Submitted to: Mr.

Warren Victor Espiritu, RN, MSN

GROUP III
1. 2. 3. 4. 5. 6. 7. 8. ACOBA, Jerlyn Joy A. BALISI, Darrel Grace BRUNO, Sheila BEJARIN, Nievelyn BUGUINA, Remely LAYUGAN, Gladilyn ENTRADA, Paul MARAVILLA, Karlmike

Name : Mr. MC Address : Zone 03, San Mariano, Isabela Birthday : August 17, 1987 Age : 23 y/o Sex : Male Civil Status : Single Religion : Roman Catholic Nationality : Filipino Occupation : Delivery Boy of Brad Date of Admission : January 10, 2010 at 10pm Personal Data Chief Complaint : loss of consciousness Attending Physician : Dr. Badua

 Present Medical History

The patient S.O. (Significant others) told that January 9, 2010at 2 am, PTA (prior to admission), the patient was a delivery boy on a bakery somewhere in San Mariano. After their working hours, he and his coworkers decided to drink alcohol as their past time unfortunately when they get drink his co-workers punched his face and head until he got loss of consciousness then his boss called to his mother to report what happened to his son but the owner of the bakery says that the boy was only drunk but the mother sees her child vomiting with blood for several times thats why she decided to rushed into the hospital in San Mariano Medicare Center, under Dr. Lazaro, where he was observed and decided to refer him at Provincial Hospital. Diagnostic exam like x-ray was perforned in IPH and CT- Scan in IDGH. They find out what has been damage in his. At present he is suffering from difficulty in speech he prefer to communicate in nonverbal manner, the patient also complaints of pain on the affected part particularly on his face and forehead. This was his first hospitalization under care of Dr. Paguirigan.

Past Health History

According to the S.O. of the patient he had completed her immunization during his childhood, and during his elementary days he had experienced having mumps and measles he also experienced common illnesses such as cough, colds, fever and managed it with OTC drugs. More over he does not notice any allergy on foods, medicine and etc. but he does not prefer any vegetables to eat. Furthermore he never been hospitalized and never experienced any kind of accidents.

Family Health History

The patient know to have a family history of hypertension to both father and mother, they are six in the family and he is the 3rd among his siblings.

Social Health History

A residence of Zone 3, San Mariano, Isabela and Ilocano in ethnicity. His family belief in atang and albularyos and need of herbal plants (leaves of pineapple & oregano) as an after native treatment in such illness. He is also a delivery boy on a bakery and lives with parents and brothers and have good relationship to their family and neighbors.

Patterns

Before Hospitalization
According to the S.O, she perceived the usual health of her son as excellent. The patient brushes his teeth 3 times a day and already consult dentist for dental check-up. He is using prosthesis. In addition, Mr. MC is not smoking but he is drinking liquor. Moreover, the S.O. stated that they uses OTC drugs whenever they experience common illnesses such as Neozep, Paracetamol, Mefenamic ..

During Hospitalization
Mr. MC presence health condition is poor due to different symptoms he experiences. He brush his teeth once a day and upon inspection, there is a presence of dental carries and has loose teeth. In addition, Mr. MC, since he was admitted in the hospital, all drugs that was being administered to him was prescribed by the physician

Analysis

1.Health perceptionhealth management pattern.

Such perception is expected for him since he can no longer performs his usual activities like oral care due to body weakness

2. Nutritional Usually, he Metabolic Pattern takes his meal 3x a day with food preferences of seafoods, meat, and chicken and seldom to eat vegetables. Reported no difficulty in swallowing and eating and eats independently . However, after the incident, he can longer eat and drink

During

our It is due to loss interview, his of appetite and poor mother stated that oral hygiene he eats thrice a day but with minimal amount. He has loss of appetite since he slowly recovers from the incident occured to him

3. Elimination Pattern

The

patients urinates 3x a day with yellowish colored urine and defecates

The patient urinates

5-7 times a day with slightly yellowish urine and defecates every once a day with other day with hard brownish formed formed stool stool

