1. INTRODUCTION:
Traumatic Brain Injury (TBI) is a leading cause of death and
disability in the U.S. The national head injury foundation defines TBI
as a traumatic insult to the brain capable of causing physical,
intellectual, emotional, social and vocational changes.
Head injury known as traumatic brain injury, is the disruption
of normal brain function due to trauma (blunt or penetrating
injury).Neurologic deficits result from shearing of white matter,
ischemia and mass effect from the hemorrhage, and cerebral edema
of surrounding brain tissue.
TYPES OF BRAIN INJURIES:
1) Concussion = involves jarring of head without tissue injury.
Temporary loss of neurologic function lasting for a few minutes
to hours.
2) Contusion = involves structural damage. The patient becomes
unconscious for hours.
3) Epidural hematoma = blood collects in the epidural space
between skull and dura matter. Usually due to laceration of the
middle meningeal artery, symptoms develop rapidly.
4) Subdural hematoma = a collection of blood between the dura
and the arachnoid mater caused by trauma. This is usually due
to tear of dural sinuses or dural venous vessels, symptoms
usually develop slowly.
5) Diffuse axonal injury = is a brain injury in which a high speed
acceleration-deceleration injury, typically associated with
motor vehicle crashes, causes widespread disruption of axons
in the white matter.

2. Risk Factors:
>adults age 15-30
>being over the age of 75
>male to female ratio of 3:1
Causes:
>motor vehicle accidents
>increased blood alcohol levels
>falls
>sports injuries
>occupational injuries
>assaults
>gunshot wounds

3. GENERAL OBJECTIVES:
After our case presentation, we will be able to gain
knowledge, skills and attitudes on how to handle patient
with brain injury and fracture of the skull.
SPECIFIC OBJECTIVES:
After 1 hour of case presentation, we will be able to:
1. Deal patient with brain injury.
2. Care patient with neurologic disorders.
3. Provide spiritual care to the patient.
4. Provide emotional support to the patient.
5.Render different nursing interventions.

4.  ASSESSMENT
A.) PATIENT’S HISTORY
• PATIENT’S PROFILE
NAME: Patient X
AGE: 30 years old
Sex: Male
Nationality: Filipino
Religion: Christian
Date of Birth: October 10, 1980
Address: Marfa, Maguikay, Mandaue City
Occupation: Production worker
Date of Admission: February 27, 2011
Time of Admission: 11:40 p.m
Case number: 122677
Ward: Neuro-surgery
Bed number: Male 2
Admitting Diagnosis: 1.) Diffuse axonal injury
2.) Fx, closed depressed (R)
frontal with contusion Hematoma
Physician: Dr. Sasing
Chief Complaint: Loss of consciousness and vomiting
Operation Performed: Debridement and suturing (L)
rd th
hand 3 -5 digits

5. • HISTORY OF PRESENT ILNESS
A case of Patient X, 30 years old, male, single, Filipino from
Marfa, MAGUIKAY, Mandaue City, admitted for the first time via
ambulance (EMERGENCY RESCUE UNIT FOUNDATION) due to
collisions of vehicles resulting to the loss of his consciousness.
• PAST HEALTH HISTORY
No previous hospitalization. Family background shows a
history of hypertension.
• VITAL SIGNS
Temperature= 36.8 degrees Celsius
Respiratory Rate= 16 cycles per minute
Pulse Rate= 70 beats per minute
Blood Pressure= 130/90 mmHg
1) GENOGRAM LEGEND:
 FEMALE
 MALE
 PATIENT
 DECEASED

6.  HYPERTEENSIV
E
PATERNAL SIDE MATERNAL SIDE
B.) GORDON’S 11 FUNCTIONAL HEALTH
PATTERN

7. 1. ) HEALTH PERCEPTION-HEALTH MANAGEMENT
PATTERN
Patient is a 30 years old, male and single. He cannot describe
thoroughly about his condition due to his unconsciousness.
2) NUTRITIONAL-METABOLIC PATTERN
Before:
Patient has complete meals (breakfast, lunch, and
dinner) and has usual fluid intake of 8-10 glasses/day.
Now:
He’s on blenderized feeding with 1600kcal/meal and has
parenteral intake of PNSS running at 30gtts/min. He consumed
300cc after the end of the shift. Later, the doctor ordered him
on NPO (Nothing per Orem) status for further observation. The
patient gained weight over short period of time due to excess
fluid volume in the body as evidenced by edema of the face and
hands.
3) ELIMINATION PATTERN
BLADDER:
Before:
He can void 5x a day without any pain felt.
Now:
He wears diaper that is fully soaked weighing
800gms (800ml) after the end of the shift.
BOWEL:
Before:
He can defecate once a day with a formed stool.
Now:

8. He was not able to defecate since the day he was
admitted, February 27, 2011.
4) ACTIVITY-EXERCISE PATTERN
Before:
He is working at San Miguel Corporation as a
production worker. He works 8hours/day and sometimes
he also works over a long period of time.
Now:
He is on the bed over a long period of time.
5) SLEEP-REST PATTERN
Before:
He has a good sleep-wake cycle. He usually sleeps
at 9pm and wakes up at 6am due to his job.
Now:
He has sleep pattern disturbance due to pain on his
eyes as evidenced by restlessness.
6) COGNITIVE-PERCEPTUAL PATTERN
Before:
He graduated at Asian College of Technology with a
Bachelor of Science in Computer Science. According to
the significant others, he has no deficit in his sensory
perception (hearing and sight) and he’s able to read and
write.
Now:
He is experiencing eye problem. He cannot
spontaneously open his eyes due to periorbital swelling
and cannot talk.

9. 7) SELF-PERCEPTION PATTERN
According to the significant others, the patient is a good
brother and son. He is not an alcoholic and smoker. He is
very dedicated to his work as a production worker. He
doesn’t have any previous history of hospitalization.
8) ROLE-RELATIONSHIP PATTERN
COMMUNICATION:
Before:
According to the significant others, before his
speech is clear and he can speak English and Tagalog
language.
Now:
He is incoherent and unable to communicate. He
just nods when his family members talk to him.
RELATIONSHIP:
He is currently residing at Maguikay, Mandaue City
with his sister for easy access to his workplace. He
assists his family with their finances.
9) SEXUALITY-SEXUAL FUNCTIONING
According to the significant others, he is in a relationship
with his 3 months girlfriend.
10)COPING-STRESS MANAGEMENT PATTERN
According to the significant others, that whenever he has
a problem, he shares it to his family members inorder to
solve it.
11) VALUE-BELIEF SYSTEM
According to the significant others, patient is a Catholic
but due to the influence by his eldest brother, he was

10. converted into Christian and has been baptized. But,
every Sunday, he attends mass at the Catholic Church.
C.) REVIEW OF SYSTEMS
1.) INTEGUMENTARY SYSTEM
a. SKIN: Light brown complexion, good skin turgor,
edema of the hands and periorbital regions, multiple
abrasions noted, 36.8 degrees Celsius skin
temperature.
b. HAIR: Short curly hair
c. SCALP: Clean and no dandruff
d. NAIL: Nails turn to pink tones when performing
Capillary Refill test at 1-2 seconds.
2.) HEAD AND NECK
a. HEAD: bulging head
b. FACE: multiple abrasions and edema noted
c. NECK: no presence of lumps
d. LYMPH NODES: non tender, can be palpated
3.) EYES: Periorbital swelling on both eyes with hematoma
noted, unable to open his eyes when giving command.
4.) EARS
a. RIGHT: with blood
b. LEFT: with blood and pus
Noted during the inspection of the EENT (Eyes, Ears,
Nose, and Throat) doctor.
5.) NOSE: With Nasogastric tubing inserted and Oxygen
inhalation at 4L/min via nasal prong.

11. 6.) SINUSES: No inflammation noted
7.) MOUTH AND OROPHARYNX
a. LIPS: Pale, dry, cracked
b. BUCCAL MUCOSA: Moist
c. GUMS: Moist and pinkish
d. TEETH: 32 white teeth with no dentures
e. TONGUE: Moist and pale, no lesions noted.
f. SOFT PALATE: Pinkish and moist
g. HARD PALATE: Moist and whitish in color
h. TONSILS: No inflammation
8.) RESPIRATORY SYSTEM
a. INSPECTION: He is not using his accessory
muscles to assist breathing, with oxygen inhalation at
4L/min via nasal cannula, respiratory rate=16cycles
per minute.
b. PALPATION: non tender
c. PERCUSSION: (+) resonance
d. AUSCULTATION: normal breath sounds heard
(bronchovesicular sound)
9.) CARDIOVASCULAR SYSTEM
a. INSPECTION: (-)palpitations
b. PALPATION: presence of visible pulsations, pulse
rate=70beats/minute
c. PERCUSSION: (+)resonance

