Gordons

2.
OBJECTIVES
General Objectives :
After the completion of the case study ,the student-nurse will be able to
gain adequate knowledge, skills ,and attitude in the care TRAUMATIC BRAIN
INJURY WITH COMPLETE AND DISPLACED FRACTURE ON THE LEFT
TIBIA for us to be able to come up with the best nursing care plan in the care
and for all the aspects that contribute to and affect the condition of patients
with the said abortion.
Specifically, the student-nurse will be able to :
2.1 Explain the nature and occurrence TRAUMATIC BRAIN

INJURY WITH COMPLETE AND DISPLACED FRACTURE ON THE
LEFT TIBIA and its impact to the Health care Delivery System,
the community and to the patient herself by:

formulating a discharge plan and prognosis for the continuous health
care even at home and recommendation for future further researches
explaining to the patient the cause or reason of having incomplete
abortion, laboratory examination, and drug administration.
Understanding better the medication given to the patient.
knowing the laboratory and diagnostic tests the patient had undergone.
taking on new or additional responsibilities of the mother who are
pregnant
discussing the normal functioning of reproductive system which is
involved on the case of our patient
determining the signs and symptoms on the current health history and
other manifestations of the patient
making and deciding on different nursing care plans
knowing the pathophysiological basis of the incomplete abortion.
organizing patients data to establish good background information
2.2 Define relevant terms:
2.2.1 developmental task
- is a skill or a growth responsibility arising at a
particular time in an individuals life, the achievement of
which will provide a foundation for the accomplishment of
future task.
2.2.2 Erik Ericson (1902-1994)
-American psychoanalyst, who made major
contributions to the field of psychology with his work on child
development and on the identity crisis.
2.2.3 middle adulthood
- it ranges from 40-65 years old (Kozier and Erbs
Fundamentals of Nursing 10th edition)
2.2.4 hemoglobin
-iron-protein compound in red blood cells that gives
blood its red color and transports oxygen, carbon dioxide,
and nitric oxide.
2.2.5 hematocrit
-percentage of blood sample that consists of red
blood cells
2.2.6 red blood cell
-also called erythrocyte. It is the oxygen-carrying
component of the blood
2.2.7 white blood cell
-infection fighting cells
2.2.8 computed tomography
-also known as computed axial tomography, or CAT scan,
medical technology that uses X rays and computers to
produce three-dimensional images of the human body
2.2.9 X-ray
-is penetrating electromagnetic radiation, having a

shorter wavelength than light, and produced by bombarding
a target, usually made of tungsten, with high-speed
electrons.
2.2.10 central nervous system
-it is the part of the nervous system, consisting of the

brain and the spinal cord that controls and coordinates most
of the fuctions of the body and mind.
2.2.11 skeletal system
- it consists of bones and other structures that make
up the joints of the skeleton
2.2.12 trauma
-a physical injury or wound to the body
2.2.13 brain
-the control center of the body
2.2.14 injury
-a harm or damage
2.2.15 traumatic brain injury
- a sudden damage to the brain caused by a blow or

jolt to the head
2.2.16 contusion
-an injury that does not break the skin
2.2.17 frontal lobe
- the largest lobe.
-the major functions of this lobe are concentration,

abstract thought, information storage or memory, and motor
function. It also contains Brocas area, critical for motor
control of speech. The frontal lobe is also responsible in
large part for an individuals affect, judgment, personality,
and inhibitions
2.2.18 occipital lobe

- the posterior lobe of the cerebral hemisphere is
responsible for visual interpretation
2.2.19 tibia
- is the weight-bearing bone of the lower leg. You can

feel the tibial tuberosity (a bump) and anterior crest (a ridge)
on the front of your own leg
2.2.20 fracture
- break or crack in a bone or in ossified cartilage
2.3 Review the profile as well as the nursing and health history of the
client.
2.4 Identify significant changes of clients Functional Health Patterns
and abnormal findings during physical examination.
2.5 Review the development tasks, milestone and changes (physical,
psychosocial, spiritual , moral , and cognitive )of a MIDDLE ADULT.
2.6 Compare the expected ill behaviour of a MIDDLE ADULT with that
of the actual clients reaction to her/his present condition.
2.7 Interpret the results of the diagnostic tests conducted and its
significance to the clients condition.
2.8 Discuss the anatomy and physiology of the Central Nervous
System and Skeletal System
2.9 Conceptualize the psychopathology and psychodynamics of
TRAUMATIC BRAIN INJURY WITH COMPLETE AND DISPLACED
FRACTURE ON THE LEFT TIBIA through a schematic diagram.
2.10 Explain the diseases process of TRAUMATIC BRAIN INJURY
WITH COMPLETE AND DISPLACED FRACTURE ON THE LEFT TIBIA.
2.11 Compare the classical symptoms and actual clinical manifestation.
2.12 Site the guidelines and general considerations of caring a client
with TRAUMATIC BRAIN INJURY WITH COMPLETE AND DISPLACED
FRACTURE ON THE LEFT TIBIA.
2.13 Formulate and implement a comprehensive NURSING CARE
PLAN.
2.14 Discuss the pharmacodynamics and nursing considerations of the
prescribed medications.
2.15 Craft a Health Teaching Plan on the nature of TRAUMATIC BRAIN
INJURY WITH COMPLETE AND DISPLACED FRACTURE ON THE
LEFT TIBIA, its promotion and preventive measures and general care
considerations.
2.16 Evaluate the effectiveness of nursing and medical management
based on manifested changes of clients condition.
2.17 Give recommendations of possible evidence-based practices to
improve the patients conditions and to prevent complication and disability.
2.18 Give the implication of the study to:
2.18.1 Nursing Research
2.18.2 Nursing Education
2.18.3 Nursing Practice
III. NURSING ASSESSMENT

3.1 Patients Profile
A case of patient GG, 61 years old, married, male and a Roman Catholic who was born
on January 11, 1956 which was currently residing at Brgy. Hibucawan, Jaro, Leyte and
currently admitted at Eastern Visayas Memorial Medical Center with chief complaints of
trauma from MVA. Upon admission, he was diagnosed and was attended by Doctor Jay
Stephen Cantay with Traumatic Brain Injury with complete and displace fracture on the
left tibia. His SO added that he was first admitted at Surgical Ward and been transferred
to Orthopaedic Ward last February 16, 2017. On the same day, he was seen and
examined by a Psychiatrist with diagnosis of to be considered Neurocognitive Disorder
due to Traumatic Brain Injury with Behavioural Disturbances.
3.2 Nursing Health History

3.2.1 Present Health History
He was going home from work when another motorcycle bumped on his rear side. That
one vehicle came into contact with one another.
He was immediately brought into Jaro Municipal Health Office and was referred to
Eastern Visayas Regional Medical Center for further evaluation. They arrive in EVRMC
at about 7:00 PM in the evening last February 13, 2017 and was examined by Dr. Jay
Stephen Cantay with Traumatic Brain Injury with complete and displace fracture on the
left tibia, hence admission.
3.2.2 Past Health History
Patient claimed that he was hospitalized at Carigara District Hospital due to
hypertension last December 2016. He added that he was been prescribed with
Metropolol and took it once a day. He confirmed that no other hospitalization was
experienced other than that.
3.2.3 Family Health History
Patient claimed of heredo-familial disease of asthma on his maternal side and
hypertension on his paternal side. No other known heredo-familial disease noted.
3.2.4 Gordons Health Functional Health Pattern

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
Before admission, patient G describes his health as okay man la, nakakatrabaho man
gihap bis amo na it akon edad as verbalized. According to him, he eats three times a
day in order for him to get rid and to prevent diseases.
During admission, patient describes his health as alkanse na ha kinabuhi kay waray na
kita dong. He claimed that there were some medications that they have not comply
because of financial constraints.
He stated that due to his condition, it would be hard for him to take care of himself and
children as well. Patient added that he had complains of vision deficit but not able to
seek proper eye care but instead he just bought an eyeglasses, gilid-gilid ko man la
gipalit dong as verbalized.
NUTRITIONAL-METABOLIC PATTERN
Before admission, patient GG eats three times a day and snacks twice a day. Patient
consumed 1-2 liter of water per day. He stated that his appetite was good and he has no
food restrictions and any allergy.
Patient claimed that he does not take any supplemental vitamins prior to admission.
Currently, Patient was prescribed to Diet as Tolerated but he claimed that his appetite
has changed.
ELIMINATION PATTERN
Before admission, patient GG claimed that he defecates once a day without
experiencing discomforts usually in the morning with a brown colored stool and is well-
formed. He also stated that he voids three times a day with yellow colored urine. No
pain when voiding as he claimed.
During admission, patient claimed that he defecates once every two to three days with a
hard stool. He also added that he voids via catheter and does not feel any urge to
urinate.
SLEEP-REST PATTERN
Before admission, patient claimed that he sometimes worked 7 days per week. Patient
verbalizes okay man la dong, makapahuway man gihap ak. He rated his tiredness as
5 out of 10. Patient also added that he usually sleeps at 9 to 10 PM and wakes up 4:30
in the morning. He does not use any sleeping aids and does not have any difficulties
when sleeping.
Currently, patient experiences disturbed sleeping pattern because of some interruptions
such as giving medications and noise in the surroundings. He claimed that he almost
sleeps 8-10 hours a day.
ACTIVITY-EXERCISE PATTERN
Before admission, patient works as a carpenter. ang mga baskog man ang
patrabahuon sa mga lisud2x dong as verbalized by the patient so he rated his
tiredness as 5 out of 10 with 10 the most tiring. He stated that he can do his activities of
daily living.
During admission, he claimed that his activities of daily living is already limited due to
his condition and relies on his wife in his self-care. Patient verbalizes that di man
kaayo ko makalihok2x dong. Makuri gihap ngan maol-ol kung maglihok akon tuda.
COGNITIVE-EXERCISE PATTERN
He claimed that he has some complaints of difficulty concentrating and reading on
small letters. He added that he does not seek proper eye medical care yet bought an
eyeglasses, gilid-gilid ko man la gipalit dong as patient verbalizes.
Patient claimed that when using the eyeglasses, he experienced headache. Patient can
speak and understand Waray-waray, Cebuano, Tagalog and a little bit English. Patients
SO claimed that the patient claims he sees flashing lights and he had 4 legs.
SELF PERCEPTION PATTERN
Patient claimed that he is concerned about the financial sources for his hospital bills.
ako la an may trabaho ha amon dong, mayda ako anak na pulis pero bago paman la
hiya naka sulod as stated by the patient. He claimed that
ROLE RELATIONSHIP PATTERN
Patient claimed that he is living with his wife and four children. He also added that he
usually decides for his family until the accident happened.
During confinement, he is accompanied by his wife and stays with him most of the time.
SEXUALITY-RELATIONSHIP PATTERN
Patient GG claimed that he was married at the age of 23. They were married for 15
years and got separated. Patient now has a common-law-wife and they have 4 children.
They are now living for almost 21 years. Patient SO claimed that they had difficulty
understanding the patients change of behaviour.
COPING-STRESS MANAGEMENT PATTERN