Changes in bowel movement is due to decrease mobility or exercise

4. Activity The patient still Before admission, Exercise Pattern the patient performed performs his daily her ADL`s (which living activities with an also serves as his assistance. exercise), such as eating, bathing grooming and etc, independently

It is due to body weakness brought about by his condition

5. Sleep- Rest Pattern

The patient sleeps 7-8 hours and not using any sleeping aids for he has no problems or any difficulty in sleeping

At present he sleeps 5-6 hours unspontaneously. He has no difficulty falling asleep and is not using any sleeping aids

Such condition is due to hospital treatment and environmental factors such as noise and lightning facilities

6. CognitivePerceptual Pattern

He has no The patient sensory deficit. He knows what knows how to read happened to him, and write however he can not tell it verbally but true gestures. He has the ability to perceive stimulus but unable to transmit it in his motor response just like in his speech

It is due to the damage of the affected area when such incident happened

7. Self- Perception pattern

According to the Though

at Loosing weight SO she described present, her mother is due inadequate her son as healthy, describes him who food intake strong and is loosing weight industrious person but still strong enough to face such situation S.O stated that Mr. MC has the ability to communicate and expressed his self verbally and has a good relationship with others. In time of needs/ difficulties, he turns to her mother to seek comfort and decision making about his problems

8. RoleRelationship Pattern

Mr. MC It is due to the communicates and damage area expressed his self affected by the through gesture, blows on his head facial expression and nodding. He has a slurred speech thats why he prefers not talk

9. SexualitySexual Pattern

His mother He is weak but viewed him as a still he can manage strong man, what is happening masculine one to him. Theres no changes in his sexuality

He had overcome many challenges in his life and he believed that each challenge makes him better person

10. Coping Stress Management

The patient makes a decision with his parents especially his mother. And cope up stress through chatting with his friends

His parents makes the decision for him especially it is about his health. He cope up stresses through sleeping and praying.

He doesnt have the ability to make decision in his own since he is still dependent on his parents

11. Value- Belief System

According to his S.O his sons source of strength is God, because his son is a religious by heart

He still doesnt Fear to God is doubt unto his faith above all with Him though such challenges comes on his way

Structure and function of the Nervous System

The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of both central and peripheral elements. 1. The CNS is composed of the brain and spinal cord. 2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves. 3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia.

Brain Coverings

1.The dura matter is a fibrous, connective tissue structure containing several blood vessels. 2. The arachnoid membrane is a delicate serous membrane. 3. The pia matter is a vascular membrane

C. The spinal cord - extends from the medulla oblongata to the lower border of the first lumbar vertebrae. - It contains millions of nerve fibers, and it consists of 31 nerves 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral.

D. Cerebrospinal fluid (CSF) - forms in the lateral ventricles in the choroid plexus of the pia matter. It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of Sylvius to the fourth ventricle. - CSF exits the fourth ventricle by the foramen of Magendie and the two foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the arachnoid membrane.

Only two principal kinds of cells exist in the nervous system: neurons and neuroglia. Neuroglia cells (also called glial cells) act as connective tissue and function in the roles of support and protection. Some of these cells twine around nerve cells or line certain structures in the brain and spinal cord. Other neuroglia cells bind nervous tissue to supporting structures and attach neurons to their blood vessels. Other small neuroglia cells protect the central nervous system from disease by surrounding invading microbes and clearing away debris. Clinically, these cells are important because they are a common source of tumors of the nervous system. Neuron cells are nerve cells, the basic unit that carries out the work of the nervous system. Impulses from one body part to another body part are conducted by neurons

