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CASE STUDY
“CRANIOCEREBRAL
TRAUMA”

2. BSN 3C1-1 GROUP 81
Francia, John Mark
Fuensalida, Aprilyn
Fagarang, Keyzl
Joven, Jeniel
SUBMITTED TO:
Ms. Rosel Estuaria, RN
INTRODUCTION:
Headinjury referstotrauma to the head.Thismay or may not include injurytothe brain.However,the
termstraumaticbrain injury andhead injury are oftenusedinterchangeablyinthe medical literature.
The incidence (numberof newcases) of headinjuryis300 per100,000 peryear (0.3% of the
population),withamortalityof 25 per 100,000 in NorthAmericaand9 per 100,000 in Britain.Inthe
Philippines,there are 100,441 reportedcasesannually.Headinjuriesincludebothinjuriestothe brain
and those toother partsof the head,such as the scalpand skull.
Headinjuriesmaybe closedoropen.A closed(non-missile)headinjuryisone inwhichthe skull isnot
broken.A penetratingheadinjury occurswhenanobjectpiercesthe skull andbreachesthe duramater.
Brain injuriesmaybe diffuse,occurringoverawide area,or focal,locatedina small,specificarea.
A headinjury maycause a minorheadache skull fracture,whichmayor maynot be associatedwith
injurytothe brain.Some patientsmayhave linearordepressedskull fractures.
If intracranial hemorrhage occurs,a hematomawithinthe skull canputpressure onthe brain.Typesof
intracranial hemorrage includesubdural, subarachnoid,extradural,andintraparenchymal
hematoma.Craniotomy surgeriesare usedinthese casestolessenthe pressure bydrainingoff blood.
Brain injury canbe at the site of impact,but can alsobe at the opposite side of the skull due to
a contrecoup effect(the impacttothe headcan cause the brainto move withinthe skull,causingthe
brainto impactthe interiorof the skull oppositethe head-impact).

3. If the impactcausesthe headto move,the injurymaybe worsened,because the brainmayricochet
inside the skull causingadditional impacts,orthe brainmaystay relativelystill(due toinertia)butbe hit
by the movingskull (bothare contrecoupinjuries).
High-riskpopulations
Some particularsegmentsof the populace are atincreasedriskof sustainingaTBI,includingthe
following:
 Young people6
 Low-income individuals
 Unmarriedindividuals
 Membersof ethnicminoritygroups
 Residentsof innercities
 Men6
 Individualswithahistoryof substance abuse
 Individualswhohave sufferedapreviousTBI
Sex
Men are approximatelytwice aslikelyaswomentosustainaTBI.7
Thisratioapproachesparityas age
increasesbecause of the increasedlikelihoodof TBIcausedby falls,forwhichmalesandfemaleshave
similarrisksinlaterlife.
The male-to-female mortalityrate forTBI is3.4:1. However,the cause-specificratioforfirearm-related
injuriesis6:1,while thatforinjuriesrelatedtoMVAsis2.4:1.
Age
Injuryisthe leadingcause of deathamongAmericansyoungerthan45 years;TBI isthe majorcause of
deathrelatedtoinjury.
The risk of TBI peakswhenindividualsare aged15-30 years.The riskishighestforindividualsaged15-24
years. Peakage is similarformalesandfemales.Twentypercentof TBIsoccur in the pediatricage group
(ie,birthto17 y).
The highestmortalityrate (32.8 casesper 100,000 people) isfoundinpersonsaged15-24 years.The
mortality rate inpatientswhoare elderly(65y or older) isabout31.4 individualsper100,000 people.
Specificproblemsafterheadinjurycaninclude:
 Skull fracture
 Lacerations to the scalp and resultinghemorrhageof the skin
 Traumatic subdural hematoma,ableedingbelow the duramaterwhichmay developslowly
 Traumatic extradural,orepidural hematoma,bleedingbetweenthe duramaterandthe skull
 Traumatic subarachnoidhemorrhage
 Cerebral contusion,abruise of the brain
 Concussion,atemporarylossof functiondue totrauma
 Dementiapugilistica,or"punch-drunksyndrome",causedbyrepetitive headinjuries,forexamplein
boxingorothercontact sports
 A severe injurymayleadtoa coma or death
 ShakenBabySyndrome - a form of childabuse
DIAGNOSIS:
The needforimaginginpatientswhohave sufferedaminorheadinjuryisdebated.A non-contrastCTof
the headshouldbe performedimmediatelyinall those whohave sufferedamoderate orsevere head
injury. Itcan be diagnosedthroughCTScan,MRI andCerebral Angiography.