Patient claimed that his mother died at the age of 93 last December 2016. He stated
that there is nothing he would like to change in his self. He also added that when he is
stressed, he usually seeks guidance from God and counsels his wife.
VALUE-BELIEF SYSTEM PATTERN
Patient claimed that he is a Roman Catholic. He stated that diri man ako makasimba
kada dominggo dong labi na kung may trabaho pero mutuo ngan nagsalig ako ha
Ginoo, priority ko man gihap it pagsimba. The patient also added that there are no
practices that affect his hospitalization. He claimed that a strong faith in God will
accounts for his fast progress.
3.2.5 Mental Health Status
Patient Name: G.G Date: 02/19/17
OBSERVATIONS
Appearance Neat Disheveled Inappropriate Bizarre Other
Speech Normal Tangential Pressured Impoverished
Eye Contact Normal Intense Avoidant Other
Motor Activity Normal Restless Tics Slowed Other
Affect Full Constricted Flat Labile Other
MOOD
Euthymic Anxious Angry Depressed Euphoric Irritable Other
COGNITION
Orientation None Place Object Person Time
Impairment
Memory None Short-Term Long-Term Other
Impairment
Attention Normal Distracted Other
PERCEPTION
Hallucinations None Auditory Visual Other
Other None Derealization Depersonalization
THOUGHTS
Suicidality None Ideation Plan Intent Self-Harm
Homicidality v None Aggressive Intent Plan
Delusions None Grandiose Paranoid Religious Other
BEHAVIOR
Cooperative Guarded Hyperactive Agitated Paranoid
Stereotyped Aggressive Bizarre Withdrawn Other
INSIGHT Good Fair Poor
JUDGMENT Good Fair Poor
3.2.6 Physical Assessment
Date and Time of Assessment: February 19, 2017 7:00 pm
Date and Time of Admission: February 13, 2017 7:00 pm
Name of Agency/Institution: Eastern Visayas Regional Medical Center
Area: Orthopedic Ward
Name of Patient: G.G. Age: 61 years old Sex: Male Civil Status: Married
Chief Complaints: Trauma from Motor Vehicular Accident
Medical Diagnosis: Traumatic Brain Injury with complete and displace fracture on the left tibia.
Admitting Physician: Dr. Jay Stephen Cantay
BODY PART SIGNIFICANT INTERPRETATION

NORMAL FINDINGS
EXAMINED FINDINGS ANALYSIS
INTEGUMENTARY SYSTEM
Inspection Abrasion lesion Motor Vehicular
Color: Tan observed in both accident
Uniform color with slightly darker exposed areas. wrist, left patients suffer
No lesions scapular area, lesion and or
No central cyanosis No peripheral cyanosis and left lumbar fractures in
Palpation area different parts
Temperature: Warm Cold *open wound left of the body
Texture: Soft/fine Coarse/thick
leg noted which caused
Skin Moisture: Dry Moist
by sudden
Turgor: Body Part: _chest_____ Seconds: ___2 sec___
Notes: abrasion lesion observed in both wrist, left scapular area, external force
and left lumbar area, open wound left leg noted that collides
with the body.
Inspection Evidences of Normal balding
Color: black with white hairs alopecia noted. pattern of aged
Distribution patient (61 y/o)
No evidences of Alopecia
Evenly distributed covers the whole scalp
Quantity: Thick Thin
Body Hair
Hair Fine body hair noted over most of the body
Increased hair growth on legs, axillae and pubic area.
Quantity: Thick Thin
Palpation:
Texture: Coarse Smooth
Moisture: Dry Moist/Oily
Notes: evidences of alopecia noted.
Inspection Skin lesion Motor Vehicular
Lighter in color than the complexion. wound observed accident
Free from lice, nits and dandruff. in the occipital patients suffer
Palpation
area and lesion/s and or
Texture: Dry Moist/Oily
tenderness noted fracture/s in
Scalp No tenderness No masses No lesions
No scars noted Freely movable different parts
Notes: Skin lesion wound observed in the occipital area, of the body
tenderness noted which caused
by sudden
external force
that collides
with the body.
Inspection
Color: Pink Light brown others: ____pale pink____
Condition,shape, and angle
Well grommed Convex Cuticle pink and intact
Nails Angle of attachement 1600
Palpation
Texture: Smooth and firm No ridges
Capillary Refill Test: _3__ second/s
Notes: fingernails are ungroomed
HEAD
Inspection
Head Size: _____ cm
Head Position: Erect and Midline position
Head Shape: Normocephalic Symmetrical
Contour Rounded
Head Palpation
Head Contour/Facial Structures
Symmetrical No masses Non tender No lesions
No unexpected contours or bulges
FACE
Inspection
Facial Appearance
Appropriate facial expresion
Symmetrical features and movement
Hair distribution appropriate for age, sex, and ethnicity
No Lesions No Abnormal movements
Face Nasolabial folds symmetrical Palpebral fissures symmetrical
Palpation
Facial bones: Smooth Intact Symmetrical Nontender

Good muscle tone No crepitation Full active ROM
Temporo- Palpation
Mandibular
Smooth Symmetrical motion
Joints No pain No crepitus/Clicking
Inspection Deviated nasal Indicates no
septum injury to the
External Nose noted_but nose.
Midline Position Symmetrical No Drainage reports that it
No Deviation No Flaring Intact Septum was due from
Internal Nasal Mucosa
previous
Pink Moist No Lesions No Edema
Basketball
No Discharges Septum located midline
Palpation contact.
Nose Non Tender No Deformities Patent Nares
Slightly mobile
Notes: Deviated nasal septum noted_but reports that it was due
from previous Basketball contact.
Inspection Normal
Pink in color Others: dark color
Moist Intact No Lesions No Halitosis
Lips Midline No Pursed lip breathing
Palpation
Soft Nontender
Inspection Normal
Oral Mucosa
and Gums Pink Moist Intact Mucosa No Bleeding
Hard and Soft Inspection Normal
Palate Pink Intact Smooth
Inspection Normal
Pink in color with white taste buds at the center
Midline position No Lesions
Full Mobility No Involuntary Movements
Tongue Intact Mucosa
Palpation
Texture: Rough Moist
Inspection Tooth # 7 has

a dental paste
Color: Yellow
*tooth # 11,
18,20, 30,
31,are
extracted_fro
m previous
circumstances
Teeth
Smooth Edge Good Occlusion No Caries

No loose tooth No Dental Fillings
Notes: tooth # 7 has a dental paste, tooth # 11, 18,20, 30, 31, are
extracted_from previous circumstances
Inspection
Frontal
Clear Positive Transillumination Non Tender
No periorbital Edema No Discoloration
Maxillary
Clear Positive Transillumination Non Tender
Sinuses No periorbital Edema No Discoloration
Palpation/Percusion
Maxillary: No Tenderness Resonant Tone
Frontal: No Tenderness Resonant Tone
EYES AND EARS

Inspection Periorbital Indicates escape
General Appearance: Clear and Bright Equal Parallel Alignment hematoma of blood from
Eyelids noted
Color consistent with clients complexion No Lesions No Edema
Nontender Sub-conjuctival
Eyelashes
Right hemorrhage may
Evenly distributed No Ectropion No Entropionsu
Lacrimal Ducts subconjunctival indicate trauma to
No excessive tearing, drainage, edema No dryness hemorrhage the eye but no
Conjunctiva noted Diagnostic Test
Eyes Clear Pink Moist No lesions yet been done.
Sclera
White and intact No lesions and tears
Cornea
Clear without opacities No lesiona and abrasions
Positive corneal reflex
Iris
Round and symmetrical
Puplis
Size 3-5 mm No miosis No mydriasis PERRLA
Palpation
Eyeball: Firm and tender
Lacrimal Gland: Non Tender
Notes: periorbital hematoma noted, nontender, right
subconjunctival hemorrhage noted
Inspection Normal
External Ear:
Vertical position with < 10 degree lateral posterior slant.
Aligned with eyes Symmetrical No redness
No lesions No drainage No foreign objects
Small amount of yellow cerumen and hair
Tympanic Membrane
Ears
Pearly gray Intact No lesions or exudates
No bulging or retraction
Palpation
External Ear:
Helix is soft and pliable Nontender No nodules or lesions
NECK
Inspection
Neck Midline position Erect

Full ROM No masses
Palpation Normal
Nonpalpable Nontender
Thyroid Gland Palpable (Small, smooth edge of thyroid may be palpable)
Auscultation
No bruits
Palpation Normal
Trachea Midline No deviation
Neck Vessels: Carotid Arteries and Jugular Veins

Inspection
Visible carotid pulsation Jugular venous presssure at 450 <3 cm
No neck vein distention Jugular pulsation undulated
Palpation
Carotid:
Regular rhythm Equal contour
Smooth upstroke with lesss acute descent
Jugular:
Easily obliterated and fills appropriately
Auscultation
Carotid: Negative carotid bruits
Jugular Veins: Negative venous hum
THORAX
Chest
Inspecton
Respiratory rate:_21cpm
Quite respiration Symmetrical Regular rythm and depth
Anteroposterior: lateral ratio 1:2 No barrel chest
No spinal deformities Skin Intact
No Retraction or use of accessory muscles
Palpation
Non tender No masses No crepitus
Symmetrical excursion anteriorly and posteriorly
Tactile fremitus equal bilaterally
Percussion
Anterior: Resonance Lateral: Resonance
Posterior: Resonance Diaphragmatic: Resonance
Auscultation
Breath Sounds
All lung fields clear Bronchial breath sounds heard over trachea
Bronchovesicular breath sounds heard over sternum anteriorly and
between scapula posteriorly
Vesicular sounds heard in most lung fields
No abnormal or adventitious breath sounds
No abnormal voice sounds No bronchophony
No whispered pectoriloquy No egophony
Normal
Indicates no infection process unto the respiratory system
Breast
Inspection
Lobular Symmetrical Slightly symmetrical
Color Consistent with body color No masses No lesions
No edema No dimpling No retractions No orange peel skin
Palpation
Premenopausal: more firm and elastic
During pregnancy and lactation: firm and tender
Postmenopausal: less firm and elastic with stringy ducts
Nontender Tender and Nodular (pre-menstruation)
No masses No lesions
Notes: raised lesion observed on left breast but claims that it was congenital, occasional tenderness claimed
Nipple and Areola
Inspection
Areola
Symmetrical Round Darker than breast tissue
No masses No lesions No discharges
Spontaneous discharge (during pregnancy & lactation)
Nipples
Everted Flat or Inverted No supernumerary nipples
Palpation
Nipple elastic Nontender No discharge
White sebaceous secretion with nipple compression
Axilla
Inspection
Skin intact No lesions or rashes
Hair growth appropriate to clients age & sex
Nonpalpable & nontender lymphnodes
Normal
HEART
Pulse
Pulses:
Pulse bpm Grade
Temporal
Grade Amplitude: Carotid
Brachial
0 = absent Radial 85 2
Apical 84 2
1 = weak Femoral 85 2
2 = normal Popliteal
Dorsalis pedis
3 = full Posterior Tibialis
4 = bounding
Auscultation
Blood Pressure: 120/80 mmhg
ABDOMEN
Abdomen
Inspection
Skin color consistent Slightly lighter than exposed areas
No lesions No striae
No superficial veins No scars
No rashes No discoloration
Flat Slightly rounded
Symmetrical No bulges
No hernia Postive respiratory movements
No peristaltic waves Slight pulsation in epigastric region
Hair distribution appropriate for clients age and gender
Umbilicus
Midline Inverted No discoloration No discharge
Auscultation
Soft, medium-pitched bowel sounds every 5-15 seconds in all four
quadrants
No borborygmi No bruits No hums No rubs
Percussion
Tympany in all four quadrants
Dullness over organs Organs Nontender
Palpation
Soft Nontender
Positive skin turgor Negative umbilical bulges
Positive abdominal reflexes No masses
Liver: Nonpalpable Nontender
Spleen: Nonpalpable Nontender
Kidneys: Nonpalpable Nontender
Inguinal Lymph Nodes: Nonpalpable Nontender
Normal
Indicates no trauma into the internal organs of the abdomen
GENITOURINARY SYSTEM
Male Genitourinary
Inspection
Color: _____________________
Skin intact No lesions No discharges
No lesions No pediculosis Foreskin retracts easily
Urinary meatus midline at tip of glans
Scrotum
Skin color darker than rest of body
Appropriate size for age of client
Testes hang freely Left testis slightly lower than right
Inguinal Area
Skin intact No bulges No palpable lymph nodes
Rectal Area
Rectal area intact No inflammation No lesions
No prolapse No hemorrhoids No discharge
No bleeding
Palpation
For nonerect penis: Soft Nontender No nodules
Scrotum, testes, and epididymis:

Scrotal skin rough No swelling of epididymis
No lesions Testes rubbery, round, movable and smooth
Inguinal Area
No hernias No masses No palpable lymph nodes
Anus and Rectum
Nontender No masses No polyps
No lesions No bleeding No hemorrhoids
Positive sphincter tone
Ausculation
No bowel sounds
Notes: attached to Foley Bag Catheter
MUSCULOSKELETAL SYSTEM
Posture & Spinal curves

Inspection:
Erect posture Head midline
Normal spinal curves Knee aligned
Notes: Not assessed
Gait
Gait smooth, fluid, and rhythmic Arms swings in opposition
No toeing in or out
Notes: Not assessed

Muscle Tone
Palpation
Soft and pliable (at rest)
Positive muscle tone, firm, no involuntary movements or tenderness
Normal
Muscle Strength
Hand grip strong and equal
Foot push and leg raise against resistance strong and equal
Grade: Grade:
Grade:
Grade:
SENSORY-NEUROLOGICAL SYSTEM
Cranial Nerves
CN I Olfactory:
Sense of smell intact

X
Assessment: able to identify the smell of the viand being served
Normal
Indicates no damage to the Cranial Nerve I
CN II Optic:
Extraocular muscles intact OU
PERRLA direct and consensual
CN III- Oculomotor, IV- Trochlear, VI Abducens:
Sense of smell intact
Assessment: able to identify the smell of the viand being served
Indicates no damage to the Cranial Nerve II, IV, and VI
CN V Trigeminal:
Jaw muscle strength score: + _____
Facial sensation intact Positive corneal reflex
Assessment: able to locate hand stimuli when to touched to specific area of the face
CN VII Facial:
Facial movements symmetrical Taste on anterior tongue intact
Assessment: able to identify the taste of the viand being place into the anterior tongue
Normal
Indicates no damage to the Cranial Nerve VII
CN VIII Acoustic:
Hearing intact Balance intact
Normal
Indicates no damage to the Cranial Nerve VIII
CN IX Glossopharyngeal and X Vagus:
Strong and clear voice Symmetrical rise of uvula
Able to swallow and cough Positive gag reflex
Taste on posterior tongue intact
Assessment: the patient was able to taste the viand being placed into the posterior tongue
Normal
Indicates no damage to the Cranial Nerve IX
CN XI - Spinal
Muscle strenght of neck and shoulders: + _____
Assessment: Not assessed
CN XII - Hypoglossal:
Full ROM of tongue Midline tongue
No atrophy
Assessment: Able to move at all directions as directed
Cerebral Functions
Behavior
Well-groomed Erect Posture
Pleasant facial expression Appropriate affect
Level of consciousness
Awake Alert Oriented

1 2 3 4 5 6
Glasgow Coma Scale
Opens eyes in
Does not open Opens eyes in Opens eyes
Eye response to N/A N/A
eyes
painful stimuli
response to voice spontaneously Score: ___14____
Oriented,
Makes no Incomprehensible Utters inappropriate Confused,
Verbal sounds sounds words disoriented
converses N/A
normally
Extension to
Abnormal flexion to Flexion /
Makes no painful stimuli Localizes painful Obeys
Motor movements (decerebrate
painful stimuli Withdrawal to
stimuli commands
(decorticate response) painful stimuli
response)
Memory
Immediate memory intact Recent memory intact
Remote memory intact
Mathematical/Calculative ability
Calculative skill intact
Delayed calculative skills

Indicates a damage to the frontal lobe
General knowledge
Vocabulary appropriate General knowledge intact
Thought process
Clear Responds appropriately
Speech coherent and logical
Abstract thinking
Abstract thinking intact

Judgement
Judgement intact
Poor judgment noted

Communication
Clear speech Fluent No dysarthria
No dysphasia No dysphonia No neologism
No circumlocution Intact communication skills
Dysphonia noted
Sensory Function
Light touch, pain, and temperature
Intact
Discriminatory Sensation:
Stereognosis: Intact
Grapesthesia: Intact
Two-point discrimination: Intact
Point localization: Intact
Extinction: Intact
Deep Tendon Reflexes

(Grade DTRs on 0-4 scale)
Biceps: Score ______
Triceps: Score ______
Brachioradialis: Score ______
Patellar: Score ______
Achilles: Score ______

3.3 Level of Growth and Development
3.3.1 Normal Development of Middle Adult
The rate of a persons growth and development is highly individual; however, the
sequence of growth and development is predictable. Stages of growth usually
correspond to certain developmental changes.
A developmental task is a skill or a growth responsibility arising at a particular time in an
individuals life, the achievement of which will provide a foundation for the
accomplishment of future task. Our patient is at the age of 61 and belongs in the Middle
Adulthood which ranges from 40-65 years old (Kozier and Erbs Fundamentals of
Nursing 10th edition). Patient in this stage will have a significant characteristics of
lifestyle changes due to other changes; for example, children leave home, occupational
goals change.
Psychosexual Development
At the age of 61 (Genital) Pleasure is directed in the development of sexual
relationships. In this final stage, sexual urges reawaken and are directed to an individual
outside the family circle. Unresolved prior conflicts surface during adolescence. Once
the individual resolves conflicts, he is then capable of having a mature adult sexual
relationship.
Psychosocial Development
Ericson defines the developmental task of Middle Adulthood as generativity versus
stagnation, generativity versus. Self-Absorption and Stagnation (Middle Age). Following
the development of an intimate relationship, the adult focuses on supporting future
generations. The ability to expand ones personal and social involvement is critical to
this stage of development. Middle age adults achieve success in this stage by
contributing to future generations through parenthood, teaching, and community
involvement. Achieving generativity results in caring for others as a basic strength.
Inability to play a role in the development of the next generation results in stagnation
(Santrock, 2008). Nurses assist physically ill adults in choosing creative ways to foster
social development. Middle age persons often find a sense of fulfilment by volunteering
in a local school, hospital, or church
Cognitive Development
Period IV: Formal Operations (11 Years to Adulthood). The transition from concrete to
formal operational thinking occurs in stages during which there is a prevalence of
egocentric thought. This egocentricity leads adolescents to demonstrate feelings and
behaviors characterized by self-consciousness, a belief that their actions and
appearance are constantly being scrutinized (an imaginary audience), that their
thoughts and feelings are unique (the personal fable), and that they are invulnerable
(Santrock, 2008). These feelings of invulnerability frequently lead to risk-taking
behaviors, especially in early adolescence. As adolescents share experiences with
peers, they learn that many of their thoughts and feelings are shared by almost
everyone, helping them to know that they are not so different. As adolescents mature,
their thinking moves to abstract and theoretical subjects. They have the capacity to
reason with respect to possibilities. For Piaget, this stage marked the end of cognitive
development
Moral Development
Level III: Post conventional Reasoning. The person finds a balance between basic
human rights and obligations and societal rules and regulations in the level of post
conventional reasoning. Individuals move away from moral decisions based on authority
or conformity to groups to define their own moral values and principles. Individuals at
this stage start to look at what an ideal society would be like. Moral principles and ideals
come into prominence at this level (Berger, 2007)
3.3.2 The ill person at particular stage of patient

HEALTH RISKS
Many middle-aged adults remain healthy; however, the risk of developing a
health problem is greater than that of the young adult. Leading causes of death in this
age group include motor vehicle and occupational injuries, chronic disease such as
cancer, and cardiovascular disease. Lifestyle patterns in combination with aging, family
history, and developmental stressors (e.g., menopause, climacteric) and situational
stressors (e.g., divorce) are often related to health problems that do arise. For example,
smoking and excessive alcohol consumption place an individual at greater risk of
developing chronic respiratory problems, lung cancer, and liver disease. Overeating can
result in obesity, diabetes mellitus, atherosclerosis, and its associated risk for
hypertension and coronary artery disease. Many diseases of older age may be
decreased by health-conscious and lifestyle decisions made, and acted on, in midlife.
The nurse can play an important role in teaching middleaged clients about preventive
health care to avoid or minimize the risk of such health problems.
INJURIES
Changing physiological factors, as well as concern over personal and work-related
responsibilities, may contribute to the injury rate of middle- aged people. Motor vehicle
crashes are the most common cause of unintentional death in this age group.
Decreased reaction times and visual acuity may make the middle-aged adult prone to
injury.
Other unintentional causes of death for middle-aged adults include falls, fires, burns,
poisonings, and drownings. Work-related injuries continue to be a significant safety
hazard during the middle years.
CANCER
Cancer is the leading cause of death in middle adulthood (Edelman & Mandle, 2010, p.
596). The patterns of cancer types and incidences for men and women have changed
during the past several decades. The ACS (2014) states that men have a high incidence
of cancer of the lung, prostate, and colon. In women, lung cancer is highest in
incidence, followed by breast cancer and colon cancer. Screening guidelines for early
detection.
OBESITY
Middle-aged adults who gain weight may not be aware of some common facts about
this age period. Decreased metabolic activity and decreased physical activity mean a
decrease in caloric need. The nurses role in nutritional health promotion is to counsel
clients to prevent obesity by reducing caloric intake and participating in regular exercise.
Clients should also be educated that being overweight is a risk factor for many chronic
diseases such as diabetes and hypertension and for problems of mobility such as
arthritis. Recent changes in the Food Guide Pyramid propagated by the U.S.
Department of Agriculture now encourage nutrient intake based on physical activity,
age, and gender. Clients may be directed to the new MyPlate website to design a
customized, healthy diet plan for themselves. Clients should seek medical advice before
considering any major changes in their diets.
ALCOHOLISM
The excessive use of alcohol can result in unemployment, disrupted homes, injuries,
and diseases. It is estimated that 4 million people in the United States are dependent on
alcohol and can be considered alcoholics. Alcohol use may exacerbate other health
problems. Nurses can help clients by providing information about the dangers of
excessive alcohol use, by helping the individual clarify values about health, and by
referring the client who abuses alcohol to special groups such as Alcoholics
Anonymous.
MENTAL HEALTH ALTERATIONS

