EPIDURAL HEMATOMA

Case presentation by: GROUP 1 Abbas, SittieOmaimah Agdon, Eduard Aguilar, Richer Basher, Isnihaya Barreda, Leizle Kaye Bato, Normasa Ducay, Newsryn Duenas, Czar Edol, Evalyn

OBJECTIVES Within 1 hour and a half of case presentation:

Presenters will be: Able to understand the disease process (Epidural Hemorrhage): the causes, effects, management, treatment, and possible preventions. Able to determine and discuss briefly the pathophysiology of the Epidural Hemorrhage with their rationale for occurrence of each manifestation. Able to determine why certain management and medications are given and provided for the condition. Able to understand how and why certain diagnostic tests are done for the condition. Able to review the concepts about the anatomy and physiology with regards to the condition. Able to provide health teachings to the patients family about certain interventions in the maintenance of health care. Able to develop plan of care for the client with Epidural Hemorrhage. Able to share the learning acquired to co-students-nurses to increase awareness and help them if they will encounter patient with the same condition. Students or audience will be able to: Know the background of the study Gather significant data to have proper assessment to the patient. Recognize the cause and risk factors of Epidural Hemorrhage. Develop a comprehensive assessment for the disease process.

Understand the anatomy and physiology of the system and its different system affected by the disease process. Ask questions that are related to our topics which seems unclear to them.

INTRODUCTION Epidural or extradural hematoma (haematoma) is a type of traumatic brain injury (TBI) in which a buildup of blood occurs between the dura mater (the tough outer membrane of the central nervous system) and the skull. The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull. Blood vessels in close proximity to the fracture are the sources of the hemorrhage in the formation of an epidural hematoma. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient's preoperative neurologic condition. Epidural hematoma should be suspected in any individual who sustains head trauma. Although classically associated with a lucid interval between the initial loss of consciousness at the time of impact and a delayed decline in mental status (10-33% of cases), alterations in the level of consciousness may have a variable presentation. Posterior fossa epidural hematoma may exhibit a rapid and delayed progression from minimal symptoms to even death within minutes. Epidural hematoma (EDH) results from traumatic head injury, usually with an associated skull fracture and arterial laceration.

The physical examination should include a thorough evaluation for evidence of traumatic sequelae and associated neurological deficits, including the following:
o

Bradycardia and/or hypertension indicative of elevated intracranial pressure

o o o o o o o

Skull fractures, hematomas, or lacerations Cerebrospinal fluid (CSF) otorrhea or rhinorrhea resulting from skull fracture with disruption of the dura Alteration in level of consciousness (ie, Glasgow Coma Scale score) Anisocoria (eg, ipsilateral dilation of the pupil due to uncal herniation with compression of the oculomotor nerve) Facial nerve injury Weakness (eg, contralateral hemiparesis due to compression of the cerebral peduncle) Other focal neurological deficits (eg, aphasia, visual field defects, numbness, ataxia)

It is important that a patient receive medical assessment, including a complete neurological examination, after a any head trauma. Intubation, sedation, and neuromuscular blockade per protocol. There is some suggestion of increased mortality with prehospital intubation in retrospective reviews of trauma patients with moderate-to-severe head injury compared with patients intubated in the ED.

As with other types of intracranial hematomas, the blood may be removed surgically to remove the mass and reduce the pressure it puts on the brain. The hematoma is evacuated through a burr hole or craniotomy. In United States epidural hematoma complicates 2% of cases of head trauma (approximately 40,000 cases per year). Spinal epidural hematoma affects 1 per 1,000,000 people annually. Alcohol and other forms of intoxication have been associated with a higher incidence of epidural hematoma. Internationally, frequency is unknown, though it is likely to parallel the frequency in the United States.

Mortality rate associated with epidural hematoma has been estimated to be 5-50%.The level of consciousness prior to surgery has been correlated with mortality rate: 0% for awake patients, 9% for obtunded patients, and 20% for comatose patients.Bilateral intracranial epidural hematoma has a mortality rate of 15-20%.Posterior fossa epidural hematoma has a mortality rate of 26%.

Hematoma type

Epidural

Subdural

Location

Between the skull and the dura

Between the dura and the arachnoids

Temper parietal locus (most likely) - Middle meningeal artery Involved vessel Frontal Occipital locus locus - anterior ethmoidal artery Bridging veins sinuses

- transverse or sigmoid

Vertex locus - superior sagittal sinus

Symptoms

Lucid interval followed by unconsciousness

Gradually increasing headache and confusion

CTappearance

Biconvex lens

Crescent-shaped

Table represents epidural and subdural hematoma regarding with locations, involved injury, symptoms & CT appearance.

DEFINITION OF TERMS Anisocoria- The pupil may appear to open (dilate) and close (constrict) but it is really the iris that is the prime mover; the pupil is merely the absence of iris. Brain death- Irreversible brain damage and loss of brain function, as evidenced by cessation of breathing and other vital reflexes, unresponsive to stimuli, absence of muscle activity, and flat electroencephalogram for a specific length of time. Brain herniation- known as cistem obliteration, is a deadly side effect of very high intracranial pressure that occurs when the brain shifts across structures within the skull. Cerebral blood flow- is the blood supply to the brain in a given time. Cerebral hypoxia- refers to deprivation of oxygen supply to brain tissue. Cerebral perfusion pressure- or CPP is the net pressure gradient causing blood flow to the brain. Compression- A force squashing, squeezing, or pressing down on an object. Contusion- A bruise that is usually produced by impact from a blunt object and that does not cause break in the skin. Craniotomy- Surgical removal of a portion of the cranium. Effusion- t he seeping of serous, purulent, or bloody fluid into a body cavity or tissue. Epidural or extradural hematoma- is a type of traumatic brain injury (TBI) in which a buildup of blood occurs between the dura mater (the tough outer membrane of the central nervous system) and the skull.

Hematoma- a mass of blood in the tissue as a result to trauma or other factors that cause the rupture of blood vessels. Intracranial pressure- pressure that occurs within the cranium. Trauma to the head, inflammation, or infection of the linings of the brain may cause an increase in pressure within the cranium, which is painful, dysfunctional and may become life-threatening. Sequelae- A pathological condition resulting from a prior disease, injury, or attack.

VITAL INFORMATION

Name: Girlalou Room Number: ICU Bed 5 Marital Status: Child Birth Date: April 28, 2001 Address: Balo-i Lanaodel Norte Age: 10 years old Birth Place: Bal-I Lanao del Norte Educational Attainment: Occupation: Student Ethnicity/Nationality: Filipino Referral (Primary Care Physician/Practitioner): Source of History: 60% chart 40% Significant Others

Final Diagnosis/Impression: Epidural Hematoma, both cerebellum area, right occipital linear fracture 4cm mid sub occipital occipital bone, posterium distal sagittal sinus lacerations with acute blood loss ( >250cc ).

REASON FOR SEEKING HEALTH CARE PRESENT HISTORY Two hours prior to admission, the patient was crossing the road where an overtaking car suddenly hit her and the impact threw her over the cemented of a certain area in Balo-i. She was flat on the ground with her left sided face severely injured included her left arms. After the accident they immediately rushed the patient to the nearest hospital in Balo-i to cure the child, but the residence doctor suggested that the child should be admitted in Iligan hospitals specifically in Mindanao Sanitarium and Hospital due to her critical condition. One hour prior to admission the patient immediately admitted at Intensive Care Unit for immediate response to her critical condition. On the same day the physician decided to have the patient undergoes craniectomy for further evaluation to her condition. PAST HEALTH HISTORY At the age of three the patient had chicken pox lasted for one week. No history of hospitalizations, surgeries, and serious illnesses or injuries. The patient completed the other immunizations except for measles. As stated by the mother the patient has no allergies in food, drugs or medicines and environmental.

GORDONS FUNCTIONAL HEALTH PATTERN

HEALTH MAINTENANCE MANAGEMENT Girlalou was admitted on July 31, 2011 at 4:45pm and diagnosed with Epidural Hematoma, both cerebellum area, right occipital linear fracture 4cm mid sub occipital occipital bone, posterium distal sagittal sinus lacerations with acute blood loss ( >250cc ) due to car accident. The 10 years old female patienthas no allergies in foods and medicines as verbalized by her mother. Patient is a fifth grade pupil, as stated by her mother the patient did not received her measles vaccine for the reason that they transferred their residence in Cebu City. NUTRITIONAL / METABOLIC The patient has an nasogastric tube attached in to her left nares with IVF of D5LR KVO hooked at her right metacarpal with on and off fever

during our shift. The patient was in liquid diet during our shift. Liquid diet was recommended, and according to her mother at home her daughters food preferences was more on rice and vegetables and has a poor appetite because she eat a little every meal and also the patient most likely had fun of drinking coffee. COGNITIVE / PERCEPTUAL Within two days of duty the patient usually has a GCS of 7 8. On august 12, 2011 she had a GCS of 10. SLEEP / REST As stated by her mother the patient usually sleeps around 8-9 pm and arises at early 6 in the morning. She slept mostly 10 hours every day. SELF-PERCEPTION / SELF-ESTEEM

The patient was an active pupil on their school though shes a quite type of person, she also loved to play outside their house with her selected playmates as stated by the mother. ELIMINATION Patient usually voided two times a day and experienced sometimes constipation and diarrhea as verbalized by the mother. ACTIVITY / EXERCISE Every week days the patient goes to school early in the morning to have her whole day class, after class she played with her friends and at home before she goes to sleep she do first her home works. VALUE / BELIEF Islam is the religion of the patient they believe that ALLAH created all and Friday is their holy day.

PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

Day 1 Date: August 01 , 2011 General appearance: Unconscious and unarousable, on right side lying position, GCS of 8, pupil bilateral reactive to light and accommodation at 4mm in size, noted nystagmus, noted dry and intact post craniotomy site on the head with drainage as bloody, episode of spasm on upper extremities noted, not on respiratory distress, with ET 16cm in lip line level attached to MV on the following set up: AC mode: TV-400, BUR-16, PEEP-3, FIO2-60%, (+) crackle sounds upon auscultation, bilateral chest expansion noted, on continuous cardiac monitoring, noted sinus tachycardia, hypoactive bowel sound, noted abrasion on face, IVF PNSS 1ltr at 60cc per hour patent and infusing well hooked at right hand, febrile, with fully bag catheter attached to urobag, draining yellowish colored urine, latest BP 100/80. SYSTEM Neurologic REVIEW OF SYSTEM PHYSICAL ASSESSMENT GCS: 8 ;Cerebral edema and epidural bleed noted upon CT scan; Affected Cranial Nerves CN I: cannot be assessed CN II: cannot be assessed CN III: PERRLA CN IV: present corneal reflex CN V: cannot masticate CN VI: nystagmus CN VII: cannot be assessed CN VIII: cannot be assessed CN IX: diminished gag reflex CN X: cannot be assessed CN XI: cannot be assessed C N XII: cannot be assessed PROBLEM IDENTIFIED Decrease level of consciousness. Febrile Ineffective cerebral perfusion Risk for secondary infection

Head/Face/EENT

Normocephalic, w/ surgical incision

Risk for aspiration Impaired skin integrity

left occipitoparietal with drain, with multiple abrasion on the face, with patent NGT attached in the left nare, Anicteric sclera ,Pinkish conjunctivae, Nystagmus noted, PERRLA. Neck No lymphoadenopathy noted, no jugular vein distention, palpable carotid pulses, no lesions Equal chest expansion, no retraction, with Mechanical Ventilator attach with ff set up: AC mode, TV-400, BUR-16, PEEP-3, FIO2-60%, Crackles noted on both lung fields. RR:21-29breaths per min ABG RESULTS: O2 Sat: 82 % pH: 7.433 PaO2: 43 mmHg PaCO2: 29.3 mmHg Ineffective airway clearance Ineffective Tissue perfusion

Thorax/Chest/ Respiration

Back/Spine Breas/Axilla

No abnormal curvature noted No lumps, abnormal discharges, lesions noted No thrills no murmurs, regular rate and rhythm, Tachycardeic PR: 97 Risk for decrease cardiac output

Cardiovascular

172 beats per min, BP- 100/70 GIT NPO, normoactive bowel With FBC attached yellowish urine. draining Risk for imbalance nutrition: less than body requirements Risk for Infection

GUT

Musculoskeletal

Unable to move, diminished deep tendon reflex Warm flushed skin, good skin turgor, multiple abrasions noted in the face, left shoulder and left knee. Symmetrical and proportionate. No abnormalities noted No lymphodenopathy, Increased WBC: 19x9/L , ABG: O2 Sat =82%

Risk for injury Activity intolerance Impaired physical mobility Risk for infection

Integumentary Extremities Endocrine Lymphatic/ Hematologic

Infection

August 4-5, 2011 Day 2 General Appearance:

Lying on bed in supine position still unconscious and arousable, GCS= 7, intact and dry head dressing with bloody drainage, pupil equally round and reactive to light and accommodation, 4mm in diameter, NGT secured to left nostril, bloody discharges upon suctioning, with ET tube at 16 cm lip-line level attached to MV with the following set-up: A/C mode, TV- 180, BUR- 15, PEEP- 3, FIO2- 50%, well-tolerated FIO, saturation. Oral airway in place, equal chest expansion, crackles heard on both lung fields, electrodes on anterior chest connected to continuous cardiac monitoring, strong peripheral pulses, decorticate posturing upon stimulation, flat abdomen with foley catheter in place connected to urobag, diaper dry and intact, Hyperactive bowel sound, IVF on right hand PNSS 1L @ 60cc/ hr patent, regulated by IV pump. Initial V/S: T- 37.0 C , P-143 bpm, RR- 20, BP110/70. SYSTEM REVIEW OF SYSTEM No verbal cues Neurologic GCS: 7;Cerebral edema and epidural bleed noted upon CT scan; Affected Cranial Nerves CN I: cannot be assessed CN II: cannot be assessed CN III: PERRLA CN IV: present corneal reflex CN V: cannot masticate CN VI: nystagmus CN VII: cannot be assessed CN VIII: cannot be assessed CN IX: diminished gag reflex CN X: cannot be assessed Ineffective cerebral perfusion Risk for aspiration Risk for injury PHYSICAL ASSESSMENT PROBLEM IDENTIFIED

CN XI: cannot be assessed C N XII: cannot be assessed Decorticate posture upon pain infliction Normocephalic, w/ surgical incision left occipitoparietal with drain, with multiple abrasion on the face, with patent NGT attached in the left nare, Anicteric sclera ,Pinkish conjunctivae, Nystagmus noted, PERRLA. No lymphoadenopathy noted, no jugular vein distention, palpable carotid pulses, no lesions Equal chest expansion, no retraction, with Mechanical Ventilator attach with ff set up: AC mode, TV-400, BUR-16, PEEP-3, FIO2-60%, Crackles noted on both lung fields. RR:20-26 breathes per min ABG RESULTS: O2 Sat: 100 pH: 7.38 PaO2: 100 PaCO2: 21

Head/Face/ EENT

No verbal cues

Risk for injury Impaired skin integrity Risk for infection

Neck

No verbal cues

No verbal cues Thorax/Lungs

Ineffective airway clearance

Back/Spine

No verbal cues

No abnormal curvature noted, no lesions

Breast/Axilla

No Verbal cues

No lumps, abnormal discharges, lesions noted

Cardiovascular

No verbal cues

GIT

No verbal cues

No thrills, no murmurs, Tachycardeic PR: 95-150 beats per min, BP- 100/70 Flat abdomen with rounded symmetrical contour and no

Risk for decreased cardiac output

Risk

for

imbalanced

tenderness; liver and bladder are not palpable. Normoactive with 17 bowel sounds. Defecated twice, semi-formed yellowish stool within our shift.; NGT in place GUT No verbal cues With FBC attached draining

nutrition: Less than body requirements Risk for aspiration

yellowish urine and urine output of 550cc within 8 hours. Musculoskeletal Bihira parin siya gumalaw as Unable verbalied by the SO to move deep purposely, reflex,

Risk for infection

diminished

tendon

Activity intolerance Impaired physical mobility Risk for impaired skin

prolonged bed rest

integrity

Integumentary

May lagnat din siya as verbalized Warm flushed skin T- 38.3 , good by the patient skin turgor, multiple abrasions

Impaired skin integrity Risk for infection hyperthermia

noted in the face, left shoulder and left knee. CRT<2 Sec, no clubbing Extremities No verbal cues Symmetrical and proportionate.

DIAGNOSTIC TESTS Diagnostic Test CBC 7/31/11 Date Result Normal Value Interpretation Significance Nursing responsibilities

Red blood cell

4.0

4-6 x 10 12/L

Normally low

. Hematocrit 0.35 0.37 0.47 Decreased Suggests hemodilution massive blood loss Hemoglobin 117.0 110 180g/l Normal anemia, or

WBC

32.3

5 10 x 10 g/L

Increased

Signals

infection,

such

as

abcess,

meningitis, appendicitis. Also

indicate leukemia or tissue necrosis. Segmenters Lymphocytes 0.71 0.19 0.50 0.65 0.25 0.35 Increased Decreased Indicates hepatitis,

tubercolosis, infectious mononucleosis Stabs Monocytes Eosinophils Basophils Platelet count 0.02 0.01 0.01 0 423 0.05 0.10 0.03 0.07 0.01 0.03 0.01 140 450x10 normal g/L decreased Decreased normal

Diagnostic Test CBC

Date

Result

Normal Value

Interpretation

Significance

Nursing responsibilities

8/1/11

Red blood cell

4.15

4-6 x 10 12/L

Normal

. Hematocrit 0.34 0.37 0.47 Decreased Suggests anemia, or

hemodilution 110 180g/l 5 10 x 10 g/L

massive blood loss Hemoglobin 113.0 Normal

WBC

19.0

Increased

Signals

infection

such as meningitis, appendicitis tonsillitis. indicates leukemia,or necrosis. Segmenters Lymphocytes 0.74 0.21 0.50 0.65 0.25 0.35 Increased Decreased Indicates hepatitis, tissue or Also

tubercolosis, infectious Stabs Monocytes Eosinophils 0 0.05 0.05 0.10 0.03 0.07 decreased normal mononucleosis

Basophils

0 0

0.01 0.03 0.01

decreased decreased

Diagnostic Test CBC

Date

Result

Normal Value

Interpretation

Significance

Nursing responsibilities

8/4/11

Preparation: Instruct SO that patient needs not to fast for this test indicates anemia, Tell the patient that this test requires a fluid overload, or blood sample. Explain who will perform the venipuncture hemorrhage. and when.. Indicates anemia, Implementation: Perform a venipuncture and collect the sample in a 4ml clot-activator tube. Apply direct pressure to the venipuncture site until bleeding stops. Handle the sample gently to prevent hemolysis. Send the sample to the laboratory immediately

Red blood cell

2.00

4-6 x 10 12/L

Decreased

Hematocrit

0.24

0.37 0.47 110 180g/l

Decreased

Hemoglobin

84.0

Decreased

recent hemorrhage, or fluid retention.

