Case Study On Subacute Subdural Hematoma

FATHER SATURNINO URIOS UNIVERSITY

NURSING PROGRAM Butuan City

An Individual Case Study On

Hemorrhagic Contusion Right Frontal Lobe Subacute Subdural Hematoma Right Convexity

Submitted by: Bondoc, James Aurelle S. N30

Submittted to: Ms Michelle Donna A. Dulu, RN Supervising Clinical Instructor

INTRODUCTION A subdural hematoma (SDH) is a common neurosurgical disorder that often requires surgical intervention. SDH is a type of intracranial hemorrhage that occurs beneath the dura and may be associated with other brain injuries. Essentially, it is a collection of blood over the surface of the brain. SDHs are usually caused by trauma but can be spontaneous or caused by a procedure, such as a lumbar puncture. SDHs are usually characterized based on their size, location, and age (ie, whether they are acute, subacute, or chronic). These factors, as well as the neurologic and medical condition of the patient, determine the course of treatment and may also influence the outcome. SDHs are often classified based on the period that has elapsed from the inciting event (if known) to the diagnosis. When the inciting event is unknown, the appearance of the hematoma on CT scan or MRI can help determine when the hematoma occurred. Generally, acute SDHs are less than 72 hours old and are hyperdense compared with the brain on CT scan. Subacute SDHs are 3-20 days old and are isodense or hypodense compared with the brain. Chronic SDHs are 21 days (3 wk) or older and are hypodense compared with the brain. However, SDHs may be mixed in nature, such as when acute bleeding has occurred into a chronic SDH.

The brain is covered by a membrane (layer of tissue) called the dura. If the veins located below the dura (subdural area) leak blood, then pressure in this area may build up and injure the brain. Head injuries may injure these veins, causing them to be torn and leak. This blood collects into a mass called a hematoma. ` For the most part, this review discusses acute and chronic SDHs; less information is available about the less common subacute SDHs.1 The entity of subdural hygroma is briefly addressed with chronic SDH.Acute SDH is commonly associated with extensive primary brain injury. In one study, 82% of comatose patients with acute SDH had parenchymal contusions.2 The severity of the diffuse parenchymal injury correlates strongly (inverse correlation) with the outcome of the patient. In recognition of this fact, an SDH that is not associated with an underlying brain injury is sometimes termed a simple or pure SDH, whereas the term complicated has been applied to SDHs in which a significant injury of the underlying brain has also been identified. The practice of trephination of the head (ie, chipping or drilling a hole through the skull) has been traced back to ancient times. The author Balzac, in 1840, described a case of chronic subdural hematoma (SDH), including its traumatic origin and surgical treatment.3 In the late 19th century, with the rise of medicine, development of aseptic technique and anesthesia, and establishment of the basic principles of neurologic localization, surgery for intracranial lesions (including SDH) became more common and, later, survival rates improved. In 1883, Hulke first described successful neurosurgical treatment of chronic SDH. 4 Although cerebral angiography could be used to localize SDH in the early–to–mid-20th century, the development of the CT scan in the late 1970s represented another leap in patient care. It is important that a patient receive medical assessment, including a complete neurological examination, after any head trauma. A CT scan or MRI scan will usually detect significant subdural hematomas. Treatment of a subdural hematoma depends on its size and rate of growth. Some small subdural hematomas can be managed by careful monitoring until the body heals itself. Other small subdural hematomas can be managed by inserting a temporary small catheter through a hole drilled through the skull and sucking out the hematoma; this procedure can be done at the bedside. Large or symptomatic hematomas require a craniotomy, the surgical opening of the skull. A surgeon then opens the dura, removes the blood clot with suction or irrigation, and identifies and controls sites of bleeding. Postoperative complications include increased

intracranial pressure, brain edema, new or recurrent bleeding, infection, and seizure. The injured vessels must be repaired. I choose this case since it catches first my interest. Having Craniectomy operation as my first major case assist really challenged me a lot to do my best during the operation. Efforts were being given and it took 4 hours of long standing for me before the operation ended. Being a part of that really means a lot to me indeed.

DEFINITION OF TERMS Here are some of the terms that are being defined and could be encountered as one gets along with this case study. Autoregulation- is a specific form of homeostasis used to describe the tendency of the body to keep blood flow constant when blood pressure varies Brain Death- Irreversible brain damage and loss of brain function, as evidenced by cessation of breathing and other vital reflexes, unresponsiveness to stimuli, absence of muscle activity, and a flat electroencephalogram for a specific length of time. Brain herniation- also known as cistern obliteration, is a deadly side effect of very high intracranial pressure that occurs when the brain shifts across structures within the skull. Cerebral blood flow- or CBF, is the blood supply to the brain in a given time. Cerebral hypoxia- refers to deprivation of oxygen supply to brain tissue. Cerebral perfusion pressure- or CPP, is the net pressure gradient causing blood flow to the brain (brain perfusion). Compression- A force squashing, squeezing, or pressing down on an object. Contusion- A bruise that is usually produced by impact from a blunt object and that does not cause a break in the skin. Craniectomy- surgical removal of a portion of the cranium. Effusion- the seeping of serous, purulent, or bloody fluid into a body cavity or tissue. Hematoma- A mass of blood in the tissue as a result of trauma or other factors that cause the rupture of blood vessels. Intracranial Pressure- Pressure that occurs within the cranium. Trauma to the head, inflammation, or infection of the linings of the brain may cause an increase in pressure within the cranium, which is painful, dysfunctional, and may become life-threatening.

NURSING HEALTH HISTORY

Nursing health history is the first part and one of the most significant aspects in case studies. It is a systematic collection of subjective and objective data, ordering and stepby-step process inculcating detailed information in determining client’s history, health status, functional status and coping pattern. These vital informations provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care and for the nursing process application as a whole. It was the 24th day of July, 2009 when our group was first exposed to the world of sterility. Under the supervision of Ms. Michelle Donna A. Dulu, Rn, all of us practiced our skills by applying the concepts we learned from school. Then we were told by our C.I to make an individual case study regarding our major cases we were able to assist with. I obtained my first major scrub assist last July 31,2009 that’s why I started gathering data about my chosen patient’s case. For the purpose of confidentiality and respect to the identity of my patient, I decided to name him as Patient X. Patient X is a native of Surigao City particularly Purok 1, San Juan. He first saw the the light on August 30, 1960. He got married to a Surigaonon woman, a NFA rice distributor here in Mindanao. Luckily, the couple was blessed with six beautiful children. Three of them already graduated from their chosen courses with flying colors while the remaining three are still studying respectively. He had just retired from his recent work. As a means of making use of his time, he takes care of his grandchildren and helps his wife in distributing the NFA rice instead. It all happened last July 25, 2009. Patient X’s family and relatives gathered together for a reunion at one of the beach of General Luna, Siargao City. Unfortunately, he met an accident along the road causing him some minor wounds and abrasion. It was believed that he was under the influence of alcoholic beverage as verbalized by his wife ,” Nakainom man to siya gamay pero dili siya grabe kahubog.” He was rushed to the nearest district hospital at Dapa, Siargao City. He stayed there for about two days for monitoring of his case. He was then transferred to Caraga General Hospital at Surigao City. He spent three days in the said hospital and given appropriate care. His condition got worsen so was referred in Butuan City. He was rushed to Butuan City via an ambulance and admitted at Manuel J. Santos Hospital for further management of his condition. They arrived at the hospital around 1:59 a.m of July 30, accompanied by his relative, lying flat on the stretcher. He was admitted because of hematoma on his subdural space. He was then managed by Dr. Marlowe S. Indo. Vital signs were obtained initially as follows, BP: 120/80 mmHg Temp: 38 C