4. Most headinjuriesare of a benignnature andrequire notreatment beyond analgesics andclose
monitoringforpotential complicationssuchas intracranial bleeding.If the brainhasbeenseverely
damagedbytrauma, neurosurgical evaluationmaybe useful.Treatmentsmayinvolve controlling
elevatedintracranial pressure.Thiscaninclude sedation,paralytics,cerebrospinalfluiddiversion.
Secondline alternativesincludedecompressive Craniotomy,barbiturate coma,hypertonicsalineand
hypothermia.Althoughall of these methodshave potentialbenefits,therehasbeennorandomized
studythat has shownunequivocal benefit.
OBJECTIVES:
1. To explainthe cause andeffectsof aCraniocerebral Trauma.
2. To furtheremphasize the importance of the craniumandthe central nervoussysteminourdaily
activities.
3. To elucidate factsaboutthe incidence of thisreport.
4. To expoundthe care managementforpatientswithCraniocerebral trauma.
5. To explainthe treatmentandtherapyneededtoachieve patient’smaximumlevelof
functioning.
PATIENT’s PROFILE
Mr. JCE,a 31 yearoldMale, FilipinoresidingatCargoPagan Diwa,Bicutan,TaguigCityand a Police
Officer2(PO2) wasadmittedinthe hospital onMay 13 2009 at 5:50 PM. He arrivedina stretcher
admittedbySPO1Laroya. Before he arrivedinthe Hospital,he waswoundedbya gunshotinthe fronto-
temporal areaof the headinZamboangaCity.He wasdiagnosedof S/PCraniotomy,Debridement,Dural
Repairand Repairof CerebrospinalFluid.Because of the trauma,hisabilitytospeakwasgreatly
compromised.He iswithhiswife;Mrs.H to helphimrespondtointerviews,hospital proceduresand
interventions.He lefthisonlysoninSamarand currentlyonstate of longing.He iscurrentlyundergoing
a therapyat the Philippine HeartCentereveryTuesday,ThursdayandSaturday.
Historyof PresentIllness:Pneumonia,SlightCardiomegaly,S/PCraniotomyDebridementDual Repair
and Aspirationof Cerebrospinal Fluidleak.

5. PHYSICAL ASSESSMENT
(September21,2010)
Vital Signs:
(September21,2010)
Temperature:37.7 C
Pulse Rate:95 bpm
RespiratoryRate:22 cpm
BloodPressure: 110/70 mmHg
Urine Output:1 time
Stool:0 times
Note:Duringthe Physical Assessment,the StudentNursesperformedandfollowedstrictaseptic
technique.Inperformingpercussionandpalpation,sterile glovesare used.The Stethoscope iscleansed
withcottonball withalcohol.
General Assessment
General Appearance:Conscious,Coherent,NICRD(NotinCardio-Respiratory
Distress)
Posture:Abnormal( Unsteadygaitandasymmetrical walking)

6. Cranial Nerves
Cranial Nerve Normal Findings Actual Findings Interpretation
CN I Abilitytocorrectly
distinguishthe odor
presentedunderthe
nares
Intact olfaction Normal
CN II Able toread paper
printswithadequate
lightningheldata
distance of 14 inches.
Abilitytoreadprecisely Normal
CN II, IV,VI Can followthe direction
of the objectholdby
the examinerbyeye
movementsonly
withoutmovingthe
neck.
Intact EOM Normal
CN V Equalityof muscle
strength,temporal
muscle whenthe teeth
are clenchedand
unclenched.
Intact EOM Normal
CN VII Symmetryof
movement.Equalityof
muscle strengthwhen
raisingthe eyebrows,
frowning,showingboth
the upperand lower
teeth,smiling,puffing
out the cheeksand
closingthe eyestightly.
Facial Assymetry. ABNORMAL (
Assymetrical Shape of
the face) September
21,2010
CN VIII Abilitytocorrectly
repeatthe whispered
word
Inabilitytorepeatwords
due to inabilityof verbal
communication.
ABNORMAL(September
21,2010)
CN IX,X Symmetrical rise of the
softpalate and uvula
when“ah” issaid.
Symmetrical rise of the
softpalate and uvula
when“ah” issaid,but
soundsdoesnot
produce.
ABNORMAL(
Symmetrical,butAHis
not produce due to
inabilityof verbal
speaking) September
21, 2010
CN XI Symmetrical strength
and contractionof the
trapeziusmusclesasthe
shouldersare shrugged
IncongruentShoulder
Shrug.
ABNORMAL (Onlyleft
side of shouldercanbe
shruggedwell,rightside
isweak) September21,

7. upwardagainst
resistance
2010
CN XII Symmetry,absence of
atrophy,midline
positionof tongue
Tongue at midline,
normal tongue
movements.
Normal
Areato be
examined
Methodof
Assessment
Normal Findings Actual Findings Interpretation
Skin Inspection Intact Skin;
Absence of swellingor
inflammation
SkinisIntact.
Skincoloris
symmetrical
Normal
Head Inspection Rounded( symmetrical
and normocephalic)
Roundshaped,no
noticed
enlargement
Normal
Face Inspection Smooth,uniform
consistency.Absence
of nodulesormasses
No masses,but
Edemais
noticeable.
ABNORMAL
(Slightlyedematous
aroundthe
eyebrows)
September21,2010
Eyes Inspection Lidsclose
symmetrically;when
lidsopen,novisible
scleraabove corneas.
Andupperand lower
bordersof cornea are
slightlycovered
The eyesare able to
close andopenwell.
No noticedeye
discharge.
Normal
Nose Inspection Absence of lesions.Air
movesfreelyasthe
clientbreathes
throughthe nares.
Absence of lesions
and blisters.Not
tender.Intactsense
of smell.
Normal
Ears Inspection Colorsame as facial
skin;soundis heardin
bothears.
Hearingis
abnormal.Absence
of lesionsand
masses.
ABNORMAL( low
hearingmechanism
due to injuryonthe
temporal area)
September21,2010
Mouth Inspection Uniformpinkincolor;
tongue hasno lesions,
pinkcolorand raised
papillae.
Uniformpinkin
color;tongue has
no lesions,pink
colorand raised
papillae.
Normal
Throat Inspection Has intact gag reflex
and swallowingreflex
Intact gag and
swallowingreflex
Normal
Neck Inspection Musclesequal insize;
Absence of swelling
and inflammation
No erosionsand
lesionsonthe neck.
Normal

