Open Skull Fracture,

Right Frontal Area

Secondary to Vehicular Accident Alcohol
Intoxicity

Introduction

Introduction
Car accident head injury cases may lead to serious
complications such as skull fracture, concussions,
facial fractures and other traumatic brain injuries.
A skull fracture is often inflicted by a hard or strong
blow to the head resulting in cracks or breaks in
the cranium. Although the cranium can heal itself
in minor injuries, it may require surgery or head
operation in cases when a brain tissue is damaged
or a piece of bone is lodged into the brain.

Introduction
This study focuses on Mr. B.B., a 30 year old male neurologic
patient diagnosed with Open Skull Fracture Right Frontal Area
Secondary to Vehicular Accident Alcohol Intoxication. He was
admitted at Corazon Locsin Montelibano Memorial Regional
Hospital on September 21, 2011 at 5:00AM with chief complaint
of lacerated wound at right frontal area.
An open skull fracture is a very serious case. It is our duty as
nurses to pursue and maintain the clients optimal level of
functioning so that our client may return to his normal life after
discharge.

Anatomy and
Physiology
A Quick Overview

The Brain
The brain is the
part of thecentral
nervous
system(CNS)
inside
theskull(the part
outside the skull is
thespinal cord). It
gives rise to
cognitive thought
processes and
controls various
body functions
including muscular
activity, speech,
sight,hearing,
breathing, and
digestion.

Physical
Assessment
Initial Assessment:
Date: September 25, 2011
Time: 11:00 PM

H.E.E.N.T

with sutures on right

side of frontal area
20mm in length, and
right side of parietal
area a 25mm in
length

head circumference
measures 56 cm

multiple abrasions
on frontal and
parietal areas

HEAD
grimaces when
talking and eating

with suture on right

eyebrow 20mm in
length

puffiness and
bruising on left
and right
periorbital areas

EYES

multiple abrasions
on both periorbital
areas

CARDIOVASCULAR

CARDIOVASCULAR
With blood pressure
of 150/100 mmHg
taken at left arm in
lying position

With weak
palpable
pulse of 56
bpm taken
at the right
radial
artery

With IVF #9
PNSS 1L infusing
well at the left
antecubital vein
regulated at
125cc/hr with
the remaining
amount of
750cc

RESPIRATORY

RESPIRATORY

Tactile fremitus
equal bilaterally

Wheezing
auscultated on
both lung fields

Productive cough
noted with light
yellow and viscous
sputum

Pathophysiology

CLICK TO ZOOM IN

Precipitating
Precipitating Factors:
Factors:
Type
Type of
of vehicle
vehicle
Speed
Speed of
of vehicle
vehicle
Place
of
Place of accident
accident
(surface)
(surface)
Alcohol
Alcohol intoxication
intoxication
Predisposing
Predisposing Factors:
Factors:
Age
Age
Genetics
Genetics (Bone
(Bone
Structure)
Structure)

Vehicular Accident

Physical force
elicits contact of
head with cement
floor

Head is arrested by
impact on a rigid
surface

Kinetic energy
transmitted to the
brain

Compression of the
soft tissues of the
brain

Break in the
Integrity of the Skin
Neural
Injury
Multiple
abrasio
ns

Open
Wound
Acute neural injury

Shrinkage of
cell body

Inflammatory
Reaction

Hematoma
Expands

Necrosis and Cell

Death

Luminal Narrowing
and cerebral
infarcts

Precipitating
Precipitating Factors:
Factors:
Type
Type of
of vehicle
vehicle
Speed
Speed of
of vehicle
vehicle
Place
of
Place of accident
accident
(surface)
(surface)
Alcohol
Alcohol intoxication
intoxication
Predisposing
Predisposing Factors:
Factors:
Age
Age
Genetics
Genetics (Bone
(Bone
Structure)
Structure)

Vehicular Accident

Physical force
elicits contact of
head with cement
floor

Head is arrested by
impact on a rigid
surface

Coup counter
coup
Change on the
momentum of the
head
Brain structures
bump in the inner
skull surface
Trauma to the
vessel walls
Extravasation of
blood under arterial
pressure
Blood accumulates
Hematoma
Expands
Compression of the
brain

