LEARNING OBJECTIVES

Prepared by:
Cabag, Eleno Jr.
 Learning Objectives
General Objectives:
To obtain a comprehensive
understanding and learning of our
client who had a Traumatic Brain Injury
(TBI) and for us student nurses to
perform responsibilities and respond
for his recovery.
 Learning Objectives
Student Centered Objectives
Attitude:
To be able to develop optimistic outlook
towards providing holistic care to the
patient.

To be able to provide support during

treatment process.
 Learning Objectives
Client Centered Objectives
To establish therapeutic communication and
rapport with the patient for effective patient
nurse interaction all throughout the care
providing process.

To carry out nursing interventions that will

promote patients comfort and safety.
 Introduction
Traumatic Brain Injury (TBI) also known as
intracranial injury, occurs when an external force
injures the brain. TBI can be classified based on
severity, mechanism (closed or penetrating head
injury), or other features.
 Definition
Traumatic brain injury (TBI) happens when a
bump, blow, jolt, or other head injury causes
damage to the brain.
Every year, millions of people in the U.S. suffer
brain injuries. More than half are bad enough
that people must go to the hospital.
The worst injuries can lead to permanent
brain damage or death. Half of all TBIs are
from motor vehicle accidents.
 Signs and Symptoms
Headache
Vomiting or nausea
Convulsions or seizures
Slurred speech
Weakness or numbness in the arms and legs
Dilated eye pupils
 Case Abstract
Patient X was on his way home and crossing to
a pedestrian and bump by a Patrol Car that is
going to deliver another patient to ER. They
rushed him into the San Pablo City Laguna
Provincial Hospital. The patient is unconscious
and had an edema and skin discoloration to
the periorbitals.
NURSING HISTORY

Prepared by:
Andaya, Ralph Lauren
Cardeno, Yury
NURSING HISTORY
Note: All of the informations were obtained from the pt.s wife

HISTORY OF PRESENT ILLNESS

Central Peripheral Hematoma extending to peri-orbital
resulted from a Vehicular Accident (hit by a Brgy. Patrol
vehicle) happened last September 3, 2017, 6:30 pm @
Negorio San Pablo City, Laguna
CT scan was done showing results of:
Comminuted fractures involving the right fronto-parietal &
left posterior partieto-occipital bones
Diffuse mild scalps of soft tissue swelling/hematoma
extending to bifrontal-nasal areas, more on the right
Abrasions @ the left shoulder lower back, and occipital
The pt. is drowsy, irritable @ times and has altered speech
Glasgow Coma Scale (GCS) score of 12
NURSING HISTORY
Note: All of the informations were obtained from the pt.s wife

PAST HEALTH HISTORY

ILLNESSESS: None
IMMUNIZATIONS: None
ALLERGIES: None
PAST ACCIDENTS AND INJURIES: None
MEDICATIONS: None
NURSING HISTORY
Note: All of the informations were obtained from the pt.s wife

FAMILY HEALTH HISTORY

No family diseases
LIFESTYLE
Personal habits: Drinking of alcoholic beverages every
other day esp. when stressed
Diet:
The pt. prefers & more often eat vegetables & fish than meat
products
Drinks 8-10 glasses of water daily
No physical exercise except during work
Normal sleep pattern before hospitalization
NURSING HISTORY
Note: All of the informations were obtained from the pt.s wife

SOCIAL DATA
The pt. has a good relationship with his friends & family

EDUCATIONAL HISTORY
Elementary graduate

OCCUPATIONAL HISTORY
Steelman for 5 years
NURSING HISTORY
Note: All of the informations were obtained from the pt.s wife

ECONOMIC STATUS
The pt. earned P 700.00 daily & is considered to be in the
lower middle class family
PSYCHOLOGICAL DATA
MAJOR STRESSORS:
Working for 6 days a week
Responsibility of providing the needs of his family
USUAL COPING PATTERN FOR STRESS:
The pt. just keeps silent of his problems & drinks alcohol
instead
GORDONS HEALTH PATTERN
Note: All of the informations were obtained from the pt.s wife

HEALTH PERCEPTION-HEALTH FUNCTION

Prior to hospitalization
N/A
During hospitalization
N/A
GORDONS HEALTH PATTERN
Note: All of the informations were obtained from the pt.s wife