Oxygen Saturation:98% Pulse Rate: 87 beats/min

He was then referred to Dr. Neil Oliver Camonggol for further management around 2:35 a.m. He was seen by Dr. Camonggol at the Emergency Room and orders were given. At 2:45 a.m , doctors orders were carried out as follows: > given Mannitol 20 %, 100cc > requested watcher to secure out PRBC type. > scheduled patient for Craniectomy and evacuation of hematoma at 2p.m same day > informed Dr. Oclarit through text for follow- up anesthesia

of

At 2: 18 in the afternoon, patient X was wheeled in into the operating room with IVF hooked at right metacarpal vein, infusing well. Then the consent for the craniectomy

operation was obtained. He was then attached to the cardiac monitor and pulse monitor as well. Plain NSS was started as venoclysis at left arm at just drip around 2:45 p.m. Around 2:28 p.m, general anesthesia was started with KVO( keep vein open) instruction and intubation was also done. Then venocylsis was started with KVO instruction now at the right arm along with the shaving and skin preparation done simultaneously. Erythromycin was instilled on both eyes at 3 p.m together with the initial counting of the sponges and instruments pre-operatively. The operation/ procedure namely “Craniectomy Right Frontotemporoparietal, Evacuation of Hematoma Expansion, Duraplexy, Bone Transplant to Right Hemiabdomen” started around 3:05 p.m with Dr. Neil Oliver Camonggol as the head surgeon, Dr. Sheree Lim as the assistant surgeon, Dr. Castulo P. Oclarit as the anesthesiologist, Ms. Vanessa P. Orboc, R.N as the instrument nurse, Ms. Micthel P. Calo, RN as the circulating nurse, me as the scrub student nurse and Ms Ruby Grace N. Insong, as the circulating student nurse. The pre operative diagnosis was “Hemorrhagic Contusion Right Frontal Lobe, Subdural Subacute Hematoma Right Convexity.” Major instruments were used, prepared in the mayo table and draping was done accordingly. Incision of body tissue was done carefully and cauterization of bleeders followed afterwards. Opening og the skull was done using power drill, an specialized instrument for cutting owned by Dr. Camonggol himself. Bone flap was then removed and placed carefully in the kidney basin filled with sterile water. Washing of the bone flap was also done carefully. Hgt results were then referred to Dr. Camonggol. At 4:15 p.m, the initial counting of the sponges, instruments, sutures and cottonoids were checked and complete. I was given the chance to report the outcome of the said counting among the doctors and the rest of the surgical team. Then the 1st unit of PRBC with serial number of 09.231 with blood type O positive was transfused to patient X obtained from proper cross- matching. Dr. Oclarit continuously monitored the vital signs seeing to it all of them were at normal level. Around 5:25 p.m, suturing of the head was done while DLR 1L was then well infused. The final counting of instruments, sutures, sponges and cottonoids was done afterwards. Patient X’s abdomen was then incised around 5:28 p.m. Bleeders were also cauterized respectively. Bone flap was then implanted at right lower abdomen after the incision was being made. Suturing then ended, betadinizing was done and Jackson Pratt was attached accordingly. The operation ended exactly 5:45 p.m with post diagnosis same with that of that of the pre operative diagnosis. Post operative care was given. Patient X’s blood pressure was obtained with 126/90 mmHg reading. At 6: 05 p.m, suctioning was done and he was brought back to the CCU with post operative orders to be carried out by the nurse on duty. According to Eric Erickson’s Psychosocial Theory, patient X belongs to the Middle Adulthood with the central task of Generativity v.s Stagnation. Positive crisis resolution results in creativity, productivity, and concern for others. Stagnation results in selfishness and lack of interest and commitments. Generativity means concern for establishing and guiding the next generation. People turn from self- and- family centered focus of young adulthood toward more altruistic activities like community involvement, charitable work and political and social endeavor. Stagnation results if the need for sharing, giving, and contributing to the growth of others is not meet. Patient X was able to share his skills and attributes for the good of others like becoming a good father to his children and a responsible husband to his wife. Somehow his concern for the people around him was appreciated by his loved ones as well.

PHYSICAL ASSESSMENT Physical examination follows a methodical head to toe format in the cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, I made every effort to recognize and respect the patient’s feelings as well as to provide comfort measures and follow appropriate safety precautions. Physical assessment is a systematic, comprehensive, continuous collection, validation and communication of the patient’s data using a variety of methods. The purposes of the physical assessment are as follows: -to collect data and establish a need for continued physical assessment; -to ascertain patient’s level of health condition and physiological functioning; -to identify factors facing the patient at risk; and -to determine the areas of preventive nursing. The physical assessment of patient X was done last August 22, 2009 at one of the private rooms of MJ Santos Hospital. The student nurses used the cepholocaudal approach in assessing the patient. The student brought with him bp apparatus, temperature, stethoscope, wristwatch, ballpen, and notebook General Survey: The patient’s general appearance seemed he was responding to treatment. He was relaxed, lying on bed with left knee flexed. Left hand was moved, flexed during interaction. He was wearing white comfortable sleeveless shirt and a diaper, bandages for both legs. He was conscious, right eye closed left eye semi-open, nods when acknowledged. Vital Signs: BP: 120/80 mmHg TEMPERATURE: 37. 2 C HEART RATE: 87 beats/ min RESPIRATORY RATE: 18 breaths/ min Skin: The skin was brown in color. Muscle tone present. Few abrasions are noted but nevertheless, the skin was not dry. Head: The head was slightly sunken on the right side due to removal of bone flap. Hair was starting to grow. Ears: Ears were symmetrical, free of abrasions. Color was good, same with the rest of the body with no pale manifestations.

Eyes: Eyebrows and eyelashes are evenly distributed. The scleras of both eyes were clear, equally round and reactive to light accommodation .Right eye can’t be opened by himself. Left is in good condition, can be opened by himself. Right eye secretions are noted. Nose: No discharges or flaring.

Lips: Lips are dry but with no pale manifestations. Mouth: Teeth are symmetrical. Plaques are noted. Upper Extremities: Right upper arm can’t be hyperextended. Pain is verbalized by patient. Right hand has healed wound but not cyanotic, has abrasions om right shoulder. Left hand flexed and moved freely. Fingers are symmetrical with no abrasions. Nails are not trimmed, manifested with dirt. Chest: Presence of tracheo tubing in the neck noted which is suctioned two times a day. Rest of the chest is with no abrasions. Color is brown, the same with the rest of the body. Abdomen: Presence of incision on right upper quadrant is noted due to transplant of bone flap. The rest of the abdomen is of the same color and with no abrasions. Back: No abrasions are noted. Lower Extremities: Abrasions present on left knee. Right foot, just above the ankle is manifested with slight abrasions. Both feet until the lower part of the thighs are covered with bandage-like socks. Toes are symmetrical, nails are not trimmed. Bowel and Urine Excretion: Bowel movement is two times a day. Urine is collected through a diaper. Neurologic Status: He can speak but not fluently due to the presence of the tracheo tubing, nods when acknowledged, raises left hand as we said goodbye. He was conscious with calm behavior. Environment: The room was clean and well-ventilated.

