Trinity University of Asia St.

Lukes College of Nursing Case Scenario #2 Neurology Patient Abstract Traumatic brain injury is the insult to the brain and cranial contents which causes changes in sensorium and bodily functions. Immediate response includes increase in ICP, changes in LOC, and vital signs changes. End result of the patient condition depends on the degree of injury the patient received and degree of insult to the brain tissue and location of the injury. Below is a case example for analysis. Patient Presentation Manny, a healthy 29 y/o male patient was rushed to the ER after incurring an injury. He has a live in partner and has one child. In the emergency room, his companion reports that he failed to clamp his safety belt to one of the bars, while working on his project a strong wind blew and he fell of two floors down the construction site. Initial assessment made revealed that he had pin point pupils, irregular breathing pattern, a GCS of 6-8, irregular pulse, episodes of vomiting and is oftentimes restless. He was immediately given mannitol, inserted with foley catheter and is immediately scheduled for a CT scan. A previous x-ray was done which revealed multiple linear fractures on the left side of his skull. CT scan revealed a progressing fronto-temporal hemorrhage of unknown nature; this also revealed a slight compression of vertebrae from T11-L2. He is a non-smoker, and a social drinker. His previous hospitalization was due to severe diarrhea 2 years ago that caused him electrolyte imbalance. His partner reveals that he eats balanced meals even though they have difficulty in his salary. His partner reveals that 2 months prior to the injury, he has been experiencing ringing in his ear which is intermittent and oftentimes occur during waking hours. Immediately after the results of the CT scan were revealed, he was scheduled for craniotomy. 8 hours after the surgery, he was transferred to the recovery room and concurrently to the NICU (Neuro ICU) for monitoring. The patient was now observed to be on assistive respiration via mechanical ventilator. 5 days after intensive monitoring the patient was transferred to a regular room with continuous monitoring and free from mechanical ventilation. Patients GCS is 11, with residual side weakness, aphasia, and episodes of nausea.

Neuro Traumatic Brain Injury

Nursing Priorities Emergency Room List down nursing, medical and pharmacological interventions performed during acute phase and give the rationale. Correlate patient history with current condition of the patient. Rationalize the immediate diagnostic procedures performed on the patient and list possible diagnostic procedures that can be used for this case. Cardio Operating Room Describe the procedure craniotomy. What are the nursing responsibilities before, during and after the procedure? List down risks and contraindications for the procedure. Neuro Intensive Care Unit Nursing priorities immediately after craniotomy for stabilization of the patients condition? List down possible medications to be given to this patient according to symptoms that is presented by a post traumatic brain injury and post craniotomy patient. The patient suddenly develops autonomic dysreflexia. What are the possible nursing and medical management for this? Medical Surgical Unit Prioritize health instructions to be given to this patient. List down possible pharmacological management to be taken during discharge. List down possible complications after discharge and how they may be prevented. Nursing Care Plan List down 3 nursing care plan for each phase of the patients admission.

Neuro Traumatic Brain Injury