NUTRITIONAL METABOLIC PATTERN

Prior to hospitalization
Eats 3-4 times a day
Usually eats egg & rice for breakfast
Prefers & more often eat vegetables & fish than meat
products
Doesnt like possessed foods
Eats Street foods very seldom
Doesnt like sweets
Drinks 8-10 glasses of water daily
Drinks alcoholic beverages every other day
During hospitalization
NPO
GORDONS HEALTH PATTERN
Note: All of the informations were obtained from the pt.s wife

ELIMINATION PATTERN
Prior to hospitalization
Voids about 4-5 times a day
Defecates OD
During hospitalization
600cc urine output obtained from urine bag
Hasnt yet defecated since hospitalization
ACTIVITY EXERCISE PATTERN
Prior to hospitalization
No physical exercise except during work
During hospitalization
Bed restricted
GORDONS HEALTH PATTERN
Note: All of the informations were obtained from the pt.s wife

SLEEP-REST PATTERN
Prior to hospitalization
8 hrs. of sleep from 10pm 6am daily
Prefers side lying position during sleep
Naps in the afternoon for 30 mins.
During hospitalization
Intermittent sleeping pattern
COGNITIVE-PERCEPTUAL PATTERN
Prior to hospitalization
Did not have any sensory deficits
Elementary level is his highest educational attainment
Did not use hearing aid or eye glasses
Able to read & write
During hospitalization
Altered sensory function
Cannot able to answer questions and follow
instructions/commands
GORDONS HEALTH PATTERN
Note: All of the informations were obtained from the pt.s wife

SELF-PERCEPTION PATTERN
Prior to hospitalization
N/A
During hospitalization
N/A
ROLE-RELATIONSHIP PATTERN
Prior to hospitalization
Jealous when it comes to his wife
Lives with his wife & 2 children
Has a good relationship with his family
Able to provide the needs of his family
During hospitalization
Unable to perform his role as a father and as a husband
GORDONS HEALTH PATTERN
Note: All of the informations were obtained from the pt.s wife

SEXUALITY-REPRODUCTIVE PATTERN
Prior to hospitalization
He is sexually active specifically 3 times per week
Circumcised
During hospitalization
Not sexually active
COPING-AREAS MANAGEMENT PATTERN
Prior to hospitalization
Keeps silent of his problems & drinks alcohol instead
During hospitalization
N/A
GORDONS HEALTH PATTERN
Note: All of the informations were obtained from the pt.s wife

VALUE BELIEF PATTERN

Prior to hospitalization
Religion: Roman Catholic
Seldom go to church
Doesnt pray
During hospitalization
Unable to go to church
PHYSICAL EXAMINATION
PHYSICAL
METHOD USE NORMAL FINDINGS ABNORMAL FINDINGS
ASSESSMENT
Appearance and Inspection Proportionate, varies with Flexes abnormally
Mental Status lifestyle Disoriented, uses
inappropriate words
Uncooperative,
unable to follow
instructions
Skin Inspection and Uniform brown skin color Dry skin
Palpation except in areas not exposed Presence of
to the sun abrasions @ left
Tattoos @ right shoulder shoulder & lower
and right & left leg back
Hair Inspection Evenly distributed hair None
Black in color
Short hair
No evidences of Alopecia
Nails Inspection and Convex curvature None
Palpation Smooth texture
Intact epidermis
Nail bed color is normal
PHYSICAL EXAMINATION
Skull and Face Inspection and Rounded Central Peripheral
Palpation Skull contour Hematoma extending
to peri-orbital
Wound @ occipital
area
Unsymmetrical facial
movements

Neck Inspection and The neck is straight None

Palpation No visible mass or lumps
Symmetrical
No jugular venous
distension
Eyes and Vision Inspection Eyebrows symmetrically No response to eye
distributed opening
Peri-orbital edema
Ears Inspection and Color same as facial skin Small amount of
Palpation Symmetrical discharge
Auricle aligned w/ outer
canthus of the eye
Can recoil
No wounds
PHYSICAL EXAMINATION
Nose Inspection Symmetric and straight None
No flaring and lesions