ANATOMY AND PHYSIOLOGY OF THE BRAIN

The scarecrow needed it, Einstein had an excellent one, and it can store a whole lot of information. What is it you say? Why, the brain of course. The brain is the control center of the body. Think of a telephone operator who answers incoming calls and directs them to where they need to go. Similarly, your brain acts as an operator by sending messages from all over the body to their proper destination. The brain is one of the largest and most important organs of the human body. Weighing in at about three pounds, this organ has a wide range of responsibilities. From coordinating our movement to managing our emotions, the brain does it all. The brain is made up of three parts: the forebrain, the brainstem, and the hindbrain. The anatomy of the brain is complex due its intricate structure and function. This amazing organ acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain. The brain serves many important functions. It gives meaning to things that happen in the world surrounding us. Through the five senses of sight, smell, hearing, touch and taste, the brain receives messages, often many at the same time. The brain controls thoughts, memory and speech, arm and leg movements, and the function of many organs within the body. It also determines how people respond to stressful situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.) by regulating heart and breathing rates. The brain is an organized structure, divided into many components that serve specific and important functions. The weight of the brain changes from birth through adulthood. At birth, the average brain weighs about one pound, and grows to about two pounds during childhood. The average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three pounds. The Nervous System The nervous system is commonly divided into the central nervous system and the peripheral nervous system. The central nervous system is made up of the brain, its cranial nerves and the spinal cord. The peripheral nervous system is composed of the spinal nerves that branch from the spinal cord and the autonomous nervous system (divided into the sympathetic and parasympathetic nervous system). The Cell Structure of the Brain The brain is made up of two types of cells: neurons and glial cells, also known as neuroglia or glia. The neuron is responsible for sending and receiving nerve impulses or signals. Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and facilitate signal transmission in the nervous system. In the human brain, glial cells outnumber neurons by about 50 to one. Glial cells are the most common cells found in primary brain tumors. When a person is diagnosed with a brain tumor, a biopsy may be done, in which tissue is removed from the tumor for identification purposes by a pathologist. Pathologists identify the type of cells that are present in this brain tissue, and brain tumors are named based on this association. The type of brain tumor and cells involved impact patient prognosis and treatment.

The Meninges The brain is housed inside the bony covering called the cranium. The cranium protects the brain from injury. Together, the cranium and bones that protect the face are called the skull. Between the skull and brain is the meninges, which consist of three layers of tissue that cover and protect the brain and spinal cord. From the outermost layer inward they are: the dura mater, arachnoid and pia mater. In the brain, the dura mater is made up of two layers of whitish, nonelastic film or membrane. The outer layer is called the periosteum. An inner layer, the dura, lines the inside of the entire skull and creates little folds or compartments in which parts of the brain are protected and secured. The two special folds of the dura in the brain are called the falx and the tentorium. The falx separates the right and left half of the brain and the tentorium separates the upper and lower parts of the brain. The second layer of the meninges is the arachnoid. This membrane is thin and delicate and covers the entire brain. There is a space between the dura and the arachnoid membranes that is called the subdural space. The arachnoid is made up of delicate, elastic tissue and blood vessels of varying sizes. The layer of meninges closest to the surface of the brain is called the pia mater. The pia mater has many blood vessels that reach deep into the surface of the brain. The pia, which covers the entire surface of the brain, follows the folds of the brain. The major arteries supplying the brain provide the pia with its blood vessels. The space that separates the arachnoid and the pia is called the subarachnoid space. It is within this area that cerebrospinal fluid flows. Cerebrospinal Fluid Cerebrospinal fluid (CSF) is found within the brain and surrounds the brain and the spinal cord. It is a clear, watery substance that helps to cushion the brain and spinal cord from injury. This fluid circulates through channels around the spinal cord and brain, constantly being absorbed and replenished. It is within hollow channels in the brain, called ventricles, that the fluid is produced. A specialized structure within each ventricle, called the choroid plexus, is responsible for the majority of CSF production. The brain normally maintains a balance between the amount of CSF that is absorbed and the amount that is produced. However, disruptions in this system may occur. The Ventricular System The ventricular system is divided into four cavities called ventricles, which are connected by a series of holes called foramen, and tubes. Two ventricles enclosed in the cerebral hemispheres are called the lateral ventricles (first and second). They each communicate with the third ventricle through a separate opening called the Foramen of Munro. The third ventricle is in the center of the brain, and its walls are made up of the thalamus and hypothalamus. The third ventricle connects with the fourth ventricle through a long tube called the Aqueduct of Sylvius. CSF flowing through the fourth ventricle flows around the brain and spinal cord by passing through another series of openings. Brain Components and Functions Brainstem

The brainstem is the lower extension of the brain, located in front of the cerebellum and connected to the spinal cord. It consists of three structures: the midbrain, pons and medulla oblongata. It serves as a relay station, passing messages back and forth between various parts of the body and the cerebral cortex. Many simple or primitive functions that are essential for survival are located here. The midbrain is an important center for ocular motion while the pons is involved with coordinating eye and facial movements, facial sensation, hearing and balance. The medulla oblongata controls breathing, blood pressure, heart rhythms and swallowing. Messages from the cortex to the spinal cord and nerves that branch from the spinal cord are sent through the pons and the brainstem. Destruction of these regions of the brain will cause "brain death." Without these key functions, humans cannot survive. The reticular activating system is found in the midbrain, pons, medulla and part of the thalamus. It controls levels of wakefulness, enables people to pay attention to their environments, and is involved in sleep patterns. Originating in the brainstem are 10 of the 12 cranial nerves that control hearing, eye movement, facial sensations, taste, swallowing and movements of the face, neck, shoulder and tongue muscles. The cranial nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves originate from the pons: nerves 5 through 8. Cerebellum The cerebellum is located at the back of the brain beneath the occipital lobes. It is separated from the cerebrum by the tentorium (fold of dura). The cerebellum fine tunes motor activity or movement, e.g. the fine movements of fingers as they perform surgery or paint a picture. It helps one maintain posture, sense of balance or equilibrium, by controlling the tone of muscles and the position of limbs. The cerebellum is important in one's ability to perform rapid and repetitive actions such as playing a video game. In the cerebellum, right-sided abnormalities produce symptoms on the same side of the body. Cerebrum The cerebrum, which forms the major portion of the brain, is divided into two major parts: the right and left cerebral hemispheres. The cerebrum is a term often used to describe the entire brain. A fissure or groove that separates the two hemispheres is called the great longitudinal fissure. The two sides of the brain are joined at the bottom by the corpus callosum. The corpus callosum connects the two halves of the brain and delivers messages from one half of the brain to the other. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex. The cerebral cortex appears grayish brown in color and is called the "gray matter." The surface of the brain appears wrinkled. The cerebral cortex has sulci (small grooves), fissures (larger grooves) and bulges between the grooves called gyri. Scientists have specific names for the bulges and grooves on the surface of the brain. Decades of scientific research have revealed the specific functions of the various regions of the brain. Beneath the cerebral cortex or surface of the brain, connecting fibers between neurons form a white-colored area called the "white matter." The cerebral hemispheres have several distinct fissures. By locating these landmarks on the surface of the brain, it can effectively be divided into pairs of "lobes." Lobes are simply broad regions of the brain. The cerebrum or brain can be divided into pairs of frontal, temporal, parietal and occipital lobes. Each hemisphere has a frontal, temporal, parietal and occipital lobe. Each lobe may be divided, once again, into areas that serve very specific functions. The lobes of the brain do not function alone – they function through very complex relationships with one another.