12. d. AUSCULTATION: Blood Pressure=130/90mmHg
PULSE SITES:
Temporal: 78bpm Popliteal: 79bpm
Carotid: 80bpm Doralis pedis: 65bpm
Brachial: 75bpm Posterior tibial: 70bpm
Radial: 70bpm Femoral: 73bpm
10.) BREAST
a. INSPECTION: No lesions noted
b. PALPATION: No mass and pain noted upon
palpation.
11.) ABDOMEN
a. INSPECTION: Free of lesions and rashes, pale,
umbilicus is midline at lateral line, noted abdominal
movement during respiratory movements.
b. AUSCULTATION:
c. PERCUSSSION: (+)tympanic sound
d. PALPATION: Free of swellings and masses
12.) GENITO-URINARY REPRODUCTIVE SYSTEM:
No Foley Bag Catheter attached, with diaper weighing
800mL after the end of the shift.
13.) ANUS AND RECTUM: unable to assessed the patient
14.) MUCULOSKELETAL SYSTEM: joints can easily
move.
15.) NEUROLOGIC SYSTEM
GLASGOW COMA SCALE

13. PARAMETERS FINDING SCORE
BEST EYE Spontaneously 4
OPENING To speech 3
RESPONSE To pain 2
(1) No response 1
BEST VERBAL Oriented 5
RESPONSE Confused 4
(3) Incoherent 3
Inappropriate 2
words
No response 1
BEST MOTOR Obeys
RESPONSE command 6
(5) Localizes pain 5
Flexion
withdrawal 4
Abnormal
flexion 3
Abnormal
extension 2
No response 1
TOTAL SCORE: [E1V3M5] =9
 DIAGNOSTIC EXAM
HEMATOLOGY
CBC REFERENCE RESULT SIGNIFICANCE
WBC COUNT 4.8-10.8 30.30 Increased:
10^g/L 10^g/L leukemia,
bacterial infection,

14. severe sepsis
HEMOGLOBIN 140-180g/ 143g/L Normal
L
HEMATOCRIT 0.42-0.52 0.43L/L Normal
MCV 80-94 87.00fL Normal
MCH 27-31 28.80pg Normal
RBC COUNT 4.70-6.10 4.98 Normal
10^12/L
MCHC 330-370 333g/L Normal
RDW 11-16 12.70fL Normal
MPV 7.2-11.1 7.60fL Normal
PLATELET 150-400 242.00 Normal
COUNT 10^g/L
DIFFERENTIAL
COUNT
NEUTROPHILS 40-74 86.40% Increased:
acute infections,
trauma or surgery,
leukemia.
malignant disease,
necrosis
LYMPHOCYTES 19-48 6.90% Decreased:
aplastic anemia,
SLE.
MONOCYTES 3-9 4.90% Normal
EOSINOPHILS 0-7 1.30% Normal
BASOPHILS 0-2 0.50% Normal
 ANATOMY AND PHYSIOLOGY

15. The nervous system is your body’s decision and communication
center. The central nervous system (CNS) is made of the brain and
the spinal cord and the peripheral nervous system (PNS) is made of
nerves. Together they control every part of your daily life, from
breathing and blinking to helping you memorized facts for a test.
The brain is made of three main parts: the forebrain, midbrain, and
hindbrain. The forebrain consists of the cerebrum, thalamus, and
hypothalamus (part of limbic system). The midbrain consists of the
tectum, and tegmentum. The hindbrain is made of the cerebellum,
pons and medulla. Often the midbrain, pons, and medulla, are
referred to together as the brainstem.
The Cerebrum: The cerebrum or cortex is the largest part of human
brain, associated with higher brain function such as thought and
action. The cerebral cortex is divided into four sections, called
“lobes”: the frontal lobe, parietal lobe, occipital lobe, and temporal
lobe.
• Frontal lobe – associated with reasoning, planning, parts of
speech, movement, emotions, and problem solving.
• Parietal lobe – associated with movement, orientation,
perception of stimuli.
• Occipital lobe – associated with visual processing.
• Temporal lobe – associated with perception and recognition of
auditory stimuli, memory, and speech.
The Cerebellum: The cerebellum, or “little brain”, is similar to the
cerebrum in that it has two hemispheres and has a highly folded
surface or cortex. This structure is associated with regulation and
coordination of movement, posture, and balance.