CELL ORGANIZATION OF THE NERVOUS SYSTEM

COMPONENTS OF NEURONS

a. Cell Body, Dendrites, and Axon. - The cell body contains a nucleus or control center. - Also, a neuron usually has several highly branched, thick extensions of cytoplasm called dendrites. The exception is a sensory neuron that has a single, long dendrite instead of many dendrites. - At the other extreme are motor neurons, each of which has many thick "tree-like" dendrites. The dendrite's function is to carry a nerve impulse toward the cell body. - An axon is a long, thin process that carries impulses away from the cell body to another neuron or tissue. There is usually only one axon per neuron. Axons vary in length and diameter and are "jelly-like" in appearance

B. Myelin Cells).

Sheath

(Schwann

-The myelin sheath is a white segmented covering made up of Schwann cells. -The covering is around axons and dendrites of many peripheral neurons. This covering wraps around the entire axon in "jelly-roll" fashion, except at the point of termination and at the nodes of Ranvier. (The nodes of Ranvier are intermittent constrictors along the myelin sheath.) - The myelin sheath is made up of a layer of protein, two layers of lipids or fats, and one more layer of protein.

c. Neurilemma - The neurilemma is the nucleated cytoplasmic layer of the Schwann cell. The neurilemma allows damaged nerves to regenerate. - Nerves in the brain and spinal cord DO NOT have a neurilemma and, therefore, DO NOT recover when damaged.

Classification of Neurons by Function

Sensory neurons - (also called afferent neurons) Sensory neurons conduct impulses from the receptors in the skin, sense organs, and viscera (the large internal organs) to the brain and the spinal cord. These neurons conduct impulses from receptors to the central nervous system. Motor neurons - (also called efferent neurons). Impulses transmitted from the brain and spinal cord to either muscles or glands are carried by motor neurons. These neurons conduct information away from the central nervous system to the skin, muscles, glands, and organs of the body.

Central Nervous System

1. a.

Brain Cerebrum - is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and right) and four lobes, each with specific functions. Parts of the Cerebrum Frontal lobe - controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses.

 Temporal lobe - is the center for taste, hearing and smell, and in the brains dominant hemisphere, the center for interpreting spoken language Parietal lobe - coordinates and interprets sensory information from the opposite side of the body
Occipital

lobe - interprets visual stimuli

b Thalamus

-further organizes cerebral function by transmitting impulses to and from the cerebrum. It also is responsible for primitive emotional responses, such as fear, and for distinguishing between pleasant and unpleasant stimuli

c Hypothalamus -is an automatic center that regulates blood pressure,temperature,libido,appetite,breathing,sleepingpatterns, and peripheral nerve discharges associated with certain behavior and emotional expression. - It also helps control pituitary secretion and stress reactions.
d. Cerebellum

- or hindbrain, controls smooth muscle movements, coordinates sensory impulses with muscle activity, and maintains muscle tone and equilibrium.
e. Brain

stem - which includes the mesencephalon, pons, and medulla oblongata, relays nerve impulses between the brain and spinal cord.
2.

Spinal cord -forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do not involve brain control

Spinal Cord

A.PNS or Peripheral Nervous System

- connects the CNS to remote body regions and conducts signals

to and from these areas and the spinal cord.

B. ANS or Autonomic Nervous System - regulates body functions such as digestion, respiration, and
cardiovascular function. Supervised chiefly by the hypothalamus, the ANS contains two divisions.

 Sympathetic nervous system - Sympathetic impulses increase greatly when the body is
under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased peristalsis, and increased perspiration. -Sympathetic stimuli are mediated by norepinephrine. -serves as an emergency preparedness system, the flightfor-fight response.

Parasympathetic nervous system

-is the dominant controller for most visceral effectors for most of the time. - Parasympathetic impulses are mediated by acetylcholine

Traumatic brain injury (TBI, also called intracranial injury) occurs when an outside force traumatically injures the brain. Head injury usually refers to TBI, but is a broader category because it can involve damage to structures other than the brain, such as the scalp and skull.

