A Case Study of a Patient with Severe Head Injury

Prepared by: Lady Diana T. Ortega

LTIM Department

I. Demographic Data

Name: Patient XAge: 19 years oldSex: MaleNationality: SaudiMarital Status: SingleDate of Admission: December 04, 2009

II. Physical AssessmentSkin warm, slightly moist,

smooth, hair evenly distributedHead skull slightly asymmetric, no

flaking of scalp, no lesions, no tenderness, scar noted in the craniotomy site, left tempoparietal area

Eyes no redness, no discharges, sclera white and clear, pupils reactive to light and accommodation,

unable to focus

Nose and Sinuses not perforated, no discharge,

NGT is present

Mouth no gum bleeding, tongue and uvula in midline position,

oral cavity is pinkish in color,

buccal mucosa smooth and moist, no ulcers, no swelling,

no palpable massesNeck no palpable lymph nodes,

trachea on midline positiontracheostomy tube is

present

Breasts nipples at the same level and protrude

slightly,no palpable masses, no

nipple dischargeThorax & Lungs thorax is symmetric, no

retraction of the Intercostal spaces, no

tenderness, back area slightly reddened

Upper Extremities decorticate position, arms are unable to extend, abduct and adduct

Nails convex curvature, smooth texture, good capillary refill

Abdomen slight abdominal distention, positive bowel sound

Lower Extremities malpositioned tibia and fibula, unable to flex, abduct and adduct

Genitalia skin of the glans penis is smooth, no ulceration, urethral meatus located ventrally on the end of the penis, no discharge, no palpable masses

III. A. Past Medical History

RTA(Dec 2003)

Intubated &

ventilated

CT scan &

skeletal exam

Craniotomy & ORIF

Weaned from

ventilation

III. A. Present Medical HistorySemiconscious, unable to speak, unresponsive to verbal stimulus

On tracheostomy tube, nasogastric feeding, voiding freely on diaper

Maintained with anticonvulsants, levetiracetam,

carbamazepine & phenytoin

Stable vital signs, good oxygen saturation, no

recent episodes of seizures

IV. Topic Presentation

“Head Injury”

V. Anatomy & Physiology

VI. EtiologyHead Injury

Acquired Traumatic

Closed Open

Diffuse Axonal

Concussion

Contusion

CoupCounter

coup

Penetrating

Cerebral edema

Increased ICP

Decreased cerebral bloodflow

Cerebral Ischemia

Confusion,coma,

seizure,loss of cognitive

&sensory function

AnoxicHypoxi

c

VII. Signs and SymptomsProlonged confusion, seizures, and multiple

episodes of vomiting Inability to awakendilation of one or both pupils, slurred

speech, aphasia, dysarthria, weakness or numbness in the limbs, loss of coordination, confusion, restlessness, or agitation.

do not respond with any body movement to pain,

do not have any speech, and do not open their eyes.

VIII. InterventionMaintain adequate cerebral blood flow, control increasing ICP by:

Proper Positioning Hyperventilation Hypertonic saline Diuretics Sedatives, analgesics & paralytics

IX. Treatment

Sedation, paralytics,

cerebrospinal diversion

Decompressive

craniectomy

Craniotomy

X. Complications Brain injury can cause prolonged or

permanent effects on consciousness (coma, brain death, vegetative state)

Lying still for long periods may cause many complications

Skull fractures & penetrating injuries may lead to meningitis & abscesses

Complications involving the blood vessels: vasospasm, aneurysms and stroke

XI. Prioritization of nursing problems① Altered cerebral tissue perfusion related to decreased cerebral blood flow secondary to head injury② Ineffective airway clearance related to accumulation of secretions and decreased

LOC③ Ineffective breathing pattern related to neurological dysfunction④ Risk for injury related to disorientation & restlessness⑤ Risk for impaired skin integrity related to

immobility

ASSESMENT

NSG Dx PLANNING INTERVENTION

RATIONALE EVALUATION

Subjective:Not applicable Objective: -semiconscious- unresponsive to verbal stimulus- unable to follow commands- unable to speak- on a decorticate position- poor motor function

Ineffective Cerebral Tissue Perfusion related to decreased cerebral blood flow secondary to head injury

° Maintain or improve level of conscious-ness,cognition,& motor/sensory function.° Demonstrate stable vitalsigns & absence ofsigns of increased ICP° Display no further deterioration in sensory, cognitive & motor function

° Monitor LOC, motor & sensory function  ° Routinely orient the patient to time, place & surroundings ° Position with head slightly elevated and in neutral position, and prevent hip flexion

 Assessment of improvement/ deterioration of cognitive & sensory functionMay help improve cognitive brain function &help minimized confusionReduces arterial pressure by promoting venous drainage, hip flexion can reduce venous drainage  

Goal partially met.°Maintained level of conscious-ness, cognition, & motor/sen-sory function°Demons-trated stable vital sign & absence ofsigns of increasedICP°Displayed no further deterioration in sensory, cognitive and motor function

ASSESMENT

NSG Dx

PLANNING

INTERVENTION RATIONALE EVALUATION

°Maintain bed rest; provide quietenvironment; Provide structured care activities & provide rest periods between care activities, limit duration of procedures.