Mouth Inspection Uniform pink color of gums None

Abdomen Inspection Symmetric contour None

Lower extremities Inspection and No sore None

Palpation No swelling
No tenderness
No signs of edema
Tattoos @ right & left leg

Chest Inspection and No sore None

palpation No swelling
No tenderness
No signs of edema
LABORATORY RESULT &
DIAGNOSTIC TEST
Prepared by:
Breis, Jillian Marie A.
 CBC RESULT (09/04/17)
TEST RESULT REFERENCE RANGE
Hemoglobin mg/L 117 M: 130-180 F: 120-160
I: 113-130 NB:136-196 C: 115-148
Hematocrit (%) 34.6 M: 40-50 F: 37-43
I: 35-40 NB: 50-58 C:38-44
RBC 9x1012/L 3.96 M: 4.5-6.2 F: 4.0-5.4
I: 3.8-5.9 NB: 5.0-7.0 C: 3.8-5.4
MCV (fI) 87.3 80-100
MCH (pg) 29.5 27-32
MCHC (g/L) 338 520-360
RDW-CV (%) 13.1 11.0-16.0
RDW-SD(fL) 43.2 37-54
Platelet ct. 152,00 A:170,000-400,000 I:350,000-660,000
C:250,000-510,000
PCT (x1012/L) 0.100 0.15-0.50
MPV (fL) 6.6 6-11
PDW(%) 16.0 11-18
Blood Chemistry (09/04/17)
Result Normal Value Result Normal Value
Fasting Blood Sugar (FBS) 70-110 mg/dl 3.85-6.05 mmol/L

Blood Uric Acid (BUA) M: 3.4-7mg/dl M: 0.20-0.41 mmol/L

F: 2.5-6 g/dl F:0.15-0.35 mmol/L
Blood Urea Nitrogen 21.6 8.0-25.0 mg/dl 7.7 2.86-8.95 mmol/L
(BUN)
Creatinine 2.6 0.50-1.70mg/dl 229.8 44.20-150.25 mol/L

SGOT/AST Up to 40 IU/L up to 40 U/L

SGPT/ALT Up to 38 IU/L Up to 38 U/L

Sodium (Na+) 135-148 mEq/L 135-148 mmol/L

Potassium (K+) 3.5-107 mEq/L 3.5-5.3 mmol/L

Chloride (Cl-) 98-107 mEq/L 98-107 mmol/L

Blood Chemistry (09/08/17)
Conventional Unit SI Units
Result Normal Value Result Normal Value
Fasting Blood Sugar (FBS) 70-110 mg/dl 3.85-6.05 mmol/L

Blood Uric Acid (BUA) M: 3.4-7mg/dl M: 0.20-0.41 mmol/L

F: 2.5-6 g/dl F:0.15-0.35 mmol/L
Blood Urea Nitrogen 14.56 8.0-25.0 mg/dl 5.20 2.86-8.95 mmol/L
(BUN)
Creatinine 0.98 0.50-1.70mg/dl 86.2 44.20-150.25 mol/L

SGOT/AST Up to 40 IU/L up to 40 U/L

SGPT/ALT Up to 38 IU/L Up to 38 U/L

Sodium (Na+) 142 135-148 mEq/L 142 135-148 mmol/L

Potassium (K+) 3.3 3.5-107 mEq/L 3.3 3.5-5.3 mmol/L

Chloride (Cl-) 98-107 mEq/L 98-107 mmol/L

SEROLOGY & BLOOD BANKING

Blood Group: A RH+

 CRANIAL CT SCAN
CLINICAL HISTORY: Vehicular accident, restlessness
COMPARISON: None
TECHNIQUE: Axial slices of the head taken without contrast
FINDINGS:
S/P trauma with pertinent finding as follows
Mixed density changes in the superficial bifrontal lobes, right
posterior temporal and ipsilateral paramedian parietal lobes, likely
attributed to parenchymal contusion hematomas with edema, the
largest of which in both frontal lobes measure approximately 25-26cc
in aggregate volume, with predominance on the right. There is
associated diffuse effacement of bilateral cerebral hemispheric
cortical sulci and cisterns, predominantly involving the immediately
adjacent/underlying ones. There is compression of the 3rd and both
lateral ventricles with relative leftward subfalcial and interventricular
septal shift to about 0.64cm from the midline
 Streaky hypodensities in the region of the pons, taking into
consideration overlying bony streak artifacts to rule out underlying
ischemic change/s.
Suggestive sinus inflammatory and/or trauma related changes as
shown by fluid densities in bilateral sphenoid sinuses and mild
mucosal changes in bilateral ethmoid sinuses.
Comminuted fractures involving the right fronto-parietal and left
posterior partieto-occipital bones, the latter with mild overriding of
the fracture fragments as well as mildly depressed occipital bone
segment causing some compression/apparent mild contusion of the
underlying brain parenchyma.
Diffuse mild scalp soft tissue swelling/hematoma extending to
bifronto-nasal areas, more on the right.