Traumatic Brain Injury

Epidural hematomas are located outside the dura but within the skull and are usually biconvex or lenticular in shape. They are uncommon representing only 0.5% of head injuries, and typically result from tearing of middle meningeal artery and less often from torn venous sinuses. Patients present with the classic lucid interval.

Epidural Hemorrhage

Normal and Abnormal

Description
A protective lining called the dura, which normally keeps the brain matter intact and supplies it with nutrition, oxygen-rich blood, and spinal fluid, normally covers the brain. When the head sustains an injury (e.g., from a severe blow, fall, or accident), the brain is jolted within the skull. This may cause the blood vessels surrounding the brain and dura to tear, allowing the blood to gush out and accumulate within the space between the dura and the skull, and eventually clot. This is known as an epidural hematoma. Swelling is due to the blood and clotting pushing against the confines of the skull, forcing the brain to compensate by shifting to accommodate the mass and pressure.

Clinical Manifestations
Depending on the degree of shift and the pressure on other brain structures, such symptoms as:
headache Drowsiness Dizziness loss of consciousness vomiting, and pupil dilation may occur. The patient may have difficulty staying awake problems with walking or moving an arm difficulty with speech increase ICP and more (seriously problems) with breathing and coma.

Pathophysiology

Predisposing Factors: - Age: 15- 24 y/o - Gender: Male

Precipitating Factors: - Direct Trauma - Motor Vehicular Crash - Physical Assaults - Sports- Related injury Direct blows to the head Transfer of pressure wave to the brain content

Structural disruption of the dural And skull vessels

jarring of soft gelatinous brain tissue against bony prominence

laceration of middle meningeal artery internal bleeding s/s - expanding hematoma

diffuse damage of frontal and temporal s/s - speech and language problems

Inadequate cerebral blood flow Cerebral ischemia

rapid pressure in the brain s/s - headache

Decrease cerebral blood perfusion s/s temporary loss of consciousness

lucid interval takes place

compensation of expanding hematoma

decrease intravascular volume

rapid absorption of CSF

if not compensated

small increase in the volume of blood clot

marked elevation of ICP

Cerebral cortices and Reticular Activating System s/s - altered mental status - severe headache -visual abnormalities - monoplegia - oval pupils - nuchal neck rigidity

hypothalamus s/s - vomiting - temperature changes

brainstem s/s - systolic hypertension - bradycardia - bradypnea - decrease reactivity to light - absent or decrease reflexes

Herniation takes place compression of other brain structure d/t shifting of place of brain parts

displacement of other structure

irreversible brain damage

Death

Physical Assessment
Area assessed
GENERAL FINDINGS Observed body build, height and weight in relation to clients age, lifestyle and health. Posture Hygiene and grooming Body and breath odor

Methods Used

Normal Findings

Actual Findings

Rationale

Inspection

the client is due to thin in relation insufficient intake to his age (23 of nutritious food. y/o), wt is 45 kg and ht is 54 with obvious bony prominent

Inspection Inspection Inspection

Slightly bent in Due to poor posture. posture Unkept Due to poor hygiene

With foul Due to poor breath odor hygiene

Obvious sign of health or illness. SKIN inspect color

Inspection

Weak in appearance

Due to his health condition

Inspection

inspect Inspection uniformity of skin color assess for edema inspect, palpate Palpation for skin lesions Palpation & observed and Inspection palpate skin moisture Observation & palpate skin Palpation temperature

Deep brown in color

Normal

Generally uniform in color

Normal

No edema

Normal Normal

No positive in skin lession Moisture in skin fold area (axilla)

Normal Normal

Palpation

Warm to touch

note skin turgor HAIR inspect the evenness of growth over the scalp inspect thinness or thickness inspect hair texture and oiliness Presence of infection and infestation

