PHYSICAL ASSESMENT

DATE: July 22, 2011 T: 37 PR: 110 BP:110/8o RR: 32

Received lying in bed, awake and coherent with ongoing IVF of D5.5NaCl at 44gtts/mininfusing well on left arm.

GENERAL SURVEY PHYSICAL APPEARANCE He appears appropriately with age. He appears calm. Body structure Body parts seemingly equal bilaterally and in relative proportion with each other. BEHAVIOR He cooperates and interacts pleasantly, however, aloof talking with somebody else. ASSESSED AREA TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDING S Tan, smooth and firm Moist RATIONA LE

SKIN

COLOR TEXTURE MOISTURE

INSPECTION PALPATION

BROWN TAN SMOOTH AND FIRM MOIST IN THE SKIN FOLDS OF AXILLA WITHIN THE RANGE

NORMAL

NORMAL NORMAL

PALPATION

TEMPERATURE

INSPECTION Using a

36.5

NORMAL

thermomether INSPECTION INSPECTION INSPECTION APPEARANCE TURGOR

(36.5-37.5)

NORMAL

SPRINGS BACK WHEN PINCHED No bruises, w/ stub wound at the left epigastri c region

NORMAL

HAIR

COLOR

NORMAL INSPECTION BLACK CURLY OR STRAIGHT HAIR FINE OR THICK AND SILKY

TEXTURE

Evenly distribut ed

INSPECTION

NORMAL INSPECTION DISTRIBUTION INSPECTION EVENLY DISTRIBUTED ABSENCE OF LESIONS NORMAL

LESIONS

NORMAL NAILS NAIL BED COLOR SHAPE AND CONTOUR CONVEX: NAIL EDGES ARE SMOOTH; CLEAN Dirty nails THICK AND FIRM, CAPILLARY NORMAL PINKISH Poor hygiene

PALPATION

THICKNESS CAPILLARY REFILL INSPECTION

REFILL IS 1-3 SEC HEAD AND NECK SIZE AND SHAPE INSPECTION SYMMETRY FACE PROPORTIONAL TO THE SIZE OF THE BODY; SKULL IS ROUNDED SYMMETRICA L SMOOTH EYES EYEBROWS INSPECTION EYELIDS AND EYELASH SAME IN SIZE AND MOVES INSPECTION CRT IS 243SEC

NORMAL

NORMAL

INSPECTION NORMAL

NORMAL

NORMAL SYMMETRICAL EQUALLY ALIGNED AND EVENLY DISTRIBUTED INSPECTION

CONJUNCTIVA, SCLERA AND COLOR OF PUPILS

PINKISH IN COLOR BLACK

NORMAL

EARS SYMMETRY

INSPECTION SYMMETRICAL AND INSPECTION SAME LEVEL WITH THE UPPERPART OF THE EARS INSPECTION EQUAL IN NORMAL NORMAL

SHAPE AND SIZE

NORMAL

SIZE AND SHAPE FIRM INSPECTION TENDERNESS PALPATION PROPORTION AL WITH OTHER FACIAL STRUCTURES AND POSITIONED IN THE MIDLINE INSPECTION PATENCY NO NASAL FLARING NORMAL NORMAL NO PAIN IN MOVEMENT NORMAL

NOSE SHAPE

LIPS COLOR TEXTURE

INSPECTION

PINKISH MOIST AND SMOOTH MOIST

NORMAL

MOISTURE

INSPECTION

NORMAL

TONGUE MOBILITY

INSPECTION

CAN BE MOVE FREELY

NORMAL

LESIONS

INSPECTION

NO LESIONS

NORMAL

INSPECTION

NO LESIONS

NORMAL

GUMS

AND SIGN OF BLEEDING

TEETH

INSPECTION

WHITE IN COLOR; FREE FROM CAVITY; COMPLETE (32)

