CONCEPT MAP

Traumatic Brain Injury

CASE STUDY F.R. 48 year old was admitted last 1/18/05 NSS at around 11:30PM, with a chief complaint of accidental fall from a bicycle when he went out of balance, hitting the ground with his head first. He was brought to a nearest hospital were suturing of wound was done. Decreased in the level of consciousness was noted although he was found to be intoxicated with alcohol (+) alcohol breath, and was transferred to UP PGH thus subsequently admitted. On admission the following were noted, abrasions on the elbow and lumbar area, no eye opening, BP 130/80, CR 90bpm, RR 20cpm, anisocoric pupils OD 4mmNRTL, OS 2mm STRL, with spontaneous movement of all extremities, with preferential movement to the right, sensory localizes painful stimuli, no response to verbal stimuli. Operation done: R FT craniotomy, R T Lobectomy. Post op: ABG result PH 7.4, PCO2 30mmhg, PO2 mmhg148, HCO3 20.7mmol/l O2 SAT 99%, (-) gag on ET pull, hook to mechanical ventilator to the following settings: AC mode TV 500 cc, FIO2 80%, BUR 12.

Objective Cues Problem1 E 1. VI, M4 ( E- no spontaneous eye opening, pupils OD 4mm NRTL, OS 3mm BRTL, V- no response to verbal stimuli, Mwithdraws from pain, pulls a part of the body away when pinched. ( 1/19/2005 Post-craniotomy R Temporal lobectomy Problem 2. ( 1/21/2005) Day 2 post-op. Objective cues: ABG result PH 7.4, PCO2 30mm/hg, PO2 mm/hg148, HCO3 20.7mmol/l O2 SAT 99%, (-) gag on ET pull, hook to mechanical ventilator to the following settings: AC mode TV 500 cc, FIO2 80%, BUR 12. Problem no 3: ( 1/21/05 Day 2 post-op) E1, V1, M4. (-) gag reflex by ET pull Problem 4 : + spastic muscle R UE , - ROM, with cervical collar, sensory withdraws to pain both LE, Dependent ADL and bed mobility (1/23/05)

Ineffective cerebral tissue perfusion ICP 20mmHg CPP 55mmHg anisocoric pupils poor capillary refill >3 GCS 6 E1, V1, M4 Hooked on mechanical ventilator AC mode TV 500 cc, FIO2 80%, BUR 12. Diuretics Steroids/antiinflammatory agents

Impaired Physical Mobility (+) spastic muscle (-) range of motion weakness Hooked on mechanical ventilator GCS 6 With cervical collar

Imbalanced nutrition: less than body requirement NGT TPN (-)gag reflex on ET pull 130 lbs, 510 Vitamins/food supplements

Traumatic Brain Injury

Post Op Craniotomy Right Temporal Lobectomy Impaired tissue Integrity Post surgical wound Post Op Craniotomy Right Temporal Lobectomy Dependent ADL Dry skin Abrasions on elbow and lumbar area

Priority Assessment:
Level of consciousness CT scan Hook to mechanical ventilator Serum electrolytes

Self Care Deficit Altered Sensory perception GCS 6 E1, V1, M4 Anisocoric pupils (-) Range of Motion (+) spastic muscle Hooked on mechanical ventilator NGT Dependent ADL