PREPARED BY:JESSY VARKEY

STAFF NURSE SURGERY WARD

CASE NO: 153917 NAME: X AGE: 28YRS SEX: Male DIAGNOSIS: RTA WITH HEAD

INJURY,SDH DOA: 27/08/2011

The patient is 28 years of age, male, approximately weighs 60kg

He is conscious with 02 by bag and mask GCS6 /15with the following vital signs.

BP=110/80 PR=70bpm RR=20mts Temp= 36.2 SPO2= 96%

Skin Fair complexion. Warm. No palpable mass or lesions, with good

turgor. Head Skull slightly asymmetric,no lesions,no

tenderness ,scar present on the craniectomy site

Level of Consciousness and Orientation Patient conscious

Eyes no redness Pupils equally round and reactive to

light

Ears No unusual discharges noted

Nose No unusual discharges No tenderness in sinus

Mouth Pink and moist oral mucosa

Neck and throat No palpable lymph nodes No masses and lesions seen

Chest and lungs Equal chest expansion Thorax is symmetric No tenderness

Heart Regular rhythm 

Abdomen Soft abdomen Bowel sound present

Genitals No discharge,ulcerationand no palpable

masses Extremities Pulse full and equal No lesions noted

PAST MEDICAL HISTORY

28yrs male patient came in ER with history of RTAWITH SEVERE HEAD INJURYAND MULTIPLE POLYTRAUMA.

In ER patient was unconscious and he was in gasping stage.

intubated in ER due to low GCS putted on portable ventilator and shifted to icu and kept for neurologic assessment

patient was examined by neurosurgery team,general surgeon and internal medicine and the finding came out radiologically as head injury and multiple trauma,SDH WITH CEREBRAL EDEMA

PAST SURGICAL HISTORY

Bifrontal craniectomy under GA on 27/08/2011 with intra peritoneal frontal bone flap preservation,along with tracheostomy.

Rt VP shunting with revision frontal flap repositioning,cranioplasty done on 10/12/2011.

Patient shifted back to icu with his condition improved well and weaned off from mechanical ventilator.

Later the patient shifted to surgery ward for further management

PRESENT MEDICAL HISTORY

Patient is conscious,oriented and able to speak

On room air maintaining saturation from 96-99%

With stable vital signs

Maintained with anticonvulsants

Taking orally well

NCCT BRAIN - RT sided temporo parietal acute subdural edema with diffuse cerebral edema,and multiple fractures as small pneumocephalus

CT CERVICAL SPINE - Normal study

CT CHEST - multiple rib fracture and mild pneumothorax

CT THORACIC SPINE - No fracture

CT LUMBOSACRAL STUDY - Normal

CT ABDOMEN - Normal

USG ABDOMEN - Small to moderate amount of fluid is seen in the pelvis

SEDATION

PARALYTICS CRANIECTOMY/CRANIOPLASTY

Any injury that results in trauma to the scalp, skull, or brain can be classified as a head injury.

The terms traumatic brain injury and head injury are often used interchangeably in medical literature.

Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries. Many of these are minor, but some can be severe enough to require hospitalization.

A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury.

Head injury is classified as either closed or open (penetrating).

A closed head injury means you received a hard blow to the head from striking an object, but the object did not break the skull.

An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

Head injuries include: Concussion - the most common type of

traumatic brain injury, in which the brain is shaken

Contusion - which is a bruise on the brainScalp woundsSkull fractures

The brain is arguably the most important organ in the human body. It controls and coordinates actions and reactions, allows us to think and feel, and enables us to have memories and feelings – all the things that make us human.

The cranium The brain is protected by a bony covering called the cranium (which, along with the bones of the face, make up the skull).

Inside the cranium, the brain is surrounded by the

meninges.

The meninges is made up of 3 layers of tissue: Pia mater – the layer closest to the surface of the

brain Arachnoid membrane – the middle layer of tissue Dura mater – the outer-most layer

The cerebrum – the front of the brain The largest part of the brain located in the front is called the cerebrum.

The cerebrum is responsible for:MovementBody temperatureTouchVisionHearingJudgmentReasoningProblem solvingEmotionsLearning

The brainstem – the middle of the brain The brainstem is located in front of the cerebellum.

The brainstem is like the hard-drive of a computer. It is the main control panel for the body that passes messages back and forth between the brain and other parts of the body.

The brainstem controls vital functions of the body, including:

BreathingConsciousnessCardiac functionInvoluntary muscle movementsSwallowingMovement of the eyes and mouthRelaying sensory messages (pain, heat, noise,

etc.)Hunger

The cerebellum – the back of the brain behind the cerebrum at the back of the head is the cerebellum.

In Latin, cerebellum means “little brain.” However, the cerebellum contains more nerve cells than both hemispheres combined.

The cerebellum is primarily a movement control center, responsible for:

Voluntary muscle movementsFine motor skillsMaintaining balancePostureequilibrium

Common causes of head injury are:

motor vehicle accidentscollisionshome and occupational accidentsfalls assaults

Some head injuries result in prolonged or nonreversible brain damage. This can occur as a result of bleeding inside the brain or forces that damage the brain directly. More serious head injuries may cause the following symptoms:

Comaconfusiondrowsinesspersonality changeSeizuresnausea and vomitingheadache and a lucid interval

Maintain a patent airway. Assist with endotracheal intubation or tracheotomy as necessary.

Administer medications as ordered.

Protect the patient for further injury by using side rails.