The visualized intraorbital areas, petromastoids and the rest of the

paranasal sinuses are grossly intact.

IMPRESSION:
POSTRAUMATIC FINDINGS, AS ABOVE-ENUMERATED
ANATOMY AND PHYSIOLOGY

Prepared by:
Arao, Angelica
 The brain is one of the largest and most
complex organs in the human body. It is made
up of more than 100 billion nerves that
communicate in trillions of connections called
synapses.
 The brain is made up of many specialized areas that
work together:
The cortex is the outermost layer of brain cells.
Thinking and voluntary movements begin in the
cortex.
The brain stem is between the spinal cord and the
rest of the brain. Basic functions like breathing and
sleep are controlled here.
The basal ganglia are a cluster of structures in the
center of the brain. The basal ganglia coordinate
messages between multiple other brain areas.
The cerebellum is at the base and the back of the
brain. The cerebellum is responsible for coordination
and balance.

 The brain is also divided into several lobes:

The frontal lobes are responsible for
problem solving and judgment and motor
function.
The parietal lobes manage sensation,
handwriting, and body position.
The temporal lobes are involved with
memory and hearing.
The occipital lobes contain the brain's
visual processing system.
 The brain is surrounded by a layer of tissue
called the meninges. The skull (cranium)
helps protect the brain from injury.
PATHOPHYSIOLOGY

Prepared by:
Apanto, John Mark Lintzi B.
 Precipitating Factors Head Injury/Brain Precipitating Factors:
Gender (Male or Injury Environment
Female) Head Injury /
Age Vehicle accidents
Significant brain damage
Manifestation: secondary to obstructed
Altered level of blood flow and decreased
consciousness tissue perfusion.
Confusion
Pupillary abnormalities
(changes in shape, size, and Traumatic Brain
response to Injury
light)
Altered or absent gag
reflex Primary Injury Secondary Injury
Absent corneal reflex
Sudden onset of The initial damage to the brain Evolves over the ensuing hours and
neurologic deficits that results from the days after the initial injury.
Changes in vital signs traumatic event.
(altered respiratory pattern,
hypertension, Manifestation: Manifestation:
bradycardia, tachycardia, Loss of consciousness Cerebral
hypothermia or Loss of reflexes edema
hyperthermia) Hemiparesis (muscular Closed Head Disruption
Vision and hearing weakness of one-half of Injury of the
impairment the body) blood-brain
Sensory dysfunction Abnormal posturing barrier
Spasticity Headache Rapid back and forth movement Death of
Headache Deteriorating of the brain that causes bruising neurons
Vertigo consciousness to deep and tearing of brain tissues and
Movement disorders coma vessels, but the skull is intact
Seizures Hemiplegia on
contralateral side
Dilated pupil on the
side of the clot
 Focal lesions Axonal damage from shearing, Diffuse Injuries
tearing, or stretching of nerve fibers.

Damage to the brain at the

point of the impact and the Caused by a
rebound effect. shaking motion, Rotational Injury
with twisting
movement
Contact phenomena injury

Sustained when the

Concussion Diffuse Axonal Injuries
head is struck by a
moving object.
A transient neurogenic Shearing of fragile axons by
Contusion dysfunction caused by acceleration-deceleration
GCS Scale mechanical force to the forces at the time of trauma.
brain
A bruise of the surface of the brain,
typically accompanied by small,
diffuse venous hemorrhages. Manifestation:
Headache
irritability
Hematoma Insomnia
Poor concentration and memory
Chronic traumatic encephalopathy
(repeated mild head injury)
Epidural Subdural Difficulty in awakening
Hematoma Hematoma Traumatic Intra- Difficulty in speaking
cerebral Confusion
Hematoma Severe headache
Located in the Vomiting
space between Weakness of one side of the body
the skull and the
dura mater
 Located in the Located
space below directly in the
the dural surface brain tissue
(between the
dura and
Due primarily to brain
arachnoid and pia
swelling or ongoing
mater layers of Broken bones
bleeding.
meninges) displace
inward.