WBC

10.0

5 10 x 10 g/L 0.50 0.65

Normally high

Segmenters

0.70

Increased

Lymphocytes

0.20

0.25 0.35

Decreased

Indicates

hepatitis, Patient Care: Apply pressure to the venipuncture site Ensure that subdermal bleeding has stopped before removing pressure.

tubercolosis, infectious mononucleosis Stabs Monocytes Eosinophils Basophils 0.01 0 0 0 0.05 0.10 0.03 0.07 0.01 0.03 0.01 Decreased Decreased Decreased Decreased

Potassium and Sodium Diagnostic Test Potassium 8/2/11 4.38 3.5 5.3 mmol/L 135 148mmol/L Normal value 3.5 5.3 mmol/L 135 148mmol/L Normal Preparation: Instruct SO that patient needs not to fast for this test Tell the patient that this test requires a blood sample. Explain who will perform the venipuncture and when. Implementation: Apply direct pressure to the venipuncture site until bleeding stops. Handle the sample gently to prevent hemolysis. Send the sample to the laboratory immediately Date Result Normal value Interpretation Significance Nursing responsibilities

Sodium Diagnostic Test Potassium 8/4/11 Date

145.0 Result

Normal Interpretation Significance

4.82

Normal

Sodium

142.0

Normal

Patient Care: Apply pressure to the venipuncture site

ABG (Arterial Blood Gas) Diagnostic Test ABG 7/31/11 95 98 % 7.35 7.45 80 108mmHg PaCO2 MCO2 TOTAL CO2 25.3 24.8 26 35 Decreased 45 Normal Normal 1. Wait at least 20 minutes before drawing O2 saturation pH PaO2 100 7.45 253 Normal Normally high Increased situations: After initiating, changing or ABG in the following Date Result Normal Value Interpretation Significance Nursing responsibilities

discontinuing oxygen therapy. After extubation After initiating or changing

settingsof mechanical ventilation

mm/Hg 22 26mmol/L 23 -27mmol/L

Diagnostic Test ABG

Date

Result

Normal Value

Interpretation

Significance

Nursing responsibilities

8/1/11 95 98 % 7.35 7.45 80 108mmHg

1. Wait at least 20 minutes before drawing ABG in the following

O2 saturation pH PaO2

82 7.433 43

Decresed normal decreased Decreased 45 Decreased Decreased -

situations: After initiating, changing or

discontinuing oxygen therapy. After extubation After initiating or changing

PCO2 MCO2 TOTAL CO2

29.3 21.4 22 35

settingsof mechanical ventilation

mm/Hg 22 26mmol/L 23 -27mmol/L

Diagnostic Test ABG

Date

Result

Normal Value

Interpretation

Significance

Nursing responsibilities

8/2/11 95 98 %

Wait at least 20 minutes before drawing ABG in the following situations:

O2 saturation

100

Normal

After initiating, changing or discontinuing

pH PaO2

7.382 100

7.35 7.45 80 108mmHg

normal normal

oxygen therapy. After extubation After initiating or changing settingsof

PaCO2 MCO2 TOTAL CO2

21.1 18.9 20 35

Decreased 45 Decreased decreased

mechanical ventilation

mm/Hg 22 26mmol/L 23 -27mmol/L

Diagnostic Test ABG

Date

Result

Normal Value

Interpretation

Significance

Nursing responsibilities

8/3/11 95 98 % 7.35 7.45 80 108mmHg

1. Wait at least 20 minutes before drawing ABG in the following

O2 saturation pH PaO2

90 7.406 108

Normal normal normal Decreased 45 Decreased decreased -

situations: After initiating, changing or

discontinuing oxygen therapy. After extubation After initiating or changing

PaCO2 MCO2 TOTAL CO2

33.3 20.9 22 35

settingsof mechanical ventilation

mm/Hg

22 26mmol/L

2. Tell the patient which site ( radial, brachial, or femoral artery) hs

23 -27mmol/L

selected for puncture 3. Instruct the patient to breathe

normally during the test and warn him that he may feel brief cramping or throbbing pain at the puncture site.

Creatinine Diagnostic Test Creatinine 7/31/11 80.2 20.0 SGPT Amino Transferase) (Alanine 5 35 IU/L 3. 53 100umol/L Normal Normal 1. For older children, draw venous Date Result Normal Value Interpretation Significance Nursing responsibilities

blood into a 3 0r 4-5 ml tube 2. Fill the collection tube completely.

4. Invert the tube gently several times to mix the sample and the

anticoagulant. 5. Handle the sample gently to

prevent hemolysis

Diagnostic Test HBSAG

Date

Result

Normal Value

Interpretation

Significance

Nursing responsibilities

7/31/11

Non reactive

Non reactive

Normal

1. Check client history for hepatitis B vaccine. 2. If the client is giving blood, explain the donation procedure to him. 3. Perform a veni puncture and collect the sample in a 10 ml clot activator tube.

BRAIN SCAN PLAIN (CT SCAN) Date: July 31,2011 Multiple and tomographic sections of the head without contrast were obtained. Plain CT images of the head shows large lentform heterogeneously predominantly hyperdense fluid collection in both posterior fossa extending in both occipito parietal areas, measuring 7.5 cm x 4.8 cm x 2.2 cm(LWT), volume = 41 cc on the right and 7.5 cm x 5.2 cm x 1.3 cm (LWT) volume = 26 cc on the left. The adjacent brain parenchymal are compressed.

Hyperdense fluid collection also seen in the intra tentorial area. The rest of the parenchymal are intact. The ventricles are normal in size, shape and position. The midline structures are undisplaced. There are linear fractures in the mid occipito parietal area and right para sagittal of the clivus. Hazziness seen in the sphenoid sinus. The sella, orbits, rest of the paranasal sinuses, and petromastoidsareunremarkable. No other significant findings. IMPRESSION: LARGE ACUTE EPIDURAL BLEED, BILATERAL POSTERIOR FOSSA EXTENDING TO BOTH OCCIPITO PARIETALAREAS, LARGER ON THE RIGHT. ACUTE SUBDURAL BLEED,, INFRA TENTORIAL AREA LINEAR FRACTURES, MID OCCIPITO PARIETAL AND CLIVUS. TRAUMATIC SPHENOID SINUSITIS Nursing Responsibilities Pre-test:

Explain to the patient the purpose of the test. Note that minimal discomfort during the test is due to the venipuncture and that during injection of the dye, transient sensations including warmth, flushing, a salty taste, and nausea may be experienced. Explain that no movement is allowed during the procedure. Check for allergies to iodine, shellfish, or contrast medium dye. Inform the radiologist of such possible allergy and obtain order for an antihistamine and steroid to be administered prior to the test. Instruct the patient to remove any metal items from the hair or mouth prior to the procedure. During the Procedure: Assist the patient to a supine position on the CT scan table. Posttest: Observe for allergic reaction to the dye for 24 hours. Apply pressure to the venipuncture site Monitor urinary output. Resume the patients diet. Encourage fluid intake of at least three glasses of liquid to speed the excretion of the dye from the body.

CHEST AP/ BUCKY (CHEST XRAY) Date: July 31, 2011 Lung fields are clear No pneomohydrothorax No fractures nor dislocation Heart and great vessels are not unusual. Costrphenic sulcus and hemidiaphragm are intact.

ET is lodged in the right main bronchus. The rest of the included structures are unremarkable. IMPRESSION: NO SIGNIFICANT CHEST FINDING ET TIP LOCATED IN THE RIGHT MAIN BRONCHUS.

ANATOMY AND PHYSIOLOGY OF THE BRAIN

The brain is one of the largest and most important organs of the human body. Weighing in at about three pounds, this organ has a wide range of responsibilities. From coordinating our movement to managing our emotions, the brain does it all. The brain is made up of three parts: the forebrain, the brainstem, and the hindbrain. The anatomy of the brain is complex due its intricate structure and function. This amazing organ acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain. The brain serves many important functions. It gives meaning to things that happen in the world surrounding us. Through the five senses of sight, smell, hearing, touch and taste, the brain receives messages, often many at the same time. The brain controls thoughts, memory and speech, arm and leg movements, and the function of many organs within the body. It also determines how people respond to stressful situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.) by regulating heart and breathing rates. The brain is an organized structure, divided into many components that serve specific and important functions.

The weight of the brain changes from birth through adulthood. At birth, the average brain weighs about one pound, and grows to about two pounds during childhood. The average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three pounds. The Nervous System The nervous system is commonly divided into the central nervous system and the peripheral nervous system. The central nervous system is made up of the brain, its cranial nerves and the spinal cord. The peripheral nervous system is composed of the spinal nerves that branch from the spinal cord and the autonomous nervous system (divided into the sympathetic and parasympathetic nervous system). The Cell Structure of the Brain The brain is made up of two types of cells: neurons and glial cells, also known as neuroglia or glia. The neuron is responsible for sending and receiving nerve impulses or signals. Glial cells are nonneuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and facilitate signal transmission in the nervous system. In the human brain, glial cells outnumber neurons by about 50 to one. Glial cells are the most common cells found in primary brain tumors. When a person is diagnosed with a brain tumor, a biopsy may be done, in which tissue is removed from the tumor for identification purposes by a pathologist. Pathologists identify the

type of cells that are present in this brain tissue, and brain tumors are named based on this association. The type of brain tumor and cells involved impact patient prognosis and treatment. The Meninges The brain is housed inside the bony covering called the cranium. The cranium protects the brain from injury. Together, the cranium and bones that protect the face are called the skull. Between the skull and brain is the meninges, which consist of three layers of tissue that cover and protect the brain and spinal cord. From the outermost layer inward they are: the dura mater, arachnoid and pia mater. In the brain, the dura mater is made up of two layers of whitish, nonelastic film or membrane. The outer layer is called the periosteum. An inner layer, the dura, lines the inside of the entire skull and creates little folds or compartments in which parts of the brain are protected and secured. The two special folds of the dura in the brain are called the falx and the tentorium. The falx separates the right and left half of the brain and the tentorium separates the upper and lower parts of the brain. The second layer of the meninges is the arachnoid. This membrane is thin and delicate and covers the entire brain. There is a space between the dura and the arachnoid membranes that is called the subdural space. The arachnoid is made up of delicate, elastic tissue and blood vessels of varying sizes. The layer of meninges closest to the surface of the brain is called the pia mater. The pia mater has many blood vessels that reach deep into the surface of the brain. The pia, which covers the entire surface of the brain, follows the folds of the brain. The major arteries supplying the brain provide the pia with its blood vessels. The space that separates the arachnoid and the pia is called the subarachnoid space. It is within this area that cerebrospinal fluid flows.