Developmental stressors, such as menopause, the climacteric, aging, and impending
retirement, and situational stressors, such as divorce, unemployment, and death of a
spouse, can precipitate increased anxiety and depression in middle-aged adults. Clients
may benefit from support groups or individual therapy to help them cope with specific
crises.
3.4 Diagnostic Results
DIAGNOSTIC NORMAL PATIENTS SIGNIFICANT
DATE TEST RESULT RESULT
FINDINGS
Decreased in
all anemias in
Hemoglobin
leukemia,
Feb. 13, 2017 count
130180 g/L 120g/L
and after
hemorrhage
Decreased in
severe
Hematocrit 42%52% 35 % anemias,
count anemia of
pregnancy,
acute massive
blood loss
Decreased in
various
anemias,
pregnancy,
Red Blood Cell 4.66.2 4.23 1012/L
severe or
Count 1012/L
prolonged
hemorrhage,
and with
excessive fluid
intake
White blood Increased in
Cell Count 4.511 109/L 18.55 presence of
infections
DATE DIAGNOSTIC TEST SIGNIFICANT FINDINGS

Feb. 15, 2017 Computed Tomography -Contusions, Frontal and Left
Occipital
-Left Occipital Bone Fracture
Feb. 17, 2107 Tibial X-ray -Shows a complete and

displaced fracture on the left
tibia. Overlying soft tissue
swelling is noted.
IV. Pathophysiology and Rationale
4.1 Anatomy and Physiology of Central Nervous System & Skeletal System
Figure 1.1 Bones and sutures of the skull

Source: Brunner and Suddarths Textbook of Medical-Surgical Nursing 10 th Edition
FIGURE 1.2 View of the external surface of the brain showing lobes, cerebellum, and
brain stem.
FIGURE 1.3 View of the external surface of the brain showing lobes, cerebellum, and
brain stem.
4.1.2 Physiologic processes of the organs/ system involved
CENTRAL NERVOUS SYSTEM

The brain is divided into three major areas: the cerebrum, the brain stem, and the
cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the
hypothalamus, and the basal ganglia. Additionally, connections for the olfactory (cranial
nerve I) and optic (cranial nerve III) nerves are found in the cerebrum.
The brain stem includes the midbrain, pons, medulla, and connections for cranial nerves
II and IV through XII. The cerebellum is located under the cerebrum and behind the
brain stem. The brain accounts for approximately 2% of the total body weight; it weighs
approximately 1,400 g in an average young adult (Hickey, 2003). In the elderly, the
average brain weighs approximately 1,200 g.
Cerebrum
The cerebrum consists of two hemispheres that are incompletely separated by the great
longitudinal fissure. This sulcus separates the cerebrum into the right and left
hemispheres. The two hemispheres are joined at the lower portion of the fissure by the
corpus callosum. The outside surface of the hemispheres has a wrinkled appearance
that is the result of many folded layers or convolutions called gyri, which increase the
surface area of the brain, accounting for the high level of activity carried out by such a
small-appearing organ. The external or outer portion of the cerebrum (the cerebral
cortex) is made up of gray matter approximately 2 to 5 mm in depth; it contains billions
of neurons/cell bodies, giving it a gray appearance. White matter makes up the
innermost layer and is composed of nerve fibers and neuroglia (support tissue) that
form tracts or pathways connecting various parts of the brain with one another
(transverse and association pathways) and the cortex to lower portions of the brain and
spinal cord (projection fibers). The cerebral hemispheres are divided into pairs of frontal,
parietal, temporal, and occipital lobes. The four lobes are as follows:
a. Frontalthe largest lobe. The major functions of this lobe are concentration,
abstract thought, information storage or memory, and motor function. It also
contains Brocas area, critical for motor control of speech. The frontal lobe is also
responsible in large part for an individuals affect, judgment, personality, and
inhibitions.
b. Parietala predominantly sensory lobe. The primary sensory cortex, which
analyzes sensory information and relays the interpretation of this information to
the thalamus and other cortical areas, is located in the parietal lobe. It is also
essential to an individuals awareness of the body in space, as well as orientation
in space and spatial relations.
c. Temporalcontains the auditory receptive areas. Contains a vital area called
the interpretive area that provides integration of somatization, visual, and
auditory areas and plays the most dominant role of any area of the cortex in
cerebration.
d. Occipitalthe posterior lobe of the cerebral hemisphere is responsible for visual
interpretation.
Corpus Callosum
The corpus callosum is a thick collection of nerve fibers that connects the two
hemispheres of the brain and is responsible for the transmission of information from one
side of the brain to the other. Information transferred includes sensation, memory, and
learned discrimination. Right-handed people and some left-handed people have
cerebral dominance on the left side of the brain for verbal, linguistic, arithmetical,
calculating, and analytic functions. The nondominant hemisphere is responsible for
geometric, spatial, visual, pattern, and musical functions.
Basal Ganglia
The basal ganglia are masses of nuclei located deep in the cerebral hemispheres that
are responsible for control of fine motor movements, including those of the hands and
lower extremities.
Thalamus
The thalamus lies on either side of the third ventricle and acts primarily as a relay
station for all sensation except smell. All memory, sensation, and pain impulses also
pass through this section of the brain.
Hypothalamus
The hypothalamus is located anterior and inferior to the thalamus. The hypothalamus
lies immediately beneath and lateral to the lower portion of the wall of the third ventricle.
It includes the optic chiasm (the point at which the two optic tracts cross) and the
mammillary bodies (involved in olfactory reflexes and emotional response to odors). The
infundibulum of the hypothalamus connects it to the posterior pituitary gland. The
hypothalamus plays an important role in the endocrine system because it regulates the
pituitary secretion of hormones that influence metabolism, reproduction, stress
response, and urine production. It works with the pituitary to maintain fluid balance and
maintains temperature regulation by promoting vasoconstriction or vasodilatation. The
hypothalamus is the site of the hunger center and is involved in appetite control. It
contains centers that regulate the sleepwake cycle, blood pressure, aggressive and
sexual behavior, and emotional responses (blushing, rage, depression, panic, and fear).
The hypothalamus also controls and regulates the autonomic nervous system.
Pituitary Gland
The pituitary gland is located in the sella turcica at the base of the brain and is
connected to the hypothalamus. The pituitary is a common site for brain tumors in
adults; frequently they are detected by physical signs and symptoms that can be traced
to the pituitary, such as hormonal imbalance or visual disturbances secondary to
pressure on the optic chiasm Nerve fibers from all portions of the cortex converge in
each hemisphere and exit in the form of a tight bundle of nerve fibers known as the
internal capsule. Having entered the pons and the medulla, each bundle crosses to the
corresponding bundle from the opposite side. Some of these axons make connections
with axons from the cerebellum, basal ganglia, thalamus, and hypothalamus; some
connect with the cranial nerve cells. Other fibers from the cortex and the subcortical
centers are channeled through the pons and the medulla into the spinal cord. Although
the various cells in the cerebral cortex are quite similar in appearance, their functions
vary widely, depending on location. The topography of the cortex in relation to certain of
its functions. The posterior portion of each hemisphere (the occipital lobe) is devoted to
all aspects of visual perception. The lateral region, or temporal lobe, incorporates the
auditory center. The mid-central zone, or parietal zone, posterior to the fissure of
Rolando, is concerned with sensation; the anterior portion is concerned with voluntary
muscle movements. The large area behind the forehead (ie, the frontal lobes) contains
the association pathways that determine emotional attitudes and responses and
contribute to the formation of thought processes. Damage to the frontal lobes as a result
of trauma or disease is by no means incapacitating from the standpoint of muscular
control or coordination, but it affects a persons personality, as reflected by basic
attitudes, sense of humor and propriety, self-restraint, and motivations.
Brain Stem
The brain stem consists of the midbrain, pons, and medulla oblongata The midbrain
connects the pons and the cerebellum with the cerebral hemispheres; it contains
sensory and motor pathways and serves as the center for auditory and visual reflexes.
Cranial nerves III and IV originate in the midbrain. The pons is situated in front of the
cerebellum between the midbrain and the medulla and is a bridge between the two
halves of the cerebellum, and between the medulla and the cerebrum. Cranial nerves V
through VIII connect to the brain in the pons. The pons contains motor and sensory
pathways. Portions of the pons also control the heart, respiration, and blood pressure.
The medulla oblongata contains motor fibers from the brain to the spinal cord and
sensory fibers from the spinal cord to the brain. Most of these fibers cross, or
decussate, at this level. Cranial nerves IX through XII connect to the brain in the
medulla
Cerebellum
The cerebellum is separated from the cerebral hemispheres by a fold of dura mater, the
tentorium cerebelli. The cerebellum has both excitatory and inhibitory actions and is
largely responsible for coordination of movement. It also controls fine movement,
balance, position sense (awareness of where each part of the body is), and integration
of sensory input.
STRUCTURES PROTECTING THE BRAIN
The brain is contained in the rigid skull, which protects it from injury. The major bones of
the skull are the frontal, temporal, parietal, and occipital bones. These bones join at the
suture lines
The meninges (fibrous connective tissues that cover the brain and spinal cord) provide
protection, support, and nourishment to the brain and spinal cord. The layers of the
meninges are the dura, arachnoid, and pia mater.
Dura mater
The outermost layer; covers the brain and the spinal cord. It is tough, thick,
inelastic, fibrous, and gray. There are four extensions of the dura: the falx cerebri, which
separates the two hemispheres in a longitudinal plane; the tentorium, which is an
infolding of the dura that forms a tough membranous shelf; the falx cerebelli, which is
between the two lateral lobes of the cerebellum; and the diaphragm sellae, which
provides a roof for the sella turcica. The tentorium supports the hemispheres and
separates them from the lower part of the brain. When excess pressure occurs in the
cranial cavity, brain tissue may be compressed against the tentorium or displaced
downward, a process called herniation. Between the dura mater and the skull in the
cranium, and between the periosteum and the dura in the vertebral column, is the
epidural space, a potential space.
Arachnoid
The middle membrane; an extremely thin, delicate membrane that closely
resembles a spider web (hence the name arachnoid). It appears white because it has
no blood supply. The arachnoid layer contains the choroid plexus, which is responsible
for the production of cerebrospinal fluid (CSF). This membrane also has unique
fingerlike projections, arachnoid villi, that absorb CSF. In the normal adult,
approximately 500 mL of CSF is produced each day; all but 125 to 150 mL is absorbed
by the villi(Hickey, 2003). When blood enters the system (from trauma or hemorrhagic
stroke), the villi become obstructed and hydrocephalus (increased size of ventricles)
may result. The subdural space is between the dura and the arachnoid layer, and the
subarachnoid space is located between the arachnoid and pia layers and contains the
CSF.
Pia mater
The innermost membrane; a thin, transparent layer that hugs the brain closely
and extends into every fold of the brains surface.
Figure 1.4 Bones of the leg and anterior view of left leg.
Source: Martini, Ober, Bartholomew Visual Essentials of Anatomy & Physiology
SKELETALSYSTEM
The skeletal system consists of bones and other structures that make up the joints of
the skeleton. The types of tissue present are bone tissue, cartilage, and fibrous
connective tissue, which forms the ligaments that connect bone to bone.
FUNCTIONS OF THE SKELETON
1. Provides a framework that supports the body; the muscles that are attached to bones
move the skeleton.
2. Protects some internal organs from mechanical injury; the rib cage protects the heart
and lungs.
3. Contains and protects the red bone marrow, the primary hemopoietin (blood-forming)
tissue.
4. Provides a storage site for excess calcium. Calcium may be removed from bone to
maintain a normal blood calcium level, which is essential for blood clotting and proper
functioning of muscles and nerves.
Femur
The femur is the long bone of the thigh. As mentioned, the femur forms a very movable
ball-andsocket joint with the hip bone. At the proximal end of the femur are the greater
and lesser trochanters, large projections that are anchors for muscles. At its distal end,
the femur forms a hinge joint, the knee, with the tibia of the lower leg.
Patella
The patella, or kneecap, is anterior to the knee joint, enclosed in the tendon of the
quadriceps femoris, a large muscle group of the thigh.
Tibia
The tibia is the weight-bearing bone of the lower leg. You can feel the tibial tuberosity (a
bump) and anterior crest (a ridge) on the front of your own leg. The medial malleolus,
what we may call the inner ankle bone, is at the distal end.
Fibula
The fibula is not part of the knee joint and does not bear much weight. The lateral
malleolus of the fibula is the outer ankle bone you can find just above your foot.
Though not a weight-bearing bone, the fibula is important in that leg muscles are
attached and anchored to it, and it helps stabilize the ankle. Two bones on one is a
much more stable arrangement than one bone on one, and you can see that the
malleoli of the tibia and fibula overlap the sides of the talus. The tibia and fibula do not
form a pivot joint as do the radius and ulna in the forearm; this also contributes to the
stability of the lower leg and foot and the support of the entire body.
Tarsals
The tarsals are the seven bones in the ankle. As you would expect, they are larger and
stronger than the carpals of the wrist, and their gliding joints do not provide nearly as
much movement. The largest is the calcaneus, or heel bone; the talus transmits weight
between the calcaneus and the tibia.
Metatarsals and Phalanges
The metatarsals are the five long bones of each foot, and phalanges are the bones of
the toes. There are two phalanges in the big toe and three in each of the other toes. The
phalanges of the toes form hinge joints with each other. Because there is no saddle joint
in the foot, the big toe is not as movable as the thumb. The foot has two major arches,
longitudinal and transverse, that are supported by ligaments. These are adaptations for
walking completely upright, in that arches provide for spring or bounce in our steps.
4.2 Pathophysiology
4.2.1 Schematic Diagram showing the pathophysiology of the disease
Pathophysiology of Traumatic Brain Injury