Precipitating
Precipitating Factors:
Factors:
Type
Type of
of vehicle
vehicle
Speed
Speed of
of vehicle
vehicle
Place
of
Place of accident
accident
(surface)
(surface)
Alcohol
Alcohol intoxication
intoxication

Vehicular Accident

Predisposing
Predisposing Factors:
Factors:
Age
Age
Genetics
Genetics (Bone
(Bone
Structure)
Structure)

Physical force
elicits contact of
head with cement
floor

Head is arrested by
impact on a rigid
surface

Skull
Fracture

Break in the
Integrity of the
Skull

Vascular
Injury

Indirect Injury to
the Parenchyma
Autoregulatio
n
Compression of
Veins and
Displacement of
the CSF

Dilation of bloodbrain barrier

Change in Capillary
Integrity

Dilated Cerebral
Blood Vessels
Increased Pressure
in the Cranium

Fluid shifts to
extracellular
spaces
Inflammation of the
brain

Brain
Swelling

Brain Edema

Coup counter
coup
Change on the
momentum of the
head
CSF leak in ears
and nose
Tear in superficial
Blood Vessels
Bruising of the
Brain

Brain structures
bump in the inner
skull surface
Trauma to the
vessel walls

Superficial arteries
and veins of the
scalp

Battles Sign
Extravasation of
blood under arterial
pressure
Supraorbital and
supratrochlear
artery and vein

Blood accumulates

Brain Tissue Injury

Periorbit
al
Swelling

Periorbit
al
Hemato
ma

Hematoma
Expands
Compression of the
brain

Kinetic energy
transmitted to the
brain

Compression of the
soft tissues of the
brain

Break in the
Integrity of the Skin
Neural
Injury
Multiple
abrasio
ns

Open
Wound
Acute neural injury

Shrinkage of
cell body

Inflammatory
Reaction

Hematoma
Expands

Necrosis and Cell

Death

Luminal Narrowing
and cerebral
infarcts

Precipitating
Precipitating Factors:
Factors:
Type
Type of
of vehicle
vehicle
Speed
Speed of
of vehicle
vehicle
Place
of
Place of accident
accident
(surface)
(surface)
Alcohol
Alcohol intoxication
intoxication

Vehicular Accident

Predisposing
Predisposing Factors:
Factors:
Age
Age
Genetics
Genetics (Bone
(Bone
Structure)
Structure)

Physical force
elicits contact of
head with cement
floor

Head is arrested by
impact on a rigid
surface

Skull
Fracture

Break in the
Integrity of the
Skull

Vascular
Injury

Indirect Injury to
the Parenchyma
Autoregulatio
n
Compression of
Veins and
Displacement of
the CSF

Dilation of bloodbrain barrier

Change in Capillary
Integrity

Dilated Cerebral
Blood Vessels
Increased Pressure
in the Cranium

Fluid shifts to
extracellular
spaces
Inflammation of the
brain

Brain
Swelling

Brain Edema

Coup counter
coup
Change on the
momentum of the
head
CSF leak in ears
and nose
Tear in superficial
Blood Vessels

Brain structures
bump in the inner
skull surface
Trauma to the
vessel walls

Bruising of the
Brain

Superficial arteries
and veins of the
scalp

Battles Sign
Extravasation of
blood under arterial
pressure
Supraorbital and
supratrochlear
artery and vein

Blood accumulates

Brain Tissue Injury

Periorbit
al
Swelling

Periorbit
al
Hemato
ma

Hematoma
Expands
Compression of the
brain

Increased
Skull
Tension

INCREASED
ICP

Pressure equals
systemic BP

Headache

Metabolic
Deprivation of
Energy

Cranial
Nerve
Compressio
n

Inappropriate
release of
excitatory amino
acid transmitters

Blurred
Vision
Optic
Nerve

Excess influx of
calcium ions

Hearing
Loss
Balance
Problems

Olfactory
Nerve

Occulomoto
r Nerve

Facial
Nerve

Severe Hypoxia

Decrease
d O2 in
Cells

Changes
in LOC

Increased
Arterial O2

Increased
Respirator
y Drive

Papilledema
Diplopia

Auditory
Nerve

Decreased Cerebral
Perfusion

Loss of
Smell
Squint or fixed dilated
pupils
Loss of some eye
movement
Unilateral facial
paralysis
Facial Paresis