The outermost layer of the meninges, the dura mater, is closely associated with the arachnoid which in turn is loosely connected to the innermost layer of the meninges, the pia mater. The meninges divide the spinal canal into the epidural space and thesubarachnoid space. The pia mater is closely attached to the spinal cord. A subdural space is generally only present due to trauma and/or pathological situations. The subarachnoid space is filled with cerebrospinal fluid and contains the vessels that supply the spinal cord, namely the anterior spinal artery and the pairedposterior spinal arteries, accompanied by a corresponding spinal veins. The spinal arteries formanastomoses known as the vasocorona of the spinal cord. The epidural space contains loose fatty tissue, and a network of large, thin-walled blood vessels called the internal vertebral venous plexuses. Spaces The subarachnoid space is the space which normally exists between the arachnoid and the pia mater, which is filled with cerebrospinal fluid. Normally, the dura mater is attached to the skull, or to the bones of the vertebral canal in the spinal cord. The arachnoid is attached to the dura mater, while the pia mater is attached to the central nervous system tissue. When the dura mater and the arachnoid separate through injury or illness, the space between them is the subdural space.

Cerebrospinal Fluid Cerebrospinal fluid (CSF) is found within the brain and surrounds the brain and the spinal cord. It is a clear, watery substance that helps to cushion the brain and spinal cord from injury. This fluid circulates through channels around the spinal cord and brain, constantly being absorbed and replenished. It is within hollow channels in the brain, called ventricles, that the fluid is produced. A specialized structure within each ventricle, called the choroid plexus, is responsible for the majority of CSF production. The brain normally maintains a balance between the amount of CSF that is absorbed and the amount that is produced. However, disruptions in this system may occur. The Ventricular System

The ventricular system is divided into four cavities called ventricles, which are connected by a series of holes called foramen, and tubes. Two ventricles enclosed in the cerebral hemispheres are called the lateral ventricles (first and second). They each communicate with the third ventricle through a separate opening called the Foramen of Munro. The third ventricle is in the center of the brain, and its walls are made up of the thalamus and hypothalamus. The third ventricle connects with the fourth ventricle through a long tube called the Aqueduct of Sylvius. CSF flowing through the fourth ventricle flows around the brain and spinal cord by passing through another series of openings.

Brain Components and Functions Brainstem The brainstem is the lower extension of the brain, located in front of the cerebellum and connected to the spinal cord. It consists of three structures: the midbrain, pons and medulla oblongata. It serves as a relay station, passing messages back and forth between various parts of the body and the cerebral cortex. Many simple or primitive functions that are essential for survival are located here. The midbrain is an important center for ocular motion while the pons is involved with coordinating eye and facial movements, facial sensation, hearing and balance.

The medulla oblongata controls breathing, blood pressure, heart rhythms and swallowing. Messages from the cortex to the spinal cord and nerves that branch from the spinal cord are sent through the pons and the brainstem. Destruction of these regions of the brain will cause "brain death." Without these key functions, humans cannot survive. The reticular activating system is found in the midbrain, pons, medulla and part of the thalamus. It controls levels of wakefulness, enables people to pay attention to their environments, and is involved in sleep patterns. Originating in the brainstem are 10 of the 12 cranial nerves that control hearing, eye movement, facial sensations, taste, swallowing and movements of the face, neck, shoulder and tongue muscles. The cranial nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves originate from the pons: nerves 5 through 8. Cerebellum The cerebellum is located at the back of the brain beneath the occipital lobes. It is separated from the cerebrum by the tentorium (fold of dura). The cerebellum fine tunes motor activity or movement, e.g. the fine movements of fingers as they perform surgery or paint a picture. It helps one maintain posture, sense of balance or equilibrium, by controlling the tone of muscles and the position of limbs. The cerebellum is important in one's ability to perform rapid and repetitive actions such as playing a video game. In the cerebellum, right-sided abnormalities produce symptoms on the same side of the body. Cerebrum The cerebrum, which forms the major portion of the brain, is divided into two major parts: the right and left cerebral hemispheres. The cerebrum is a term often used to describe the entire brain. A fissure or groove that separates the two hemispheres is called the great longitudinal fissure. The two sides of the brain are joined at the bottom by the corpus callosum. The corpus callosum connects the two halves of the brain and

delivers messages from one half of the brain to the other. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex. The cerebral cortex appears grayish brown in color and is called the "gray matter." The surface of the brain appears wrinkled. The cerebral cortex has sulci (small grooves), fissures (larger grooves) and bulges between the grooves called gyri. Scientists have specific names for the bulges and grooves on the surface of the brain. Decades of scientific research have revealed the specific functions of the various regions of the brain. Beneath the cerebral cortex or surface of the brain, connecting fibers between neurons form a white-colored area called the "white matter." The cerebral hemispheres have several distinct fissures. By locating these landmarks on the surface of the brain, it can effectively be divided into pairs of "lobes." Lobes are simply broad regions of the brain. The cerebrum or brain can be divided into pairs of frontal, temporal, parietal and occipital lobes. Each hemisphere has a frontal, temporal, parietal and occipital lobe. Each lobe may be divided, once again, into areas that serve very specific functions. The lobes of the brain do not function alone they function through very complex relationships with one another. Messages within the brain are delivered in many ways. The signals are transported along routes called pathways. Any destruction of brain tissue by a tumor can disrupt the communication between different parts of the brain. The result will be a loss of function such as speech, the ability to read, or the ability to follow simple spoken commands. Messages can travel from one bulge on the brain to another (gyri to gyri), from one lobe to another, from one side of the brain to the other, from one lobe of the brain to structures that are found deep in the brain, e.g. thalamus, or from the deep structures of the brain to another region in the central nervous system. Research has determined that touching one side of the brain sends electrical signals to the other side of the body. Touching the motor region on the right side of the brain, would cause the opposite side or the left side of the body to move. Stimulating the left primary motor cortex would cause the right side of the body to move. The messages for movement and sensation cross to the other side of the brain and cause the opposite limb to move or feel a sensation. The right side of the brain controls the left side of the body and vice versa. So if a brain tumor occurs on the right side of the brain that controls the movement of the arm, the left arm may be weak or paralyzed.

Cranial Nerves There are 12 pairs of nerves that originate from the brain itself. These nerves are responsible for very specific activities and are named and numbered as follows: 1. Olfactory: Smell 2. Optic: Visual fields and ability to see 3. Oculomotor: Eye movements; eyelid opening 4. Trochlear: Eye movements 5. Trigeminal: Facial sensation 6. Abducens: Eye movements 7. Facial: Eyelid closing; facial expression; taste sensation 8. Auditory/vestibular: Hearing; sense of balance 9. Glossopharyngeal: Taste sensation; swallowing 10. Vagus: Swallowing; taste sensation 11. Accessory: Control of neck and shoulder muscles 12. Hypoglossal: Tongue movement Hypothalamus The hypothalamus is a small structure that contains nerve connections that send messages to the pituitary gland. The hypothalamus handles information that comes from the autonomic nervous system. It plays a role in controlling functions such as eating, sexual behavior and sleeping; and regulates body temperature, emotions, secretion of hormones and movement. The pituitary gland develops from an extension of the hypothalamus downwards and from a second component extending upward from the roof of the mouth. The Lobes

Frontal Lobes The frontal lobes are the largest of the four lobes responsible for many different functions. These include motor skills such as voluntary movement, speech, intellectual and behavioral functions. The areas that produce movement in parts of the body are found in the primary motor cortex or precentralgyrus. The prefrontal cortex plays an important part in memory, intelligence, concentration, temper and personality. The premotor cortex is a region found beside the primary motor cortex. It guides eye and head movements and a persons sense of orientation. Broca's area, important in language production, is found in the frontal lobe, usually on the left side. Occipital Lobes These lobes are located at the back of the brain and enable humans to receive and process visual information. They influence how humans process colors and shapes. The occipital lobe on the right interprets visual signals from the left visual space, while the left occipital lobe performs the same function for the right visual space. Parietal Lobes These lobes interpret simultaneously, signals received from other areas of the brain such as vision, hearing, motor, sensory and memory. A persons memory and the new sensory information received, give meaning to objects. Temporal Lobes These lobes are located on each side of the brain at about ear level, and can be divided into two parts. One part is on the bottom (ventral) of each hemisphere, and the other part is on the side (lateral) of each hemisphere. An area on the right side is involved in visual memory and helps humans recognize objects and peoples' faces. An area on the left side is involved in verbal memory and helps humans remember and understand language. The rear of the temporal lobe enables humans to interpret other peoples emotions and reactions.

Limbic System This system is involved in emotions. Included in this system are the hypothalamus, part of the thalamus, amygdala (active in producing aggressive behavior) and hippocampus (plays a role in the ability to remember new information). Pineal Gland This gland is an outgrowth from the posterior or back portion of the third ventricle. In some mammals, it controls the response to darkness and light. In humans, it has some role in sexual maturation, although the exact function of the pineal gland in humans is unclear. Pituitary Gland The pituitary is a small gland attached to the base of the brain (behind the nose) in an area called the pituitary fossa or sellaturcica. The pituitary is often called the "master gland" because it controls the secretion of hormones. The pituitary is responsible for controlling and coordinating the following:

Growth and development The function of various body organs (i.e. kidneys, breasts and uterus) The function of other glands (i.e. thyroid, gonads, and adrenal glands)

Posterior Fossa This is a cavity in the back part of the skull which contains the cerebellum, brainstem, and cranial nerves 5-12. Thalamus

The thalamus serves as a relay station for almost all information that comes and goes to the cortex. It plays a role in pain sensation, attention and alertness. It consists of four parts: the hypothalamus, the epythalamus, the ventral thalamus, and the dorsal thalamus. The basal ganglia are clusters of nerve cells surrounding the thalamus. Language and Speech Functions In general, the left hemisphere or side of the brain is responsible for language and speech. Because of this, it has been called the "dominant" hemisphere. The right hemisphere plays a large part in interpreting visual information and spatial processing. In about one third of individuals who are left-handed, speech function may be located on the right side of the brain. Left-handed individuals may need specialized testing to determine if their speech center is on the left or right side prior to any surgery in that area. Many neuroscientists believe that the left hemisphere and perhaps other portions of the brain are important in language. Aphasia is simply a disturbance of language. Certain parts of the brain are responsible for specific functions in language production. There are many types of aphasias, each depending upon the brain area that is affected, and the role that area plays in language production. There is an area in the frontal lobe of the left hemisphere called Brocas area. It is next to the region that controls the movement of facial muscles, tongue, jaw and throat. If this area is destroyed, a person will have difficulty producing the sounds of speech, because of the inability to move the tongue or facial muscles to form words. A person with Broca's aphasia can still read and understand spoken language, but has difficulty speaking and writing. There is a region in the left temporal lobe called Wernicke's area. Damage to this area causes Wernicke's aphasia. An individual can make speech sounds, but they are meaningless (receptive aphasia) because they do not make any sense.

