Amal L.

Rangiris
Name: Patient X
Sex: Male
Age: 44
Civil status: Married
Religion: Catholic
Occupation: Driver
Address: Buanoy, Balamban, Cebu
Date of admission: February 02, 2014
Chief complaint: Motor vehicular accident
Admitting diagnosis: Acute subdural
hematoma (R), Multiple contusion (L) and
Traumatic subarachnoid hemorrhage (SAH):
Diffuse
Initial vital signs:
T: 36.2
P: 89 bpm
R: 21 cpm
BP: 130/90 mmHg
Level of Consciousness
Eye opening 4
Verbal response 0
Motor response 6
Total glasgow coma score = 11
(+) Pupillary light reflex
Oriented to place, time and person



NAME OF THE
PROCEDURE
RESULT NORMAL VALUE
Blood compatibility
testing
Blood type
Rh compatibility
Compatibility


AB
Rh+
Compatible


N/A
N/A
Compatible
ABG
Temp
pH
PCO2
PO2
UCO3
TCO2
SO2

36.5
7.471
45.1mmHg
136 mmHg
33.0 mmol/L
34,4 mmol.L
99.3%


7.35-7.45
35-45 mmHg
80-105 mmHg
22-26 mmol/L
23-27 mmol/L
95-98%
NAME OF THE
PROCEDURE
RESULT NORMAL VALUE
Blood
Chemistry
Creatinine
Urea
Sodium
Potassium
Chloride

0.61 mg/dL
5.13 mg/dL
140.3 mmol.L
3.84 mmol/L
3.84 mmol/L
102.3mmol/L

0.9-1.3 mg/dL
8.87-20.55 mg/dL
135-148 mmol/L
3.50-5.30 mmol/L
98-107 mmol/L
IVF FLUID AN VOLUME DROP RATE NUMBER OF HOURS
#71 PNSS IL 30gtts/min 8.33 hrs
#72 PNSS IL 30gtts/min 8.33 hrs
#73 PNSS IL 30gtts/min 8.33 hrs
#74 PNSS IL 30gtts/min 8.33 hrs
MEDICATIONS dosage, frequency, route
Meropenem 1gm q8hr IVTT Anti-
infective
Salbutamol + ambroxol 2cc q8hr neb Bronchodilat
or
Orahex oral care 10cc TID Ant-
iinfective
Omeprazole 40mg OD NGT Antiulcer
Lactulose syrup 30cc NGT Constipation
Kalium durule tab TID NGT Potassium
supplement
Brain
Cerebrum
Two hemispheres
Thalamus
Hypothalamus
Basal ganglia
Brain stem
Midbrain
Pons
Medulla
Cerebellum
Structures protecting the brain
Skull
Meninges
Dura mater
Arachnoid
Pia mater

MVA
Brain suffers
traumatic injury
Contusion, laceration and
torn blood vessels
Brain swelling or bleeding
increases intracranial pressure
Rigid cranium allows no room for expansion of
contents so intracranial pressure increases
Non-modifiable risk
factors:
Age
Sex
Race
Modifiable risk
factors:
Alcohol use
Pressure on blood vessels within the brain cause
blood flow to the brain to slow
Cerebral hypoxia
and ischemia
Intracranial pressure
continues to rise
Cerebral blood flow ceases
BRAIN DEATH
CLINICAL
MANIFESTATIONS:
Altered LOC
Condusion
Pupillary
abnormalities
Altered or absent gag
reflex
Absent corneal reflex
Sudden onset of
neurologic deficits
Changes in vital signs
Vision and hearing
impairment
Sensory dysfunction
Headache
Seizures
Treatment of increased ICP
Provision of ventilatory support
Prevention of seizure
Maintenance of fluid and electrolyte
Nutritional support
Management of pain and anxiety
Closed tube thoracostomy
Tracheostomy
Monitor neurologic function
Maintain the airway
Monitor fluid and electrolyte balance
Provide adequate nutrition
Prevent injury
Maintain body temperature
Improve cognitive functioning
Maintain skin integrity
Maintain sleep-pattern disturbance
Support family coping
Monitor and manage potential complication
Cues Nursing
Diagnosis
Objective Interventions Evaluation
Objective
cues:
Facial
grimacin
g noted
Ineffecti
ve
coughing
noted
Crackle
breath
sound
noted
Ineffective
Airway
Clearance
Within 8hr
of holistic
care,
patient will
be able to
maintain
patent
airway
Monitor vital signs
Auscultate chest
for breath sound
Regulate IVF at
the prescribed
rate
Provide bedside
care
Observe for signs
of respiratory
distress
Establish effective
suctioning of oral
and tracheal
secretions
Elevate head of
bed
Perform chest
physiotherapy
Encourage deep
breathing
exercises
After 8hr of
holistic care,
patient was able
to maintain
patent airway
Cues Nursing
Diagnosis
Objective Interventions Evaluation
Objective
cues:
Facial
grimacin
g noted
Patient
unable
to sit
without
assistanc
e
Edema
noted at
the (L)
arm
impaired
Physical
Mobility
related to
injury @ L
arm
Within 8hr
of holistic
care,
patient will
be able to
maintain
patent or
increase
strength
and
function of
affected
body part
Monitor vital signs
Auscultate chest
for breath sound
Regulate IVF at
the prescribed
rate
Encourage use of
side rails
Support affected
body part using
pillow
Assist patient in
turning or
repositioning
Encourage ROM
exercises
Obser affected
side for color,
edema, or other
signs of
compromised
circulation

After 8hr of
holistic care,
patient was
able to maintain
or increase
strength and
function of
affected body
part
Cues Nursing
Diagnosis
Objective Interventions Evaluation
Objective
cues:
Facial
grimacin
g noted
Patient
unable
to sit
without
assistanc
e
Poor
hygiene
noted
Self-care
Deficit:
bathing,
dressing,
feeding,
toileting
related to
pain @ (L)
arm
Within 8hr
of holistic
care,
patient will
be able to
perform
self-care
activities
within level
of own
ability
Monitor vital signs
Auscultate chest
for breath sound
Regulate IVF at
the prescribed
rate
Determine current
activity level
Encourage patient
to perform self-
care to the
maximum of
ability as defined
by patient
Note presence of
fatigue
Allot sufficient
time to perform
task and display
patience when
movements are
slow
After 8hr of
holistic care,
patient was
able to maintain
or increase
strength and
function of
affected body
part
Cues Nursing
Diagnosis
Objective Interventions Evaluation
Reposition
frequently when
patient is
immobile
Provide massage
and active/passive
ROM exercises
Administer
medications as
ordered