16. Limbic system: The limbic system, often referred to as the
“emotional brain”, is found buried within the cerebrum. This system,
from a midsagittal view of the human brain.
Brai stem: Underneath the limbic system is the brain stem. T his
structure is responsible for a basic vital life functions such as
breathing, heartbeat, and blood pressure. Scientists say that this is
the “simplest” part of the human brains because animas’ enter
brains, such as reptiles (who appear early scale) resemble our brain
stem.
The brain stem is made of the midbrain, pons, and medulla.
 Midbrain
 Pons
 Medulla
 PATHOPHYSIOLOGY
BRAIN INJURY
PREDISPOSING FACTORS CAUSE
>adults age (15-30) >motor vehicle accidents
>over the age of 70 Brain
>living in a high crime area
>male to female ratio 3:1
A blow to the head, even with no break in the skull, can cause
serious and diffuse brain injury.

17. Injury to the axons
Disrupts oligodendroglia and direct mechanical disruption caused by debris
and leakage.
There is immediate vascular response to the injury.
Results in increased capillary permeability to solutes.
COMPLICATIONS
Infections immobility hydrocephalus neurologic deficits SIADH
MANIFESTATIONS:
>Disturbance in level of consciousness
>headache
>vertigo
>agitation
>restlessness
>CSF leakage at ears and nose
>contusions about eyes and ears

18. >pupillary abnormality
>sudden onset of neurologic deficits
DIAGNOSTIC EXAMINATION
>CT scan
>skull x-ray
>complete blood count
>neuropsychological test
Date: March 02, 2011
CT scan
Procedure: Brain (Completion)
Findings:
Follow up study with examination done last February 28, 2011 shows
there is slight interval increase in the size of the contusion hematoma in
the right frontal parenchyma now measuring 2.2 x 1.8 previously 1.8 x 1.5
cm. There is more pronounced perilesional edema noted in the right frontal
lobe and basal ganglia. The frontal horns appear compressed. There is
resolving soft tissue swelling and hematoma in the left frontal scalp.
MEDICAL MANAGEMENT
>Placement of NGT with intubation to prevent aspiration
>Administer antibiotics
SURGICAL MANAGEMENT
>Shunting to relieve persistent fluid build up
>evacuation of intracranial hematomas
>debridement of penetrating wounds

19. >subdural tapping to remove fluid
NURSING MANAGEMENT
>monitor for declining LOC
>elevate the head of bed at 30 degrees as ordered
>turn patient every 2 hours
>monitor potential complications
>provides skin care every 4 hours
 SUMMARY OF FINDINGS
 DRUG THERAPEUTIC RECORD
NA DOSA CL MECHANIS INDI CONT SID NURSING RESPONSIBLITIES
ME GE AS M OF CATI RA- E
OF SIF ACTON ON EFF
DR IC INDIC ECT
UG AT ATION S
-
IO
N
TR 50mg An Binds with To Alcoh CNS BEFORE:
AM IVTT alg mu- reliev ol :
AD q8 esi receptor e intoxi >Check the medication record.
Dizz

20. OL hrs. c and mode cation ines >performed skin test.
HC inhibits the rate exces s,
L reuptake to sive fati DURING:
of mode use of gue
(UL >monitored the patient every now and then.
norepineph rately centra
TR rine and sever l CV:
AFTER:
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which may pain. analge >urge S.O to notify prescriber about unusualities.
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21. h
Ery Eye Ant Binds the To Hyper CNS BEFORE:
thr ointm ibi 50s treat sensiti :
om ent to oti ribosomal mild vity to >Check the medication record.
yci both c subunit of to erythr Fev
er, DURING:
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QID ribosome rate n or mal
>Instruct S.O not to let the patient to scratch his eye
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yth types of and compo >Report for any reactions.
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cells, s.
causing Hea
them to ring
diet loss
GI:
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GU:
Vag