Messages within the brain are delivered in many ways. The signals are transported along routes called pathways. Any destruction of brain tissue by a tumor can disrupt the communication between different parts of the brain. The result will be a loss of function such as speech, the ability to read, or the ability to follow simple spoken commands. Messages can travel from one bulge on the brain to another (gyri to gyri), from one lobe to another, from one side of the brain to the other, from one lobe of the brain to structures that are found deep in the brain, e.g. thalamus, or from the deep structures of the brain to another region in the central nervous system. Research has determined that touching one side of the brain sends electrical signals to the other side of the body. Touching the motor region on the right side of the brain, would cause the opposite side or the left side of the body to move. Stimulating the left primary motor cortex would cause the right side of the body to move. The messages for movement and sensation cross to the other side of the brain and cause the opposite limb to move or feel a sensation. The right side of the brain controls the left side of the body and vice versa. So if a brain tumor occurs on the right side of the brain that controls the movement of the arm, the left arm may be weak or paralyzed. Cranial Nerves – There are 12 pairs of nerves that originate from the brain itself. These nerves are responsible for very specific activities and are named and numbered as follows: 1. Olfactory: Smell 2. Optic: Visual fields and ability to see 3. Oculomotor: Eye movements; eyelid opening 4. Trochlear: Eye movements 5. Trigeminal: Facial sensation 6. Abducens: Eye movements 7. Facial: Eyelid closing; facial expression; taste sensation 8. Auditory/vestibular: Hearing; sense of balance 9. Glossopharyngeal: Taste sensation; swallowing 10. Vagus: Swallowing; taste sensation 11. Accessory: Control of neck and shoulder muscles 12. Hypoglossal: Tongue movement Hypothalamus – The hypothalamus is a small structure that contains nerve connections that send messages to the pituitary gland. The hypothalamus handles information that comes from the autonomic nervous system. It plays a role in controlling functions such as eating, sexual behavior and sleeping; and regulates body temperature, emotions, secretion of hormones and movement. The pituitary gland develops from an extension of the hypothalamus downwards and from a second component extending upward from the roof of the mouth. The Lobes Frontal Lobes – The frontal lobes are the largest of the four lobes responsible for many different functions. These include motor skills such as voluntary movement, speech, intellectual and behavioral functions. The areas that produce movement in parts of the body are found in the primary motor cortex or precentral gyrus. The prefrontal cortex plays an important part in memory, intelligence, concentration, temper and personality. The premotor cortex is a region found beside the primary motor cortex. It guides eye and head movements and a person’s sense of orientation. Broca's area, important in language production, is found in the frontal lobe, usually on the left side. Occipital Lobes These lobes are located at the back of the brain and enable humans to receive and process visual information. They influence how humans process colors and shapes. The occipital

lobe on the right interprets visual signals from the left visual space, while the left occipital lobe performs the same function for the right visual space.

Parietal Lobes These lobes interpret simultaneously, signals received from other areas of the brain such as vision, hearing, motor, sensory and memory. A person’s memory and the new sensory information received, give meaning to objects. Temporal Lobes These lobes are located on each side of the brain at about ear level, and can be divided into two parts. One part is on the bottom (ventral) of each hemisphere, and the other part is on the side (lateral) of each hemisphere. An area on the right side is involved in visual memory and helps humans recognize objects and peoples' faces. An area on the left side is involved in verbal memory and helps humans remember and understand language. The rear of the temporal lobe enables humans to interpret other people’s emotions and reactions. Limbic System This system is involved in emotions. Included in this system are the hypothalamus, part of the thalamus, amygdala (active in producing aggressive behavior) and hippocampus (plays a role in the ability to remember new information). Pineal Gland This gland is an outgrowth from the posterior or back portion of the third ventricle. In some mammals, it controls the response to darkness and light. In humans, it has some role in sexual maturation, although the exact function of the pineal gland in humans is unclear. Pituitary Gland The pituitary is a small gland attached to the base of the brain (behind the nose) in an area called the pituitary fossa or sella turcica. The pituitary is often called the "master gland" because it controls the secretion of hormones. The pituitary is responsible for controlling and coordinating the following: • • •

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

Posterior Fossa This is a cavity in the back part of the skull which contains the cerebellum, brainstem, and cranial nerves 5-12. Thalamus The thalamus serves as a relay station for almost all information that comes and goes to the cortex. It plays a role in pain sensation, attention and alertness. It consists of four parts: the hypothalamus, the epythalamus, the ventral thalamus, and the dorsal thalamus. The basal ganglia are clusters of nerve cells surrounding the thalamus.

Language and Speech Functions

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

LABORATORY RESULTS Hematology Complete Blood Count Test

Definition

Result

Hemoglobin

It is the main component of red blood cells. Its main function is to carry oxygen from the lungs to the body tissues and to transport Carbon Dioxide, the product of cellular metabolism, back to the lungs. It is the measurement of the percentage of red blood cells in the total volume of blood. It is expressed as the percentage of red cells in the total blood volume. The total white blood count (WBC) is the absolute number of white blood cells (leukocytes) circulating in a cubic millimeter of blood. Also called thrombocytes, are large, nonnucleated cells derived from the megakaryotes produced in the bone marrow. They promote coagulation.

151

Hematocrit

Leukocytes (WBC)

Platelet Count

Reference Range (137-167 g/ml)

Interpretation

Clinical significance

Normal

Elevated level denotes for hematoconcentration and polycythemia. Decreased level denotes for hemorrhage, anemia or hemodilution ( overhydartion).

0.45

13.20

(0.40- 0.50)

(5.0- 10.0)

Normal

Increased

Elevated level may account for hemoconcentration and polycythemia vera. Decreased level may account for anemia, acute blood loss or hemodilution. Elevated level accounts for anemia. Decreased level may account for anemia or bone marrow transplant.

(205) x 10 ˆ g/L

150-390

Normal

Elevated level signifies thrombocytosis resulting from hemorrhage, surgery, chronic inflammatory disease.

Differential Count Test

Definition

Result

Eosinophil

They play a role in allergic reactions, possibly inactivating histamine.

0.00

Reference Range (0.00-0.06)

Interpretation Normal

Clinical significance Elevated level on eosinophil count may be caused by hyperimmune or more or allergic reaction where there is antigenantibody response. Decreased eosinophil count may be associated

Lymphocyte

Basophil

Monocyte

Neutrophils

They play a role in our immune response.