Manifestation: Affect perfusion and

Acute: oxygenation of brain
Headache cells.
Drowsiness Comminuted
Agitation Fractures
Slowed thinking Manifestation:
Confusion Hypoxia
Sub-acute: Hypotension
Same as those of acute cytotoxic
subdural edema
hematoma but develop Ischemia
more slowly
Chronic:
Manifestations may not
appear until weeks to
months after injury
Confusion, slowed
thinking, drowsiness

Prepared by:
Apanto, John Mark Lintzi B.
DRUG STUDY

Prepared by:
Abawag, Charisse
 Metoclopramide
DRUGS MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS NURSING
ACTION CONSIDERATIONS
GENERIC Blocks To prevent Hypersensitivity to Drowsiness Monitor blood
NAME: dopamine chemotherapy drug Restlessness pressure
Metoclopram receptors by -induced Parkinsons disease Fatigue during I.V.
ide disrupting CNS vomiting/ Suspected GI Lethargic administration
BRAND chemorecepto To facilitate obstruction, Dizziness Stay alert for
NAME: r trigger zone, small-bowel perforation or Anxiety depression
Apo- increasing intubation;rad haemorrhage Headache and other
Metoclop peristalsis and iologic Hx of seizure Insomnia adverse CNS
promoting examination disorder Constipation effects.
CLASSIFICATI gastric when delayed Tachycardia Tell patient to
ON emptying. gastric take 30
Antiemetic,GI emptying minutes
Stimulant interferes. before meals.
Pregnancy Diabetic Instruct
risk category gastroparesis. patient to
B Gastroesopha report
geal reflux involuntary
DOSAGE: Prevention of movements of
1 amp IV q 8 postoperative face, eyes, or
hrs nausea and limbs.
PRN if vomiting.
nausea/vomi
ting
 Diazepam
DRUGS MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS NURSING
ACTION CONSIDERATIONS
GENERIC Produces Anxiety Hypersensitivity to Drowsiness Monitor heart
NAME: axioltyic effect disorder drug, other Fatigue rate
Diazepam and CNS Before benzodiazepines, Ataxia Respiratory rate
BRAND depression by cardioversio alcohol, or Headache Monitor B/P
NAME: stimulating n tartrazine Hypoactivity Mental status
Apo- gamma- Before Coma or CNS Constipation Evaluate for
Diazepam, aminobutyric endoscopy depression Nausea therapeutic
Valium acid receptors. Status Narrow-angle response
CLASSIFICATI Relaxes skeletal epilepticus glaucoma Avoid task that
ON muscles of and severe require
Anti- spine by recurrent alertness, motor
convulsant inhibiting convulsive skills until
,sedative- polysypnatic seizure response to
hypnotic afferent Acute drugs is
DOSAGE: pathways. alcohol established
5g IV PRN if Controls withdrawal
severe seizures by
agitation/seiz enhancing
ure presypnatic
inhibition.
 Phenytoin
DRUGS MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS NURSING
ACTION CONSIDERATIONS
GENERIC Thought to Status Hypersensitivity to Drowsiness Observe
NAME: limit seizure epilectus drug Lethargy frequently
Phenytoin activity by Seizure Sinus bradycardia Confusion for
BRAND promoting control Sinoatrial block Slurred speech recurrence
NAME: sodium efflux Generalized Adams stroke- Irritability of seizure
Dilantin from nervous tonic-clonic syndrome Hypersensitivity activity
CLASSIFICATI in motor cortex seizure reaction Assess for
ON and reducing Headache clinical
Anticonvulsa activity in Insomnia improveme
nt, anti- brainstem Muscle twisting nt
arrythmic centers Monitor for
DOSAGE: responsible for signs and
100g cap TID tonic phase of symptoms
tonic-clonic of
seizures depression,
suicidal
tendencies,
unusual
behaviour
Assist with
ambulation
if
drowsiness
 Mannitol
DRUGS MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS NURSING
ACTION CONSIDERATIONS
GENERIC Increases Test dose for Active Dry mouth; Monitor
NAME: osmotic pressure marked intracranial thirst urinary
Mannitol of plasma in oliguria or bleeding Blurred vision Assess
BRAND glomerular suspected Anuria Increased vital signs
NAME: filtrate, inhibiting inadequate secondary to urinary Skin
Osmitrol tubular renal severe renal frequency/vol turgor
CLASSIFICATI reabsorption of function. disease ume. Mucous
ON water and To prevent Progressive Headache membran
Osmotic electrolytes(inclu oliguria heart failure Backache es
diuretic,anti ding sodium and during Severe Nausea Muscle
hemolytic potassium)These cardiovascul pulmonary Vomiting cramps
DOSAGE: actions enhance ar and other congestion or Urticia Altered
150 ml q water flow from surgeries pulmonary Dizzines mental
4hrs various tissues To reduce edema status
and ultimately intracranial Severe
decrease pressure and dehydration
intracranial and brain mass.
intraocular
pressures.
 Quetiapine
DRUGS MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS NURSING
ACTION CONSIDERATIONS