Modifiable Factors
-motor vehicular Non-modifiable
accident Factors
-Age (61 years old)
-Sex (Male)
External Force collides with
Fractured skull Crashing of the brain back and forth of
Brain suffers from
Cerebral and tearing of the
Primary Brain Injury
CT scan reveals contusion on the left occipital area and frontal
Secondary Brain
Brain Intracranial haemorrhage
Decreased ability to perform the function of the Increased Intracranial

affected part
Contusion at the frontal Contusion at left Increased Intracranial Pressure

signs and symptoms
-decreased level of
Signs and symptoms of Signs and symptoms of consciousness
contusion at the frontal contusion at the occipital -headache
lobe Area -visual disturbances
-impulsiveness -visual illusions
-expressive aphasia -hallucinations
-short term memory loss Visual disturbances
Tibia Fracture
Non Modifiable Factors:
Modifiable Factors:
Age (61 years old)
Motor Vehicular Accident Sex (Male)
External force Slams unto the
tibia
Fractured Tibia
The periosteum and blood

vessel in the cortex and marrow
of the tibia are disrupted.
Soft tissue damage occurs
Bleeding occurs from both soft

tissue and from the damage
ends of bones.
Hematoma occurs as a
compensatory mechanism
(For healing)
Bones tissue surrounding

site dies
Inflammation Occurs
Vasodilation, edema, pain, loss

of function, exudation of
plasma and leukocytes and
4.2.2 Disease process andinfiltration
its effect of
to white
the organ/
blood system
cells. involved
Traumatic Brain Injury occurs when an external mechanical force causes brain
dysfunction. This usually result from a violent blow or jolt to the head and it can have a
wide ranging physical and psychological effect.
An external force collides with the head, causing skull fracture and brain suffers from
traumatic injury. The fracture causes the leakage of CSF from nose and ear, potential
entry and invasion of pathogen in the delicate structures of the brain, then possible
infection. Brain trauma leads to primary brain injury. Crashing of the brain back and forth
of the skull and eventually cerebral tearing. Intracranial hemorrhage happens and as a
compensatory mechanism brain swelling occurs. There is a decreased ability to
perform the function of the affected part. The affected part are the frontal lobe and left
occipital area. Signs and symptoms of contusion at the frontal lobe that the patient
manifested were impulsiveness, expressive aphasia and short term memory loss. Signs
and symptoms of contusion at the occipital area that the patient manifested were visual
illusions hallucinations and visual disturbances.
Due to increased brain size into a fixed and rigid cranium, there is an increase of
intracranial pressure. As manifested by the patient signs and symptoms of increases
intracranial pressure; decrease level of consciousness, headache, & visual
disturbances. As a compensatory mechanism to accommodate the increased ICP;
compression of intracranial veins, decrease CSF, & decreased cerebral blood flow.
Cerebral hypoxia happens which then may lead to ischemia and failure of the brain to
go further compensatory mechanism. If the brain fails to go further compensatory
mechanism, cessation of the blood flow may occur which eventually leads to brain
death. Brain death may occur and causes irreversible loss of all functions of the brain
and cessation of detectable electrical activity.
Tibia fracture is a break or crack in one of the bones in your leg. The tibia or shinbone,
the major weight bearing in your lower leg. Common cause includes motor vehicular
accident, and sports injuries.
An external force or any high impact trauma causes the break, leading to the disruption
of the organs on the said injury. Break into skin then results to bleeding putting the
patient at risk for invasion of pathogen and eventually infection.
As a compensatory mechanism of the body goes into inflammatory response. Blood
vessel in the affected area vasodilates. Leading to hyperemia, the increase oxygenation
of the injury then causes redness and feels warmer than other parts of your body.
Swelling also happens which then increases the pressure in nerve endings resulting to
pain. Loss of function is associated with pain.
4.2.3 Comparative chart showing the classical and clinical signs and symptoms
of the disease and rationale
V. Nursing Intervention
5.1 Care guide of patient with Traumatic Brain Injury with complete and displaced
fracture of the left tibia
Primary concerns when treating TBI are ensuring proper oxygen supply to the
brain and body. As well as maintaining an adequate blood flow and managing blood
pressure. There are medications and surgeries to treat the symptoms of TBI. But the
most important treatment in many cases is rehabilitation. Patients may require services
from a Psychiatrist, Occupational and Physical Therapist as well as speech pathologist.
Psychiatrists and social workers may help individuals and families to manage behavior
changes and learn coping strategies. Maintaining skin integrity (avoiding skin ulcers)
and appropriate nutrition may also be challenges.
External fixators are used to manage open fractures with soft tissue damage.
They provide stable support for severe comminuted (crushed or splintered) fractures
while permitting active of damaged soft tissues. Complicated fractures of the humerus,
forearm, femur, tibia, and pelvis are managed with external skeletal fixators. The
fracture is reduced, aligned, and immobilized by a series of pins inserted in the bone.
Pin position is maintained through attachment to a portable frame. The fixator facilitates
patient comfort, early mobility, and active exercise of adjacent uninvolved joints.
Complications related to disuse and immobility are minimized. It is important to prepare
the patient psychologically for application of the external fixator. The apparatus looks
clumsy and foreign. Reassurance that the discomfort associated with the device It is
important to prepare the patient psychologically for application of the external fixator.
The apparatus looks clumsy and foreign. Reassurance that the discomfort associated
with the device is minimal and that early mobility is anticipated promotes acceptance of
the device. After the external fixator is applied, the extremity is elevated to reduce
swelling. If there are sharp points on the fixator or pins, they are covered to prevent
device-induced injuries. The nurse monitors the neurovascular status of the extremity
every 2 to 4 hours and assesses each pin site for redness, drainage, tenderness, pain,
and loosening of the pin. Some serous drainage from the pin sites is to be expected.
The nurse must be alert for potential caused by pressure from the device on the skin,
nerves, or blood vessels and for the development of compartment syndrome. The nurse
carries out pin care as prescribed to prevent pin tract infection. This typically includes
cleaning each pin site separately three times a day with cotton-tipped applicators
soaked in sterile saline solution. Crusts should not form at the pin site. If signs of
infection are present or if the pins or clamps seem loose, the nurse notifies the
physician.
Skeletal traction is also a modality of care patients with fracture. It is applied

directly to the bone. This method of traction is used occasionally to treat fractures of the
femur, the tibia, and the cervical spine. The traction is applied directly to the bone by
use of a metal pin or wire (e.g. Steinmann pin, Kirschner wire) that is inserted through
the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons, and
joints.. The orthopedic surgeon applies skeletal traction, using surgical asepsis. The
insertion site is prepared with a surgical scrub agent such as povidone-iodine solution. A
local anesthetic is administered at the insertion site and periosteum. The surgeon
makes a small skin incision and drills the sterile pin or wire through the bone. The
patient feels pressure during this procedure and possibly some pain when the
periosteum is penetrated. After insertion, the pin or wire is attached to the traction bow
or caliper. The ends of the wire are covered with corks or tape to prevent injury to the
patient or caregivers. The weights are attached to the pin or wire bow by a rope-and-
pulley system that exerts the appropriate amount and direction of pull for effective
traction. Skeletal traction frequently uses 7 to 12 kg (15 to 25 lb.) to achieve the
therapeutic effect. The weights applied initially must overcome the shortening spasms of
the affected muscles. As the muscles relax, the traction weight is reduced to prevent
fracture dislocation and to promote healing. Often, skeletal traction is balanced traction,
which supports the affected extremity, allows for some patient movement, and facilitates
patient independence and nursing care while maintaining effective traction. The Thomas
splint with a Pearson attachment is frequently used with skeletal traction for fractures of
the femur. Because upward traction is required, an overbed frame is used. When
skeletal traction is discontinued, the extremity is gently supported while the weights are
removed. The pin is cut close to the skin and removed by the physician. Internal
fixation, casts, or splints are then used to immobilize and support the healing bone.
5.2 Nursing Care Plan
CUES NURSING DIAGNOSIS SCIENTIFIC BASIS OBJECTIVES
Subjective: Impaired physical Fractures occur when the GENERAL:

Maul-ol tak bali ha tiil mobility related to loss bone is subjected to stress After 4 days of holistic
Dong, as verbalized by the of integrity of leg bone greater that it can absorb. nursing care, the patient will
patient structures When the bone is broken, be able to reach optimum
adjacent structures are also level of functioning.
affected, resulting in soft
Objective: tissue edema, hemorrhage SPECIFIC:
-Limited Range of Motion into the muscles and joints, After 8 hours of student
noted joints dislocations, ruptured nurse-patient interaction,
-Guarding behavior noted ten-dons, severed nerves, the patient will be able to
upon moving leg and damaged blood demonstrate a decrease
-Slowed movement noted vessels. rate of independence from 3
-Rate of independence, (3) Body organs may be injured to 2
three by the force that caused the
-Requires help from another fracture fragments. After a
person and equipment fracture, the extremities
device cannot because normal
functions of muscle depend
on the integrity of the bones
which they are attached.
REFERENCE: Fundamental
in Nursing, Medical and
Surgical in Nursing
NURSING INTERVENTIONS RATIONALE EVALUATION
1.Encouraged significant others to 1. To promote optimal level of GOAL UNMET

reposition patient every 2 hours functioning Still patient requires help from
2. Supported affected body part with 2. To maintain position of function another person and equipment
soft linen and reduce risk of pressure ulcers device, still rate of 3
3. Encouraged participation in self- 3. To enhance sense of independence
care 4. To ensure safety
4. Raised side rails up 5. To relieve pain pharmacologically
5. Administered meds as prescribed
(ketorolac) 6. To reduce fatigue
6. Scheduled activity with adequate
rest periods 7. To prevent constipation
7. Encouraged adequate intake of
fluids and foods high in fiber 8. Routine inspection of the skin
8. Check for skin integrity for signs of (especially over bony prominences)
redness and tissue ischemia will allow for prevention or early
(especially over ears, shoulders, recognition and treatment of pressure
elbows, sacrum, hips, heels, ankles, ulcers
and toes) 9. Immobility promotes constipation,
9. Note elimination status (e.g., usual decreasing the motility of the
pattern, present patterns, signs of gastrointestinal tract
constipation)
REFERENCE:
Nurses Pocket Guide, 13th Edition,
Doenges, Moorhouse, Murr
Subjective : Acute pain related to Unpleasant sensory and Specific:
Maol-ol tak bali ha tiil Left Leg Fracture emotional experiencing from After 8 hours of student nurse-
actual tissue damage; sudden
Dong, as verbalized by the patient interaction, the patient
or slow onset with pain intensity
patient from mild to severe with an
will be able to verbalize a
anticipated or predictable end decreased pain intensity to
and a duration of less than 6 3-4
Objective: months. Fractures occur when
-Guarding behavior noted the bone is subjected to stress
-Pain scale of 5/10 greater that it can absorb. When
the bone is broken, adjacent
C- sharp stabbing pain
structures are also affected,
O-upon exertion of force on
resulting in soft tissue edema,
affected leg hemorrhage into the muscles
L-fractured site at Left lower and joints, joints dislocations,
leg ruptured ten-dons, severed
D-2-3 min nerves, and damaged blood
E- more movement of leg vessels. Body organs may be
injured by the force that caused
D-deep breathing
the fracture fragments. After a
R-not
fracture, the extremities cannot
A-none because normal functions
of muscle depend on the
integrity of the bones which they
are attached.
Surgical in Nursing

1. Instructed in and encouraged use 1.To distract attention and reduce GOAL PARTIALLY MET.
of Deep Breathing Exercise tension Patient demonstrated a pain scale of
5/10
2. Provided hot and warm compress 2. To reduce pain via non-
at interval frequency pharmacologic use
3.Encouraged verbalization of feelings 3. To report pain immediately
4. Administered pain relievers as 4. To reduce pain via pharmacologic

ordered use
5. Positioned at comfort 5.To reduce tension
6.Maintain immobilization of affected 6.Relieves pain and prevents bone

part by means of bed rest and mold displacement and extension of tissue
injury.
REFERENCE:

Subjective: Risk for self-directed At risk for behaviors in Specific:
Maisog man hiya Dong kun violence related mental which an individual After 8 hours of student nurse-
diri masunod it hiya gusto health problem demonstrates that he can patient interaction, the patient
as verbalized by her wife be physically, emotionally, will be able to demonstrate self-
and or sexually harmful to control as evidenced by
Objective: self and or others. In manic nonviolent behavior
-Irritable phase negative,
-Verbal threats of violence uncontrolled thoughts
feeling and behavior pose a
threat or danger to harm
self or other. They are
aggressive, hostile and
cannot evaluate the
consequence of their
behavior.
Surgical in Nursing

1.Observed and listened for early 1.May indicate possibility of loss of GOAL MET
cues of distress or increasing anxiety control, and intervention at this point The patient doesnt demonstrate
can prevent a blow up violent behaviors.
2.Developed student nurse- client 2.Allows client to discuss feelings

trusting relationship freely
3.Discussed impact of behavior on 3.To assist client to accept

others and consequences of actions. responsibility of impulsive behavior
and potential for violence
4. Assisted client distinguish reality 4. To aid client validated to reality

from hallucinations by presenting the
reality
5. Administered prescribed 5. To prevent and treat anxiety and
medications as prescribed (diazepam psychosis
and risperidone)
6. Identified support systems 6.Those who are around him need to

learn how to be a positive role model
and display a broader array of skills of
REFERENCE: resolving problems

Subjective: Self-Care Deficit related The nurse may encounter Specific:
Nakukurian man ak to musculoskeletal the patient with a self-care After 8 hours of student nurse-
pagnilihuk Dong as impairment deficit in the hospital which patient interaction, the patient
verbalized by the SO may result of transient will be able to demonstrate a
limitations to perform the level of independence of II or l.
Objective:
activities required to care for
-Inability to bath self-noted
himself.
-Independence rate of 3
Surgical in Nursing

1.Performed and assisted with clients 1.To assist in dealing with situation GOAL UNMET.
needs The patient still demonstrated a level
of dependence of iII behaviors, still
2.Developed student nurse- client 2.Allows client to discuss feelings rate of 3
trusting relationship freely
3. Bathed client 3. To promote proper good hygiene
4.Demontrated the proper bathing 4. To educate SO bathing technique.

technique to SO
5. Provided for adequate warmth 5. To prevent hypothermia
6. Encourage food and fluids choices 6. To meet nutritional needs

that if possible meet nutritional needs
REFERENCE:
Subjective: Spiritual Distress related Spiritual distress in an Specific:

- Waray na ako paglaum to Anxiety experienced of profound After 8 hours of student nurse-
ha akon kinabuhi tungod disharmony in the persons patient interaction the patient
han nahitabo akon yana. belief or value system that will be able to verbalize
as verbalized by the patient. threatens the meaning of his acceptance of self as not
Objective: or her life. During spiritual deserving illness or situation;
- No spiritual materials such distress the patient loses, No one is to blame.
as rosaries and bible in hope, questions his/her belief
patients bed noted. system, or feels separated
from his/her personal source
of comfort and strength.
Surgical in Nursing
1.Developed therapeutic nurse-client 1. Promotes trust and comfort, WALA PA!

relationship encouraging client to be open about
sensitive matters.
2. Listened to clients report or 2. Suggests need for spiritual adviser
expressions of concern, beliefs that to address client beliefs system if
illness or situation is a punishment for desired.
wrong doing.
3. Encouraged to pray or to meditate
3.Clients need time to be alone during
times of health change.
4. Asked how to be most helpful, then
4.Listening attentively and being
actively listen, reflects and seek
physically present can be spiritually
clarification
nourishing.
5. Discussed the clients perception of
5.Different religions view illness from
God in relation to the illness
different perspective.
REFERENCE:
5.2 Drug Therapeutic Record
NURSING
DRUG CLASSIFICATION INDICATION SIDE EFFECTS RESPONSIBILITES
RISPERIDONE THERAPEUTIC -Schizophrenia CNS: parkinsonism, BEFORE:

, 2mg, 1tab CLASS: -Irritability, including
suicide attempt, -Obtained vital signs for
Oral, Hours of Antipsychotic aggression somnolence, baseline data.
sleep -Self-injury and temper
agitation, anxiety, -Assessed for hypersensitivity
tantrums associated dizziness, fever, -Health teaching done
PHARMACOLOGI with an autistic impaired regarding adverse effects
C CLASS: disorder. concentration,
Benzisozole abnormal thinking, DURING:
dermative dreaming tremor, -To relieve thirst and dry
CONTRAINDICATION: fatigue, depression mouth, advised to have
-Hyper- sensitive to frequent mouth care or fluids.
MECHANISM OF drug and in CV: tachycardia, -Advised to avoid alcohol
ACTION: breastfeeding women peripheral edema, while taking this drug.
-Caution in patients HPN, syncope -Warned patient to avoid
Blocks dopamine with increase QT hazardous activities.
and 5h2 receptors interval EENT: rhinitis, -Provided safety to patient.
in the brain. sinusitis,
pharyngitis, double AFTER:
vision -Monitored for S/S of overdose
(Drowsiness, sedation,
tachycardia, hypotension,
EPS, seizures
-Instructed to do deep
breathing exercise
NURSING
GI: constipation, -Warned patient to notify

nausea, vomiting, prescriber if adverse reactions
abdominal pain, occur.
anorexia, dry -Advised patient high fiber diet
mouth, increased -Instructed patient to elevate
saliva, diarrhea, feet if not contraindicated
GU: increased
urination, abnormal
orgasm REFERENCE:
Metabolic: weight Nursing Drug Guide, 13th
gain, weight loss Edition, Lippincott etal
hyperglycemia,
Musculoskeletal:
arthralgia, back
pain, limb pain,
myalgia
Respiratory:
dyspnea, coughing,
upper respiratory
tract infection
Skin: rash, dry
skin, acne,
photosensitivity,
NURSING
BEFORE:
DIAZEPAM, THERAPEUTIC -Anxiety CNS: drowsiness, -Monitored V/S and BP
5mg, 1 tablet/ CLASS: -Muscle Spasm slurred speech, -Assessed for
day, oral, hours Anxiolytic -Tetanus transient amnesia, hypersensitivity and allergic
of sleep fatigue, headache, history
PHARMACOLOGIC insomnia, -Monitored I&O
CLASS: CONTAINDICATION: paradoxical anxiety, DURING:
Benzodiazepine -Hypersensitive to drug hallucination, minor -Warned patient to avoid
or soya protein changes in EEG activities that require alertness
MECHANISM OF -Experiencing shock pattern -Advised to increased fiber
ACTION: and coma CV: CV collapse, diet & avoid alcohol
-Acute angle closure bradycardia, hpn -Advised patient to take drug
Probably potential glaucoma EENT: diplopia, with food.
the effects of GABA, -Caution in patient with blurred vision AFTER:
depress the CNS and liver or renal GI: constipation, -Monitored for dizziness,
suppress the spread impairment, diarrhea with rectal ataxia, mental state changes
of seizure activity depression, history of pain -Instructed patient not to
substance abuse GU: urinary abruptly withdraw drug.
incontinence/ - Warned patient to notify
retention prescriber if adverse reactions
RESPI: depression, occur
apnea -Provided safety to patient
SKIN: rash REFERENCE:
Nursing Drug Guide, 13th
Edition, Lippincott etal
NURSING
CEFTRIAXONE THERAPEUTIC -Perioperative CNS: BEFORE:

, 500mg , IVTT CLASS: prevention dizziness, -Monitored Vital signs and
every 24 hours Antibiotic -UTI, septicemia, skin headache, lethargy I&O for baseline data.
(8am-8pm) structure infection -Obtained culture and
PHARMACOLOGI GI: sensitivity results.
C CLASS: pseudomembranou -Assessed patients allergic
Third Generation CONTRAINDICATION: s colitis, diarrhea history
Cephalosporin, -Hypersensitive to dry DURING:
Pregnancy risk or other cephalosporin HEMA: -Health teaching done
category B -Cautiously in patient Eosinophilia, regarding adverse effects.
hypersensitive to thrombocytosis, -Advised patient to avoid
MECHANISM OF penicillin leukopenia alcohol during therapy
ACTION: -Cautiously in breast -Warned patient to avoid
Inhibits cell wall feeding women SKIN: pain, activities that require
synthesis, induration, rash alertness
promoting osmotic AFTER:
instability, usually OTHER: -Instructed patient to report
bactericidal hypersensitivity discomfort at IV site
reactions, -Advised patient to report
anaphylaxis adverse reactions promptly
-Advised patient to notify
prescriber if having loose
stools.
-Assessed bowel pattern daily
-Provided safety to patient.
NURSING
MANNITOL, THERAPEUTIC -To reduce intraocular CNS: BEFORE:

100ml IVTT CLASS: or intracranial pressureseizures, dizziness, -Monitored Vital signs and
every 12 hours Diuretic or cerebral edema headache, fever I&O for baseline data.
(8 am- 8pm) -To prevent oliguria or CV: -Assessed for allergic history.
PHARMACOLOGI acute renal failure edema, DURING:
C CLASS: -Oliguria thrombophlebitis, -To relieve thirst, advised to
Osmotic diuretic hypotension, have frequent mouth care or
hypertension, heart fluids
MECHANISM OF CONTRAINDICATION: failure, tachycardia, -Emphasized importance of
ACTION: -Hypersensitive to drug vascular overload drinking only the amount of
Increases osmotic -Anuria, active EENT: fluids ordered.
pressure glomerular intracranial bleeding, blurred vision, -Warned patient to avoid
filtrate, thus severe dehydration, rhinitis activities that require
inhibiting tubular metabolic edema GI: alertness.
reabsorption of H2O thirst, dry mouth, -Advised patient to avoid
and electrolytes. It nausea, vomiting, alcohol during therapy
elevates plasma diarrhea AFTER:
osmolarity and GU: urine retention -Monitored vital sign and
increased H2O flow META: dehydration intake and output
into extracellular SKIN: local pain, -Instructed patient to
fluid. urticaria promptly report adverse
OTHERS: reactions and discomfort at
thirst, chill I.V. site.
NURSING
KETOROLAC THERAPEUTIC -Short term CNS: Headache, BEFORE:

TROMETHAMINE CLASS: management of pain (up dizziness, insomnia, -Monitored Vital signs and
, 10 ml IVTT every NSAID to 5days) fatigue, tinnitus, I&O for baseline data.
8 hours (8 am- -Ophthalmic: Relief of ophthalmologic -Assessed for allergic
4pm- 12 am) PHARMACOLOGIC ocular itching due to effects. history
CLASS: seasonal conjunctivitis DERMATOLOGIC: DURING:
NSAID and relief of Rash, pruritus, -Warned patient to avoid
postoperative sweating, dry activities that require
THERAPEUTIC inflammation and pain mucous alertness.
ACTIONS: after cataract surgery. membranes, -Advised patient to avoid
Anti inflammatory GI: Nausea, alcohol during therapy.
and analgesics CONTRAINDICATIONS: dyspepsia, GI pain, -Health teaching done
activity; inhibits Contraindicated with diarrhea, vomiting, regarding adverse effects
prostaglandins and significant renal constipation, AFTER:
leukotriene impairment, during labor flatulence, hepatic -Monitored vital sign and
synthesis. and delivery , lactation; impairment. intake and output
patients wearing soft GU: Dysuria, renal -Instructed patient to
contact lenses impairment promptly report adverse
(ophthalmic); aspirin HEMATOLOGIC: reactions and discomfort
allergy; Bleeding at I.V. site.
concurrent use of RESPIRATORY: -Kept emergency
NSAIDs; Dyspnea, equipment readily
bronchospasm, available at time of initial
rhinitis. dose, in case of severe
hypersensitivity reaction.
NURSING
active peptic ulcer OTHER:

disease or GI, bleeding; Peripheral edema
hypersensitivity to
ketorolac; as
prophylactic analgesics
before major surgery;
treatment of
perioperative pain in
CABG; suspected or
confirmed
cerebrovascular
bleeding; hemorrhagic
diathesis, incomplete
hemostasis, high risk of
bleeding; use with
probenecid,
pentoxyphylline.
NURSING
RANITIDINE THERAPEUTIC -Short term treatment CNS: Headache, BEFORE:

HYDROCHLORID CLASS: of active duodenal ulcer. malaise, dizziness, -Monitored vital signs,
E Antiulcer -Maintenance therapy insomnia, vertigo. intake and output for
IVTT 25mg every 8 for duodenal ulcer at CV: Tachycardia, baseline data.
hours (8am- 4pm- PHARMACOLOGIC reduced dosage. bradycardia -Instructed patient not to
12am) CLASS: -Short term treatment DERMATOLOGIC: take new medication w/o
Histamine 2 of GERD. Rash, alopecia consulting physician.
antagonists -Short term treatment GI: Constipation, -Allow 1 hour between any
and maintenance diarrhea, nausea, other antacid and
THERAPEUTIC therapy of active, benign vomiting, ranitidine.
ACTIONS: gastric ulcer. abdominal pain, DURING:
Competitively -Treatment and hepatitis. -Warned patient to avoid
inhibits the action of maintenance of healing GU: Impotence or activities that require
histamine at the H2 of erosive esophagitis. decreased libido alertness.
receptors of the -Treatment of heartburn, HEMATOLOGIC: -Informed patient that
parietal cells of the acid indigestion, sour Leukopenia, increased fluid and
stomach, inhibiting stomach. granulocytopenia, fiber intake may minimize
basal gastric acid thrombocytopenia constipation
secretion and CONTRAINDICATION: LOCAL: Pain at IM -Informed patient that
gastric acid Contraindicated with site local burning or meds may temporarily
secretion that is allergy to ranitidine, itching at IV site cause stools and tongue
stimulated by food, lactation. OTHER: Arthralgia to appear gray black.
insulin, histamine, AFTER:
cholinergic agonists, -Advised patient to report
gastrin, and adverse effects or
pentagastrin. discomfort
NURSING
DEXAMETHASON THERAPEUTIC -Hypercalcemia CNS: Seizures, BEFORE:

E SODIUM CLASS: associated with cancer vertigo, -Monitored vital signs,
SULPHATE Anti inflammatory -Cancer chemotherapy headaches, intake and output for
IVTT 10mg every 8 induced nausea and insomnia, mood baseline data.
hours (8am- 4pm- PHARMACOLOGIC vomiting. swings, -Instructed patient not to
12am) CLASS: -Cerebral edema depression, take new medication w/o
Corticosteroid associated with brain psychosis, consulting physician.
tumor, craniotomy, or intracerebral
MECHANISM OF head injury. hemorrhage, DURING:
ACTION: -Ulcerative colitis, acute cataracts, -Warned patient to avoid
Suppresses edema, exacerbations of MS, glaucoma. activities that require
fibrin deposition, and palliation in some CV: Hypertension, alertness.
capillary dilation, leukemia and heart failure. -Informed patient that
leukocyte migration, lymphomas. ENDOCRINE: increased fluid and
capillary Growth retardation, fiber intake may minimize
proliferation, and CONTRAINDICATIONS: diabetes mellitus constipation
collagen deposition. Contraindicated in GI: Peptic or
patients hypersensitivity esophageal ulcer, AFTER:
to drug or its ingredients. pancreatitis, -Advised patient to report
Drug contain sulphite. abdominal adverse effects or
Contraindicated in those distention discomforts to health care
with fungal or viral professional promptly.
diseases of cornea and -Monitored weight
conjunctiva;
5.3 FDAR Charting
Date and Time Focus Problem Data Action Response
February 20, 2017 Disturbed sleeping Received patient on -Vital Signs taken and Kept watched
12:00 pm pattern bed sleeping with recorded
Intravenous Fluid of -Intake and Output
Plain Non-Saline Monitored
Solution 1 liter 980 -Positioned patient
mL level at 30drops/ comfortably
minute infusing well at -supported affected
right arm, with Long leg with soft linen
Leg Posterior Mold -encouraged
Left, with Foley Bag adequate intake of
Catheter attached to fluids and nutritious
Urobag infusing well; foods
Diri ako nahingaturog -encouraged to do
hin tuhay as deep breathing
verbalized by the exercises
patient; lethargic -adequate rest
noted; disoriented to provided
time and lace noted -balanced activity with
rest periods
-bed side care done
-Instructed client or
SO to avoid
caffeinated drinks like
cola and coffee.
February 22, 2017 Impaired Physical Received patient on -Vital Signs taken and Kept watched
1:00 pm Mobility bed sleeping with recorded
Plain Non-Saline Monitored
Solution 1 liter kept -Positioned patient
set sterile, with Long comfortably
Leg Posterior Mold -supported affected
Left, with Foley Bag leg with soft linen
Catheter attached to -encouraged
Urobag infusing well; adequate intake of
masakit akun tiil kun fluids and nutritious
gikikiwa as foods
verbalized by the -encouraged to do
patient. deep breathing
exercises
-adequate rest
provided
-balanced activity with
rest periods
-bed side care done
February 23, 2017 Self-Care Deficit Received patient on -Vital Signs taken and Kept watched
1:00 pm bed sleeping with recorded
Plain Non-Saline monitored
Solution 1 liter kept -positioned patient
set sterile, with Long comfortably
Leg Posterior Mold -assisted on wound
Left, with Foley Bag dressing
Catheter attached to -supported affected
Urobag infusing well; leg with soft linen
Inability to bath self -encourage to do
noted; Deep Breathing
guarding behaviour Exercise
noted upon moving -adequate rest
left leg. provided
-performed bed bath
-emphasized the
importance of bed
bath
-safety provided
5.4 Health Teaching
OBJECTIVES CONTENT METHODOLOGY
General:
After 4 days of holistic student nurse-
patient interaction, the patient will be
able to gain knowledge, skills and
attitude in dealing with the condition
traumatic brain injury.
Specific:
After 4 hours of holistic student nurse-
patient interaction, the patient will be
able to;
Discussion
1. define Traumatic Brain Injury -Also, known as intracranial injury
and/or TBI.
-Is a substantial head injury that
results in damage to the brain. This
damage can cause a wide spectrum of
possible health outcomes
-The brain is launched into a collision
course with the inside of the skull,
resulting in possible bruising of the
brain, tearing of the nerve fibers and
bleeding.
- Is a complex injury with a broad
spectrum of symptoms and disabilities
2. identify the causes of brain Bullets or smashed piece of skull Discussion

traumatic injury penetrating brain tissue
Falls
Vehicle accidents
Severe jolt or blow to the head
Open head injury
Closed head injury
Deceleration injury
Chemical/toxic
Hypoxia
Infections
Stroke
3. determine symptoms of brain Discussion

traumatic injury that needs to be
reported immediately Headache that gets worse and
does not go away.
Weakness, numbness or
decreased coordination.
Repeated vomiting or nausea
Confusion
Fatigue (tiredness and lethargy)
Becoming more easily distracted
Loss of sense of smell and taste
Moodiness
Persistent pain in the back
Light headedness
Dizziness
Tinnitus

