency
Monitor BP, pulse and
 Acts at many s 0.08 respiration continuously
levels of the  Over mg/kg
CNS to during IV
sedation
administration. Oxygen
produce  Drowsiness Route: and resuscitative
generalized  Ataxia IM, IV equipment should be
CNS  Rash immediately available
depression  Paradoxical
 Effects may Reactions If overdose occurs
be mediated Amnesic monitor pulse,
by GABA, an
episodes respiration and BP
inhibitory
contiously
neurotransmit
ter
 46

DRUG MECHANISM SIDE EFFECTS USE AND CONTRAINDICATION NURSING

OF ACTION DOSAGE RESPONSIBILITIES
Propofol (Diprivan) Propofol is a  Involuntary muscle Adult: 40 DO NOT USE Patient must be
short-acting movements mg injection  Electroconvulsive intubated and ventilated
 Hypnotic anesthetic  Nausea or infusion therapy
agent given for  Vomiting every 10  Obstetrics Monitor: HR, ECG,
induction and  Headache seconds.  Pregnancy Pulse Ox, BP
maintenance of  Fever Usual dose:  Lactation
 Pain  Egg hypersensitivity Abrupt discontinuation
general 1.5-2.5
of infusion may result in
anesthesia.  Burning or stinging mg/kg  Soya lecithin
rapid awakening with
at injection site Maintenance:  Hypersensitivity; use
agitation, anxiety
Onset: 3-10 4- 12 cautiously in
minutes Potentially fatal mg/kg/hr or hypotensive patients
Discard tubing/bottle
Distribution:  Apnea Intermittent after 12 hours
Extensively  Bradycardia bolus
redistributed  Hypotension injection of Do not use if emulsion
from brain to  Convulsions 20-50 mg appears separated
other tissues;  Anaphylaxis
crosses the Child:>8 Maintain strict aseptic
placenta and years old f technique because
emulsion will support
enters breast 2.5 mg/kg
rapid growth of
milk Maintenance
microorganisms
Metabolism: dose: 9-15
Extensively mg/kg/hr by If hypotension or
hepatic; IV bradycardia occurs,
converted to a Infusion or decrease or stop
water-soluble intermittent Diprivan and monitor
sulfate and bolus BP and HR, notify
glucuronide injection physician
 47

conjugates
Excretion: Document nuero
Elderly: assessment on
Urine (as Including awakening (Ramsey
metabolites); neurosurgical level of sedation scale)
feces and
Elimination debilitated
half-life; 40 patients:
mins (initial); Infuse at the
4-7hr rate of 20 mg
every 10
seconds.
Maintenance:
3-6 mg/kg/hr
 48

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
No subjective cues Ineffective Following an 8-hr  Assessed  Provides a basis At the end of the
airway clearance nursing intervention, respiratory rate. for evaluating shift, the client was
related to the client will be adequacy of able to display
Objective: hypoxia. able to: ventilation. patency of airway as
 Dyspnea;  Normal manifested by:
use of breathing  Noted chest  Use of  Client’s
accessory pattern: movement; use of accessory respiratory
muscles for RR= 12-20 accessory muscles muscles of rate is within
respiration: cpm during respiration. respiration may normal range:
elevated occur in RR-18 bpm.
shoulders. response to
ineffective
 Increase in ventilation.
 Auscultated breath
respiratory sounds; noted areas
rate:  Crackles
with presence of
RR- 25cpm indicate
adventitious
accumulation of
sounds.
secretions and
inability to clear
airways
 49

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
No subjective cues Ineffective After 4 hours of  Monitored blood  To know the After 4 hours of
cerebral tissue nursing intervention pressure every base line of BP nursing intervention
perfusion related the patient blood 4hours. the patient’s blood
Objective: to increased pressure will pressure was
PR = 85 bpm intracranial decrease from  Instructed to have  Sodium tends to decreased from
RR = 30 bpm pressure and enough rest on be excreted at a 160/100mmHg to
160/100mmHg to
BP = vasoconstriction semi-fowlers faster rate. 140/90mmHg.
120/80mmHg. position.
160/100mmHg of blood vessels.
 To reduce
 Instructed to eat edema that may
low fat and low salt activate renin
diet. angiotensin-
aldosterone
system.