Palpation

Good skin turgor

Normal Normal

Inspection

Evenly distributed over the scalp

Inspection

Thick hair

Normal

Inspection

Smooth and oily hair

Normal

Inspection

Amount of body hair

No presence of infection and infestation

Normal

Inspection

Variable amount of body hair

Normal

NAILS inspect nail plate shape to determine its curvature and angle inspect texture inspect nailed color inspect tissues surrounding nails perform blanch test to test capillary refill

Inspection & Palpation

Convex curvature

Normal

Inspection
Inspection

Smooth texture

Normal Normal

Light pink in color

Inspection

Intact dermis

Normal

palpation

springs back to its normal color within 3 sec.

normal

SKULL & FACE Inspect for size and shape Palpate for nodules, mass or depressions Inspect facial features Note symmetry of facial movement

Inspection

Rounded in shape

Normal Normal

Palpation

Smooth, no modules or mass

Inspection

Symmetric facial structures Symmetric

Normal

facial movement

Inspection

normal

EYE STRUCTURE/ VISUAL ACUITY Inspect eyebrow for hair distribution Eyelashes and direction of curl Inspect eyelids/conjutiva Inspect lacrimal gland perform cornea for clarity and texture

Inspection

Hair evenly distributed

Normal

Inspection

Inspection Inspection

Evenly distributed and curled slightly outward Light pink in color

Normal

Normal

No swelling and tenderness

Normal

Inspection

Transparent and shiny

Normal

Appearance of pupil: Color Symmetry in size shape

Inspection Black in color Symmetric in size Round in share

Normal

Assess reaction to light

Inspection

Pupil constricts

Normal

Assess for ocular movement

Inspection

Both eyes coordinated, move in unison with parallel alignment

Normal

Peripheral Visual field

Inspection

can see object in his periphery

EARS & HEARING Assess elasticity External ear canal

Inspection Inspection

Recoils after it is folded Contains hair follicle

Hearing acuity

Inspection

Normal voice tones audible

Slightly It is due to poor increase in hygiene during his normal amount hospitalization of dry cerumen since he cant manage it due to body weakness

NOSE & SINUSES External nose

Inspection

Nasal cavities
Facial sinuses

Inspection Inspection

Symmetric & straight; no discharge or flaring; uniform in color and no lesions Mucous lining is pink Not tender, well outlined

MOUTH & OROPHARYNX Lips & buccal mucosa Inspect dentures Tongue

Inspection

Inspection Inspection Inspection

Uniform pink in color soft moist, & able to purse lips Smooth, intact dentures

Palate

Uvula Inspection

Central in slightly thick position whitish coating Light pink, smooth, soft palate lighter pink, hard palate more irregular texture Positioned in midline of soft palate

Due to poor oral hygiene brought by body weakness

Oropharynx

Inspection

Tonsils

Inspection

Pink & smooth, no discharge Pink & smooth, no discharge Present

Normal

Normal Normal

Gag reflex

Inspection

NECK Inspect neck muscles Observe head movement Lymph node Trachea

Inspection

Muscles equal in size, head centered Coordinated smooth movement with no discomfort

Normal

Normal

Inspection
Not palpable Central placement in midline of neck

Palpation Palpation

Normal Normal

THORAX & LUNGS Posterior Thorax Inspect chest shape Inspect spine alignment Palpate posterior thorax Auscultate for breath sound Anterior Thorax Inspect breathing pattern Palpate anterior chest

Inspection

Oval in shape

Normal Normal Normal

Inspection
Palpation

Spine vertically aligned Note nderness/ mass

Ausculatation

absent of adventitious sounds. Broncovesicular sound

Normal

Inspection

Normal rate & rhythm

Normal

Inspection

Full & symmetric chest expansion

Normal

CARDIOVASC ULAR SYSTEM/HEA RT Inspection & Inspect & Palpation and palpate the auscultation pericardium area of the chest overlying the heart ABDOMEN Color