They contain histamine and heparin and appear to be involved in immediate hypersensitivity reactions.

They are the second line of defense against bacterial infections and foreign substance.

Most numerous circulating WBC’s and they respond more rapidly to the inflammatory and tissue injury sites than other types of WBCs.

0.09

0.00

0.06

0.85

(0.20-0.50)

(0.0-0.1)

(0.08-0.14)

(0.37-0.72)

Decreased

with congestive heart failure or anemia. Elevated level may be associated with presence of viral infection and hormonal disorders.

Normal

Decreased level may account for burns, trauma and the administration o corticosteroids. Elevated level accounts for inflammatory process, leukemia, healing stage of infection.

Decreased

Decreased level accounts for stress or hypersensitivity reactions. Elevated level accounts or viral diseases or monocytic leukemia.

Increased

Decreased level accounts for lymphocytic leukemia and aplastic anemia. Increased level denotes presence of a bacterial or aplastic infectious process. Decreased levels may be caused by hamatoloic diseases and acute viral infecrion.

Microscopic Examination of Urinary Sediment Constituents WBC and WBC casts

RBC and WBC casts

Epithelial Cells

Definition Casts are formed within the kidney tubules from agglutination of protein cells, of red and white cells of epithelial cells.

Result 6-10/1pf

Reference Value > 4 per lower power field

Interpretation Increased

Casts are formed within the kidney tubules from agglutination of protein cells, of red and white cells of epithelial cells. Casts are formed within the kidney tubules from

8-10/ lpf

>2/11 pf

Increased

Occasional

Occasional

Normal

Clinical significance Accumulation of red cells and white cells indicates an infection o the urinary tract. Accumulation of white cells casts occurs in glumerolonephritis, pyelonephritis,and Rickey inflammation. Accumulation of red cells indicates bleeding in the glomeruli or tubules of presence of calculi. Accumulation of red cell casts indicates glumerolonephritis. Epithelial cells accumulate from casts of tubular cells

agglutination of protein cells, of red and white cells of epithelial cells.

damaged by nephrosis, eclampsia and poisoning from heavy metals and toxins. URINALYSIS

Property/Constituents

Definition

Color

Transparency PH

It is the hydrogen concentration of the urine. It is a measurement of the acid or alkaline status of he urine.

Result

Reference Value

Interpretation

Yellow

Light straw to dark amber yellow

Normal

Clear 5.0

Clear 4.5-8.0

Normal Normal

Specific Gravity

it is the measurement of the concentration of urine

1.025

Protein

Protein found in the urine albumin, a serum protein that normally does not leak into the glomerular filtrate

Negative

Sodium

It is the principal cation of the extracelluar fluids and is the most important antelectrolyte in the maintenance of fluid balance in the body.

Potassium

It is one of the major electrolytes in the body fluid that is responsible for maintaining life-sustaining neuromuscular

1.005-1.030

Normal

Qualitative Analysis > negative

Normal

135.3 mEq/l

Quantitative Analysis > 10-100 mg/24 h 135-1487 mEq/l

Normal

4.30 mEq/l

3.5-5.5 mEq/l

Normal

Clinical significance A pale color usually indicates diluted urine and dark yellow or amber indicates concentrated urine. Acid urine is associated with diabetes mellitus, diarrhea and dehydration. Alkaline urine is found in patients with UTI and chronic renal failure. Increased urine specific gravity are caused by increased concentration of various substances contributing to urine concentration and increased water loss in the body Proteinuria is a sensitive indicator of kidney dysfunction.

Deviations that result in concentrated body fluid state is referred to as hypertonic that is caused by either a sodium excess or body water. Excess of body water or a decrease sodium intake and is reflected by hyponatremia with serum sodium level below 120 mEq/l Excess signifies hyperkalemia that occurs when a serum level of accumulated potassium rises above 5.5 mEq/1.

functioning.

It is caused by kidney disease, such as renal shutdown. Deficit signifies hypokalemia that is caused by administration of thiazide diuretics without potassium replacements.

DRUG STUDY Name of Drug: Tramadol Brand Name: Ultram Classification: Opioid analgesic Dosage/ Frequency: Tablets 50 mg, 1 cap every 6 hours Mechanism of Action: Binds to certain opioid receptors and inhibits reuptake of norepinephrine and serotonin; exact mechanism of action unknown. Indications: Relief of moderate to moderately severe pain (immediate-release); relief of moderate to moderately severe chronic pain for patients who require around-the-clock treatment for an extended period of time (ER). Contraindications: Acute intoxication with alcohol, hypnotics, centrally acting analgesics, narcotics, opioids, or psychotropic agents; hypersensitivity. Adverse Reactions: Nursing Considerations: • • • • • • • •

Instruct patient to take the prescribed dose at the recommended intervals. Advise patient to swallow the ER tablet whole and not to break, cut, or crush the tablet. Instruct patient to report any serious adverse reactions to health care provider. Advise patient not to wait until pain level is high to self-medicate; drug will not be as effective. Advise patient to avoid using alcohol or other CNS depressants (eg, sleeping pills). Advise patient that this medication may cause drowsiness and to use caution while driving or using heavy equipment, or performing other tasks requiring mental alertness. Advise patient not to abruptly discontinue this medication; when discontinuing treatment, taper the dose. Advise patient to notify health care provider if pain is not relieved by the medication at prescribed dosage.

Name of Drug: Phenytoin Brand Name: Dilantin Classification: Anticonvulsant Dosage/ Frequency: 100mg 1cap QID Mechanism of Action: It works by slowing down impulses in the brain that cause seizures. Indications:

Treating certain types of seizures (eg, status epilepticus). It is also used to prevent and treat seizures that may occur during or after brain or nervous system surgery. It may also be used for other conditions as determined by your doctor. Contraindications: • •

you are allergic to any ingredient in Phenytoin or to another hydantoin (eg, fosphenytoin) you have certain types of heart problems (eg, very slow heart beat, certain types of heart block, Adams-Stokes syndrome)

Adverse Reactions: Constipation; dizziness; headache; mild nervousness; nausea; trouble sleeping; vomiting. Nursing Considerations: Phenytoin may cause dizziness. This effect may be worse if you take it with alcohol or certain medicines. Use Phenytoin with caution. Do not drive or perform other possibly unsafe tasks until you know how you react to it. Check with your doctor before you drink alcohol while you are taking Phenytoin . Alcohol may increase or decrease the amount of medicine in your blood. Do not change brands or dose forms (eg, tablets, suspension, injection) of Phenytoin without talking with your doctor. Do NOT take more than the recommended dose without checking with your doctor. Proper dental care is important while you are taking Phenytoin . Brush and floss your teeth and visit the dentist regularly. Phenytoin may raise your blood sugar. High blood sugar may make you feel confused, drowsy, or thirsty. It can also make you flush, breathe faster, or have a fruit-like breath odor. If these symptoms occur, tell your doctor right away.