8. Cardio
Vascular
Assessment
Auscultation Audible S1andS2 Pulmonic:
S2 is heardlouder
than S1 without
murmurs.
Aortic:
S2 is heardlouder
than S1 without
murmurs.
Normal
Anterior
Chest
Percussion Percussion:Resonate
exceptoverscapula
Resonantall over
the lungfields.
Normal
Auscultation Vesicularand
bronchovesicular
breathsoundsare
heard
Bronchial soundare
heardoverthe
manubrium,
bronchovesicular
overthe 1st
and 2nd
ICS andvesicular
overthe rest of the
lungfields.
Normal
Posterior
Chest
Percussion Percussion:Resonate
exceptoverscapula
Resonantall over
the lungfields
Normal
Auscultation Vesicularand
bronchovesicular
breathsoundsare
heard
Bronchial soundare
heardoverthe
manubrium,
bronchovesicular
overthe 1st
and 2nd
ICS andvesicular
overthe rest of the
lungfields.
Normal
Abdomen Inspection Unblemishedskin;
uniformcolor
UniformFairSkin
on parts of the
abdomen
Normal
Auscultation Audible bowel sounds;
Absence of frictionrub
Has 6 bowel sound
heardper minute in
each quadrantof
the abdomen
Normal
Percussion Tympanyoverthe
stomachand gas filled
bowels;dullness
especiallyoverthe
liverandspleen,ora
full bladder.
RUQ: Dull
LUQ: Tympanic
RLQ: Tympanic
LLQ: Tympanic
Normal
Palpation Nottender; relaxed
abdomenwithsmooth,
consistenttension
Absence of
tenderness.Relaxed
abdomen.
Normal
Lungs Inspection Breathingisregular
withoutuse of
Breathingisregular
withoutuse of
Normal

9. Palpation accessorymuscles,
chestexpandsupon
inhalation and
depressesupon
expiration
accessorymuscles,
chestexpandsupon
inhalationand
depressesupon
expiration
Back Inspection UnblemishedSkin;
UniformColor
Unblemishedand
UniformSkincolor
Normal
External
Genitalia
Inspection Smooth,uniform
consistency;absence
of nodulesormasses.
No noticedlesions
and nodules.
Normal
Upper
Extremities
Inspection UniformConsistency;
Absence of Redness
and Rashes
No Rednessand
Rashes,Colorsame
as Bodycolor, but
FlexedRightArm.
ABNORMAL (Weak
RightArm)
September21,2010
Palpation NotTender,Absence
of Edemaand Masses
SmoothSkin Normal
Lower
Extremities
Inspection UniformConsistency;
Absence of Redness
and Rashes
No Rednessand
Rashes,Colorsame
as Body color. But
incongruentwalking
and unsteadygait.
ABNORMAL (Weak
rightleg)
September21,2010
Palpation NotTender,Absence
of Edemaand Masses
SmoothSkin Normal
ANATOMYof CENTRAL NERVOUSSYSTEM
The central nervoussystemismade upof the
 spinal cord and
 brain
The spinal cord
 conducts sensory informationfromthe peripheral nervoussystem (bothsomaticand
autonomic) tothe brain
 conducts motor informationfromthe brain to ourvariouseffectors
o skeletal muscles
o cardiac muscle
o smoothmuscle
o glands
 servesasa minorreflex center
The brain
 receivessensoryinputfromthe spinal cord aswell asfrom itsownnerves(e.g., olfactoryand
opticnerves)
 devotesmostof itsvolume (andcomputationalpower) toprocessingitsvarioussensory inputs
and initiatingappropriate — andcoordinated — motoroutputs.

10. The Meninges
Both the spinal cordand brainare coveredinthree continuoussheetsof connectivetissue,the
meninges.Fromoutsidein,these are the
 dura mater — pressedagainstthe bonysurface of the interiorof the vertebrae andthe cranium
 the arachnoid
 the pia mater
The regionbetweenthe arachnoidandpiamaterisfilledwith cerebrospinal fluid(CSF).
The ExtracellularFluid(ECF) of the Central Nervous System
The cellsof the central nervoussystemare bathedinafluidthatdiffersfromthatservingasthe ECF of
the cellsinthe rest of the body.
 The fluidthatleavesthe capillariesinthe braincontainsfarlessproteinthan"normal"because
of the blood-brainbarrier,a systemof tightjunctions betweenthe endothelial cellsof the
capillaries.Thisbarriercreatesproblemsinmedicine asitpreventsmanytherapeuticdrugsfrom
reachingthe brain.
 cerebrospinal fluid (CSF),asecretionof the choroidplexus.CSFflowsuninterruptedthroughout
the central nervoussystem
o throughthe central cerebrospinal canal of the spinal cordand
o throughan interconnectedsystemof four ventriclesinthe brain.
CSF returnsto the bloodthroughveinsdrainingthe brain.
The Spinal Cord
31 pairsof spinal nervesarise alongthe spinal cord.These are "mixed" nervesbecause each contains
bothsensoryandmotor axons.However,withinthe spinal column,
 all the sensory axons passintothe dorsal root ganglionwhere theircell bodiesare locatedand
thenon intothe spinal corditself.
 all the motor axons passintothe ventral roots before unitingwiththe sensoryaxonstoform
the mixednerves.
CrossingOver of the Spinal Tracts
Impulsesreachingthe spinalcordfromthe leftside of the bodyeventuallypassovertotracts runningup
to the right side of the brainand vice versa.Insome casesthiscrossingoveroccurs as soon as the
impulsesenterthe cord.Inothercases,it doesnot take place until the tracts enterthe brainitself.
The Brain
The brain of all vertebratesdevelopsfromthree swellingsatthe anteriorendof the neural canal of the
embryo.Fromfrontto back these developintothe