GENERIC Antipsychotic Schizophrenia none Headache Monitor

NAME: effects may Acute manic Drowsiness mental status
Quetiapine occur episodes Dizziness Supervise
BRAND through associated with Constipation suicidal-risk
NAME: antagonism bipolar I Dry mouth pt closely
Seroquel of dopamine disorder Dyspepsia during early
CLASSIFICA D2 and Depression Rash therapy
TION serotonin associated with Abdominal Monitor B/P
Antipsychot 5HT-2 bipolar disorder pain for
ic receptors Adjunctive Hypotension hypotension
DOSAGE: treatment of Assess pulse
200g tab major for
1tab BID depressive tachycardia
hold if disorder
sedated
 DRUG STUDY 2

Prepared by :
Biaculo, May Ann Syra S.
 CEFTRIAXONE

NAME OF MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING

DRUGS OF ACTION ATIONS EFFECT RESPONSIBILITIES
BRAND NAME: Bind to the Treatment of Hypersensitivity SEIZURES SEIZURES INTERVENTION/
bacterial cell the following to (high doses), (high doses), EVALUATION
CEFTRIAXONE cephalosporins; headache. headache. Assess for
wall infections
Serious GI: GI: infection (vital signs;
GENERIC NAME: membrane, caused by hypersensitivity PSEUDOME PSEUDOME appearance of
causing susceptible to penicillins; MBRANOUS MBRANOUS wound, sputum,
ROCEPHIN cell death. organisms: Pedi: COLITIS, COLITIS, urine, and stool;
Therapeutic Hyperbilirubinem diarrhea, diarrhea, WBC) at beginning
CLASSIFICATION: Effects: Skin and ic neonates nausea, nausea, of and throughout
ANTIBACTERIAL (ceftriaxone only; vomiting, vomiting, therapy.
Bactericidal skin
may cholelithiasis cholelithiasis Before initiating
DOSAGE: action structure lead to (ceftriaxone) (ceftriaxone) therapy, obtain a
2mg IV q12 against infections kernicterus); , cramps. , cramps. history to determine
susceptible Urinary Derm: Derm: previous use of and
bacteria. and STEVENS- STEVENS- reactions to
gynecologi JOHNSON JOHNSON penicillins
SYNDROME, SYNDROME, or cephalosporins.
c
rashes, rashes, Persons with a
infections urticaria. urticaria. negative
Respirator history of penicillin
y tract sensitivity may still
infections have an allergic
response.
NAME OF MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING
DRUGS OF ACTION ATIONS EFFECT RESPONSIBILITIES
Observe for signs and
Pedi: Neonates Hemat:
symptoms of
28 days requiring agranulocytos anaphylaxis
calcium- is, bleeding (rash, pruritus,
containing IV eosinophilia, laryngeal edema,
wheezing).
solutions (qrisk of hemolytic
Discontinue
precipitation anemia, drug and notify
formation); lymphocytosis health care
Carnitine , neutropenia, professional
immediately if these
deficiency or thrombocytop
symptoms occur.
inborn enia, Keep epinephrine,
errors of thrombocytos an antihistamine, and
metabolism is. GU: resuscitation
equipment close by in the
(cefditoren only); hematuria,
event of an anaphylactic
Hypersensitivity vaginal reaction.
to milk protein moniliasis.
(ceftidoren only; Local: pain at PATIENT/FAMILY
contains IM TEACHING
sodium caseinate site, phlebitis Instruct patient to
take medication
at IV site.
around the
Misc: allergic clock and to finish the
reactions medication completely,
including even if feeling better. Take
missed doses as soon
as possible unless almost
time for next dose; do
not double doses. Advise
patient that sharing of
this medication may be
dangerous.
 Senokot
NAME OF MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING
DRUGS OF ACTION ATIONS EFFECT RESPONSIBILITIE
S