° Maintain a patent airway, administer supplemental oxygen as indicated. ° Prevent straining at stool, may administer stool softener or laxatives as ordered ° Administer medications as ordered including anticonvulsants, enoxaparin Na, carbamazepine, phenytoin

Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent stimulation Provides cerebral oxygenation Valsalva maneuver increases ICP and risk of cerebral hemorrhage to improve cerebral blood flow and prevent clotting, embolus and episode of seizures

ASSESMENT NSG Dx PLANNING NTERVENTION RATIONALE EVALUATION

Subjective:Not ApplicableObjective:+cough-frequent sneezing-secretions characterized as; yellowish in color, thick in consistency- respiratory rate: 24bpm

Ineffective Airway Clearance related to accumu-lations of secretions and decreased LOC

° Maintain a patent airway & will de-monstrate signs of reduction in respiratory congestion°Respiratory rate within normal range: 16 to 20bpm° Display decreasing amount of secretions

• Auscultate lung sounds before & after tx noting areas of de-creased venti-lation & presence of adventitious breath sounds

• Position the patient on semi fowler’s position

• Clear secretions from the mouth and trache. Suction as necessary

Assist in evaluating prescribed treatments and client outcomes

allows good lung expansion and maximum ventilationTo prevent obstruction/ aspiration.

Goal met.° Patient maintained a patent airway & demonstrated signs of reduction in respiratory congestion° Respiratory rate within normal range: 20bpm° Displayed decreasing amount of secretions

ASSESMENT

NSG Dx PLANNING INTERVENTION

RATIONALE

EVALUATION

•Humidify inspired air as indicated by treatment

•Institute respiratory treatment as needed such as CPT and nebulization.

• Give medications such as bronchodilators and mucolytic

This prevents drying of mucous membranes

A variety of respiratory treatments may be used to open constricted airways and liquefy secretions

Helps lowering the viscosity and liquefying the secretions

ASSESMENT NURSING DIAGNOSI

S

PLANNING

INTERVENTION RATIONALE EVALUATION

Subjective:Not ApplicableObjective:- confined to bed-unable to move, turn to side to side-unable to abduct and adduct extremities-medium-sized body built-back area and buttocks slightly reddened

Risk for impaired skin integrity related to immobility

° Patient’s skin will remain intact and will not develop any skin breakdown during the stay at the facility.

• Reposition the patient from side to side at least every 3hours

• Lift the patient during turning, do not drag or pull. Encourage use of lift sheets to move patient in bed

• Clean, dry, & moisturize skin, especially over bony prominences. Use powder or creams as necessary

Positioning interventions reduce pressure and shearing force to the skinFriction may cause break of skin

Moisture softens the skin &causes a break in the skin integrity. Creams or powder may help smoothen the skin

Goal met.Patient’s skin remained intact and did not developed any skin breakdown during the stay at the facility.

ASSESMENT NURSING DIAGNOSI

S

PLANNING

INTERVENTION RATIONALE EVALUATION

• Use good quality air mattress, avoid wrapped and wrinkled bed sheets

• Massage on the area of pressure avoiding reddened skin part

This helps in reducing pressure

Increase tissue perfusion by massaging around affected area

XIII. Nursing Health TeachingHealth teaching primarily focused on educating the watcher of care and management:

1. Review the signs of increased ICP or episodes of seizure with the watcher.

2. Teach the watcher with the proper techniques: therapeutic use of touch, massage and music

3. Eliminations of distractions (television, radio, crowds)

4. Provide one on one communication with the pt.5. Provide the necessary education to watcher

including proper positioning, ROM exercises and so forth.

XIV. ConclusionHead injury can be mild, moderate or severe. A mild head injury may cause confusion & headache and most people recover from it. A severe head injury may happen if the head is violently shaken without coming in contact with a hard object. When patient recover from moderate to severe head injury they may be left with long term effects such as cognitive disabilities & sensory problems & may lead to long time or maybe permanent bed confinement & sometimes in coma state. In this case, patient needs full time care & management. Comfort should always be consider, support to the back & joints when turning & lifting to prevent strain. Hygiene of the patient, bed & surroundings are also important. A daily bed bath should be given to cleanse, refresh & relax the patient. It also promotes circulation & provides a mild form of exercises. In general, nurses have a big role in assisting these patients in attending their activities of daily living while giving respect to their privacy & dignity.