11.  forebrain (alsoknownasthe prosencephalon — showninlightcolor)
 midbrain (mesencephalon — gray)
 hindbrain (rhombencephalon — darkcolor) The humanbrain isshownfrombehindsothat the
cerebellumcanbe seen.
The human brainreceivesnerve impulsesfrom
 the spinal cord and
 12 pairsof cranial nerves
o Some of the cranial nervesare "mixed",containingbothsensoryandmotoraxons
o Some,e.g.,the opticandolfactorynerves(numbersIandII) containsensoryaxonsonly
o Some,e.g.numberIIIthatcontrolseyeball muscles,containmotoraxonsonly.
The Hindbrain
The main structuresof the hindbrain(rhombencephalon) are the
 medullaoblongata
 pons and
 cerebellum
Medullaoblongata
The medullalookslike aswollentiptothe spinal cord.Nerve impulsesarisinghere
 rhythmicallystimulatethe intercostalmusclesanddiaphragm — makingbreathingpossible
[More]
 regulate heartbeat
 regulate the diameterof arteriolesthusadjustingbloodflow.
Pons
The pons seemstoserve asa relaystationcarryingsignalsfromvariouspartsof the cerebral cortex to
the cerebellum.Nerveimpulsescomingfromthe eyes, ears,andtouchreceptors are senton the
cerebellum.The ponsalsoparticipatesinthe reflexesthatregulatebreathing.
Cerebellum
The cerebellumconsistsof twodeeply-convolutedhemispheres.Althoughitrepresentsonly10% of the
weightof the brain,itcontainsas many neuronsasall the rest of the brain combined.

12. Its mostclearly-understoodfunctionistocoordinate bodymovements.Peoplewithdamage totheir
cerebellumare able toperceive the worldasbefore andtocontract theirmuscles,buttheirmotionsare
jerkyanduncoordinated.
So the cerebellumappearstobe a centerfor learningmotorskills(implicitmemory).Laboratorystudies
have demonstratedboth long-termpotentiation (LTP) andlong-termdepression (LTD) inthe
cerebellum.
The Midbrain
The midbrain(mesencephalon)occupiesonlyasmall regioninhumans(itisrelativelymuchlargerin
"lower"vertebrates).We shall lookatonlythree features:
 the reticular formation: collectsinputfromhigherbraincentersandpassesitonto motor
neurons.
 the substantia nigra: helps"smooth"outbodymovements;damage tothe substantianigra
causesParkinson'sdisease.
 the ventral tegmental area (VTA):packedwith dopamine-releasingneuronsthat
o are activatedby nicotinicacetylcholine receptors and
o whose projectionssynapse deepwithinthe forebrain.
The midbrainalongwiththe medullaandponsare oftenreferredtoasthe "brainstem".
The Forebrain
The human forebrain(prosencephalon) ismade upof
 a pair of large cerebral hemispheres,calledthe telencephalon.Because of crossingoverof the
spinal tracts,the lefthemisphere of the forebraindealswiththe rightside of the bodyandvice
versa.
 a group of structureslocateddeepwithinthe cerebrum,thatmake upthe diencephalon.
Diencephalon
We shall considerfourof itsstructures:the
 Thalamus.
o All sensoryinput(exceptforolfaction) passesthroughthese pairedstructuresonthe
wayup to the somatic-sensoryregions of the cerebral cortex andthenreturnstothem
fromthere.
o signalsfromthe cerebellumpassthroughthemonthe wayto the motorareas of the
cerebral cortex.
 Lateral geniculate nucleus (LGN).All signalsenteringthe brainfromeachopticnerve entera
LGN and undergosome processingbefore movingonthe variousvisual areasof the cerebral
cortex.

Hypothalamus.
o The seat of the autonomicnervoussystem.Damage tothe hypothalamusisquicklyfatal
as the normal homeostasisof bodytemperature,bloodchemistry,etc.goesoutof
control.
o The source of 8 hormones,twoof which
pass intothe posteriorlobe of the
pituitary gland.
 Posteriorlobe of the pituitary.
Receives
o vasopressin and
o oxytocin

13. fromthe hypothalamusandreleasesthemintothe blood.
The Cerebral Hemispheres
Each hemisphere of the cerebrumissubdividedintofourlobesvisible fromthe outside:
 frontal
 parietal
 occipital
 temporal
ACTIVITIES OF DAILY LIVING
BEFORE DURING INTERPRETATION

14. HEALTH
MANAGEMENT
PERCEPTION
PATTERN
NUTRITION
METABOLIC
PATTERN
SUBJECTIVE:
The patient is healthy
and seldom to get sick.
SUBJECTIVE:
The patient eats lots of
foods. Eats on time and
does not skip meal.
SUBJECTIVE:
The patient take his
medications on
time without
hesitation.
SUBJECTIVE:
The patient remains
vigorous in eating.
The patient manifests
patterns of health
management which is
normal for an adult.
Remain unchanged.
BEFORE DURING INTERPRETATION
ELIMINATION
PATTERN
SUBJECTIVE:
The patient has a
normal bowel
movement and
urination.
SUBJECTIVE:
The patient remains
normal in
Elimination and
Urination pattern.
Remain unchanged.
BEFORE DURING INTERPRETATION
ACTIVITY
EXERCISE
PATTERN
SUBJECTIVE:
The patient is active on
his duties and daily
activities.
SUBJECTIVE:
The patient loses his
flexibility, unable to
lift things due to
immobilization of
right arm.
The patient is active
before hospitalization but
became weak due to
immobilization of the
right arm.