Presence of S1 and S2:No lift pulsations

Normal

Inspection

Uniform color. No appearance of bulges. Symmetric movement

Normal

Auscultation

Audible bowel sounds. Absence of anterial bruits sounds

Normal

Palpation

No tenderness, relaxed with smooth

Normal

Percussion

Resonance sound is present

Normal

EXTREMETIES

Color Muscle size

Inspection Inspection

Consistent with rest of the body

Normal Normal

Muscle strength Muscle tone

Inspection

Inspection Inspection Inspection

Hard/foot coordination Peripheral pulses

Equal size on both sides of the body Slightly strong grip normal muscle tone coordinated movements

Normal Normal Normal Normal

Present

NEUROLOGIC Mental Status Attitude Mood/affect

Inspection Inspection

Cooperative Appropriate to situation

Language
Orientation Memory

Inspection
Inspection Inspection

Associated thoughts

Slurred speech

Oriented to time, place and person

Level of Consciousness Verbal responses Motor responses

Can recall past & recent events

Due to damage area of the brain especifically the Speecg area, affected by the incident

Respond to verbal commands and answers appropriately

Respond to painful stimuli

Nursing Diagnosis

Defining Characteristics

Planning

Intervention

Rationale

Evaluatio n

Acute pain r/t traumatize d nerve endings.

> >irritable >facial grimace >restlessness

After 2 hours of rendering appropriate nursing interventions, the patients degree of pain will be reduced

>provided comfort >to provide non measures such as back pharmacologic rub. pain management >to distract and >encourage use of attention relaxation techniques reduce tension such as deep breathing exercises, listening to music >To divert pain >encourage divertional activities such as socialization >it may relieve >reposition as indicated pain and enhance circulation >prevent fatigue >encourage rest periods adequate

Goal met. The patients degree of pain was able to reduced to 2/10 scale of pain.

Nursing Diagnosis Self-care deficit: Hygiene and grooming r/t inability to perceive body part

Defining Characteristics Poor hygiene, inability to wash body Unkept ;inability to maintain appearance at a satisfactory level

Planning

Intervention

Rationale

Evaluation

After 1 to 2 hrs. of giving appropriate nursing interventions, the patient will be able to perform self-care activities within level of ability.

1.Established good rapport. 2.Assessed abilities and level of deficit for performing ADLs 3.Promoted clients/ SOs participation in problem identification and desired goals and decision making. 4.Spared time for listening to clients /SOs feelings and concerns. 5. Avoided doing things for client that client can do for self. 6.Encouraged so to allow client to do as much as possible for self. 7.Assisted client in meeting needs when is unable to meet needs. 8.Provided communication among those who are involved in caring for and assisting the client.

1.To gain trust and cooperation 2.To aid planning for meeting clients needs. 3.To enhance commitment to plan, optimize outcome and support recovery 1.To discover barriers to participation in regimen and to work on problem solutions. 2.To maintain selfesteem and promote recovery. 3.To establish sense of independence and foster self-worth. 4.To assist client in dealing with the situation. 5.To enhance coordinate and continuity of care.

Goal met: After 1-2 hrs of giving appropriate nursing intervention s, the patient performed self care activities within level of own ability.

Nursing Diagnosis Altered transmissi on r/t brain trauma

Defining Characteristics Speaks/ verbalizes with difficulty Slurring of speesh Use of nonverbal cues(pleading eyes)

Planning After 1 to 2 hrs. of rendering appropriate nursing interventions, the patient will be able to establish method of communication in which needs can be expressed.

Intervention 1.Review history of neurological condition that could affect speech. 2.Noted SOs speech patterns and manner of communicating with the client. 3.Established relationship with the client, listening carefully and attending to client verbal/non- verbal expressions . 4.Maintained eye contact, preferably at clients level considering their culture. 5.Kept communication simple, speaking in short sentences and using appropriate words. 6.Reduced environmental stimuli. 7.Used and assisted client/SO to learn the therapeutic communication skills of acknowledgement and active listening. 8.Involved family/SO in plan of care as much as

Rationale 1.To assess causative factor . 2. To assess contributive factor

Evaluatio n Goal met: After 1-2 hrs of giving appropriat e nursing interventio ns, the patient established method of communic ation in which needs can be expressed.