Name of Drug: Mannitol Brand Name: Osmitrol Classification: Diuretic Dosage/ Frequency: 100cc q8h IV Bolus Mechanism of Action: It works by increasing the amount of fluid excreted by the kidneys and helps the body to decrease pressure in the brain and eyes. Indications: Mannitol is used to force urine production in people with acute (sudden) kidney failure. Increased urine production helps prevent the kidneys from shutting down, and also speeds up elimination of certain toxic substances in the body. Mannitol is also used to reduce swelling and pressure inside the eye or around the brain. Contraindications: • • •

you are allergic to any ingredient in Mannitol you have a history of heart failure you have decreased or absent production of urine due to severe kidney disease, certain severe lung problems (eg, pulmonary congestion or pulmonary edema), bleeding in the brain, or severe dehydration

Adverse Reactions: • • •

dry mouth, increased thirst, blurred vision, or seizure (convulsions); swelling, pain, or skin changes where the medicine was injected; chest pain, fast heart rate;

• • • •

feeling like you might pass out; feeling short of breath, even with mild exertion; swelling, rapid weight gain; or if you stop urinating.

Nursing Considerations: Mannitol may cause dizziness. These effects may be worse if you take it with alcohol or certain medicines. Use Mannitol with caution. Do not drive or perform other possibly unsafe tasks until you know how you react to it. Use Mannitol with caution in the ELDERLY; they may be more sensitive to its effects. Mannitol should be used with extreme caution in CHILDREN younger than 12 years old; safety and effectiveness in these children have not been confirmed.

Name of Drug: Sevoflurane Brand Name: Sevorane Classification: Anesthetic, general Dosage/ Frequency: Inhalation Mechanism of Action: Sevoflurane is used to cause general anesthesia (loss of consciousness) before and during surgery. It is inhaled (breathed in) Indications: Contraindications: Diseases that can cause muscle weakness, such as familial periodic paralysis, muscular dystrophy, myasthenia gravis, or myasthenic syndrome, Head injury, kidney disease, liver disease, malignant hyperthermia and portwine stain. Adverse Reactions: Cough; dizziness; drowsiness; increased amount of saliva; nausea; shivering; vomiting and headache Nursing Considerations: •

•

Sevoflurane may cause some people to feel drowsy, tired, or weak for a while after they receive it. It may also cause problems with coordination and ability to think. Therefore, for about 24 hours (or longer if necessary) after receiving sevoflurane, do not drive, operate moving machinery, or do anything else that could be dangerous if you are not alert. Unless otherwise directed by your doctor or dentist, do not drink alcoholic beverages or take other central nervous system (CNS) depressants (medicines that may make you drowsy or less alert) for about 24 hours after you have received sevoflurane. Taking these medicines or drinking alcoholic beverages may add to the effects of sevoflurane. Some examples of CNS depressants are antihistamines or medicine for hay fever, other allergies, or colds; other sedatives, tranquilizers, or sleeping medicine, prescription pain medicine or narcotics; barbiturates; medicine for seizures; and muscle relaxants.

Name of Drug: Silver Sulfadiazine Brand Name: Flamazine Class: Broad spectrum Sulfonamide

Dosage/ Frequency: cream 1% Mechanism of Action: Acts on cell membrane and cell wall: it’s bactericidal for many gram-positive and gram- negative organisms Indications: Used to prevent or treat wound infection in second- and- third degree burns. Contraindications: - hypersensitivity - pregnant women or near term and in premature or full term neonates - increase possibility of kernicterus Adverse Reactions: Interstitial; nephritis, leukopenia, altered serum osmolality, erythema multiforme, pain, burning, rash, pruritus, skin necrosis and skin discoloration. Nursing Considerations: .Wash, rinse, dry affected areas before application. . Prolonged used may be needed when treating acne vulgaris, which result in overgrowth of nonsusceptible organisms. . Tell patient to stop using drug and notify prescriber if no improvements occur or if condition worsens in 3 to 12 weeks. . Caution patient to keep drug away from the heat and open flame. Name of Drug: Abscorbic Acid Brand Name: Cecon Class: Vitamin Dosage/ Frequency: 500mg 1tab OD Mechanism of Action: Stimulates collagen formation and tissue repair: involved in oxidation- reduction reactions throughout body. Indications: Extensive burns, delayed fracture or wound healing, post operative wound healing, severe febrile or chronic disease states. Contraindications: Use cautiously among pregnant women, give only if clearly needed. Adverse Reactions: Dizziness with rapid I.V delivery, faintness, diarrhea, acid urine, oxaluria, renal calculi, discomfort at infection site. Nursing Considerations: . Assess patient's condition before starting therapy and regularly thereafter to monitor drug's effectiveness. . When giving for urine acidification, check urine pH to ensure effectiveness. . Be alert for adverse reactions and drug interactions. . Assess patient's and family’s knowledge of drug therapy. Name of Drug: Acetaminophen

Classification: Non-opioid analgesic, anti-pyretic Dose and Frequency: 325 to 650 mg PO every 4 hours prn Mechanism of Action: Blocks pain impulses, probably inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting on hypothalamic heat-regulating center. Indications: Mild pain or fever Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with a history of chronic alcohol abuse because hepatotoxicity may occur. Adverse Reactions: Hematologic: hemolytic anemia, leukopenia Hepatic: liver damage, jaundice Metabolic: hypoglycemia Skin: rash, urticaria Nursing Considerations: • Assess patient’s pain and temperature before giving any drugs. • Assess patient’s drug history and calculate daily dosage accofdingly. • Be alert for adverse reactions and drug interactions. • Assess patient and family’s knowledge of drug use. • Tell patient not to use drug for fever higher than 103 degrees Fahrenheit or lasts longer than 3 days or recurs. • Tell patient to keep track of daily acetaminophen intake. Name of Drug: Baclofen Classification: Chlorophenyl derivative Brands: Kemstro, Lioresal Dose and Frequency: Initially 5 mg PO TID for 3 days. Based on response, increase dosageat 3day intervalsby 15 mg daily up to maximum of 80 mg daily. Mechanism of Action: Appears to reduce transmission of impulses from spinal cord to skeletal muscles. Indications: Spasticity in multiple sclerosis, spinal cord injury Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with impaired renal function or seizure disorder. Adverse Reactions:

Metabolic: hyperglycemia Skin: pruritus CNS: confusion, dizziness, headache, paresthesia CV: ankle edema, hypotension GI: constipation, nausea and vomiting GU: sexual dysfunction RESPIRATORY: dsypnea EENT: blurred vision, nasal congestion Nursing Considerations: • Obtain history of patient’s pain and muscle spasms. • Be alert for adverse reactions and drug interactions.

• • • •

Tell patient to avoid activities that require alertness. Tell patient to avoid alcohol while taking drug. Advise patient to follow prescriber’s orders about rest and physical therapy. Advise patient to take drug with food or milk to prevent GI disorders.