POOR HYGIENE

THORAX CHEST

INSPECTION

EXPAND EQUALLY UPON INHALATION NO ADVENTITIOUS SOUND 17BPM

INCOMPLETE; SOME ARE STAINED

NORMAL

NORMAL

LUNG

AUSCULTATION

RESPIRATORY RATE HEART SOUND ABDOMEN CONTOUR

CLEAR INSPECTION INSPECTION FLAT AND CONVEX

NORMAL NORMAL

NORMAL PROPORTIO NAL WITH THE SIZE OF THE OTHER BODY PARTS

SYMMETRY

NORMAL

INSPECTION

SKIN INTEGRITY INSPECTION

GOOD INTEGRITY UPPER EXT. NORMAL EQUAL IN SIZE; LOWER EXT. ARE EQUAL IN

EXTRIMITIES

SIZE INSPECTION

SIZE

NORMAL

SYMMETRIC AL SYMMETRY NORMAL INSPECTION EVENLY DISTRIBUTED HAIR DISTRIBUTION

NORMAL INSPECTION

INTRODUCTION
The term traumatic brain injury (TBI) refers to injuries to the brain that are caused by some form of traumatic impact. Traumatic brain injuries usually are caused by a blow to the head, violent shaking or penetration of the brain tissue. Depending on the cause and severity of the brain injury, brain damage can be mild, moderate or severe. Initial symptoms of a traumatic brain injury may include: Headache , Dizziness, Loss of consciousness, Blurred vision, Confusion, Memory loss Seizures, Paralysis, Coma In more serious cases of traumatic brain injury, complications can be fatal. While the severity of traumatic brain injuries varies, the long-term effects are often devastating and life-altering.Types of traumatic brain injuries are divided into two categories: open head injury and closed head injury. Open head injuries are injuries in which the skull has been fractured or the membranes surrounding the brain (dura mater) have been breached. Open head injuries are very serious and often require surgery to extract pieces of the fractured skull and implant synthetic pieces. Closed head injuries, on the other hand, do not break the skull and are typically caused by blows to the head. Both open and closed head injuries can cause mild to severe brain damage. Damage from traumatic brain injuries is classified as either focal or diffuse. Focal damage is confined to a small area of the brain where the head has been hit by an object or where an object has penetrated the brain. Diffuse damage is damage to several areas of the brain; it can be caused by lack of oxygen, aneurisms, infection, neurological diseases or violent collisions of the brain with the inside of the skull.Traumatic brain injuries are typically caused by blows to the head, collision between the brain and the inside of the skull, or both. Some of the most common causes of traumatic brain injury include falls, transportation accidents and assaults. Transportation accidents account for more than half of all traumatic brain injuries, including concussions, and are the leading cause of traumatic brain injury in people under 75 years old. Falls are the leading cause of traumatic brain injury in people over 75 years old. In addition, many traumatic brain injuries (about 20 percent) result from violent acts such as firearm assaults or child abuse. Sports-related accidents account for about 3 percent of all traumatic brain injury cases. Diagnosing traumatic brain injury often requires doctors to perform a physical examination of the head and a variety of verbal tests. Using either the Glasgow Coma Scale or the Rancho Los Amigos Coma Scale they ask, traumatic brain injury patients several questions to assess their level of consciousness and their ability to speak, move and open their eyes. To further evaluate brain damage, doctors may order magnetic resonance imaging (MRI) scans, computed tomography (CT) scans or X-rays to identify any skull fractures, brain swelling or bleeding in the brain or skull (hematoma). In some instances, traumatic brain injury can lead to increased intracranial pressure. These cases often require surgery to accommodate brain swelling and excess fluid. Open head injuries

may require surgery to remove broken skull fragments and insert synthetic pieces that protect delicate brain tissue. Traumatic brain injury rehabilitation is an important part of treatment because it helps patients regain or manage impaired brain functions and minimizes long-term traumatic brain injury disabilities. Through rehabilitation, patients are sometimes able to regain important brain functions such as speech, memory and mobility. Rehabilitation can also help a victim's family cope with the tragedy. Traumatic brain injury has many other causes, complications and treatments. Please read other articles on this site for more information on diagnosis, treatment and prevention of traumatic brain injury.

PATHOPHYSIOLOGY

NON-MODIFIABLE: Gender:male Age:15-24 y/o

MODIFIABLE : Lifestyle occupation

Brain suffers traumatic injury(primary injury)

Brain swelling or bleeding intracranial pressure Rigid cranium allows no room for expansion of contents so intracranial pressure increases Head ache dizziness Confusion Pressure on blood vessels within the brain causes blood flow to the brain to slow

