Mini-case Presentation : Mild Head Injury

CASE STUDY

Mild Head Injury

Group C

Week 1 (September 16-18, 2009) GALANG, Katrina OBLEFIAS, Marianne NUCUM, Jordan PANGILINAN, Ian

Patient’s Profile : Biographical Data Name: SERRANO, Czarmaine Cecilia M. Sex: Female Occupation: Student Father: SERRANO, Lovino Mother: SERRANO, Clariza Address: 19 Cotabato St. Bago Bantay, Q.C.

Patient’s Profile : Vaccinations and Family Hx VACCINATIONS: • PPT • Measles, Mumps, Rubella (MMR) • HEPATITIS A • HEPATITIS B FAMILY HISTORY • HYPERTENSION • DIABETES MELITUS (type unspecified)

Patient’s Profile : Physical Examination HEAD Symmetrical; no visible deformities; visible redness at right side of forehead.   EYES Normal eyes; symmetrical; pupils reactive to light   EARS No visible abnormalities   NOSE Symmetrical; no visible abnormalities.   HAIR Shiny, healthy hair.  

Patient’s Profile : Physical Examination MOUTH  Normal without presence of injury   SCALP No pediculosis, dandruff   TEETH 1 Missing tooth (extracted last Aug. 30); 1 Erupting tooth   SKIN (general) Normal; No visible lesions or lacerations LYMPH NODULES Normal

Patient’s Profile : Physical Examination ARMS Symmetrical HANDS Normal CAPILLARY REFILL Normal Others Knee reflex : Normal Gait : Normal stance; balanced

 

Patient’s Profile : Physical Examination Vital Signs   Temperature 36.4°C   Heart Rate 93 bpm   Respiratory Rate 16 breaths / min   Blood Pressure N/A

Nursing Management: NCP: Assessment Subjective Cues:   “Nautog ako sa kaklase ko” as verbalized by the client.   Objective Cues:   Palpable, slightly protruding and slightly inflamed red spot on right forehead; as evidenced by: – Redness – Swelling – Heat – Pain   Possible disorientation due to dependence on schoolmate to arrive at clinic  

Nursing Management: NCP: Planning – Short Term Within 1h of nursing interventions, client will verbalize that she feels lesser pain. Skin demonstrates lesser, if not the non-existence of inflammation of the underlying injury.

Nursing Management: NCP: Planning – Long Term Within 2 days of nursing interventions, client will verbalize that she no longer feels any pain. Swelling will reduce considerably with minimal bruising.

Nursing Management: NCP: Interventions Apply cold compress to inflamed area. Rationale: Cold compress facilitates vasoconstriction thus reduces swelling and pain and minimalizes bruising.

Nursing Management: NCP: Interventions Observe for signs of confusion and disorientation. May be exhibited by: – Excessive irritability or sleepiness. – Recurrent vomiting – Increasing headache – Unsteady balance or movements – Disorientation or confusion

Nursing Management: NCP: Interventions Rationale: Force of impact to client’s head is unknown; Proper observation may detect possibility of a more serious injury.

Nursing Management: NCP: Evaluation of Short Term Goal

Partially met. Client verbalized that she “feels better” after intervention. However, the inflamed area still needs continuous care at home for complete healing of injury.

Nursing Management: NCP: Evaluation of Long Term Goal

Partially met. Limited time to interact and observe client gives little opportunity to monitor and document condition post-visit.