4. identify preventive measures to Always wear a seatbelt in a motor Discussion
avoid brain traumatic injury vehicle
Never drive under the influence of

alcohol or drugs
Always wear a helmet when on

bicycle, motorcycle, scooter, and
other open unrestrained vehicles.
Use the rails on stairways
Provide adequate lightning, especially

on stairs for people with poor vision
or who have difficulty walking
Keep firearms unloaded in a locked

cabinet or safe
5. Demonstrate on how to do wound Demonstration

Handwashing
dressing properly
Removing the old Dressing
Carefully loosen the tape from your
skin

Use a clean (not sterile) medical glove
to grab the old dressing and pull it
off.
If the dressing sticks to the wound,
wet it and try again, unless your
provider instructed you to pull it off
dry.
Put the old dressing in a plastic bag
and set it aside.
Caring for the Wound
You may use a gauze pad or soft cloth

to clean the skin around your wound:
Use a normal saline solution (salt

water) or mild soapy water.
Soak the gauze or cloth in the saline

solution or soapy water, and gently
dab or wipe the skin with it.
Try to remove all drainage and any

dried blood or other matter that may
have built up on the skin.
Putting on the new Dressing
Place the clean dressing on the

wound as your provider taught you
to. You may be using a wet-to-dry
dressing.

Clean your hands when you are
finished.
Throw away the old dressing and
other used supplies in a waterproof
plastic bag. Close it tightly, then
double it before putting it in the
trash.
Wash any soiled laundry from the
dressing change separately from
other laundry. Ask your provider if
you need to add bleach to the wash
water.
Use a dressing only once. Never
reuse it.
VI. Evaluation and Recommendation
6.1 Prognosis based on Nursing assessment and rationale
Traumatic Brain Injury is really a debilitating moment to experience. Recovering
from a brain injury relies on the brain's plasticitythe ability for undamaged areas of the
brain to take over functions of the damaged areas. It also relies on regeneration and
repair of nerve cells. And most importantly, on the patient's hard work to relearn and
compensate for lost abilities. The only way he can do is to follow therapeutic regimen as
prescribed and to follow therapeutic recommendations to prevent further insult to the
brain. It is also a debilitating event for the significant others. They must learn to have
patience when taking care with and must advise and orient the patient with the reality.
Based on the gathered data by the student-nurses, the prognosis of patient is

good for the reason that he and his significant others had followed all the therapeutic
regimen prescribed.
6.2 Recommendations to promote early recovery and rehabilitation
The patient is recommended to follow therapeutic regimen and maintain good

fixator or traction care. Most patients are discharged from the hospital when their
condition has stabilized and they no longer require intensive care. A social worker will
work closely with the family as preparations are made for a return home or for transfer
to a long-term care or rehabilitation center. A rehabilitation facility is a place for patients
who do not require a ventilator but who still require help with basic daily activities.
Physical and occupational therapists work with patients to help them achieve their
maximum potential for recovery. A speech therapist helps patients by monitoring their
ability to safely swallow food and helping with communication and cognition. A
neuropsychologist helps patients relearn cognitive functions and develop compensation
skills to cope with memory, thinking, and emotional needs.
VII. Evaluation and Implications to:
7.1 Nursing Education
This case study gathered all information, statistics interventions to stop and
control the disease and the valuation to provide baseline data for health teaching
strategies. This study will also strengthen the students learning foundation about
Traumatic Brain Injury with left open oblique tibial fracture.
7.2 Nursing Practice

This case study as intended as a basic text for the undergraduate and as a
reference for professional nurse. This study also explores new interventions,
mechanism of action and strategies to stop or minimize the occurrence of the disease
and to control the underlying disease that has been experienced by the patient.
7.3 Nursing Research

Ongoing research is necessary in the effectiveness of interventions and the
various treatments and therapies of the disease. This case study aims to help for the
new researches to obtain factual datas intentionally, nationally, and locally.
VIII. Discharge Planning

Objectives:
After 30 minutes of discharge instructions, the patient will be able to:
1. Verbalize understanding about her present condition;
2. Identify methods that will provide relief of anxiety regarding
her condition; and
3. Repeat the instructions provided
Exercise / Activity:
Type of activity allowed/ to be continued: ROM exercises
Procedure or steps:
Perineal Care
1. Wash and retract Labia majora
2. Wipe from the Mons pubis to the anus
3. Wipe each side and last at the center forming (-1-7)
4. Use one tissue on each wipe
Health Teachings
1. Emphasized the importance of complying with therapeutic regimen
religiously
2. Advised client to take adequate rest and sleep.
3. Encouraged to do early ambulation with resumption of normal activity
as tolerated.
4. Encouraged family member to provide patient emotional support.
5. Advised to do proper perineal care regularly.
6. Educated client about the importance of taking proper diet.
7. Instructed client to take variety of nutritious foods such as fruits and
vegetables.
8. Encouraged patient to eat protein, vitamin C and Iron rich foods.

9. Advised that sexual intercourse will be resume after two to four weeks.
10. Demonstrated and do proper perineal care regularly.
11. Emphasized the importance of keeping the baby healthy as possible if
pregnancy is acquired
12. Discussed the importance of providing a healthy atmosphere for
conception to occur.
13. Discussed the possible risk factors of having miscarriage
14. Discussed the possible complications of Dilatation and Curettage post-
operatively.
15. Enumerated the possible signs and symptoms that qualifies for notifying
a health care provide
16. Discussed the normal side effects of D and C and therapeutic regime
17. Demonstrated and discussed ways of promoting comfort
Observed Signs and Symptoms that need reporting:
1. Bleeding that's heavy enough that you need to change pads every hour
2. Light bleeding that lasts longer than two weeks

3. Fever
4. Cramps lasting more than 48 hours
5. Pain that gets worse instead of better
6. Foul-smelling discharge from the vagina
Diet: Diet as tolerated
Restrictions: NONE
Follow-up: March 23, 2016 at Biliran Provincial Hospitals Out-Patient Department.
IX. Bibliography
Books:
Potter & Perry Fundamentals of Nursing 8th Edition
Kozier and Erbs Fundamentals of Nursing 10th edition
Martini, Ober, Bartholomew Visual Essentials of Anatomy & Physiology
Marrilyn E. Doenges Nurses Pocket Guide Diagnoses, Prioritized Interventions
and Rationales 12th Edition
Lippincott Manual of Nursing Practice Handbook 3 rd Edition
Lippincott William and Wilkins Nursing 2013 Drug Handbook
Brunner and Suddarths Textbook of Medical-Surgical Nursing 10 th Edition
Pillitteri Maternal and Child Health Nursing- Care of the Childbearing and
Childrearing Family 6th Edition
Lippincott William and Wilkins Medical-Surgical Nursing Made Incredibly Easy 3 rd
Edition
Kemp, Burns, and Browns The Big Picture Pathology
Internet sources:
Merckmanuals.com
Currentnursing.com
WebMED.com
Emedicine.medscape.com
Nurseslabs.com
MayoClinic.com

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2.

Specifically, the student-nurse will be able to :

2.1 Explain the nature and occurrence TRAUMATIC BRAIN

the community and to the patient herself by:

-is penetrating electromagnetic radiation, having a

2.2.10 central nervous system

-it is the part of the nervous system, consisting of the

-a physical injury or wound to the body

-the control center of the body

2.2.15 traumatic brain injury

- a sudden damage to the brain caused by a blow or

-an injury that does not break the skin

2.2.17 frontal lobe

- the largest lobe.

-the major functions of this lobe are concentration,

2.2.18 occipital lobe

- is the weight-bearing bone of the lower leg. You can

- break or crack in a bone or in ossified cartilage

III. NURSING ASSESSMENT

3.2 Nursing Health History

3.2.4 Gordons Health Functional Health Pattern

COPING-STRESS MANAGEMENT PATTERN

BODY PART SIGNIFICANT INTERPRETATION

Facial bones: Smooth Intact Symmetrical Nontender

Inspection Tooth # 7 has

Smooth Edge Good Occlusion No Caries

EYES AND EARS

Neck Midline position Erect

Neck Vessels: Carotid Arteries and Jugular Veins

Visible carotid pulsation Jugular venous presssure at 450 <3 cm

No neck vein distention Jugular pulsation undulated

Regular rhythm Equal contour

Smooth upstroke with lesss acute descent

Easily obliterated and fills appropriately

Carotid: Negative carotid bruits

Jugular Veins: Negative venous hum

Quite respiration Symmetrical Regular rythm and depth

Anteroposterior: lateral ratio 1:2 No barrel chest

No spinal deformities Skin Intact

No Retraction or use of accessory muscles

Symmetrical excursion anteriorly and posteriorly

Tactile fremitus equal bilaterally

Anterior: Resonance Lateral: Resonance

Posterior: Resonance Diaphragmatic: Resonance

Bronchovesicular breath sounds heard over sternum anteriorly and

between scapula posteriorly

Vesicular sounds heard in most lung fields

No abnormal or adventitious breath sounds

No abnormal voice sounds No bronchophony

No whispered pectoriloquy No egophony

Lobular Symmetrical Slightly symmetrical

Color Consistent with body color No masses No lesions

No edema No dimpling No retractions No orange peel skin

Premenopausal: more firm and elastic

During pregnancy and lactation: firm and tender

Postmenopausal: less firm and elastic with stringy ducts

Nontender Tender and Nodular (pre-menstruation)

Symmetrical Round Darker than breast tissue

No masses No lesions No discharges

Spontaneous discharge (during pregnancy & lactation)

Everted Flat or Inverted No supernumerary nipples

Nipple elastic Nontender No discharge

White sebaceous secretion with nipple compression