Inappropriate
activation of
signaling cascades
Vertigo

Free radical
generation
Mitochondrial injury

Cell
Death

Kinetic energy
transmitted to the
brain

Compression of the
soft tissues of the
brain

Break in the
Integrity of the Skin
Neural
Injury
Multiple
abrasio
ns

Brain Tissue
Displacement

Open
Wound
Acute neural injury

Shrinkage of
cell body

Inflammatory
Reaction

Hematoma
Expands

Necrosis and Cell

Death
Herniation
Syndrome
Luminal Narrowing
and cerebral
infarcts

Coma

Damage to
pyramids
Motor
Abnormalitie
s

Lethargy

Damage to
Red Nuclei

Confusion

Irritability

Restlessness

Central
Neurologic
Hyperventilation

Sleep wake
cycle

Reticular
activating
system

Reticular
Formation

CheyneStokes
respirations

Failure of
respiratory
centers

Pons

Medulla
Oblongata

Apneustic
Breathing
Swallowing
Ataxic
Breathing

Coughing

Diminished
Reflexes

Nausea
Increased systolic BP
of 150/100 mmHg
Vomiting
Widened pulse
pressure of 50mmHg
Increased Cardiac
Output
Bradycardia of
56bpm

Failure of
respiratory
centers

Brain Stem
Compression

Drug Study

Mannitol

Drug Study
Mannitol
C
Classification:
Osmotic Diuretic
Diagnostic Agent
Urinary Irrigant

H
Osmotic effect (Leads
to loss of water
sodium and chloride);
reduces IOP

E
Dosage:
100cc
Frequency:
Q6h (6, 12)
Route:
IV Bolus

Drug Study
Mannitol
C
Patient may experience
these side-effects:
Increased urination; GI
upset (eat frequent small
meals); dry mouth (suck
sugarless lozenges);
headache, blurred vision
(use caution when
moving, ask for
assistance).
Report difficulty
breathing, pain at the IV
site, chest pain

K
Do not expose solutions to low temperatures;
crystallization may occur. If crystals are seen
warm the bottle in a hot water bath, then cool
to body temperature before administering.
Make sure the infusion set contains a filter if
giving concentrated mannitol
Monitor serum electrolytes periodically with
prolonged therapy.
Warning: Do not give electrolyte-free mannitol
with blood. If blood must be given, add at least
20 mEq of sodium chloride to each liter of
mannitol solution.

Celecoxib

Drug Study
Celecoxib
C
Classification:

H
Decreases
Inflammation

E
Dosage:
40mg/tab

Analgesis (nonopioid)
NSAID

Frequency:
OD (8 AM)

Specific COX-2
Enzyme Inhibitor

Route:
Per Orem

Drug Study
Celecoxib
C

Take drug with meals if GI

upset occurs

Monitor accordingly since patient is at

risk for CV events and GI bleeding

Take only prescribed dosage

Provide further comfort measures to

reduce pain and inflammation

Side effects include:

Dizziness, drowsiness (avoid
driving or use of dangerous
machinery while taking drug)
Report sore throat, fever,
rash, itching, weight gain,
swelling in ankles or fingers,
changes in vision

Omeprazole

Drug Study
Omeprazole
C
Classification:

Supresses gastric acid Dosage:

secretion
40mg/tab

Antisecretory Drug
Proton Pump
Inhibitor

Frequency:
OD (8 AM)
Route:
Per Orem

Drug Study
Omeprazole
C
Take drugs before meals.
Do not chew or crush
tablets.
Have regular medical
follow-ups
Report severe headache,
worsening of symptoms,
fever, chills
Side-effects include:
dizziness, headache,
nausea and vomiting
diarrhea, cough

K
Administer before meals
Administer antacids if needed

Erythromycin
(Ointment)