Cerebral hypoxia and ischemia occur

Intracranial pressure continues to rise. Brain may herniate

Cerebral blood flow ceases

ANATOMY AND PHYSIOLOGY

The Central Nervous System The CNS consists of the brain and spinal cord, which are located in the dorsal body cavity. The brain is surrounded by the cranium, and the spinal cord is protected by the vertebrae. The brain is continuous with the spinal cord at the foramen magnum. In addition to bone, the CNS is surrounded by connective tissue membranes, called meninges, and by cerebrospinal fluid. Meninges There are three layers of meninges around the brain and spinal cord. The outer layer, the dura mater, is tough white fibrous connective tissue. The middle layer of meninges is arachnoid, which resembles a cobweb in appearance, is a thin layer with numerous threadlike strands that attach it to the innermost layer. The space under the arachnoid, the subarachnoid space, is filled with cerebrospinal fluid and contains blood vessels. The pia mater is the innermost layer of meninges. This thin, delicate membrane is tightly bound to the surface of the brain and spinal cord and cannot be dissected away without damaging the surface.Meningiomas are tumors of the nerve tissue covering the brain and spinal cord. Although meningiomas are usually not likely to spread, physicians often treat them as though they were malignant to treat symptoms that may develop when a tumor applies pressure to the brain. Brain The brain is divided into the cerebrum, diencephalons, brain stem, and cerebellum. Cerebrum The largest and most obvious portion of the brain is the cerebrum, which is divided by a deep longitudinal fissure into two cerebral hemispheres. The two hemispheres are two separate entities but are connected by an arching band of white fibers, called the corpus callosum that provides a communication pathway between the two halves. Each cerebral hemisphere is divided into five lobes, four of which have the same name as the bone over them: the fontal lobe, the parietal lobe, the occipital lobe, and the temporal lobe. A fifth lobe, the insula or Island of Reil, lies deep within the lateral sulcus. Diencephalon The diencephalons is centrally located and is nearly surrounded by the cerebral hemispheres. It includes the thalamus, hypothalamus, and epithalamus. The thalamus, about 80 percent of the diencephalons, consists of two oval masses of gray matter that serve as relay stations for sensory impulses, except for the sense of smell, going to the cerebral cortex. The hypothalamus is a small region below the thalamus, which plays a key role in maintaining homeostasis because it regulates many visceral activities. The epithalamus is the most dorsal portion of the diencephalons. This small gland is involved with the onset of puberty and rhythmic cycles in the body. It is like a biological clock. Brain Stem The brain stem is the region between the diencephalons and the spinal cord. It consists of three parts: midbrain, pons, and medulla oblongata. The midbrain is the most superior portion of the brain stem. The

pons is the bulging middleportion of the brain stem. This region primarily consists of nerve fibers that form conduction tracts between the higher brain centers and spinal cord. The medulla oblongata, or simply medulla, extends inferiorly from the pons. It is continuous with the spinal cord at the foramen magnum. All the ascending (sensory) and descending (motor) nerve fibers connecting the brain and spinal cord pass through the medulla. Cerebellum The cerebellum, the second largest portion of the brain, is located below the occipital lobes of the cerebrum. Three paired bundles of myelinated nerve fibers, called cerebellar peduncles, form communication pathways between the cerebellum and other parts of the central nervous system. Ventricles and Cerebrospinal Fluid A series of interconnected, fluid-filled cavities are found within the brain. These cavities are the ventricles of the brain, and the fluid is cerebrospinal fluid (CSF). Spinal Cord The spinal cord extends from the foramen magnum at the base of the skull to the level of the first lumbar vertebra. The cord is continuous with the medulla oblongata at theforamen magnum. Like the brain, the spinal cord is surrounded by bone, meninges, and cerebrospinal fluid. The spinal cord is divided into 31 segments with each segment giving rise to a pair of spinal nerves. At the distal end of the cord, many spinal nerves extend beyond the conus medullaris to form a collection that resembles a horse's tail. This is the cauda equina. In cross section, the spinal cord appears oval in shape. The spinal cord has two main functions: Serving as a conduction pathway for impulses going to and from the brain. Sensory impulses travel to the brain on ascending tracts in the cord. Motor impulses travel on descending tracts. Serving as a reflex center. The reflex arc is the functional unit of the nervous system. Reflexes are responses to stimuli that do not require conscious thought and consequently, they occur more quickly than reactions that require thought processes. For example, with the withdrawal reflex, the reflex action withdraws the affected part before you are aware of the pain. Many reflexes are mediated in the spinal cord without going to the higher brain centers.

OBJECTIVES

General Objectives:

This case study aims to explain the development of such a disease condition and it could help a lot for us student nurses to appreciate and to get the most out of our knowledge, skills in giving appropriate intervention to such case.

Specefic Objectives:
To know what causes to have Acute Tonsillopharyngitis. To be familiar with this condition. To trace the pathophysiology of this disease and be able to understand its prognosis. To gain some important consideration through nursing care to the patient suffering from this disease To render health care services into the patient

CASE STUDY ON TRAUMATIC BRAIN INJURY

BY: GROUP 32 set A Taguiam, K-ann Taguinod, Danica Lorine Tagupa, Paula Marie Talosig, Fremie Gay