Name of Drug: Cefixime Brand: Tergecef Classification: Third-generation cerhalosporin, amtibiotics Dose and Frequency: 200 mg 1 tab BID Mechanism of Action: Inhibits cell wall synthesis promoting osmotic instability, usually bactericidal. Indications: Infections of lung, skin, soft tissue, bones, joints, urinary and respiratory tracts, blood, abdomen and heart. Infections develop after surgical procedures classified as potentially contaminated. Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with renal or hepatic impairment. Adverse Reactions: Hepatic: hepatitis, jaundice Skin: pruritus CNS: dizziness, fatigue GI: abdominal pain, diarrhea and vomiting GU: genital pruritus Nursing Considerations: • Review patient’s history of allergies. • Monitor patient for adverse reactions. • Obtain culture and sensitivity of specimen. • Monitor renal function, PT and platelet count. Name of Drug: Clindamycin Brand: Cleocin Classification: Lincomycin derivative Dose and Frequency: 150 – 450 mg PO every 6 hours Mechanism of Action: Inhibits bacterial protein synthesis by binding 50s subunit of ribosome. Indications: Infections caused by sensitive staphylococci, streptococci, pnuemococci, bacteroides, and other sensitive anaerobic and aerobic organisms. Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with renal or hepatic disease, asthma and a history of GI disease or significant allergies. Adverse Reactions: Hematologic: thrombocytopenia, leukopenia Skin: urticaria CV: thrombophlebitis GI: abdominal pain RESPIRATORY: EENT: pharyngitis

Nursing Considerations: • Assess patient’s infection before and regularly throughout therapy. • Obtain specimen for culture and sensitivity. • Monitor renal and hepatic functions. • Be alert for adverse reactions and drug interactions. • Tell patient how to store oral solutions. • Instruct patient to report diarrhea and avoid self-treatment because of the threatening pseudomemebranous colitis.

Name of Drug: Ranitidine Brand: Zantac Classification: Histamine-receptor antagonist Dose and Frequency: 150 mg PO BID or 300 mg at bedtime Mechanism of Action: Competitively inhibits action of histamine2 receptor sites of parietal cells, decreasing gastric acid secretion. Indications: Acute duodenal or gastric ulcer and gastroesophageal reflux Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with impaired renal and hepatic function. Adverse Reactions: Hepatic: jaundice Skin: rash CNS: malaise GI: abdominal discomfort EENT: blurred vision Nursing Considerations: • Monitor patient for adverse reactions, especially hypotension and arrhythmias. • Peridically monitor lab tests, such as cbc and renal and hepatic studies.

Name of Drug: Epinephrine Brand: Adrenalin chloride Classification: Adrenergic Dose and Frequency: 0.1 to 0.5 ml of 1: 1000, subcutaneously or IM Mechanism of Action: Stimulates alpha and beta receptors an sympathetic nervous system. Indications: Bronchospasm, prolonging local anesthetic effect Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with angle-closure glaucoma, shock, organic brain damage. Adverse Reactions: Metabolic: glycosuria Skin: urticaria CNS: cerebral hemorrhage CV: anginal pain

GI: nausea and vomiting RESPIRATORY: dsypnea Nursing Considerations: • Obtain history of patient’s underlying condition before starting therapy, assess regularly. • Be alert for adverse reactions and drug interaction. • Tell patient to take drug exactly as prescribed and to take it around the clock. • Tell patient to reduce intake of foods containing caffeine such as coffee. • Tell patient to obtain approval from physician before taking OTC drugs and herbal medicines. Name of Drug: Lidocaine Brand: Lidopen Classification: Amide derivatives Dose and frequency: 50-100 mg by IV bolus at 25-50mg per minute Mechanism: Decrease depolarization, automaticity and excitability in ventricles during diastolic phase by direct actions on tissues. Indication: Ventricular arrythmias resulting from MI, cardiac manipulation or digoxin toxicity. Contraindication: contraindicated to patients hypersensitive to the drug, use cautiously and reduce dosage in patients with complete or second-degree heart block or sinus, and to patients with renal and hepatic disease. Adverse reactions: CNS: confusion CV: bradycardia EENT: blurred vision RESPIRATORY: respiratory arrest Skin: diaphoresis Nursing Considerations: • Assess patient condition before starting therapy and regularly thereafter to monitor drug effectiveness. • Monitor patient’s response especially ECG, BP, electrolytes, BUN, and creatinine levels. • Be alert for adverse reactions and drug interactions.

NURSING CARE PLANS Nursing Care Plan Pre Operative Phase Problem Identified: Impaired Physical Mobility Date Identified: July 30, 2009 Date evaluated: Subjective Cues: Objective Cues:     

limited range of motion inability to perform gross motor skills difficulty upon turning unable to transfer to bed decreased muscle strength

Assessment: Impaired Physical Mobility r/t Sensoriperceptual Impairment secondary to injury, bedrest and unresponsive state Planning: Within the pre operative phase of nursing interventions, the patient will be able to maintain/ increase strength and function of affected and/or compensatory body part and regain optimal position function as evidenced by absence of contractures and footdrop. Interventions: 1. Review functional ability and reasons for impairment. R: Identifies probable functional impairments and influences choices of interventions 2. Assess the degree of immobility, using a scale to rate dependence(0-4) R: The client may be completely independent (0), may require minimal assistance/equipment (1), moderate assistance/ supervision/ teachings (2), extensive assistance / equipment and devices (3),or be completely dependent on caregivers (4) 3. Provide/ assist with range of motion exercises. R: Maintains mobility and function of joints/functional alignment of extremities and reduces venous stasis. 4. Place the client in designated therapeutic position. R: Designated therapeutic position should cause no undue stress on muscles or joint. 5. Apply a foot board to the bed. R: A foot board will prevent foot drop. 6. Elevate the head of bed, as appropriate. R: The head of the bed may be elevated to provide counteraction of for comfort if permitted. 7. Place frequently used objects within reach. R: Placing frequently used objects within reach permits the client safe and convenient access. 8. Provide meticulous skin care, remove wet linen/clothing and keep bedding free from wrinkles. R: Promotes circulation and skin elasticity and reduces risk of skin excoriation. 9. Monitor bowel elimination and provide for/ assist with a regular bowel routine.\ R: A regular bowel routine requires simple but diligent measures to prevent complications. 10. Provide air/ water mattress, kinetic therapy as appropriate. R: Equalizes tissue pressure, enhances circulation, and helps reduce venous stasis to decrease risk of tissue injury. Evaluation

Nursing Care Plan Intra Operative Phase Problem Identified: Ineffective Cerebral Tissue Perfusion Date Identified: July 30, 2009 Date evaluated: Subjective Cues: Objective Cues:  changes in vital signs  altered level of consciousness  disproportionate increase in ICP Assessment: Ineffective tissue perfusion r/t interruption of blood flow by space- occupying lesions as evidenced by hemorrhage and hematoma. Planning: Within the intra operative phase of nursing interventions, the patient will be able to demonstrate stable vital signs and absence of signs of increased intracranial pressure (ICP). Interventions: 1. Monitor patient’s vital signs. R: To provide baseline data. 2. Determine factors related to individual situation, cause for coma/decreased cerebral perfusion and potential for increased ICP. R: Influences choices of intervention. Deterioration in neurological signs/ symptoms may reflect decreased intracranial adaptive capacity requiring client be transferred to critical care unit for ICP monitoring and/or surgical intervention. 3. Calculate and monitor cerebral perfusion pressure (CPP). R: A CPP equal to or greater than 60-70 mmHg is needed to provide adequate oxygenation and nutrition to brain tissue. 4. Monitor respiratory status like rate, rhythm and depth of respirations. R: Adequate gas exchange is required for tissue oxygenation. 5. Evaluate eye opening (e.g spontaneous (awake), opens only to painful stimuli, keeps eyes closed (coma). R: Determines arousal ability/ level of consciousness. 6. Note presence/ absence of reflexes like blink, cough or gag reflex. R: Altered reflexes reflect injury at level of midbrain or brainstem and have direct implications for client safety 7. Monitor temperature and regulate environmental temperature as indicated. R: Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen consumption occur (especially with fever and shivering) which can further increase ICP. 8. Monitor I & O and note skin turgor, status of mucous membrane. R: Useful indications of total body weight, which is an integral part of tissue perfusion. Alterations may lead to hypovolemia, or vascular engorgement, either which can negatively affect cerebral pressure. 9. Provide rest periods between care activities and limit duration of procedures. R: Continual activity can increase ICP by producing a cumulative stimulation effect. 10. Observe for seizure activity and protect client from injury. R: Seizures can occur as a result of cerebral irritation, hypoxia, or increased ICP that further elevate ICP, compounding cerebral damage. 11. Administer medications as indicated such as diuretics like Mannitol and Furosemide. R: Diuretics may be used in acute phase to drain water from blood cells, reducing cerebral edema and ICP. 12. Initiate cooling measures, as indicated. R: May be needed to regain or maintain normal core body temperature. Evaluation