BRAND NAME: Prepared from Acute Hypersensitivity; Abdominal GI: Abdominal Assessment & Drug
SENNA dried leaflet of constipation appendicitis, cramps, cramps, Effects
Cassia acutifolia fecal impaction, flatulence, Reduce dose in
and flatulence,
GENERIC NAME: or Cassia irritable colon, nausea, patients who
Black-Draught, angustifolia. preoperative nausea, vomiting, watery nausea, experience
Gentlax B, Sen- Similar to and undiagnosed diarrhea, watery considerable
exon, Senokot, cascara sagrada preradiographi abdominal pain, excessive diarrhea, abdominal
Senolax but with more c bowel intestinal loss of excessive loss cramping.
potent action. evacuation obstruction; water and of water and
CLASSIFICATION: Senna glycosides electrolytes, Patient & Family
pregnancy electrolytes,
GASTROINTESTI are converted in weight loss, Education
NAL AGENT; colon to active
(category C),
melanotic weight loss, Be aware that
STIMULANT lactation. segmentatio melanotic drug may alter
LAXATIVE n of colonic segmentation urine and feces
mucosa of colonic color; yellowish
DOSAGE: (reversible). mucosa brown (acid),
2 TABS ODHS reddish brown
(reversible).
(alkaline).
NAME OF MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING
DRUGS OF ACTION ATIONS EFFECT RESPONSIBILITIE
S
aglycone, which Continued use
stimulates may lead to
peristalsis. dependence.
Concentrate is Consult
purified and physician if
standardized for constipation
uniform action persists.
and is claimed to See bisacodyl
produce less colic for additional
than crude form. nursing
implications.
Therapeutic Do not breast
Effects feed while
Peristalsis taking this
stimulated by drug.
conversion of
drug to active
chemical.
 OMEPRAZOLE
NAME OF MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING
DRUGS OF ACTION ATIONS EFFECT RESPONSIBILITIE
S
BRAND NAME: Actions Duodenal and Long-term use dizziness, CNS:Headache, Assessment &
Losec,Prilosec An antisecretory gastric ulcer. for fatigue dizziness, Drug Effects
compound that Gastroesophageal
gastroesophag Diarrhea, fatigue. Lab tests:
reflux disease
GENERIC NAME: is a gastric acid including severe eal reflux abdominal GI:Diarrhea, Monitor
pump inhibitor.
OMEPRAZOLE Suppresses erosive disease, pain, abdominal urinalysis for
gastric acid esophagitis (4 to duodenal nausea, pain, nausea, hematuria and
CLASSIFICATION: secretion by 8 wk treatment). ulcers; mild mild transient proteinuria.
gastrointestinal inhibiting the Long-term lactation. transient increases in Periodic liver
H+, K+-ATPase treatment of
agent; proton increases liver function function tests
pathologic
pump inhibitor enzyme system hypersecretory in liver tests. with prolonged
[the acid
(proton H+) conditions such function Urogenital:He use.
DOSAGE: pump] in the as Zollinger- tests. maturia,
40mg IV OD parietal cells. Ellison syndrome, proteinuria.
Skin:Rash
NAME OF MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING
DRUGS OF ACTION ATIONS EFFECT RESPONSIBILITIE
S
Therapeutic Patient & Family
effects Education
Report any
Suppresses
changes in
gastric acid urinary
secretion elimination
relieving such as pain or
gastrointestina discomfort
l distress and associated with
urination, or
promoting
blood in urine.
ulcer healing. Report severe
diarrhea; drug
may need to be
discontinued.
Do not breast
feed while
taking this
drug.
NURSING CARE PLAN

Prepared by:
Casacop, Katherine
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Short term INDEPENDENT: Goal met