Assist the unsteady patient with walking.

Insert an indwelling urinary catheter if ordered.

If the patient is unconscious, insert a nasogastric tube to prevent aspiration.

Monitor the patient’s intake and output as needed to help maintain a normovolemic state.

Monitor vital signs continuously and check for additional injuries.

Observe the patient for headache, dizziness, irritability, and anxiety.

Monitor fluid and electrolyte levels and replace them as necessary.

Carefully observe the patient for CSF leakage.

Tell the patient to return to the hospital immediately if he experiences a persistent worsening headache, forceful or constant vomiting, blurred vision, any change in personality, abnormal eye movements, and twitching.

Most head injuries are of a benign nature and require no treatment beyond analgesics and close monitoring for potential complications such as intracranial bleeding.

Treatments may involve controlling elevated intracranial pressure. This can include:

sedationparalyticscerebrospinal fluid diversion

Second line alternatives include decompressive craniectomy.

Altered consciousness Coma Vegetative state Minimally conscious state Locked-in syndrome

A person in a locked-in state is aware of his or her surroundings and awake,

but he or she isn't able to speak or move.

Seizures Fluid build up Infections Blood Vessel damage Nerve damage Cognitive, Communication and Behavioral

changes

Self care deficit Impaired Physical mobility Activity intolerance Risk for impaired skin integrity Risk for fall

Assesement

Subjective: Pt. is unconsciousObjective:

- limited range of motion as evidenced by

unsteady gait- uncoordinated movements- postural instability

Nursing DiagnosisImpaired Physical mobility related to neuromuscular impairement secondary to head injury.

PlanningPatient will be able to maintain position of function and skin integrity as evidenced by absence of contractures during shift.

Intervention Reposition the patient from side to side.

(Positioning interventions reduce pressure and shearing force to the skin.)

Provide ample time to the patient to perform mobility-related tasks.(To develop patient’s optimum potential)

Reinforce the use of side rails.(To assist patient in position transfers.)

EvaluationGoal fully met. Patient did not

develop any complications of immbolity.

Assesement

Subjective: Pt. is unconsciousObjective:

- Memory deficit- altered attention span- impaired ability to make decisions

and problem solving

Nursing DiagnosisDisturbed Thought Process

PlanningThe patient will maintain usual mental orientation.

Intervention Assess attention span of the patient.

(To determine ability to participate in planning .)

Test ability to receive, send and interpret communication.(To assess degree of impairment.)

Perform periodic neurologic assessment as indicated.(Early recognition of changes.)

Provide safety measures such as side rails. ( To provide further deterioration.)

Maintain a pleasant and quiet environment. (May aid in reducing attention span.)

o EvaluationGoal partially met. Patient partially maintained usual mental orientation.

Taking care of yourself at home:

Be guided by your doctor, but self-care suggestions include: Don’t drive home from the hospital. Ask someone to give you a lift or catch a taxi.

Rest quietly for the day.

Use icepacks over any swollen or painful area.

Take simple painkillers such as paracetamol for any headache. Check the packet for the right dose.

Arrange for someone to stay with you for the next 24 hours, in case you need help.

Don’t eat or drink for the first six to 12 hours, unless advised otherwise by the doctor.

Once you can eat again, have small amounts of light food and drink in moderation.

Avoid alcohol for at least 24 hours.

Don’t take sedatives or other drugs unless instructed by your doctor.

Children are allowed to sleep, but should be woken every four hours to check their condition and gauge their reaction to familiar things.

What to expect after a head injury

There is no specific treatment for mild head injury other than plenty of rest and not overdoing things.

Keep in mind that: It is common to not be able to remember the events surrounding the head injury.

It is normal to feel more tired than usual.

It can take some time for the brain to recover from a head injury. During this time, headaches, dizziness and mild cognitive (thought) problems are common.

Brain function problems can include mood changes

and difficulties with concentrating, remembering things and performing complex tasks.

Most people make a full recovery and the symptoms only last a few days.

When to seek urgent medical care: Severe headaches

Vomited more than twice

Memory problems

Blackouts

A seizure (fit or spasm of arms, legs or face)

Difficulty staying awake

Blood or clear fluid coming from your ears or nose

Neck stiffness

Numbness, tingling, pins and needles, or weakness in your arms or legs

Confusion, slurred speech or unusual behaviour

Blurred or double vision

Dizziness

A high temperature, which may indicate the presence of infection

Adults suffer head injuries most frequently due to falls, motor vehicle crashes, colliding or being struck by an object, and assaults.

Falls and being struck are the most common causes of head injury in children.

Head injury is a major cause of death and disability, therefore patients with such kind of case must be handled with utmost care.

^ McCaffrey RJ (1997). "Special Issues in the Evaluation of Mild Traumatic Brain Injury". The Practice of Forensic Neuropsychology: Meeting Challenges in the Courtroom. New York: Plenum Press. pp. 71–75. ISBN 0-306-45256-1. 

^ "What is Head Trauma?". News Medical. Retrieved 2013-05-04. 

^ a b "Head injury- first aid". MedlinePlus. Retrieved 2013-05-04. 

^ "Head Injury (Brain Injury)". eMedicinehealth. Retrieved 2013-05-04. 

^ name="Head Injury (Brain Injury)" ^ Carlson, Neil R. (2013). "Physiology of Behavior". In

Campanella, Craig. Neurological Disorders. Pearson Education, Inc. pp. 526–527. ISBN 0-205-23939-0.

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