Nursing Care Plan Post Operative Phase Problem Identified: Risk for Infection Date Identified: July 31, 2009 Date evaluated: Subjective Cues: Objective Cues:  Touches operative wound with bare hands  Slight increase in vital signs  diaphoresis Assessment: Risk for Infection r/t traumatized tissue secondary to post- craniectomy. Planning: Within 2 days of nursing interventions, the patient will be able to maintain free signs of infection and achieve stable vital signs. Interventions: 1. Monitor patient’s vital signs. R: To provide baseline data. 2. Monitor for systemic & localized signs and symptoms of infection. R: Elevated temperature, pulse, respirations, and fever indicate systemic infection. Redness, heat, swelling and pain indicate localized infection. 3. Provide meticulous, aseptic care, maintaining good handwashing technique. R: First line of defense against nosocomial infection. 4. Inspect the condition of any surgical incision/ wound. R: Early identification of developing infections permits prompt intervention and prevention of further complications. 5. Monitor temperature routinely. Note presence of chills, diaphoresis and changes in mentation. R: May indicate developing sepsis requiring further evaluation/ intervention. 6. Encourage deep breathing and coughing, as appropriate. R: Coughing and deep breathing clear the lungs of secretions that may encourage the growth of pathogenic microbes. 7. Encourage sufficient nutritional intake. R: Adequate nutrition is essential for immune system formation and for the repair of damaged body tissues to provide protection against external pathogens. 8. Promote rest periods and encourage fluid intake. R: Mending tissues requires energy. Adequate fluid intake provides for renal clearance of toxins produced by pathogens. 9. Administer antibiotic therapy, as ordered/ appropriate. R: Antibiotic therapy should assist the body to destroy pathogens. 10. Screen/ restrict of visitors or caregiver, with upper respiratory infections (URI). R: Reduces exposure of “compromised host”.

Evaluation:

DISCHARGE PLANNING

M – Medication - Advise patient to take home medications following right drug, frequency, dosage and timing as prescribed by the Physician such as follows: > Tramadol, 50 mg 1 cap q6h > Cecon, 500mg 1 tab OD > Flamazine

E – Environment - Instructed patient to stay in calm, quiet environment - Home environment must be free from slipping or accident hazards T – Treatment - Informed patient to have a follow-up check up after 1- 2 weeks H – Health Teachings - Inform patient to avoid lifting heavy objects for 1-2 weeks - Stress the importance of proper hygiene like handwashing, toileting, toothbrushing and bathing. - Encourage client to engage to range of motion exercises. - Instruct patient to increase intake of protein-rich foods to promote faster wound healing - Advise patient to increase adequate fluid intake for hydration purposes. - Discourage patient to participate in strenuous activities that might precipitate stress and trauma to the wound. - Tell patient not to hesitate to ask for assistance when waking up in bed or when going to comfort room. - Promote rest periods among the client but also encourage ambulation. - Advise patient to avoid touching the operative wound with hands dirty that may cause infection.

- Encourage deep breathing and coughing exercises among the client.

O – Observable Signs and Symptoms - Instruct patient to report signs and symptoms of increased intra cranial

pressure

like seizures, vomiting or headache to nearest hospital to avoid further complications. - Instruct patient to report to physician any signs of infection like inflammation, redness or swelling - Instruct patient to report any case of hemorrhage or abnormal bleeding D – Diet - Encourage client to increase intake of fiber to avoid constipation - Instruct to increase fluid intake - Instruct to increase intake of nutritious foods such as fruits and vegetables S- Spirituality -

Advise patient to keep believing on God’s holy will so that he could be spiritually motivated. Tell patient to constantly participate to religious activities so that his faith could be more strengthened.

LEARNING OUTCOMES

Life is indeed full of surprises. Things happen as what expected to them to happen. No one ever travels the highway of success without ever crossing the road of failures instead. All we need to is to follow path that leads us to the unknown road. But we should always be glad that as we get stumbled along the road, we learn to stand on our own feet putting our heads up. From those experiences, we learn to grow as a person accountable for every action we take. That’s how learning process takes place. It comes naturally as it may seem. How could I ever forget the experience I have acquired upon exposure to operating/delivery room of Manuel J. Santos Hospital. It was the 24th day of July, when I first heard during our NCM 100 RLE concept last summer classes. I have to admit on my part that I got anxious and nervous as I found out that our group was assigned to OR/DR area for the 2nd rotation, as early as that. Preparations were being made. I also reviewed my OR/DR lecture notes within that short span of time, if that would be possible. As day progressed, I have gained new learnings and insights most especially during exposure to surgical operations. It’s just that in OR/DR area, there is no room for mistakes perhaps. Principle of sterility should strictly be observed. For being a part of surgical team means being a part of a battle we need to win. It entails cooperation and presence of mind as one engages to the world of sterility. Imagine yourself standing for about 4-6 hours during an operation, I bet it’s going to be hard perhaps. But patience and dedication area somewhat the virtues to keep, so one should keep the fire burning. When it comes to operation, one should be fully prepared. One must be assertive enough to do all things needed to be carried out. One must be fully equipped with the knowledge, skills and attitude before exposing to the area so that one could be productive and useful during operations/delivery. One should really pay attention so that things would run smoothly. Upon exposure, I was able to appreciate the organs of the body. It somehow made me appreciate myself and lot more becoming a part of the team. Things could be much more appreciated if one puts it into practice. It’s a great feeling being part of a team, trying to save a life of a person. No one can ever replace that happiness I felt for the successful operations I had assisted with may it be major or minor operation instead. What a great relief seeing my patient lying flat on bed, well and normally breathing after a risky procedure. “Life is uncertain, treasure every moment”-a quotation on worth to lived for. As for now, I should live my life doing good things not just for myself but also for others. I should bear in mind that I should not count the number of times I felt better just because I made them happy. Twelve days of exposure may be short enough yet with the experiences and

learnings I gained, the hardships were all worth it. The experience was truly superb and remarkable indeed.