Subjective To assess the 1 .Pt. was able to
Di ko makausap ng DISTURBED SENSORY 1.To provide counter 1 Assess Neurological baseline status and communicate fully
maayos ang asawa PERCEPTION measure for possible signs. prevent increases in conscious, verbally, and
ko as vervaliozed by RELATED to Trauma complications in pt. ICP. response normally.
pt. Wife. in vehicular accident. cerebral part of the 2.Asses GCS .
head. 2. Pt. exhibits absence
3.Asses LOC of any complications.
2. To be able to
attain the normal 4. Assess V/S ,ABG, 3. Pt. was able to
Objective level of O2 demonstrate his
Facial grimace consciuosness of pt. To promote feelings and needs.
PT. Is irritable and 5.Elevate HOB,(10 0) circulation venous
move arms and 3.To be able to take maintain head and return through 4. Absence of pain in
hand, facial pallor V/S of pt. and neck midline neural jugular vein the head injury.
T- 36.7 maintain normal position.
P- 44 status level of
R- 18 consciousness DEPENDENT Prevent dehydration
BP- 130/90 1.Given D5LRS Promotes venous
O2 99 4.To be able to 2.Given manitol as return
GCS decrease the pain in prescribed by
E-3 pt. head injury. physician
V-3
M-6 Longterm COLLABORATIVE
Total 12 Maintain no possible Advice Pt. to have a
complications in Pt. CT-SCAN and other
head and body. test that refered by
physician
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Short term Independent:
Subjective
Sa tngin ko masakit Acute pain with After 4 hrs. Of 1..Assess 1.to determine
parin ang ulo nya nursing intervention contributing factors underlying cause of
decreased
dahil sa impact ng the pt. Will be able to pain,(noise wrong pain and teat
pagkabannga sa cerebral blood to: positioning, accordingly.
kanyaas verbalize by flow secondary to General environment). Goal met:
pt. wife. physical trauma as 2.certain drugs may Patient verbalizedI feel
manifested by Become relieve signs 2.Review medication cause fatigue better now It is just a
guarding and symptoms of regimen. drowsiness. little one from all the
Objective pain experience by swelling but it is
behavior,facial
Facial grimace pt. 3. ask client to rate 3. to assist in tolerable pain rated
Pt. Is irritable grimace and pain on 0-10 if evaluating impact of pain 4 out of 10.
,Guarding pallor Specific: conscious pain on client life.
behaviour(clutches Verbalize pain is
head and moves in relieved ( rate 4 out 4.provide comfort 4.to allow
different position 10). measure such as nonpharmalogical
Facial pallor After 4 repositioning the pain relief and
hrs. Of nursing client in a promote good Goal met:
intervention the pt. Demonstrate of comfortable position circulation to the Patient was able to
Will be able to: divertional activities and providing a hot brain and decrease relax by utilizing bed
General such as relaxing and or cold compress. vasoconstriction. rest and deep
or sleeping. breathing.
1..Assess contributing
factors to pain,(noise Goal met:
wrong positioning, Patient was discharge
environment) suceessfully no
presence of
2.Review medication complications.
regimen
3. ask client to rate
pain on 0-10 if
conscious
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
5.Provide calm and 5.To decrase
4.provide comfort quiet environmental
measure such as environment,(adjust factors which
repositioning the lights temperature contribute to
client in a and eliminate migraine and
comfortable position offensive odors promote rest.
and providing a hot which may
or cold compress contribute to head
ache
5.Provide calm and
quiet 6.instruct keep the
environment,(adjust pt. Relaxed.
lights temperature
and eliminate
offensive odors
which may
contribute to head
ache

6.instruct keep the

pt. Relaxed.
T- 36.7
P- 44
R- 18
BP- 130/90
O2- 99
GCS
E-3
V-3
M-6
Total 12
DISCHARGES PLANNING

Prepared by:
Akbar, Vanesa Y.
 Instruct the relatives should not be left the patient alone. Have a relative or
friend stay with patient until they think are back to normal.
Initially, instruct the relatives that the patient will be on a light diet. The doctor
may advance the diet as the patient feel better.
Do not drink alcoholic beverages, including beer and wine.
Instruct the relatives and patient to Avoid strenuous activities for the patient
with TBI. No lifting or straining.
Do not take sedatives, tranquilizers or other medicine that make the patient
sleepy. If you have any questions about your medications, call your doctor.
Do not drive or operate machinery.
Avoid medicine containing aspirin or anti-inflammatory medications, such as
ibuprofen
(Motrin, Advil), Naprosyn, etc. You may use acetaminophen (Tylenol) or the
medicine your doctor has recommended for mild pain.
Keep distractions and noise down. Move to a quieter room.
Use simple words and sentences, speak slowly. Keep your voice lower. Repeat
if needed. Use familiar names and places. Tell them when you are going to
change the subject.
If possible, make eye contact before touching or speaking to them.
Ask questions so the person can answer "yes" or "no." When possible, give
clear choices. Use props or visual prompts when possible. DO NOT give the
person too many options.
When giving instructions:

Break down instructions into small and simple

steps.
Allow time for the person to understand.
If the person becomes frustrated, take a break
or consider redirecting them to another
activity.
 Return to the Emergency Department or see your own doctor
right away if any problems develop, including the following:
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking movements of the eyes,
arms, legs or body.
A change in the size of one pupil (black part of your eye) as compared to the
other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms.