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INTRODUCTION DEFINITION: It is an insult to the brain that is capable of producing physical, intellectual, emotional, social, and vocational changes.

STATISTICS: In the United States, a head injury is experienced approximately every 15 seconds. It occurs in about 7 million Americans every year. In our country, hospitalized cases among these severely head-injured people runs at about 500,000 and 100,000 of these experience chronic disability, and about 2000 are left in a persistent vegetative state. Clients with traumatic head injuries often have other major injuries including injury to the facial structures, lungs, heart, cervical spine, abdomen and bones. Facial fractures and lung injury may contribute to respiratory insufficiency. Airway obstruction and decrease ability to breathe (e.g. from pulmonary contusion, flail chest, pneumothorax) contribute to respiratory insufficiency and poor oxygenation of the brain and other tissues. Ischemia of brain tissue may result. RISK FACTORS: Motor-vehicle accidents are the leading cause of head injuries. Of clients admitted to the Emergency Department, most are males younger than 30 years and 50% have evidenced of ingestion of alcohol or other substances of abuse. Second risk factor is driving without seat belts. Peak occurrence is during evenings, nights, and weekends. Other causes are assaults, falls, and sports-related injuries. PREVENTION: Of all those incidents, major treatment for us to consider is prevention such as avoiding from drinking alcohol when driving, use helmets and other protective gears for those driving a 2-wheeled-vehicles and if possible do not drive during night time. BACKGROUND OF THE STUDY: The reason why I have chosen head injury as my topic for my case study is because these incidents are prevalent nowadays not only to our country but for some other foreign countries also. I am also concerned on this matter since every year it is gradually increasing in mortality and morbidity rate. Moreover, the case is not only exclusive to traumatic brain injury but the condition have further complicate into

pneumonia which is common among patients during their prolonged hospital stay. Thus, this has added to my interest to choose the case. SCOPE AND LIMITATION: For scope and limitation, we only focus on patients condition and his hospitalization period September 16-17, 2011. I then assessed the patient in a cephalocaudal approached. I gathered data in order to give necessary interventions and health teachings to the patient.

CLIENTS PROFILE SOCIO-DEMOGRAPHIC DATA This is a case of Patient Inday, 21-year-old, female, a Roman Catholic, and a residence from Baloy, Cagayan de Oro City admitted last September 3, 2011 at Capitol University Medical City (CUMC) due to a vehicular crush. I. Heath Perception and Health Management Pattern History of Present Illness Few hours prior to admission, she was driving 2-wheeled-vehicle which was hit by a 4-wheeled-vehicle upon her way home from a birthday party of a friend. Since then, admitted. Previous Hospitalization/Surgeries Patient Inday has no previous hospitalization or surgeries experienced. Statement of Patients General Appearance Patient Inday appears to be well-nourished, but restless, and does not maintain eye contact. Patient is not known to be hypertensive, diabetic and asthmatic. He also has no food or drug allergies. A non cigarette smoker but used to drink alcoholic beverages occasionally .consuming about 500mL of beer. II. Nutrition and Metabolic Pattern She is in an Osteorized Feeding diet of 1,500-2,000mL per day and also advice to consumed one jelly ace every 4 hours. III. Elimination Pattern Patient inday wears diaper and defecates once in two days with well-formed stool and brownish in color. She was on a foley catheter attached to urobag draining with yellowish colored urine amounting 1,500 2,000mL daily. IV. Activity and Exercise Pattern (During admission) Type of exercise is range of motion exercise everyday. Leisure activity includes watching television.

Activities of Daily Living (during admission) ADL Status Feeding 4 Meal preparation Bathing 4 Cleaning Dressing 4 Laundry grooming 4 Toileting 0- Total independence 1- Assist with device 2- Assist with person 3- Assist with person & device 4 -Total dependence V. Cognitive-Perceptual Pattern

4 4 4 4

Mobility Status Bed mobility 2 Chair/toilet transfer Ambulation R.O.M. 2 2 0

Patient Inday appears to be restless especially during assessment. She had also loss her ability to articulate and verbalized feelings. She does not maintain eye contact, lack interest in communication. She only raised her eyebrows when being asked. VI. Sleep-Rest Pattern Patient Inday usually sleeps 8-10 hours a day. She sleeps at around 9pm and wakes up at around 8-9am. According to the watcher, patient is usually awaken at night due to pain and cough. VII. Self-perception and Self-concept Pattern Self-perception and self-concept pattern was not assessed since patient since patient refuses to speak. VIII. Role-Relationship Pattern Patient is living with her family at Baloy. The person that helped the most during hospitalization was her brother-in-law. Patient Indays parents are both alive and well. IX. Coping Stress Tolerance Ptter This was not assessed since patient Inday refused to speak. X. Value Belief Pattern Patient Inday is a Roman Catholic and patients mother states that it is really important in a way of making them strong in times of any problems and struggles they may encounter in their lives.

PHYSICAL ASSESSMENT I conducted a one day assessment to determine the present condition of my patient. I took patients vital signs and Neuro-Vital Signs. I also conducted a cephalocaudal physical assessment utilizing the Gordons physical assessment tool. Texts in red indicate abnormal findings. VITAL SIGNS Day 1 36.5 degree Celsius 88 bpm 28 cpm 110/70 mm Hg 80% Day 2 36.0 degree Celsius 78bpm 25 cpm 120/80 mm Hg 90% Day 3 36.8 degree Celsius 80 bpm 23 cpm 120/80 mm Hg 93%

Temperature Pulse rate Respiratory rate Blood pressure O2 saturation NEUROVITALSIGNS Glasgow Coma scale Eye opening Verbal Motor TOTAL

Day 1
Response Open spontaneously None Obeys command Moderate TBI Points 4 1 6 11

Day 2
Response Open spontaneously None Obeys command Moderate TBI Points 4 1 6 11

Day 3
Response Open spontaneously None Obeys command Moderate TBI Points 4 1 6 11

PHYSICAL ASSESMENT MOUTH Lips Mucosa Tongue Teeth Gums PHARYNX Uvula Tonsils Posterior Pharynx Day 1 Midline Not inflamed Not inflamed congested Day 2 Midline Not inflamed nor Not inflamed congested DAY 3 Midline Not inflamed nor Not inflamed nor congested Day 1 Cracked/dry Pinkish Midline Missing tooth noted (front tooth) Pinkish Day 2 Pinkish Pinkish Midline Missing tooth noted (front tooth) Pinkish DAY 3 Pinkish Pinkish Midline Missing tooth noted (front tooth) Pinkish

NECK Trachea Thyroids Cervical nodes Others SKIN Day 1 General Color Texture Turgor Temperature Moisture Others Dusky Smooth Supple Warm Dry With abrasion over Day 2 Dusky Smooth Supple Warm Dry With abrasion over dry DAY 3 Dusky Smooth Supple Warm Dry With abrasion over Day 1 Day 2 Midline Midline Non-palpable Non-palpable lymph Not enlarged nor Not enlarged inflamed Normal ROM inflamed Normal ROM DAY 3 Midline Non-palpable nor Not enlarged nor inflamed Normal ROM

the left arm and the left arm and left the left arm and left leg; dry with leg; granulation tissues ABDOMEN General No veins, Configuration Bowel Sounds Percussion Palpation Day 1 superficial No scars or veins, Day 2 superficial No scars or veins, DAY 3 superficial scars or with left leg; dry with granulation tissues granulation tissues

lesions Symmetrical Normoactive Tympanic Nontender

lesions Symmetrical Normoactive Tympanic Nontender

lesions Symmetrical Normoactive Tympanic Nontender

CARDIOVASCULAR STATUS Day 1 Pericardial area Flat Point of Maximal 5th Impulse space, Flat Intercostal 5th mid- space, clavicular normal 90bpm, rhythm regular Symmetrical, regular (+2) 2 seconds Othostatic 120/80mm in standing Day 2 Flat Intercostal 5th mid- space, clavicular normal 88bpm, DAY 3 Intercostal midnormal

clavicular Apical Rate and 92 bpm, Rhythm rhythm Heart sounds regular Peripheral Pulses Symmetrical, Capillary Refill Others regular (+2) 2 seconds Othostatic hypotension

rhythm regular Symmetrical, regular (+2) 3 seconds Othostatic

noted hypotension noted hypotension

(from 120/80mm Hg (from in standing position Hg

to

90/60

upon position

to

90/60

sitting) RESPIRATORY STATUS Breathing pattern Day 1 Tachypnea, dyspnea, use of accessory muscles for respirationelevated shoulders. Shape of Chest Lung Expansion Vocal/Tactile Fremitus Percussion Breath Sounds AP:L = 1:2 symmetrical symmetrical Hyperresonant Rales heard upon auscultation on (R) Cough and (L) lung bases Productive cough noted with yellowish sputum in color and 20 ml in amount collected in an 8-hr shift. BACK AND EXTERMITIES

upon sitting)

Day 2 Eupnea, absence of use of accessory muscles for respiration.

DAY 3 Eupnea, absence of use of accessory muscles for respiration.

AP:L = 1:2 symmetrical symmetrical Hyperresonant Rales heard upon auscultation on (R) and (L) lung bases Productive cough noted with yellowish sputum in color and 40 ml in amount collected in an 8-hr shift.

AP:L = 1:2 symmetrical symmetrical Resonant Normal breath sounds Productive cough noted with yellowish sputum in color and 2 ml in amount collected in an 8-hr shift.

Day 1 Day 2 Range of Motion Full Full Muscle tone and Muscle Weakness Muscle Weakness strength in extremities, in extremities, symmetrical in size symmetrical in size Spine Midline Midline Gait Staggering Staggering Others With IV insertion at With IV insertion at vein COGNITION Day 1 Day 2 vein

DAY 3 Full Improved stregnth, symmetrical in size Midline Staggering With IV insertion at vein

the L metacarpal the L metacarpal the L metacarpal

DAY 3

Level Consciousness Orientation Emotional State Others

of Conscious and alert Conscious and alert Conscious Oriented to time, Oriented to

and

alert time, Oriented to time, place person calm Dizziness upon sitting or standing; Inability to articulate

place person Restless Dizziness upon sitting or standing ; Inability to articulate

place person calm Dizziness upon sitting or standing; Inability to articulate

HEAD Shape Facial Movements Fontanels Hair Scalp EYES lids Periorbital region Day 1 symmetrical No Day 2 symmetrical DAY 3 symmetrical edema, not Day 1 Normocephalic Symmetrical Closed Fine, distributed Dandruff Day 2 Normocephalic Symmetrical Closed evenly Fine, distributed Dandruff DAY 3 Normocephalic Symmetrical Closed evenly Fine, distibuted Dandruff

evenly

edema, No

edema, No

discoloration, Conjunctiva Cornea & Lens sunken pink Not opaque,

not discoloration, sunken pink no Not opaque, lesions Anicteric Equal, 3mm Brisk Uniform constriction/ convergance Grossly normal Intact/full

not discoloration, sunken pink no Not opaque, lesions Anicteric Equal, 3mm Brisk Uniform constriction/ convergance Grossly normal Intact/full

no

lesions Sclera Anicteric Pupils Equal, 3mm Reaction to light Brisk Reaction to Uniform accommodation Visual Acuity Peripheral Vision EARS External pinnae External canal Day 1 Normoset constriction/ convergance Grossly normal Intact/full

Day 2 Normoset

DAY 3 Normoset

No discharge, with No discharge, with No discharge, with cerumen (not cerumen (not cerumen (not

Tympanic membrane Gross hearing NOSE Mucosa Patency Septum Discharge Gross Smell Sinuses

impacted) Intact Normal

impacted) Intact Normal

impacted) Intact Normal

Day 1 Pinkish R with NGT,

Day 2 Pinkish L R with NGT,

DAY 3 Pinkish L R with NGT, L

patent Midline None Normal/symmetrical Nontender

patent Midline None Normal/symmetrical Nontender

patent Midline None Normal/symmetrical Nontender

SEXUALITY-REPRODUCTIVE PATTERN Penis No Day 1 discharge, No Day 2 discharge, No DAY 3 discharge, lesions catheter to the

nodules, foley attached Scrotum Others

lesions nodules, catheter foley to the attached

lesions nodules, catheter foley to the attached

nor growths, with nor growths, with nor growths, with

urethra urethra urethra Equal shape with L Equal shape with L Equal shape with L lower than R lower than R lower than R No prostate No prostate No prostate problem, hernia nor problem, hernia nor problem, hernia nor hydrocele hydrocele hydrocele

DIAGNOSTIC AND LABORATORY FIDINGS The following are results of laboratory and diagnostic procedures done to the patient. These were the latest among the results. Abnormal findings are in red texts.

LABORATORY RESULTS Complete Blood Count (September 13, 2011)


Test Hemoglobin Definition It is the main component of red blood cells. Its main function is to carry oxygen from the lungs to the body tissues and to transport Carbon Dioxide, the product of cellular metabolism, back to the lungs. It is the measurement of the percentage of red blood cells in the total volume of blood. It is expressed as the percentage of red cells in the total blood volume. The total white blood count (WBC) is the absolute number of white blood cells (leukocytes) circulating in a cubic millimeter of blood. Also called thrombocytes, are large, non-nucleated cells derived from the megakaryotes produced in the bone marrow. They promote coagulation. A mature blood cell that contains hemoglobin to carry oxygen to the bodily tissues Result 11.0 Reference range 13.7-16.7 g/mL Interpretation Decreaseddenotes for hemorrhage

Hematocrit

33

40.5-49.7 gm %

Decreasedaccount for acute blood

White Blood Cell

16,600

5,000-10,000 cell/mm3

Increasedindicates infection

Platelet Count

660,000

144,000372,000 cell/mm3

Increased Elevated level signifies thrombocytosis resulting from hemorrhage, Decreasedindicates hemorrhage

Red Blodd Cells

3.69

4.7 6.1 10^6/uL

DIFFERENTIAL COUNT
Test Lymphocytes Definition They play a role in our immune response They play a role in allergic reactions, possibly inactivating histamine. Responds more rapidly to inflammatory and tissue injury sites Result 86 Reference range 45-70% Interpretation Increasedpresence of viral infection Decreasedhemorrhage Increasedpresence of bacterial infection

Eosonophil

13

18-45%

Neutrophil

86

45-70%

URINALYSIS (September 12, 2011)


Test Color transparency Specific gravity Sugar Measurement of the concentration of urine Serum sugar normally does not leak into the glomerular filtrate Serum protein normally does not leak into the glomerular filtrate Definition Result Pale yellow Clear 1.005 Reference range yellow Slightly turbid 1.005-1.030 Interpretation Diluted urine May indicate bacteria Normal- no significant clinical finding Normal no clinical significance Normal- No clinical significance Normal- No clinical significance Normal - No clinical significance Normal -No clinical significance Normal no clinical significance

negative

negative

Protein

Negative

Negative

PUS cells RBC Epithelial cells Bacteria

Negative Negative Negative Rare

Negative Negative Negative Rare/few

CLINICAL CHEMISTRY (September 8, 2011)


Test Sodium Definition
Sodium is the dominant extracellular cation and cannot freely cross the cell membrane. Its homeostasis is vital to the normal physiologic function of cells.
an electrolyte, a substance that conducts electricity in the body.

Result 135

Reference range 135-148 mmoL/L

Interpretation Normal- no clinical significance

Potassium

3.0

3.5-5.3 mmoL/L

Hypokalemia inadequate potassium intake

DIAGNOSTIC FINDINGS

CT SCAN OF THE HEAD Multiple pain (non-contrast-enhanced) axial tomographic sections of the head reveal two irregular densities in the right caudate nucleus and right internal capsule measuring 1.2cm and 0.7cm in widest diameters respectively. The ventricles basilar cistern and peripheral sulci are otherwise normal in size and configuration, with no midline shift or gross mass effect. The silla, pineal gland, posterior fossa structures including cerebellum, brain stem and cerebello-pontine are otherwise not unusual. Intact eye globes, skull base and calvarium. There are comminuted and depressed fractures of all the walls of the of the left maxillary antrum. A minimally displaced fracture of the left lateral orbital wall is also noted associated with extensive left maxilla-facial and periorbital soft tissue swelling. There is minimal mid-frontal subgaleal edema. Densities are noted within the left maxillary, ethmoid sinuses and left nasal cavity. The rest of the visualized paranasal sinuses are remarkable. IMPRESSION: Small acute intracerebral hemorrhage, right caudate nucleus and right internal capsule multiple left maxilla-facial and orbital fractures with extensive overlying tissue swelling left maxillary, ethmoid hemosinus and nasal cavity hematoma. Minimal frontal subgaleal edema.