15. BEFORE DURING INTERPRETATION
SLEEP REST
PATTERN
SUBJECTIVE:
The patient sleeps
comfortably. He sleeps
on-time when off-
duty.
SUBJECTIVE
The patient’s sleep
pattern varies.
Patient is observed
to have frequent
awakening in the
evening.
Sleeping Pattern of the
patient remain unchanged.
BEFORE DURING INTERPRETATION
COGNITIVE-
PERCEPTUAL
SUBJECTIVE:
The patient cooperates
well and participates
precisely on activities.
SUBJECTIVE:
The patient does not
cooperate with
health practitioners.
The patient is unable to
perform activities.
BEFORE DURING INTERPRETATION
SELF-
PERCEPTION and
SELF-CONCEPT
SUBJECTIVE:
The patient expresses
his emotions. He is
full of hope and with
high self-esteem.
SUBJECTIVE:
The patient has
willful refusal to
speak. He has
observable
discomfort in social
interaction.
OBJECTIVE:
During assessment,
patient appears non-
cooperative. Patient
do not responds to
questions.
Self-perception and self-
concept of the patient was
altered.
BEFORE DURING INTERPRETATION
ROLE
RELATIONSHIP
PATTERN
SUBJECTIVE:
The patient has a good
relationship with his
wife, family and co-
workers. He is able to
interact with other
SUBJECTIVE:
The patient loses the
ability to talk. He
cannot share his
feelings, do not
interact with health
Hospitalization of one
family member may largely
affect other members of
the family. This will assert
him of the need for
interactions not only with

16. people, verbalizes his
feelings and thoughts.
practitioners.
OBJECTIVE:
Dysfunctional Role-
Relationship Pattern
and impaired verbal
communication and
social interaction.
family members but also
with friends she has
outside. Isolation can be
seen to the patient under
the age of 31.
BEFORE DURING INTERPRETATION
SEXUAL-
REPRODUCTIVE
SUBJECTIVE:
Super sexually active.
SUBJECTIVE:
Decrease sexual
activity due to
hospitalization.
Hospitalization affects
sexual activity. The patient
prioritize more on health
management.
BEFORE DURING INTERPRETATION
COPING-STRESS
TOLERANCE
SUBJECTIVE:
He talks to his wife
when there are
problems. He
verbalized his feelings.
SUBJECTIVE:
He cannot share his
thoughts due to
impaired verbal
language.
Impaired verbal language
greatly affects Coping-
Stress Mechanism.
BEFORE DURING INTERPRETATION
VALUES-BELIEF SUBJECTIVE:
The patient is
attending church mass
weekly.
SUBJECTIVE:
The patient cannot
go to church due to
anguish, anxiety,
hospitalization and
scheduled therapy.
When an undesirable and
uncontrollable event
happens to a person. One
of the two things may
happen. A decline in faith
or a stronger belief for
healing. In this case, he
tends to decline his faith.

17. DEVELOPMENTAL TASK
Young adulthood:18 to 35
Intimacy and Solidarity vs. Isolation
Basic Strengths: AffiliationandLove
In the initial stage of beinganadultwe seekone ormore companionsandlove.Aswe try to find
mutuallysatisfyingrelationships,primarilythroughmarriage andfriends,we generallyalsobegintostart
a family,thoughthisage hasbeenpushedbackformany coupleswhotodaydon'tstart theirfamilies
until theirlate thirties.If negotiatingthisstage issuccessful,we canexperience intimacy ona deeplevel.
The clientisexperiencing isolation anddistance fromothers occurs.Andwhenthe client doesnotfindit
easyto create satisfyingrelationships. The problemisheightenedmerelybyhisinabilitytospeakand
socialize withotherpeople suchashealthpractitioners.
The client’s significantrelationshipsare withmarital partnersandfriends.
COURSEIN THE WARD:

18. (Upon Admissionand Time of our Duty)
May 22, 2009 (Friday)
 The patientadmittedtothe hospital fordebridement,dural repairing,andfor repairingCSFleak
due to a gunshotwoundon histemporal lobe.The patientreceivedasleeponbedandnotin
respiratorydistress,depressedforeheadonleftside withcondomcatheterconnectedtourine
bag, drainingtoyellowcoloredurine output.The vital signsare takenandhasrecorded.Hisoral
medicationslikeparacetamol,vitaminBcomplex,CandE are givenandstill forrefferal toDr.
Orata for evaluationof managementandspeechtherapy.He iskeptcomfortableanditis
endorsedwell.
September20,2010
 At 0700H, the patientreceivedasleeponbedandnotin respiratorydistressandthusafebrile.
His vital signstakenandrecordedandhisoral medicationsare alsogivenaftermonitoringhis
v/s.
September21,2010
 Patientreceivedsittinginbedwithhiswife,consciousandcoherent,positive use of non-verbal
communicationandpleadingeyes,positive willful refusal tospeakandflexionof rightarm.Vital
signswastaken,negative bowelmovementandpositive urination2x.Medicationwasgiven
such as VitaminC,VitaminBComplex,andVitaminE.
September27,2010
 The patientreceivedonbedawake andnotinrespiratorydistressandnotfebrile.Hisvital signs
are takenbutnot recorded.Hisoral medicationsare well givenandhe iskeptcomfortable and
endorsed.
DISCHARGE PLANNING:

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

20. NCP- September21,2010
OtherNursingDiagnosis:ImpairedSocial InteractionrelatedtoCommunicationbarriersecondarytoinabilitytotalk.
ImpairedPhysical MobilityrelatedtoNeuromuscularImpairmentsecondarytoCraniocerebraltrauma.
ASSESSMENT DIAGNOSIS NURSINGANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
The patientloses
the abilitytotalk.
He cannotshare his
feelings,donot
interactwithhealth
practitioners.
Objective:
Vital Signsare as
follows:
T:
PR:
BP:
RR:
(+) use of
nonverbal
communicationand
cues
(+) pleadingeyes
(+) willful refusal to
speak
ImpairedVerbal
Communication
relatedto
Anatomical deficit
secondaryto
Craniocerebral
trauma on
Frontotemporal
Area.
Short-termgoal:
After2 hours of
Nursing
Intervention,the
clientindicatesan
understandingof
communication
difficultyandplans
for waysof
handling.
The nexttwo hours,
the patient
establishesmethod
of communication
inwhichneedscan
be expressed.
Long-termGoal:
Withinourshift,the
patient
demonstrates
congruentverbal
and non-verbal
communication.
To assistclientto
establishameansof
communicationto
expressneeds,wants,
ideasandquestions.
 Determine
meaningof
wordsuse by
the client
(non-verbal
message).
 Planfor
alternative
methodof
communicatio
n (e.gletter
board).
To promote wellness
 Use and assist
clientand
teachfamilyto
learn
therapeutic
communication
skillsof
management
(Active
listeningandI
message)
To helphimexpress
ideasandpromote
social interaction.
Improvesgeneral
communication
skills,enhances
participationand
commitmentto
plans.
The goal wasmet.
He response to
interventionsand
teachingsand
actionsperformed.
He practice non-
verbal
communicationand
I message.
The goal was
partiallymet.

21. DRUG STUDY
Name/
classification
Dosage/
Route
Action Indication Contraindication Side effect Nursing intervention
Amlodipine 5 mg cap/
oral
Calcium is needed by
the body for muscle
contraction. The heart is
a muscle that is
constantly contracting
to pump blood through
out the body. Calcium
channel blockers like
amlodipine work by
blocking the flow of
calcium into the
muscles of the heart
and smooth muscles of
blood vessels. The
blood vessels relax and
become wider plus the
pumping action of the
heart is reduced.
For the treatment of
hypertension, chronic
stable angina and
confirmed or suspected
vasospastic angina.
mlodipine is
contraindicated in
patients with
known sensitivity to
amlodipine.
- dizziness;
- dizziness or lightheadedness;
- drowsiness;
- excessive tiredness;
- fainting;
- fainting;
- flushing (feeling of warmth);
- headache;
- more frequent or more severe
chest pain;
- rapid heartbeat;
- rapid, pounding, or irregular
heartbeat;
- stomach pain;
- swelling of the hands, feet,
ankles, or lower legs;
- upset stomach;
Monitor patient carefully
(BP, cardiac rhythm, and
output) while adjusting
drug to
therapeutic dose; use
special caution if patient
has CHF.
•
Monitor BP very carefully
if patient is also on
nitrates.
•
Monitor cardiac rhythm
regularly during
stabilization of dosage and
periodically
during long-term therapy.
•
Administer drug without
regard to meals.
Name/
classification
Dosage/
Route
Action Indication Contraindication Side effect Nursing intervention
Paracetamol
Analgesic
Oral 500 mg
tab.
Blocks pain
impulses, proably
by inhibiting
prostaglandin or
pain receptor
sensitizers. May relieve
fever by
acting in
hypothalamic heat-
regulating center.
The preparation is
indicated in diseases
manifesting with pain
and fever: headache,
toothache, mild and
moderate postoperative
and injury pain, high
temperature, infectious
diseases and chills (acute
catarrhal inflammations
of the upper respiratory
tract, flu, small-pox,
parotitis, etc.).
Paracetamol
should not be
used in
hypersensitivity to
the preparation
and in severe liver
diseases.
Paracetamol only rarely causes
gastrointestinal problems or allergic
skin reactions. Blood dyscrasia (e.g.
thrombocytopenia),
methaemoglobinemia, and
hemolytic anemia are very rare. A
minority of the subjects with so-
called aspirin intolerance responds
to paracetamol with bronchospasms.
It is not safely established if
paracetamol can cause a
nephropathy, like drug combinations
containing phenacetin.
- Tell patient that
drug is for short-
term use.
- Warn patient that
high doses or
unsupervised long-
term use can cause
liver damage.