Nursing Care Plans Problem identified: Ineffective cerebral tissue perfusion Nursing diagnosis: Ineffective cerebral perfusion related to interruption of blood flow by space occupying lesions as evidenced by hemorrhage or hematoma Cause analysis: Due to a breakdown of tight endothelial junctions which make up the blood-brain barrier (BBB). This allows normally excluded

intravascular proteins and fluid to penetrate into cerebral parenchymal extracellular space. Once plasma constituents cross the BBB, the edema spreads; this may be quite fast and widespread. As water enters white matter it moves extracellularly along fiber tracts and can also affect the gray matter. This type of edema is seen in response to trauma, tumors, focal inflammation, late stages of cerebral ischemia (Medical-Surgical Nursing by Ignatavicius et al., vol.1 p.1049). Cues STO: Objective: GCS-8 Cerebral edema After 8 hrs. of independent and collaborative management the pt. will be able to manifest stable vital signs as evidenced by absence of Objectives Nursing Intervention INDEPENDENT 1. Monitor vital signs; e.g. Heart rate e.g ( rhythm , noting Rationale 1. Normally, maintains Evaluation

autoregulation STO: Unmet constant Vital signs:

cerebral blood flow despite T: 36.8-40C fluctuation in systemic BP. P:100-172bpm Loss of auto regulation RR:20-29cpm may follow local or diffuse BP: 90/60-120/80 mmhg cerebrovascular damage.

bradycardia, alternating bradycardia/

seen upon bradycardia/tachycardia/dysrythmias. CT scan LTO: O2 sat- After 2 days of effective nursing 82% interventions and collaborative

tachycardia dysrythmias)

or

Elevating

systolic

BP by

accompanied decreasing diastole

BP

management

pt.

will

manifest

(widening pulse pressure) is an ominous sign of increased accompanied decreased consciousness. level ICP when by LTO: met of After 2 days of effective nursing interventions and

improvement on GCS score from 7 to 9 and stable O2 saturation from 85% to 98%.

Changes in rate (bradycardia) collaborative management or dysrythmias may develop, pt. was able to reflecting brainstem pressure. manifest improvement on GCS score from 7 to 9 and stable O2

2. Maintain head/neck or neutral position , support with towel rolls and pillows.

2. Turning one head to one side saturation compresses the jugular veins 98%. and inhibits cerebral venous drainage, thereby increasing ICP. Tight fitting collar/ties can also limit jugular venous drainage.

from

85%

to

Avoid placing head on large pillow.

Check position .

3. Maintain airway

patent and

3. Enhance

O2

supply

for

cerebral oxygenation. Hypoxia

ventilation, SpO2 to 100%

keep

is

an

arteriolar dilator,

cerebrovascular

SaO2 is on ABG; SpO2 is pulse oximetry

causing IICP (Brasher, 2008.)

4. Help client avoid/ limit vomiting, at stool, coughing, straining bearing when

4. These

activities

increase

intrathoracic

and intra

abdominal pressures, which can increase ICP.

down

possible. Reposition client slowly,

prevent client from bending knees and pushing heels

against mattress to move up in bed.

5. Inform client or SO that intellectual

5. Loss

of

internal in

structure memory,

(changes

function, and

behavior emotional will improve

reasoning,

and

ability

to

conceptualize) and fear of the unknown affect processing

functioning gradually

and retention of information and can compound anxiety, confusion, and disorientation.

but that some effect may persist for

months or even be permanent.

COLLABORATIVE

1. Diuretics;

e.g.

Diuretics may be used to acute phase to draw water from reducing brain cells,

mannitol (osmitrol)

reducing cerebral edema and ICP

Problem identified: Impaired swallowing Nursing diagnosis: Risk for nutritional imbalanced: less than body requirements r/t impaired swallowing and decreased level of consciousness Cause analysis: The client who is moderately or severely injured usually has a decreased level of consciousness, at least temporarily. As a result, the client is unable to chew or swallow and must receive nutrition and fluids by an alternative methods; also due to cerebral edema there is compression to the brain thus affecting medulla oblongata and hypothalamus responsible for protective reflexes such as vomiting and controls and regulates appetite( Medical-Surgical Nursing by: Ignatavicius et al. vol.1 p.1053). Cues Objectives Nursing Intervention INDEPENDENT Objective: NGT of OF once every shift CN damageimpaired swallowing LTO: After 3 days of independent and collaborative management the pt. will be able to maintain no signs of poor nuttition IX STO: Within 8 hours of continuous 1. Review swallow, extent clarity facial, involvement; to of individual 1. Nutritional interventions/choice STO: Met of feeding route is determined After 8 hours of continuous by these factors. nursing patient was interventions able to Rationale Evaluation

pathology/ ability to noting paralysis; speech; tongue ability protect of

nursing interventions patient will be able to manifest no signs of poor nutrition as evidence by having fluid and electrolyte balance, and good skin turgor.

manifest no signs of poor nutrition as evidence by having fluid and electrolyte balance, and good skin turgor.

airway/episodes

coughing o choking ; presence adventitious sounds; of breath amount/ LTO: Met

character secretions. periodically indicated. 2. Have at especially

of

oral Weigh as

After

days

of and

independent

collaborative management the pt. was able to maintain

suction

2. Timely limit

intervention

may no signs of poor nutrition.

equipment available bedside, during

amount/untoward

effect of aspiration.

early feeding efforts. Promote effective

swallowing; e.g.: 3. Schedule activities/ medications to provide a minimum of 30 mins. rest 3.Promotes optimal muscle

function, helps limit fatigue.

before eating; 4. Counteracts aiding in hypertension, prevention and of

4. Assist head

client

with

control/support, and position based on specific dysfunction.

aspiration ability to

enhancing Optimal facilitate

swallow. can

positioning

intake/reduce aspiration.

risk

of

5. Place upright

client

in

5. Uses

gravity

to

facilitate

position

swallowing and reduces risk of aspiration.

during/after feeding as appropriate.

6. Clients with dry mouth require 6. Provide need meal. to oral care moisturizing agent before and after eating; clients with based on individual prior to

excess saliva will benefit from use of a drying agent before meal and a moisturizing agent afterward.

7. Increases salivation, improving 7. Stimulate close lips to bolus formation and or manually

swallowing effort.

open mouth by light pressure lips/under needed. chin on if

. 8. Feed allowing slowly, 30-45 8. Aids in sensory retraining and promotes muscular control.

minutes for meals

9. Offer and

solid liquids

foods at

9. Provides sensory stimulation, which may increase salivation and trigger swallowing efforts, enhancing efforts.

different times.

10. Limit/ avoid use of drinking liquids; straw for

10. Feeling rushed can increased stress/level of frustration, may increase risk of aspiration, and may result in clients

terminating meal early.

11. Maintain count.

accurate

11. If swallowing efforts are not sufficient to meet fluid/nutrition needs, alternative methods of feeding must be pursued. .

I&O; record calorie

Collaborative:

Review

results

of

Aids determining phase of difficulties. swallowing

radiographic studies, eg., video fluoroscopy. Administer ed IVF

May be necessary for fluid replacement and nutrition if client in

D5LR and NGT of OF and milk.

unable to take anything orally.

Collaborate with dietitian to determine whether caloric needs are being met.

Increase

effectiveness

of long-term plan, and evaluates the plan.

Problem identified: Multiple Abrasions Nursing diagnosis: Risk for secondary infection r/t broken skin, attachment of FBC Cause analysis: Person at risk for infection are those whose natural defenses mechanisms are inadequate to protect them from the inevitable injuries and exposure that occur throughout the course of living. Infections occur invades susceptible host. Breaks in the integumentary, the first line of defense , and/or the mucous membranes allow invasion by pathogens. If the host reach immune system cannot combat the invading organism adequately, an infection occurs. Open wound, traumatic/surgical, can be sites of infections, soft tissues and organs can be also sites of infection either after trauma, invasive procedures or by invasion of pathogens carried to the bloodstream or lymphatic system (Medical-Surgical Nusing by: Black et al., 8th ed. vol.2 p.1945) Cues Objectives Nursing Intervention Rationale Evaluation

Objective: Cerebral edema seen

STO: Within 8 hours of giving nursing interventions, pt. will be able to manifest absence signs of infection as evidence by absence of redness, swelling, and abnormal discharges on the notables skin breakdown

INDEPENDENT 1. Apply sterile dressing

1. Prevents environmental contamination of fresh wound 2. Contamination by environmental/personnel contact renders the sterile field unsterile, thereby increasing the risk for infection. 3. Disruptions of skin integrity are sources of contamination . 4. Package content integrity

STO: Met After 8 nursing hours of giving pt.

interventions, to

upon CT scan Decrease WBC (<4 x 109/L) Disruption the (multiple abrasions of skin

2. identify breaks in aseptic technique and resolve immediately on occurrence

was

able

manifest

absence signs of infection as evidence by absence of redness, swelling, and

3. examine skin for breaks or irritation, signs of infection

abnormal discharges on the notables skin breakdown

4. Verify sterilized item integrity

noted face,

in

the left and LTO: After 3 days of giving effective nursing intervention and health teaching, the patient will be free of signs of infection and will be DEPENDENT: able to maintain a 1. Administer antibiotics as indicated clean and desirable environment. 2. Provide antiseptic 5. Ensure clients appropriate hygienic care with hand washing, bathing, hair care, nail care, and perineal care, performed either by client or nurse

expiration dates dictate item use time elements. LTO: Met 5. Hygienic care is an important measure to prevent infection in at risk patient After 3 days of giving effective nursing intervention and health teaching, the patient was free of signs of infection and SO and the medical team was able to maintain a clean and desirable environment.

shoulder left knee.) With FBC

May be given prophylactically for suspected infection or contamination May be used with intraoperatively to reduce bacterial counts at surgical site

Problem identified: Elevated Body Temperature Nursing diagnosis: Hyperthermia r/t compression of hypothalamus, inflammatory process as evidenced by increased body temperature and warm, flushed skin. Cause analysis: Compression of the hypothalamus causes alteration in the thermoregulation of the body ( Sommers, Diseases and Disorders, 3rd ed) . Inflammatory mediators causes release of endogenous pyrogens which causes hypothalamic thermostat reset ( Smeltzer, Medical and Surgical Nursing 11th ed)

Cues

Objectives

Nursing Intervention INDEPENDENT

Rationale

Evaluation STO: Met

Objective: Temp. 40oC Increased 109/L) Skin warm to touched

STO:

1.Mointor

client

temperature and

1. To determine if

theres an Within 8 hours of giving nursing

Within 8 hours of giving and

record

(degree

increased level of temperature interventions, the patient temp and to obtain accurate core was reduced from 40 C to 38.5 temperature. C.

nursing interventions, pt. pattern) 40oCto 38.5oC .

WBC ( 19 x temp. will reduce from

LTO: After 3 days of and

2.Monitor heart rate or rhythm

2. Dysrythmias

and

ECG

changes are common due to toectrolytes imbalance and

LTO: Unmet After 3 days of independent and collaborative management, the patient was not able to

independent collaborative

direct effect of hyperthermia on the blood and cardiac

management the pt. will be able to maintain body 3. Monitor environmental limit/add bed

tissues

maintain temperature.

normal

body

normal temperature.

3. Room temperature/number of blankets should be altered to maintain near-normal body

temperature,

linens as indicated

temperature

4. May help reduce fever. 4.Provide tepid sponge , avoid use alcohol. 5. Handwashing prevents spread of infection. 5. Emphasize to the S.O the importance of hand washing and maintain strict hand

washing

-used to reduce fever by its central action by its central action on the hypothalamus; Collaborative: Paracetamol .

-for hydration

IVF .

Problem identified: Multiple skin breakdown Nursing diagnosis: Impaired skin integrity r/t mechanical interruption of skin and tissues as evidenced by disruption of skin surface, and skin layers and tissues Cause analysis: Interruption of skin layers and tissues compromises the integrity of the skin allowing easy entrance of microorganisms and other foreign material( Black, Medical and Surgical Nursing 8th ed, p451.)

Cues Subjective:

Objectives

Nursing Intervention INDEPENDENT:

Rationale

Evaluation STO: Met After 8 hrs. of independent management the pt.s wound was maintained intact, and dry, and free of discharges, and erythema

STO: Maraming ang After 8 hrs. of independent mukha at katawan nyaas management the pt.s wound verbalized by S.O. will be maintain intact, and dry, absence of discharge, erythema to facilitate healing. LTO: Objective: sugat 1. Examined the skin for open wound, foreign bodies, rashes, bleeding, discoloration, duskiness, blanching. 2. Massaged skin and bony prominences. Kept the bed dry and free of wrinkles. Provided elbow/heel pads as indicated. 3. Repositioned frequently. 1. Provides information regarding skin circulation of problems that may cause edema formation that may require further medical interventions. 2. Promotes circulation, reduces risk of abrasions/skin breakdown. 3. Lessens constant pressure on same areas and minimizes risk of skin abrasions. 4. Enhance venous return, reducing venous stasis/edema

After of 2 days 4. Elevated lower extremities when sitting. effective

 Skin

Disruption of

nursing interventions collaborative management pt. will achieve timely healing of the affected areas.

formation. 5.Assisted significant others in developing methods of preventive care and daily maintenance 5.This will allay fear and serves as an alternative form in giving care with the health care providers absence

LTO: Met After of 2 days effective nursing collaborative

interventions

management pt. achieved timely healing of the affected areas.

6.Observed aseptic/clean technique for dressing changes and proper disposal of soiled dressings. 7.Assisted SO to learn about the importance of regular observation and effective skin care in preventing problems.

6.To avoid contamination and infection

7.This will allay fear and serves as an alternative form in giving care with the health care providers absence. This will also prevent further complications.

Problem identified: Risk for aspiration Nursing diagnosis: Risk for aspiration r/t presence of NGT Cause analysis: Chronic conditions including altered consciousness from head injury, neuromuscular weakness, use of take feedings for nutrition, endotracheal intubation, or mechanical ventilation may be encountered agents and cognitively impaired patients are at higher risk and aspiration is a common cause of death in comatose patient.(Med Surg. Nursing by Smeltzer& B. Bare pp. 993-994) Cues Objectives Nursing Intervention INDEPENDENT: Subjective: STO: After 8hrs. of effective nursing intervention pt will able to be free from aspiration as evidence by noiseless respiration, clear breath sounds and odorless secretions LTO: 1.Monitor consciousness level of 1. A decreases level Rationale Evaluation STO: Met of After 8hrs. of effective nursing intervention pt was able to be consciousness is a prime risk free from aspiration as evidence by noiseless respiration, clear factor for aspiration breath sounds and odorless secretions

2.Ausculatate bowel sounds to evaluate bowel motility

2. Decreased

gastrointestinal

motility increases with the risk of aspiration because food/

Objective: NGT feeding Decreased LOC

3. Assess pulmonary status for clinical evidence of

fluids

accumulate

in

the

stomach. 3. Aspiration of small amounts can occur without coughing or sudden onset of especially

aspiration. Auscultate breath sounds for

After 2 days of effective development of crackles and

nursing intervention the patient will be able to maintain clear airway and be free signs of aspiration.

/or rhonchi

respiratory distress, especially in pt. w/ decreased level on

4. In patient w/ endotracheal tube, monitor the

consciousness.

LTO: Partially Met

effectiveness the cuff.

5.

Keep

suction

setup

After 2 days of effective nursing intervention the patient was 4. An effective cuff can increase able to maintain clear airway and be free signs of aspiration. the risk of aspiration

available and use as needed 5. This is necessary to maintain a patent airway.

6. Position patient who have a decreased level on of their

consciousness sides.

6. This Proper

protects

the

airway. can of

positioning the risk

decrease 7.Check placement of NGT before feeding

aspiration. Comatose patients need frequent turning to of

facilitate 9. Check residuals before feeding. Hold feedings if residual are high and modify the physician. secretions. 7. A

drainage

displaced

tube deliver

may tube

erroneously

feeding into the airway.

. Maintain upright position for 30 mins. after feeding

8. High

amount

of

residual gastric

indicate

delayed

emptying can cause distention of the stomach leading to reflux emesis.

9. The upright position facilitates 10.Assist postural drainage the gravitational flow of food or fluid through the alternating tract. If the head of the bed cannot be elevated because of pts condition, position use after

suctioning

feeding to facilitate passage of stomach content into the

duodenum. 10. Mobilize thickened secretions

Problem identified: Immobility Nursing diagnosis: Impaired physical mobility related to neuromuscular impairment secondary to epidural hematoma Cause analysis: During traumatic brain injury there is an acute neurologic deficit due to disruption of blood flow at the cerebral vessels causing

altered function of the neuromuscular. (Physical Examination and Health Assessment. 3rd edition pp. 295-296) Cues Subjective: STO: 1. Change position at least After 8 hours of giving effective nursing care and intervention, the patient will achieved an improved tissue perfusion/ circulation as evidenced by having stable CRT of less than 3 seconds. Objective: Prolonged bed rest Unable move purposely to LTO: 2 hours and possibly move often if placed on affected side. 2. Prevent external hip rotation 2. Maintain leg in neutral position with trochanter roll. . 3. Inspect skin regularly, particularly prominences. After 2 days of giving nursing care and health Dependent: teachings, the patients watcher will be able to over bony 3. . Pressure points over bony prominence are most at risk for decreased perfusion and ischemia. 1. Reduce risk of tissue ischemia/injury. Objectives Nursing Intervention INDEPENDENT Rationale Evaluation STO: Met After 8 hours of giving effective nursing care and intervention, the patient achieved an improved tissue perfusion/ circulation as evidenced by having stable CRT of less than 3 seconds.

performed proper positioning and passive ROM exercise for the patient to prevent tissue injury and contractures on the affected part.

1. Collaborate with the care of the physical therapies Collaboration will provide the best for the patient progress or improvement LTO: Met

After 2 days of giving nursing care and health teachings, the patients watcher was able to performed proper positioning and passive ROM exercise for the patient to prevent tissue injury and contractures on the affected part.

Problem identified: Risk for Decreased Cardiac Output Nursing diagnosis: Risk for Decreased Cardiac Output r/t increased contractility and increased heart rate Cause analysis: When heart rate is high, cardiac output may fall due to increased time for ventricular filling ( Smeltzer, Medical and Surgical Nursing 11th ed) Cues Subjective: STO: After 8 hours of giving Independent: nursing care, the pt. will Assess vital signs. be able to demonstrate Auscultate apical regular heart rate and pulse; note heart rhythm within patients sounds; and palpate range with absence, peripheral pulses. control of dysrhythmias. Check for calf tenderness; diminished pedal pulse; swelling, local redness, or pallor of extremity. Monitor urine output, LTO: noting decreasing output and After 2 days of dark/concentrated continually rendering urine. nursing interventions Encourage rest, patient will be able to semirecumbent in demonstrate adequate Objectives Nursing Intervention INDEPENDENT . Rationale Evaluation STO: Unmet After 8 hours of giving nursing care, the pt. wasnt able to demonstrate regular heart rate and rhythm within patients range. PR- 100-172cpm

Vital signs may be elevated because of increased SVR. The body may no longer be able to compensate and hypotension may occur. Reduced cardiac output, venous pooling/stasis, and enforced bed rest increases risk of thrombophlebitis. Kidneys respond to reduced cardiac output by retaining water and sodium. Physical rest should be maintained during acute or refractory HF to improve efficiency of cardiac contraction and to decrease to myocardial oxygen demand.