3. To convey interest and concern

4. To provide sincerity with the patient 5. To provide a nonexhausting type of gommunication 6. To provide comfort 7. To identify any appropriate type of intervention to be implemented
8. To promote a quality and effective

Name of Drug cefuroxime (Zinacef) -Second generation Cephalospori ns -Anti infectives

Action Inhibits bacterial cell wall synthesis. Most effective against rapidly growing organisms.

Indication Indicated to Gram negative organisms

Contraindication Hypersensitivity to cephalosporins or penicillin. Caution with renal/ hepatic impairment, bleeding disorder, or G.I. disease.

Side Effects -nausea -vomiting -diarrhea -nephro toxicity thrombocytopen ia -headache -abdominal pain

Nursing Interventions -Monitor WBC counts, culture and prothrombine time. -Assess BUN and creatinine levels in client with renal impairment. -Monitor vital signs and; intake and output. -Administer on an empty stomach for better result. -May take with food if gastric irritation develops. - Complete full course of medication, even if you feel better. -Maintain adequate hydration unless instructed to restrict fluid intake.

NAME OF DRUG

CLASSIFICATION

ACTION

INDICATION

ADVERSE REACTION

NURSING RESPONSIBILITY

Mannitol

Diuretics

Increases osmotic pressure of glomerular filtrate, thus preventing reabsorption of water. Increases excretion of sodium and chloride.

Oliguria Edema Increased ICP Increased IOP

CNS: seizures, dizzenes, headache, fever CV: edema, hypotension, heart failure, tachycardia EENT: blurred vision, rhinitis GI: thirst, dry mouth, nausea, vomiting, diarrhea GU: urine retention METABOLI C: dehydration SKIN: local pain, urticaria

Monitor intake and output Report increasing oliguria Check weight, and rena; function To relieve thirst, give frequent mouth care of fluids Monitor vital signs

Name of Drug ranitidine (Zantac) -Anti Ulcer medication -Histamine Antagonists

Action Reduces gastric acid secretion; prevents histamineinduced acid release by competing with histamine for H2 receptors.

Indication

Contraindication

Side Effects -nausea -confusion -diarrhea or constipation -nephro toxicity -hepatic toxicity -depression -headache -blurred vision -rash

Nursing Interventions -Monitor G.I. discomfort -Assess vital signs. -Monitor CBC and liver function tests. -Tell patient that smoking may decrease drug effects.. -May take drug with/ without food. - Using ranitidine may increase your risk of developing pneumonia. - Do not drive or perform other possibly unsafe tasks until you know how you react to it.

Hyper Hypersensitivity secretion of to drug or its stomach component. acids, gastro esophageal reflux, and short-term treatment prophylaxis of duodenal ulcer prevention of upper G.I. bleed in critically ill clients.

CT Scan

There are biconvex shaped foci of high attenuation density, surrounded by a hypodense rim, seen of the left fronto-parietal and left parietal regions. The said foci measures approximately 4-5 cm3 and 19.1cm3 in volume respondent (kothari method). The left lateral vertical is slightly compressed. Adjacent cortical sulci of the left cerebral hemisphere are tight. Midline structure are displaced to the right about 0.5 cm. A small hyperdense focus is also noted insinuating c/n & the interhemispheric fissure Right lateral 3rd & 4th ventricles arent dilated nor displaced Cortical sulci of the left Cerebral Hemisphere and cisterns arent unusual There is diastatic fracture involving the right lambdoid suture extending inhto the base if the skull Epidural Hemorrhages, Left fronto parietal and left parietal region, with surrounding edema, mass affect & mild subfalcine herniation small, subdural hemorrhage, internemispheric fissure Diastatic Fracture, right lambdoid suture with extension into ipslaterd skull base.