22. Name/
classification
Dosage/
Route
Action Indication Contraindication Side effect Nursing intervention
Piracetam 1.2 tab./ oral Piracetam protects the
cerebral cortex against
hypoxia. It also inhibits
platelet aggregation and
reduces blood viscosity.
Piracetam, solution for
injection is used in cases
of severe brain diseases:
cerebro-cranial trauma in
acute stage, comatose
states, ischemic stroke,
acute psychic
disturbances due to
intoxications, alcohol
delirium. Piracetam
tablets are used in
cerebro-vascular disease;
degenerative cortical
dementia (Alzheimer’s
disease); senile
psychoorganic syndrome
(“aging brain”); cortical
myoclonia; dyslexia of
vascular and other
origin; vestibulopathies;
protection of the nervous
tissue in a brain hypoxia;
postoperative deliriums.
First trimester of
pregnancy; severe
parenchymal liver
or kidney diseases;
agitated
depression,
particularly in the
elderly.
Rarely in susceptible patients can
be observed the following
symptoms: increased
aggressiveness, headache, sleep
disturbance, gastrointestinal
problems, blood pressure
instability.
Prior to:
Wash hands
thoroughly.
Ask the patients
name
Always observe
aseptic technique
During: Explain the
procedure to the
patient/SO..
After: Record the drug
after
its administration
(charting). Observe the
patients
for possible untoward
reaction. Instruct to take
the
medication exactly as
directed.

23. Name/
classification
Dosage/
Route
Action Indication Contraindication Side effect Nursing intervention
Mefenamic
acid
/NSAID
oral 500 mg
tab.
Anti-inflammatory,
analgesic and
antipyretic
activities related
to inhibition of
prostaglandin
synthesis; exact
mechanisms of
action are not
known.
Like other anti-
inflammatory drugs,
mefenamic acid can
impair the effect of
antihypertensive agents
and it can increase the
toxicity of lithium and
methotrexate. Mefenamic
acid increases only
marginally (but still more
than e.g. ibuprofen) the
risk of bleeding under
oral anticoagulants.
Inflammatory
intestinal diseases.
Active peptic ulcers.
Hypersensitivity to
aspirin
(acetylsalicylic acid)
or other non-
steroidal anti-
inflammatory
agents. Renal
failure.
Dependent on the dose and the
duration of treatment, mefenamic
acid frequently causes diarrhea.
Long-term treatment can lead to
enteritis or colitis (sometimes with
steatorrhea). The drug can also
cause nausea, vomiting and upper
abdominal pain. Like other anti-
inflammatory agents, it
occasionally is the cause of peptic
ulcers or even of bleeding or
perforations.
BEFORE:
Assess the physical for skin
color and lesions; orientation,
reflexes, opthalmolgic, and
andiometric evaluation,
peripheral sensation; P, edema
R, adventitious sounds,; renal
function tests, serum
electrolytes, stool guaiac
R’s
AFTER:
•
Take drug with food; take only
the prescribed dosage and
teach not to take the drug
longer than 1 week
•
Discontinue drug and consult
health care provider if rash,
diarrhea, or digestive problems
occur.
•
Dizziness or drowsiness can
occur ( so avoid driving and
using dangerous machinery )

24. Name/
classification
Dosage/
Route
Action Indication Contraindication Side effect Nursing intervention
Gloclav
CO-AMOXICLAV
625mg/ cap.. Amoxicillin inhibits
transpeptidase,
preventing cross-
linking of bacterial
cell wall and leading
to cell death.
Addition of
clavulanate (a beta-
lactam) increases
drug's resistance to
beta-lactamase (an
enzyme produced by
bacteria that may
inactivate
amoxicillin).
Co-amoxiclav is
indicated for
treatment of the
following bacterial
infections due to
susceptible
organisms: -Upper
respiratory tract
infection. -Genito-
urinary tract
infections. -Skin and
soft tissue infections,
e.g. boils, abscesses,
cellulitis, animal bites,
wound infections. -
Bone and joint
infections, e.g.
osteomyelitis. -Dental
infections, e.g.
dentoalveolar
abscess. -Other
infections, e.g.
puerperal sepsis,
septic abortion, intra-
abdominal sepsis.
Co-amoxiclav is
contraindicated in
patients with a history
of allergic reactions to
any penicillin. It is
also contraindicated in
patients with a
previous history of
amoxicillin-potassium
clavulanate-associated
cholestatic jaundice/
hepatic dysfunction.
Co-amoxiclav is well
tolerated. Side effects, as
with amoxicillin, are
uncommon and mainly of
mild and transitory nature.
The reported adverse
effects include diarrhea,
nausea, vomiting,
antibiotic-associated colitis
(including
pseudomembranous
colitis), and candidiasis
have been reported.
Hepatitis and cholestatic
jaundice have been
reported rarely.
Uriticarial and
erythematous rashes
sometimes occur. Rarely
erythema multiforme
(including Stevens-
Johnson syndrome), toxic
epidermal necrolysis,
exfoliative dermatitis and
vasculitis have been
reported.
• Assess for infection
•
Obtain specimens for culture and
sensitivity prior to therapy. First
dose
may be given before receiving the
result
Monitor bow function
•
Instruct the patient to take the
medication around the cock and to
finish the drug completely as
directed.
•
Review use and preparation of
tablets for oral suspension

25. Name/
classification
Dosage/
route
Action Indication Contraindication Side effect Nursing intervention
Citicoline
CNS stimulant.
½ tab. Oral Citicoline increases
blood flow and O2
consumption in the
brain. It is also
involved in the
biosynthesis of
lecithin.
Cardiac stroke, Head
trauma, Ischaemic
heart disease,
Paralysis of lower
extremities, and can
also be given in
adjunctive therapy as
an alternative drug of
choice in Parkinson's
disease.
Unconciousness,
Brain surgery,
Pregnancy, Breast
feeding.
The severe or irreversible adverse
effects of Citicoline, which give rise to
further complications include
Hypotension.
The symptomatic adverse reactions
produced by Citicoline are more or less
tolerable and if they become severe,
they can be treated symptomatically,
these include Excitement, Insomnia.
•Somazine must not be
administered along with
medicaments containing
meclophenoxate
Name/
classification
Dosage/
route
Action Indication Contraindication Side effect Nursing intervention
LACTULOSE 30 cc Inhibits
bacterial
DNA
gyrase
thus
preventin
greplication in
susceptibe
bacteria
Constipatio
n,
salmonello
sis.
Treatment
of hepatic
encephalo
pathy
Pt who require a
low lactose diet.
Galactosemia
deficiency.
Intestinal
obstruction
Lactose
intolerance,
diabetes
Adverse Rxn:
Abdominal
discomfort
associated
with
flatulence and
intestinal
cramps.
Nausea,
vomiting,
diarrhea on
prolonged
use
>Assess condition
before therapy and
reassess regularly
thereafter to monitor
drug’s effectiveness
>Monitor pt for any
adverse GI reactions,
nausea,vomiting,diarr
hea,
>Assess for adverse
reactions
>for pt. with hepatic
encelopathy:
regularly assess
mental condition
>monitor I & O
>monitor for Inc.
glucose level in
diabetic pts

26. Name/
classification
Dosage/
route
Action Indication Contraindication Side effect Nursing intervention
AMLODI-
PINE
BESYLATE
5 mg cap/
oral
• Antianginal
• Antihyperte
nsive
• Calcium
channel
blocker
• Angina pectoris
due to
coronary artery
spasm
(Prinzmetals’
variant angina)
· Chronic stable
angina, alone or
in combination
with other drugs
· Essential
hypertension,
alone or in
combination with
other anti-
hypertensives
• Contraindicated
with allergy to
amlodipine,
impaired
hepatic or renal
function, sick
sinus
syndrome, heart
block (second or
third degree), and
lactation.
• Use cautiously
with
heart failure,
pregnancy
CNS: Dizziness,
lightheadedness, headache,
asthenia, fatigue, lethargy
CV: Peripheral edema,
arrhymias
Dermatologic: Flushing,
rash jaundice (yellowing of
the skin or eyes).
GI: Nausea, abdominal
discomfort
Urinating more or less than
usual, or not at all;
Fever, chills, body aches,
flusymptoms;Tiredfeeling,
muscle
weakness,andpoundingor
unevenheartbeats;
chest pain;
swelling, rapid weight gain
· Monitor BP carefully if patient is also
on nitrates.
· Monitor cardiac rhythm regularly
during stabilization of
dosage and periodically during
long term therapy.
· Administer drug without regard
to meals.
• Always remember and follow
the 10 R’s of drug
administration.
Name/
classification
Dosage/
route
Action Indication Contraindication Side effect Nursing intervention
Moriamin
Forte/multivita
mins and
minerals
1 cap/oral multivitamins and
minerals
malnutrition, protein
and vitamin
deficiencies, anemia,
convalescence,restor
ationand
maintenance of
bodyresistance,
pregnancyand
lactation,adjuvant
inthe therapyof
pepticulcerandTB
contraindicated for
patient’s with
malabsorption
syndrome
Form: cap 100’s
hypervitaminosis (large doses) contraindicated for patient’s with
malabsorption syndrome
Form: cap 100’s

27. LABORATORY RESULTS
May 22, 2010
Result Normal Interpretation
Hemoglobin 148 140-180 g/L Withinthe normal range but it is
near toabnormal.
Hematocrit 0.44 0.42-0.54 The level is just normal but it falls
near the boundary. So Hct level
shouldbe monitoredwell.
WBC 5.2 5.0x10x10 g/L WithinNormal Range but needs
continous monitoring due to close
to abnormal level.
DIFFERENTIAL COUNT
Segmenters 0.47 0.50-0.65 The result is lowand abnormal.
Lymphocytes 0.46 0.25-0.40 The result is very high, and
requires continous monitoring.
Eosinophil 0.07 1.3 The result is very low.
CONCLUSION:
**We therefore conclude that the Differential Counts of the patient suchas
Segementers, LymphocytesandEosinophil shouldbe monitoredregularly since it
shows abnormal results.

28. PATHOPHYSIOLOGY
Gunshot
Skull Penetration
Skull Fractures
CSF Leak Open brain injury
on frontotemporalarea
RISK FORINFECTION
TissueInflammation
and Bleeding
IncreaseIntracranialVolume
IncreaseICP
Slow Blood Flow to the Brain
TissuePerfusion
Cell Death or Cell Damage
Neurologic Dysfunction
Muscle Weaknessonthe
Right Extremitiesopoosite
to the affectedarea,
Hemiplagia
SEPTEMBER 21,2010
AlteredBehaviour
(frontal area is
affected)
SEPTEMBER 21,2010
Aphasia
Difficultyexpressing
speaking(temporal areais
affected)
SEPTEMBER 21,1010
RISK FOR INFECTION

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