Drug Study
Erythromycin (Ointment)
C
Classification:
Macrolide antibiotic

H
Prevents infection by
causing bacterial cell
death

E
Dosage:
---------Frequency:
Three times a day (8,
4, 12)
Route:
Eye

Drug Study
Erythromycin (Ointment)
C
Pull lower eyelid down
gently and squeeze a
one-half inch ribbon of
the ointment into the sac,
avoid touching eye or lid.
Gently close eyes and roll
eyeball in all directions
Drug may cause
temporary blurring of
vision, stinging or itching
Report stinging or itching
that becomes pronounced

K
Culture site before beginning therapy
Administer as prescribed

Lactulose

Drug Study
Lactulose
C
Classification:
Ammonia reduction
drug

H
Treatment for
constipation; Bowel
Movement

E
Dosage:
30cc
Frequency:
ODHS (8 PM)

Laxative
Route:
Per Orem

Drug Study
Lactulose
C
Do not use other
laxatives. The drug may
be mixed in water, juice,
or milk to make it more
tolerable.
Client may experience
these side effects:
abdominal fullness,
flatulence and belching.
Report diarrhea, sever
belching, abdominal
fullness

K
Hold medication if there are > 2 bowel
movement per day.

Citicoline

Drug Study
Citicoline
C
Classification:
Nootropics
Neurotonics

H
Treatment of stupor
caused by head
trauma, cerebral
surgery, acute stage
of cerebral infarction

E
Dosage:
1g/tab
Frequency:
OD
Route:
Per Orem

Drug Study
Citicoline
C
Contact the physician
immediately if allergic
reaction such as hives,
rash, or itching, swelling
in your face or hands,
mouth or throat, chest
tightness or trouble
breathing are
experienced.

K
Citicoline may be taken with or without
food. Take it with or between meals.
The supplement should not be taken in
the late afternoon or at night because it
can cause difficulty sleeping.

Penicillin G

Drug Study
Penicillin G
C
Classification:
Antibiotic
Penicillin Antibiotic

H
Treatment of severe
infections caused by
sensitive organisms

E
Dosage:
4,000,000 IU
Frequency:
q6h
Route:
IVTT

Drug Study
Penicillin G
C

A full course of drug therapy

is needed.

Culture infection before beginning

treatment.

Client may experience these

side effects: upset stomach,
nausea, vomiting (eat
frequent meals), sore mouth
(frequent mouth care may
help), diarrhea, pain or
discomfort at the injection
site.

Monitor serum electrolytes and cardiac

status if penicillin G is given by IV
infusion.

Report unusual bleeding,

sore throat, rash, hives,
fever, severe diarrhea,
difficulty breathing.

Keep epinephrine, IV fluids,

vasopressors, bronchodilators, oxygen,
and emergency equipment readily
available in case of serious
hypersensitivity reaction.

Dolcet

Drug Study
Dolcet
C
Classification:

Indicated to moderate Dosage:

to severe pain
1 tab

Analgesic
Antipyretic

Frequency:
q6h
Route:
Per Orem

Drug Study
Dolcet
C
Report CNS & GI
disturbances, nausea,
dizziness, somnolence,
asthenia, fatigue, hot
flushes, constipation,
diarrhea, flatulence, dry
mouth, pruritus,
increased sweating,
tinnitus.

K
May be taken with or without food.

Health Teaching
Plan

Complete Blood Count

& Platelet Monitoring

Blood Typing
& Crossmatching

Computed Tomography
Scan

Chest Xray

Skull AP

Plain Normal
Saline Solution

Open Reduction
Internal Fixation

Regular Check Up

Medication Compliance

Have a Healthy Diet

Refrain from Smoking and

Drinking Alcohol

Conclusion

Patient B.B. with the diagnosis of Open Skull

Fracture, Right Frontal Area Secondary to Vehicular
Accident, Alcohol Intoxicity, has been admitted in
CLMMRH since September 21, 2011. During the
start of the exposure, the patients head wounds
have already been sutured and his condition has
improved with a Glasgow Coma Scale of 15.
Through this case study, the student nurses were
able to highlight key points in the care of a patient
with open skull fracture. They were able to
prioritize appropriate nursing interventions
according to the patients needs through exploring
the underlying causes of his condition