22. inal
can
didi
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SKI
N:
jau
ndic
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Chl 1g Ant Produces a To Hyper CNS BEFORE:
ora IVTT ibi bacteriosta treat sensiti :
mp (ANS oti tic effect or bacte vity to >Check the medication record
he T) q6 c susceptible remia chlora Con
fusi >performed skin test.
nic hrs. organisms or mphe
ol by meni nicol on,
DURING:
Na inhibiting ngitis or its feve
protein . compo r >assess the patient for any unusualities.
(ch synthesis, nents.
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thereby
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yce amino y
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to growing EEN
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23. HE
ME:
Ane
mia
SKI
N:
Ras
h
Oth
er:
Ang
ioed
ema

24.  NURSING CARE PLAN
DATE CUES/ NURSING SCIENTIFIC EXPECTED NURSING RA
BASIS OUTCOME INTERVENTION
EVIDENCES DIAGNOSIS S
March 5, Subjective: Risk for The client After >Monitor for >O
2011 infection with a skull otorrhea or fra
related to fractures it at rhinorrhea. th
possible high risk for inc
access to the infection po
Objectives: cranial through the lea
contents wound that fro
through a tear may be or
in the dura contaminated >Keep the
by dirt, hair, nasopharynx >W
or other and the external dr
debris. ear clean. Place fac
a piece of sterile mo
SOURCE: cotton in the or
ear, or tape a
Medical-
sterile cotton
Surgical
pad loosely
Nursing,
under the nose;
Vol.2, 3rd ed.
change
By Priscilla
dressings when
Lemone
they become
wet.
>Use aseptic >U
technique at all te
times when re
changing head po
dressings and int
insertion sites. inf
>Test drainage >C
of clear fluid dr
from ear and te
nose for glucose fo
by using a ind
glucose reagent lea
strip, such as CS
Dextrostix.

25. •

26. S: Fluid Volume Nursing care After 2 hours >Measure >T
Excess for the client of nursing intake and th
with fluid care output. pa
volume interventions,
O: >Assess vital >H
excess there is
includes decrease of signs and ac
BP=130/90nnH
administering edema. breath sound hy
g
diuretics and every 4hours.
>T
PR=70bpm maintaining
>Turn the sk
fluid
RR=16cpm patient every br
restrictions.
2hours.
Temp=36.8 >O
SOURCE:
degrees Celsius >Provide oral co
Medical- care every cli
Edema of the 2-4hours. an
Surgical
hands and mu
Nursing,
periorbital me
Vol.2, 3rd ed.
regions int
By Priscilla
Lemone re
Skin cool and
flu
pale, dry lips
re
>T
>Elevate head go
of the bead at br
30-45degrees.
>T
>Assess the if
extent of edema de
particularly in ed
the lower
extremities and
periorbital
regions
Self Care After 2hours
The client
Deficit of nursing
needs
care
assistance
interventions,
with dressing,
the significant •
grooming,
others will be
and feeding.
able to
The help
perform daily
needed can
care
range from
activities.
minimal
guidance to
total
dependence.

27. Discharged Planning
Medication
Encouraged the patient
to take the prescribed
medications and follow
instructions of dosage and

28. time intervals as prescribed
by the physician. The
medications are as follows:
Penicillin
Doxycycline 100mg 1
tab BID
Kalium ii tab TID

29. Instructed patient for
following check up after 1
week
Environment
Instructed the patient to
use protective clothing and
boots during getting food
for the animals.

30. Encouraged to clean the
household to prevent
pesticides from circulating
the house
Treatment
Encouraged the patient
to take vitamin C and

31. medications as prescribed
by the physician
Health Teaching
Educated the patient to
increase awareness about
the disease and the
importance of health
maintenance and wearing of

32. protective clothing and foot
wear.
Observable Signs and
Symptoms
Instructed patient if he
noticed signs and
symptoms, immediately

33. refer or report it to the
nearest hospital
Diet
Instructed patient to
always eat nutritious food
like fruits and vegetables
and have a proper diet.
Spiritual

34. Encouraged patient to
always pray to God and
don’t forget to visit his
house every Sunday and
asked guidance
Objectives Methodology
Evaluation
General:
After 8 hours of nursing intervention, the patient will be able to understand and
participate of doing some dependent activities
Specific:
After 30 minutes of nursing interventions the patient will be able to gain knowledge about
the disease

35. Content
• Therapeutic regime
• Protective Clothing
• Mode of Transmission
• Signs and Symptoms
Proper hygiene
Methodology
Demonstration
Taking examples
Health teaching

36. Evaluation
After 8 hours of nursing
intervention the patient
was able to verbalize
knowledge and asked
questions