 To control the
BP and to avoid
 Administered anti- other
hypertensive drug complications.
as ordered.
 50

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
No subjective cues Risk for injury After 3 hours of  Monitor peripheral  To assess After 3 hours of
related to brain nursing intervention, pulses and vital baseline data. nursing intervention,
damage. the client will be signs, especially the the client was able to:
Objective: able to: heart rate every  Verbalized
T: 36.7  Verbalize hour to every four understanding
PR: 65 bpm understandin hours depending on of individual
RR: 18 cpm g of the client’s factors that
individual condition. contribute to
BP: 120/70 mmHg
factors that possibility of
contribute to injury and
 To assist client
possibility of  Provide information to reduce or
take steps to
injury and regarding correct
correct
take steps to disease/condition situations.
individual risk
correct that may result in factor. Goal was met.
situations increased risk of
injury.
 51

DISCHARGE PLAN

A. METHODS
1. Medications
Name of Dosage Route Curative Effects Side Effects Instructions
Drug Preparation
(Generic and Frequency
Trade Name) Duration
Aspirin 325 - 650 mg ORAL GI: Hepatic Inform the
q 4hr Failure Attending
Hepatotoxicity physician or
GU: renal nurse if
failure allergic to
DERM: rash, any kinds of
urticaria oral
medications.
Atorvastatin 5 - 10 mg OD ORAL CNS: Dizziness,
Headache,
insomnia,
weakness,
GI: abdominal
cramps,
constipation,
diarrhea, flatus,
heartburn,
nausea
Trazodone 150 mg/day in ORAL CNS:
3 divided drowsiness,
doses confusion,
dizziness,
fatigue,
hallucinations,
headache
CV:
hypotension
GI: dry mouth,
altered taste,
constipation,
diarrhea, nausea
and vomiting
 52

2. Exercise/Activity and Home Environment

Type of Activity Allowed/To be continued: Attention and Concentration

Exercises for TBI

Procedure or Steps:
a. Repeat numbers and letters
b. Rhythm Matching
c. Practice fine motor exercises
d. Sit outside and journal
e. Use your non-dominant hand

3. Treatments/Therapies: Cognitive Rehabilitation

a. Picture Recall
b. Naming Therapy
c. Grocery list

4. Health Teaching/Education
Health Prevention/Promotion
a. Prevent from getting into accidents
b. Wear safety helmets when traveling in a motorbike
c. Good Nutrition
d. Family Participation and Education

5. Diet
3- Day Sample Menu

Day 1 Day 2 Day 3

Breakfast: English Muffin, Breakfast: Cereal with banana Breakfast: Toast
fried egg and fruit juice and blueberries

Lunch: Tuna Salad Lunch: Salmon Lunch: Broccoli & Cheese

baked potatoes
Dinner: Meat loaf and & Dinner: Spaghetti Dinner: Baked penne w/tuna
Mashed Potato and spinach
 53

a. Diet Restrictions:

 Dairy products (butter, cream, milk, cheese etc…)

 Fatty meat cuts like ribeye steak or lamb chops
 Processed meat (salami or sausages)
 Sugary drinks

6. Spiritual Care and Psychological or Sexual Needs (Give special consideration to

religious and cultural practices)
Spiritual and Psychological Needs
(-) Spiritual Counseling
( ) Grief Work
( ) Anger Management
( ) Confession
(-) Family Therapy
( ) Reconciliation of Conflicted Relationships
(-) Supportive Counseling
( ) Join Church Organizations/Activities
(-) Prayer
(-) Meditation, Reflection, and Spiritual Devotion
( ) Religious Rituals
( ) Religious/Spiritual Materials

Sexual Needs
(-) Marriage Counseling
( ) Sex Therapy
( ) Sexual Violence
( ) Referral to Appropriate Agencies
 54

REFERENCES
 Doenges, Moorhouse, &Murr (2006).Nurse’s pocket guide: diagnoses, prioritized

interventions and rationales. 10th edition. Philadelphia. PHL: F.A. Davis company

 Doenges, Moorhouse, &Murr (2010).Nurse’s pocket guide: diagnoses, prioritized

interventions and rationales. 12th edition. Philadelphia. PHL: F.A. Davis company

 Doenges, Moorhouse, &Murr (2013).Nurse’s pocket guide: diagnoses, prioritized

interventions and rationales. 13th edition. Philadelphia. PHL: F.A. Davis company

 Hinkle,J&Cheever,K(2014). Medical-surgical nursing volume 13th Edition. London:

Lippincott Williams & Wilkins

 Ralph & Taylor (2011). Nurse’s pocket guide: diagnoses, prioritized interventions and

rationales. 13th edition. Philadelphia. PHL: F.A. Davis company

 Smeltzer, Bare, Hingkle, and Cheever, K (2010).Textbook of medical-surgical nursing,

12th edition.Philadelpha, PA:Lippincott Williams & Wilkins

 Workman, I. (2010). Medical- surgical nursing: patient centered care approach. 6th

edition. Singapore. SG: Saunders Elsevier

 Workman, I. (2018). Medical- surgical nursing: concepts for interpersonal collaborative

care. 9thedition.Canada. CA: Saunders Elsevier

55