Objective:

Tachycardeic PR: beats min, 97-172 per BP-

100/70

cardiac output as evidenced by vital signs within normal range, palpable peripheral pulse, brisk capillary refill and improved mentation. .

bed or chair. Assist with physical care as indicated; elevate legs, avoiding pressure knee. Collaborative: Administer IV fluids as indicated

rapid fluid replacement maybe necessary to improve circulating volume but must be balance against signs of cardiac failure/ needs for inotropic support.

LTO:Met After 2 days of continually rendering nursing interventions patient was able to demonstrate adequate cardiac output as evidenced by vital signs within normal range, palpable peripheral pulse, brisk capillary refill and improved mentation.

HEALTH EDUCATION PLAN Objectives Within 30 minutes of health teachings, the mother will be able to identify 3 recommended activities to aid the clients condition Within 30 minutes of health teachings regarding lifestyle, the mother will be able to identify at least 3 ways to prevent infection Within 30 minutes of health teachings regarding Diet, the mother will be able to enumerate 2 recommended diets for the improvement of her daughters condition Materials Books Cartolina Pen

GENERAL HEALTH TEACHINGS

SPECIFIC HEALTH TEACHINGS -Do not allow the patient to engage in strenuous exercise or activity instead plan activities that limit the energy consumption of the client to prevent fatigue. -Stress importance of reporting signs of fatigue, weakness and pain -Encourage client to promote rest -provide safety environment for the client to reduce the risk of injury/accidents -always introduce your name in every interaction -maintain sleep-wake cycle, with scheduled rest periods. Orient to time, place and reason for hospitalization -wake the patient for every 3 4 hours for the first 2 days, then ask the patients name, where

ACTIVITY AND SAFETY

he or she is, and the name of the person who is asking. - Teach client(when not in coma) and SO ( when patient is coma) to avoid extreme flexion or extension of the neck by maintaining the head in the midline, neutral position and the head of the bed must be 30 degrees or as recommended by the health care provider. POSITIONING - encourage client to eat increase protein on the diet - encourage client to eat soft or semi-soft foods (mechanical soft or dental diet, junior baby foods, custards, or scrambled eggs) and also thin liquid diet (water, juice or milk) DIET -encourage patient to have a frequent hand washing -do not allow nose blowing or hear cleaning for 48 hours -Encourage/assist with good oral hygiene before and after meals -Encourage client to avoid contact to people with disease INFECTION CONTROL -Avoid going to places with crowded people -Encourage client to take a bath daily and wear clean clothes

-Emphasize the importance of regular follow up visits with therapist and other health care providers.

OP

DISCHARGE PLANNING M Medication Encourage the client to comply with all the prescribed medications. Emphasize to the client and her family of the importance of taking the medications at the prescribed schedule, dosage and frequency. Educate the mother about the purpose of the drugs. Advice the significant others not to leave the client during medication to secure that the client has taken the medicines. Explain to the mother the side effects and adverse reaction of the drug she takes by describing its manifestation. Client and significant others should be aware so that prompt medical intervention can be given if in case such reactions occur. Advise mother to take home medications of her daughter to follow the right drug, frequency, dosage and timing as prescribed by the Physician such as follows: E Environment - Instruct the mother to make her daughter stay in calm, quiet environment - Home environment must be free from slipping or accident hazards T Treatment - Inform the mother to have her daughter have a follow-up checkup after 1- 2 weeks - Follow up diagnostic test examination for possible reoccurrence Tramadol, 50 mg 1 cap q6h Cecon, 500mg 1 tab OD Flamazine

H Health Teachings - Inform the mother that her child should avoid lifting heavy objects for 1-2 weeks - Stress the importance of proper hygiene like handwashing, toileting, toothbrushing and bathing. - Encourage client to engage to range of motion exercises. - Instruct patient to increase intake of protein-rich foods to promote faster wound healing - Advise patient to increase adequate fluid intake for hydration purposes. - Discourage patient to participate in strenuous activities that might precipitate stress and trauma to the wound. - Avoid head injuries by using seat belts, bicycle and motorcycle helmets, and hard hats when appropriate. - Tell patient not to hesitate to ask for assistance when waking up in bed or when going to comfort room. - Promote rest periods among the client but also encourage ambulation. - Advice patient to avoid touching the operative wound with hands dirty that may cause infection. - Encourage deep breathing and coughing exercises among the client. O Observable Signs and Symptoms - Instruct patient to report signs and symptoms of increased intra cranial to avoid further complications. - Instruct patient to report to physician any signs of infection like inflammation, redness or swelling - Instruct patient to report any case of hemorrhage or abnormal bleeding pressure like seizures, vomiting or headache to nearest hospital

D Diet - Encourage client to increase intake of fiber to avoid constipation

- Instruct to increase fluid intake - Instruct to increase intake of nutritious foods such as fruits and vegetables S- Spirituality Advise patient to keep believing on Gods holy will so that he could be spiritually motivated. Tell patient to constantly participate to religious activities so that his faith could be more strengthened.

MEDICATIONS Generic name Classification Indication Mechanism action Ceftriaxone Anti-infective (third generation cephalospori ns) Use as Use in the of Binds to the CNS: Seizure (high Drug-drug: bacterial cell doses). wall membrane, causing death. Bactericidal action against susceptible bacteria. GI: Nausea, Probenecid decreases excretion and increases serum levels (cefixime, Rashes, cefotaxime, ceftizoxime) Blood Vomiting, Diarrhea, of Adverse reaction Drug interaction Route dosage 1gm IV q 12 hours and Nursing consideration Assess patient infection (vital signs; appearance of wound, for

treatment

meningitis due to susceptible organism

cell Cramps, Pseudomembranous Colitis, Pseudolithiasis (ceftriaxone) Derm: Urticaria Hemat: dyscrasias, Hemolytic anemia Local: phlebitis at IV site, pain at IM site Misc: Superinfection, allergic reactions

perioperative prophylactic anti-infective

sputum, urine and

stool; WBC) at beginning and throughout course therapy. Before initiating therapy, obtain a of

including ANAPHYLAXIS and SERUM SICKNESS.

history determine previous

to

use of and reactions to penicillin sensitivity may have allergic response. Obtain specimens for and sensitivity before initiating therapy. First may dose be culture still an

given before

receiving results. Observe patient signs for and

symptoms of anaphylaxis (rashes, pruritus, laryngeal edema, wheezing). Discontinue the and the physician or other health care provider immediately drug notify

if

these

occur. Keep epinephrine, an antihistamin e, and

resuscitatio n equipment close by in the event of an anaphylactic reaction.

Generic name

Classification

Indication

Mechanism action

of Adverse reaction

Drug interaction

Route dosage

and Nursing consideration Before giving the

Oxacillin

Anti-infectives (penicillins)

Respiratoty tract or skin infection

Binds

to CNS: Seizures

CHOLESTYRAMINE 1gm IVTT q COLESTIPOL 6 houts

bacterial cell GI: wall, inhibiting cell Epigastric wall colitis

Nausea, and

Vomiting, Diarrhea, may decrease the ANST distress, absorption of oral

medication, assess for

Bacterial meningitis or

Pseudomembranous penicillin G.

anyallergies

septicemia Treatment in enterococcal infections (requires the addition of an aminoglycosi de) Prevetion rheumatic fever of

synthesis during bacterial multiplication

GU: nephritis DERM: urticaria

Interstitial

with oxacillin.

Rashes,

Obtain specimen for and sensitivity before giving the culture

, resulting in HEMAT: cell death. Bactericidal action against susceptible bacteria. Eosinophilia, hemolytic leukopenia LOCAL: Phlebitis at IV site, pain at IM site MISC: Superinfection, allergic including ANAPHYLAXIS and SERUM SICKNESS reactions anemia,

first dose. Give 1-2 before drug hours 2-3

hours after meals. When given orally, drug may cause GI disturbance s. may Food

interfere with absorption. When giving IV dont mix or add other with drug

because they be incompatibl e. Advise pt to report discomfort at injection site. IV might

Generic name

Classification

Indication

Mechanism action

of Adverse reaction

Drug interaction

Route dosage

and Nursing consideration Tell parents to consult

Acetaminopen

Nonopioid analgesic and antipyretic

For

treatment of

Thought produce analgesia blocking impulses, probably inhibiting synthesis

to Hematologic: hemolytic anemia, by neutropenia, pain leucopenia, pancytopenia. by Hepatic: liver

Barbiturates, carbamazepine, hydantoins, rifampin, sulfinpyraHigh zone: or

250mg slow IV q 8 hours

mild to moderate pain and for fever

prescriber before giving drug to children

doses

damage, jaundice. of Metabolic:

long-term use of these drugs may reduce therapeutic effects of acetaminophen. Lamotrigine: May decrease lamotrigine level.

younger than age of 2. Advise pt

prostaglandin in hypoglycemia the CNS or of Skin: rash, urticaria other substances that pain sensitize preceptors

that drug is only for

short-term use and to consult prescriber if giving to

to mechanical or chemical stimulation. Its

Monitor

pt

for

thought to relive fever by central action hypothalamic in

therapeutic effects. Warfarin: increase May

children for longer than 5 days or

heat center.

regulating

hypoprothrombine mic effects with long-term use with high dose of

adults

for

longer than 10 days. Tell pt not to use for marked fever (temp

acetaminophen. Monitor closely Zidovudine: decrease zidovudine effect. Monitor pt closely May INR

higher than 39.5C), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber. Tell breast

feeding woman that acetaminop hen

appears

in

breast milk in low levels (less 1% than of

dose). Drug may be

used safely in therapy is short-term and doesnt exceed recommend ed doeses.

Generic name

Classification

Indication

Mechanism action

of Adverse reaction

Drug interaction

Route dosage

and Nursing consideration

Mannitol

Diuretic (Osmotic)

IV: Adjunct in the treatment of acute

Increases the CNS: headache Hypokalemia osmotic pressure the glomerular and confusion. of EENT: increase the risk digitalis

50cc IV q 6 hours; bolus

Monitor signs,

vital urine

blurred of

output, CVP, and pulmonary

oliguric renal failure

vision and rhinitis glycoside CV: transient toxicity

Adjunct the

in

filtrate, thereby inhibiting reabsorption

volume expansion, tachycardia, chest pain,

artery pressure (PAP) prior to an hourly

treatment of edema

Reduction intracranial or intraocular pressure

of water and congestive heart electrolytes Causes excretion water, sodium, potassium, chloride, calcium, phosphorus, magnesium, urea, acid.

throughout administratio n. Assess for and

failure, polmunary of; edema. GI: thirst,

patients signs

To

promote

the excretion of toxic substances

nausea, vomiting GU: renal failure, urinary retention FE: hyponatremia, hypernatremia,

symptoms of dehydration or fluid overload. Assess patient anorexia, muscle weakness, numbness, tingling, paresthesia, for signs of

certain

GU

Irrigant:

Used as an irrigant during transurethral procedures (2.5- 5% soln only)

uric hypokalemia, hyperkalemia, dehydration

Mobilization of fluid excess in

oliguric renal failure or

edema

confusion and excessive thirst. Notify

Reduction of intraocular or intracranial pressure

physician promptly if

Increase urinary excretion toxic materials

these signs of of electrolytes imbalance occur. Increase ICP: monitor neurologic status and

intracranial pressure readings patients receiving this medication to decrease cerebral in

edema

Increase intraocular pressure: monitor for

persistent or increase eye pain decrease visual acuity or

Generic name

Classification

Indication H2

Mechanism action

of Adverse reaction

Drug interaction

Route dosage

and Nursing consideration Assess for abdominal pain. Note presence of blood: emesis, pt

Ranitidine

Anti-ulcer; Receptor Antagonist

Duodenal and Completely gastric ulcer GERD Erosive esophagitis Heartburn

CNS:

headache blurred

Antacids: May 25mg IVTT q 8 interfere ranitidine absorption. Diazepam: May decrease absorption of diazepam. with hours

inhibits th action and vertigo. of histamine on EENT: the H2 at vision

receptor sites of Hepatic:jaundice partietal decreasing gastric secretion. cells, OthersL and burning at site,

itching

acid injection anaphylaxis,

angioedema.

Glipizide: May increase hypoglycemic effect. Adjust glipizide dosage, directed. as

stool gastric aspirate

or

Instruct pt to take daily prescription drugs bedtime at for once

best result. Instruct to

take without regard meal because absorption isnt affected for result. Avoid smoking because this best to

increases gastric acid secretion. Advise report abdominal pain blood stool emesis Warn pt with phenylketon uria that and in or to

EFFER dose granules and contain aspartame. tablet

Generic name

Classification

Indication

Mechanism

of Adverse

Drug interaction

Route

and Nursing

action Salbutamol Bronchodilators For bronchospas m Relaxes bronchial smooth

reaction CNS: headache, nervousness ,agitation by vertigo. blurred and CNS Stimulants: May increase CNS stimulation. Avoid using

dosage 1 neb q 6

consideration Teach pt / SO toperform proper oral

hours

Reversible air muscles obstruction Asthma attacks

stimulating beta EENT: 2 receptor and vision alpha

inhalation correctly. Give following instruction for nebulization:

beta CV: tachycardia,

together. Digoxin: May decrease digoxin level. Monitor digoxin closely. Propanolol, other blockers: May mutual antagonism. Monitor carefully. pt cause beta level

receptors in the palpitations, sympathetic nervous system hypertension and angina pain GI: nausea and vomiting Respiratory: dyspnea OthersL burning and itching at site,

a. Put meds properly

the

to

the nebulizer set. b. Clear nasal passages and throat c. Breathe out, expelling as

injection anaphylaxis,

angioedema.

much from lungs possible. d. Place

air the as

mouthpiece well mouth inhale deeply as unto and

you breath. e. Hold breath for about 5 10 sec and exhale slowly with a purse lips. f. Continue this procedure until such

medication

runs out.

Generic name

Classification

Indication

Mechanism action

of Adverse reaction CNS: headache and confusion. by EENT: vision rhinitis CV: volume expansion, tachycardia, chest pain, blurred and

Drug interaction

Route and Nursing dosage consideration Determine whether the pt sensitive other corticosteroi ds. Tell pet not to stop the drug abruptly May or without prescribers consent. Most adverse reaction to is to 2.5mg IVTT

Dexamethasone Corticosteroids (Decilone)

Cerebral Edema Inflammatory conditions, allergic reaction, neoplasis

Decrease inflammation, mainly stabilizing leukocyte lysosomal membranes; suppress immune responses;

Aminoglutethimide: May loss

of q 8 hours

dexamethasoneinduce adrenal

suppression. transient Antidiabetics: may decrease response Barbituraes, carbamazepine, phenytoin, rifampin: decrease corticosteroid effect. thirst, Increase

stimulates bone congestive narrow ; and heart failure,

influences

polmunary

protein, fat, and edema. carbohydrate metabolism GI: nausea, vomiting GU: renal

corticosteroids dosage.

corticosteroi

failure, retention FE:

urinary

ds are doseor duration dependent. For results once dose morning. Give injection deeply gluteal muscle. Rotate injection site to prevent into IM better give daily in

hyponatremia, hypernatremia, hypokalemia, hyperkalemia,

muscle atrophy. Avoid injection cause atrophy and SC

sterile abscesses may occur. Watch for

depression or psychotic episodes, especially with dose. Instruct pt to take drugs high

with food or milk. Warn about pt easy

bruising.

MEDICAL-SURGICAL MANAGEMENT Craniotomy Craniotomy is a procedure to remove a lesion in the brain through an opening in the skull (cranium). Purpose: A craniotomy is a type of brain surgery. It is the most common surgery for brain tumor removal. It also may be done to remove a blood clot (hematoma), to control hemorrhage from a weak, leaking blood vessel (cerebral aneurysm), to repair arteriovenous malformations (abnormal connection of blood vessels), to drain a brain abscess, to relieve pressure inside the skull, to perform or to inspect the brain. Procedure: In a craniotomy, the skin over a part of the skull is cut and pulled back. Small holes are drilled into the skull, and a special saw is used to cut the bone between the holes. The bone is removed, and a tumor, clot or other defect is visualized and repaired. The bone is replaced, and the skin is closed. Nursing Responsibilities: Before surgery: Before surgery the patient may be given medications to ease anxiety and to decrease the risk of seizures, swelling, and infection after surgery. Blood thinners (Coumadin, heparin, aspirin) and non-steroidal anti inflammatory( Ibuprofen, Motrin, Advil, aspirin, Naprosyn , Daypro) have been correlated with an increase in blood thinning effects. Additionally, the surgeon will order routine or special laboratory tests as needed. The patient should not eat or drink after midnight the day of surgery. The pts scalp is shaved in the operating room just before the surgery begins. After Surgery:

Craniotomy is a major surgical operation performed under general anesthesia. Immediately after the surgery, the patients pupillary reaction are tested, mental status is assessed after anesthesia, and movement of the limbs (arms/ legs) is evaluated. Shortly after the surgery, breathing exercises are started to clear the lungs. Typically, after surgery patients are given medications to control pain, swelling, and seizures. Codeine may be prescribed to relieve headache. Special leg stocking are used t prevent blood clot formation after surgery. The bandages on the skill are removed and replace regularly. The sutures closing the scalp are removed by the surgeon, but the soft wires used to reattach the portion of the skull that was removed are permanent and require no further attention. Patients should keep the scalp dry until the sutures are removed. If required (depending on area of brain involved), occupational therapist and physical therapist assess the patient status postoperatively and help the patient improve strength, daily living skills and capabilities, speech. Full recovery may take up to two months, since it is common for patients to feel fatigued for up to eight weeks after surgery. Naso-Gastric Feeding For pts who cannot take anything by mouth (NPO) and have a nasogastric tube or a gastrostomy tube in place, an alternative route for administering medications is through the nasogastric or gastrostomy tube. A nasogastric (NG) tube is inserted by way of the nasopharynx and is placed into the clients stomach for the purpose of feeding the client or to remove gastric secretions. A gastrostomy tube is surgically placed directly into the clients stomach and provides another route for administering medications and nutrition. Nursing Responsibilities: Before Procedure: Posistionpt to high Fowlers Position if his or her condition permits Perform hand hygiene and observe other appropriate control procedures Assess clients nares. Determine how far the tube to be inserted.

After Procedure: Ascertain the correct placement of the tube. Secure the tube by taping it to the bridge of the clients nose. Once correct position has been determined, attach the tube to a suction source or feeding apparatus as ordered, or clamp the end of the tube.

PROGNOSIS

The outcome of Epidural or extradural hematoma (haematoma) depends on how promptly treatment is received and how much damage the brain has received. Degree and rate of recovery varies from patient , depending upon the severity, as well as how quickly it was discovered and treated. As a general rule of thumb adults experience most of their recovery within six months, while children recover more quickly and more completely. Seizure, which can most often be controlled with medication, is a common long-term complication.

BIBLIOGRAPHY BOOKS Marieb, Elaine N. 2006, Essentials of Human Anatomy and Physiology 8 th ed. Philippines Dillion, Patricia M. 2007, Nursing Health Assesssment.2nd ed. Philippines Ignatavacius, Donna D. and Workman, Linda M.2006, Medical Surgical Nursing vol.1 .5 thed.Philippines Black, Joyce M. and Hawks Jane. 2008, Medical Surgical Nursing 8th ed. vol. 2.Philippines Doenges, Marilyn E. et. al. 2006, Diagnostic Tests. Philippines Heegaard WG, Biros MH. Head. In: Marx, JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2006: chap 38. Mosby, et.al.2007, Medical Surgical Nursing 7th edition vol. 2 Philippines

ELECTRONIC SOURCE www.scribd.com/journal_SDH.2375375473/info.txt www.wikipedia.org/epidural_hemorrhage.html www.medlineplus.com/epiduralhemorrhage/html/347928/ppt www.wrongdiagnosis.com/epidural_hemorrhage/info/journal_presentation/23989340/html