C.

M PATEL COLLEGE OF NURSING

GANDHINAGAR

SUBJECT: ADVANCED NURSING PRACTICE

TOPIC: CASE STUDY:

“HEAD INJURY”

SUBMITTED TO:
MR. RAJESH RAVAL
ASSOCIATE PROFESSOR
C. M .PATEL OF NURSING

SUBMITTED BY:
SIJI S. SADASIVAN
F.Y. M.Sc. Nursing
Roll No-16.

SUBMITTED ON:

1
 (A) BIODATA OF THE PATIENT:
 Name of the patient : Mukesh Shantilal Prajapati
 Age : 32 Years Sex : Male
 Marital status : Married.
 Date of Admission : 6-02-2014. Time : 8.54 am am
 Indoor No : 876828
 Ward : Trauma ICU.
 Resident Address : Sector no 12, Gandhinagar, Gujarat.
 Religion : Hindu.
 Education : 10 std.
 Diagnosis : head injury
 Operation if any : Tracheostomy done.
 Name of Doctor : Dr. Jaydeep Gadhvi.
 Occupation : shop keeper
 Monthly Income : Rs. 3000=00 per month.
 Weight : 54 Kg.
 Health Habit :
- Smoking : Yes
- Tobacco chewing : No
- Alcohol Consumption : No
- Vegetarian / Non-vegetarian : No
(B) CHIEF COMPLAINTS:
Mukeshbhai was asymptomatic before 1 day. He got head injury by slipping of
motorcycle on the date 5-02-2014 at 9.00 am and he developed following signs and
symptoms.
 History of loss of consciousness
 History of vomiting once
 History of convulsion
 Injury to occipital region and hematoma over their
 Bleeding from ear

(C) HISTORY OF PRESENT ILLNESS:

Mukeshbhai was asymptomatic before 1 day. Then one day on the date 5-2-2014 at
9.00 am he went outside from his house to Mandasor by bike .He reach at mansand
village he received the mobile call on the high way and talking with his friend during
that time he was slipped from the motorcycle. He got head injury and hematoma over

2
 back side of head and become unconscious, bleeding from ear was present and also
he develop vomiting and convulsion. Than he shifted at near hospital at mandasor
and took treatment from their. Doctor advised his relative to refer higher centre for
further investigation and for better treatment on date 6-2-2014. He transfer from
mandsor hospital to civil hospital Gandhinagar on date: 6-2-2014 at 9.00 am and
admitted in civil hospital Gandhinagar in trauma ICU.

(D) HISTORY OF PAST ILLNESS:

There was no any past history of major illness like T.B, Hypertension, Diabetes mellitus,
Hepatitis
No H/o Vomiting, diarrhoea, constipation, Abdo.lump haemoptysis, Trauma, hematuria

(E) Family History:

Age
Name of Family Relationship Illness in Family
Sr.No. in Education
Members With patient Members
Year
1 Mukeshbhai Shantilal 32 Self Head injury Secondary education
Prajapati
2 Santoshben Mukeshbhai 25 Wife No 5th std.
Prajapati
3 Laxmiben Mukeshbhai 9 Daughter No Studying in 3rd std.
prajapati
4 Ashaben Mukeshbhai 6 Daughter No Studying 1st std.
Prajapati
5 Lokesh Mukeshbhai 4 Son No
Prajapati

(F) Health facility near Home:

There was a one dispensary near by patient’s home. Only 0.6 kilometer away from
his house. There are other private doctors in his area where he is residing. The primary
health centre is 6 kilometer from his house, so they are using UHC as a medical treatment.
Transport facility is available in the form of Government bus services as well as private
vehicles are also available for transportation.
(G) Housing:
Mukeshbhai has his own pakka house in village. The house is having one hall and
2 rooms, 1 kitchen and facilities of toilet and bathroom are also available in house. There
are also facilities of electricity and drinking water.
(H) Nursing Assessment:
Vital sign:
 Temp: 98.6 F.

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  Pulse: 88 /min. Regular Regular Irregular Low volume Bounding
Water hammer
 Respiration: 20 /min. Normal Normal Tachypnea Crackle
 BP: 122/82 mm of Hg.

Subjective data

 Abdominal pain : Not Present

 Palpitation: Not Present
 Fatigue: Not Present
 Dizziness: Patient is unconscious

Objective Data

Assessment of Cardiovascular system:

 Heart rate: 88 beats/min.
 Rhythm : Regular
 Apical Pulse: 88beats/min.
 Jugular vein distention: No.
 Heart sound: S1, S2 Present, No murmur.
Respiratory System:
 Respiration rate: 20 breaths /min.
 Breathe sound: No foreign sound.
 Dyspnea: not present.
 Pulmonary effusion: No.
 Cough: Not present.
Abdomen:
 Hepatomegaly: No. Abdomen is soft and no mass palpate
 No tenderness
Skin:
 Color of mucous membrane :Mild Pale
 Peripheral Cyanosis: yes mild.
 Clubbing: No.
 Ecchymosed : No
Urinary system:
 Urine output: 1000 ml/24hrs.
Extremities:
 Edema: No
 Color and Temperature of Skin: Warm and moist.

(I) PROVISIONAL DIAGNOSIS: - Head injury

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(J) FINAL DIAGNOSIS: -Head injury

(K)CAUSES AND ETIOLOGY:- (IN BOOK)

1. Assaulted injury
2. Gun shot injury
3. Fall down from height
4. Blowing Injury
5. Motorbike injury
6. Road traffic accident
7. Dying in water during swimming
8. Any types of accidental injury
9. Boxing injury
10.Sports injury
11.Hit by some one

In my patient the etiological factor or cause is motorcycle is slipped on highway and he

fall down from bike and got head injury.

(L)Biochemical and diagnostic test:

Biochemical test/
In patient Normal reference rang
Diagnostic test
Blood test
 Hb 9.4 gm/dl. M: 13-18gm/dl
F: 12-16gm/dl
 Total WBC 14400 / cumm 4000-10000/cu mm
 DC P-68%, E-20%, B-2%, L-1% P-45-73%, E-0-4%,B-0-1%
M 00 % M-2-8%
 ESR 20 mm/Hr. M:<15 mm/hr.F:<25mm/hr
 SGPT -
 LDL -
26 mEu/l.
 S. Urea
 S,creatinine
0.8 mEu/l. 0.7-1.4mg/dl.
 S. Na+ 136 mg/dl. 135-145 mEq/L
 S.K+ O.8 mg/dl 3.5-5.0 mEq/L
 Bl.Sugar(RBS) 98 mg/dl 65-140mg/dl.
 S.Bilirubin 0.8 0.1-1.0 mg/dl
 S.HIV Negative Negative
 HBsAg Negative Negative
 S.Acetone < 10 mg/dl Up to 10 mg/dl
 S.Calcium - 65 mg -140 mg/dl
 Total protein - 8.1-10.5 mg/dl
 Albumin - 6.6-8.3 mg/dl

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  Globulin - 3.5-5.00 mg/dl
- 2.3-3.3 mg/dl
X-ray chest NAD - Lungs clear.
- No cavity
- BVM Normal
ECG WNL - Rate : 60-100/min
- P : Height<2.5mm
- Width< 2.5mm
- QRS: < 0.10 Sec.
- Depth & width of
Q wave : <0.04mm
USG Abdomen NAD NAD

Ct brain Hemorrhagic contusion noted Normal CT Brain

in left frontal region
Hemorrhagic contusion noted
in left temporoparital region
Approximately 54+14 mm
size extra dural hemorrhage
noted in right temporoparital
region.
Fracture noted through right
temporal bone
Left maxillary +sphenoid
hemosinus
Basal cisterns and ventricle
appear normal
Cerebellum and brain stem
appear normal
No c/o mass effect/midline
shift noted.
x-ray skull Fracture note d on right NAD
temporal lobe

(M) PATHOPHISIOLOGY:
Due to head injury

Contusion occur & edema develop and increase intracranial pressure

High blood pressure in cerebral vessels

Cerebral vessels are break down because of brain injury

Cerebral hemorrhage

Cerebral hematoma

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 Ischemia to particular part of brain

As per affected area of brain, functions of the brain disturbed

All signs and symptoms of head injury develop like vomiting, giddiness

Loss of communication function loss of motor function, perceptual disturbance,

bladder and bowel dysfunction

Patient become unconscious and COMA

Death

(N) CLINICAL MANIFESTATION (SIGN ANSYMPTOMS):-

IN BOOK IN PATIENT
1. CSF drain from the ear or from the nose ABSENT
2. Evidence of various cranial nerve injury PRESENT
3. Blood behind the tympanic membrane PRESENT
4. Bleeding from the ear or nose PRESENT
5. Periorbital ecchimosis(Bruise around the eye) ABSENT
6. Later , a bruise over the mastoid process (Battle’s PRESENT
sign)
7. Vision change from optic nerve damage PRESENT
8. Hearing loss from auditory nerve damage PRESENT
9. Nausea and vomiting PRESENT
10 Headache due to intracranial pressure increase ABSENT
11. Loss of the sense of smell from olfactory nerve PRESENT
damage
12 Squite or fixed , dilated pupil and loss of some eye PRESENT
movement s
from Occulomotor nerve damage
13. Vertigo caused by damage from otolits in the inner ear ABSENT
14 Nystagmus from damage to the vestibular system ABSENT
15 Skull fracture due to direct blow on skull PRESENT
16 Unconsciousness for few seconds,minute,hours or PRESENT
days

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(O) TYPES OF HEMORRHAGE:
CEREBRAL HEMORRHAGE:
(Rupture of a cerebral blood vessel with bleeding into the brain tissue or spaces
surrounding the brain). The result is an interruption in the blood supply to the brain,
causing temporary or permanent loss of movement, thought, memory, speech, or
sensation.

 EPIDURAL HEMMORRHAGE: Hemorrhage may occur outside the duramatter

(extradural or epidural hemorrhage)
 SUBDURAL HEMMORRHAGE: Bleeding between duramater and arachnoids
membrane.
 SUB ARRACHNOID HEMMORRHAGE: Hemorrhage occurring in the
subarachnoid space.
 INTRACEREBRAL HEMMORRHAGE: Hemorrhage or bleeding into the
brain substances.
(P) CONCUSSION:
A cerebral concussion after a head trauma is a temporary loss of neurological functions
from which there is a complete recovery. There is no apparent structure damage and
recovery quickly. A concussion generally involves aperiod of unconsciousness lasting
from a few seconds to a few minutes

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(Q)CONTUSION:
A cerebral contusion is a more severe cerebral injury in which the brain is bruised with
possible surface hemorrhage. The patient is unconscious for a considerable period. The
symptoms as would be expected are more marked. The patient may lies motionless, the
pulse is feeble, the respiration shallow, and skin cold and pale. Often there is involuntary
evacuation of bowels and the bladder. The patient may be aroused with effort but soon
slips back in to unconsciousness .The Blood Pressure and the temperature are subnormal
and the picture is somewhat similar to that of shock.
(R) FRACTURE OF THE SKULL:
A skull fracture is a break in the continuity of the skull caused by trauma. It may occur
with or without damage to the brain. The presence of a skull fracture usually means that
there was considerable force on impact. Skull fracture are classified as open or closed. In
an open fracture, the dura is torn, and in closed fracture the dura is not torn.

IN MY CLIENT: Depressed fracture of the skull.

Hematoma

( Depressed fracture of the skull.)

(S) EMERGENCY MANAGEMENT:

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1. Maintain the airway and exchange of air-hypoxia and Hypercapnia can increase
brain swelling and cell damage.
 Keep the patient in a lateral recumbent, prone or semi prone position with to
one side, after making certain that, there is no cervical spine injury. Prone
position facilities drainage from the tracheobronchial tree and minimizes
aspiration of nasopharyngeal and gastric secretions.
 Cleared the respiratory passage by means of suctioning.
 Ensured adequate oxygenation and humidification.
 Obtained portable x-ray of lateral cervical spine and ruled out that no cervical
spine injury or fracture.
 Assisted in endotracheal intubation first and later on assisted in tracheostomy
procedure and started oxygen from tracheostomy tube6-8 liter per minute.
 Utilize assisted ventilation if necessary. Keep ready the assisted ventilator for
emergency ventilation.
2. Controlled hemorrhage and shock.
 Looked for extra cranial source of bleeding e.g., Abdomen, thorax, long bone
fracture, scalp injury, and there was a hematoma on the back side of head rt.
Lateral side of occipital.
 Marked intracranial injury and bleeding from ear also present.
 Brain injury is present, CTBRAIN SUGGESTED in two points injury noted
and mentioned contusions.
3. Determined the based line condition of the patient.
 Assessed level of responsiveness by GCS AND REVISED TRAUMA
SCORE which was
GCS---7/15
Speech absent - 1
Motor localized pain - 5
Eye opening absent -1

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 REVIZED TRAUMA SCORE ---10/12
A. GCS B. RESP.RATE C. SYSTOLIC B.P.
13-15 ----4 10-29----- 4 > 90---- 4
9-12 ----3 > 30 ----- 3 76-89 --- 3
6-8 ---- 2 6-9 ------ 2 50-75 --- 2
3-5 ----- 1 1-5 ----- 1 1-49 ---- 1
0 ---- 0 0 ----- 0 0 ---- 0
 Determined the presence of vomiting and bleeding from ear.
 Evaluated the pupil which was fixed and semi dilated and not reacting to
light.
 Measured vital signs which was
Pulse - 88/minute
Blood pressure-- 120/80 mm of Hg
Resp.rate --20/minute
Temp. ----- 98.6 F
Spo2 ---- 95
 Evaluated for signs of raising intracranial pressure which was deterioration
in level of responsiveness here patient is unconscious and condition of patient is
deteriorate , also pulse is increase and no reacting pupil,ans also tracheostomy is
done and patient is on the oxygen therapy 6-8 liter per minute.
 Assessed for injury to other organs system which was not present only brain
injury and fracture skull are present.

4. evaluated for changes in patients condition

 Patients condition is critical because of brain injury and ct brain s/o
contusion in brain two or more sites of brain.

11
5. Utilized intracranial monitoring for recognition of increased intracranial
Hypertension and to help guide therapy
6. Maintained an opened airway and ensure maximum respiratory functions.
 Checked spo2—continuously which was 95 %
 Oxygen started by tracheostomy tube 6-8 liter per minute
 Gave pron position to patient.
 Turned the position of patient frequently side to side.
7. Observed ,evaluated and carried out repeated clinical examination done
Makes specific documentation of clinical findings.
 Responsiveness(Consciousness)
 Quality of breathing breathing is little fast.
 Change in respiratory pattern increased rate
 Pupil reaction and size-Semi dilated and not reacting to light.
 GCS and REVIZED TRAUMA SCALE recorded.
 Obtained CT-BRAIN to determine intracranial pathology.
 Started intravenous fluids INj.-DNS 2 Paints.
 Kept patient nil by mouth.
 Catheterization done and maintain urine out put chart.
8. Treated shock for that
 Maintain prone position of patient.
 Gave intravenous fluid like INj. R.L.2 paint.
 Gave injection Epsolin 50 mg 8 hourly for control of seizures.
 Gave head low position
 Covered the patient with blanket.
 Watch for gastrointestinal complication.
9. Carried out rehabilitation techniques.
 Positioned the patient correctly to prevent contracture.

12
  Put all extremities through rang of motor exercises
 Keep the skin dry, clean and free of pressure to prevent pressure sores.
 Gradually increase physical and mental activity.

(T) MEDICAL MANAGEMENT:

1. Injection Taxim 1gram 8 hourly
2. Injection Lactagard 1500 mg 12 hourly
3. Injection Epsolin 50 mg 8 hourly
4. Injection Mannitol 100mg 8 hourly
5. Injection Metrogyl 100 mg 8 hourly.
6. Injection Lasix 10 mg 12 hourly
7. Inj Fibrinil 500 mg 8 hourly
8. Injection Citinova 250 mg 8 hourly
9. Injection MVI one ampoule in Paint daily
10.Injection Pantaprasol 20 mg 12 hourly
11.Injection DNS 2 paints i/v slowly.
12.Injection Dextrose 5 % i/v slowly.
13.Injection Ringer lactate 2 paint i/v slowly.
14. Oxygen therapy by tracheostomy tube 6-8 liter per minute.
15.Ciplox eye drops in both eyes 4 hourly 2 drops.
16.Catheterization care daily with antiseptic solution.
17.Dressing of wound with beta dines ointment every day.
18.Observe vital signs 4 hourly and recording.
19.Suction every hourly and as per requirement.
20.Maintain u/o I/O chart daily.

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 DRUG SHEET

DRUG & ACTION USES CONTRAINDIC SIDE

DOSE ATION EFFECT
Injection Bactericidal Bacterimia , Hypersensitivity Pain at
Lactagard action by cell septicemia, to salbactum and injection site
1500 mg wall synthesis Endocarditic, Bone cefoparazone if injection
BD and joint infection given by i/m
,Genitourenary,obstr route, g i
etic and gyenic and upset, renal
intraabdominal impairment
infection
Inj.Taxim Bactericidal by Bacterimia, Hypersensitivity Renal failure
1000 mg 8 cell wall septicemia, to cefotaxime and ,Leucopenia,
hourly synthesis Endocarditic, Bone cephalosporin Eosiniphelia,
and joint infection, Pain at
Genitourinary, injection site
obstetric and gyenic
and intraabdominal
infection, soft tissue
injury, Use as a
prevent infection in
post oper.
Calcium Supplementatio Tetani, Lactation Renal Anorexia dry
gluconate n in calcium ,calcium calculi,Hypophos mouth , thirst,
137.5 mg deficiency, for supplementation in phataemia, Polyurea,
/ml 10 ml calcification in pregnancy, Growing Hypercalcimia, constipation
ampul fractured bone children, Elderly, Digitalis therapy,
once a day ,treatment in a Osteoporosis Galactosemia
tetani
Inj.Fibrinil Antipyretic and Malarial fever Hepatitis, If over dose
500 mg 8 analgesic,antiinf ,Typhoid Analgesic goes than
hourly lamatory fever,Pyrexia,Releiv nephropathy jaundice
ed to mild pain ,hypoglycemi
a and
metabolic
acidosis occur

Inj.Epsolin Anticonvulsant Grand mal and Pregnancy(Unless Skin reaction

14
100 mg 8 Mechanism of psychomotor the benefit ,nystagmus,
hourly action not fully seizure, Also used in obtained clearly Ataxia,
understood certain cardiac outweighs the Confusion
although they arrhythmias possible risk) ,G.I.Desterban
are thought to ceHersuitism ,
increase the lymph node
seizure enlargement
threshold in the
motor cortex
possibly by
interfering with
the movement
of ions

Inj MVI 1 It prevent Vita b-complex Hypersensitivity Gastritis ,

ampul in pernicious deficiency, to vita b complex nausea,
pint anaemia, use as stomatitis digestive
a nerve tonics a ,Polyneuropathy, disturbance
supportive cervical lumber
therapy syndrome,Scietica
Pantapraz Inhibits gastric Zollinger Ellison Sensitivity to Rare
ole 20/40 acid by syndrome, pantaprazole
mg once a blocking the hyperacidity
day hydrogen disorders, chronic
–potasiumATP episodic dyspepsia
enzyme system
in gastric
parietal cells
Fibrinil Antipyretic and Malaria Fever Hepatitis Dry mouth ,
500 mg 12 also analgesic ,Pyrexia and thirst
hourly and action typhoid fever and
SOS for any types of
pain
Metrogyl Bactericidal Desentry, Active CNS G-I
500 mg 8 specially prevention and diseases Blood disturbance,
hourly anaerobic treatment of dyscrasias, first furred tongue,
bacteria anaerobic infection trimester of unpleasant
pregnancy taste
leucopenia ,
dark urine
Inj. Lasix Potent diuretics Head injury , Anuria ,hepatic Anorexia
20 mg i/v which act Hypertension coma nausea ,
12hourly primarily by ,lgucoma,Pulmonar ,Concomitant vomiting
15
 blocking y edema Congestive lithium therapy ,Diarrhea,
sodium & cardiac failure, ,Hypersensivity to Hypotension,
chloride edema Renal diuretics Fluid and
reabsorbtion in insufficiency electrolyte
the ascending imbalance
limb of the loop paraesthesia ,
of henle. May cramps ,
also exert the Weakness,
additional effect Azotaemia
on the proximal Hyperglycemi
and distal tube a,
Precipitation
of acute gout,
Headache
,Rashes
,confusion,
blurred vision
Disturbance of
hearing
Inj. Reduce Head injury Pregnancy Dryness of
Manitol intracranial ,Cerebrovascular mouth
100ml 8 pressure by accident, Brain ,Hypotension
hourly diuretics action tumorGlucoma

Inj. Protect of Specially used in Previous Nausea

Citinova integrity of cell cerebrovascular hypersensivity to ,Rashes
250 mg 8 membranes in disorders, ischemic citinova or to any ,insomnia,
hourly brain ischemia, shock ,and head of the ingredient feeling of
with resultant injury of this drug. warmth,
improvement abnormal
of neurological values of liver
function functions.,
Attenuation of hypotension
progression of ,bradycardia
ischemia cell ,gastralgia
damage by ,vomiting
suppressing
release of free
fatty acids ,
Improve of
cerebral
16
 function by
interaction with
other
transmitters and
/or
receptors.Vasoa
ctive and
antiplatelate
properties
leading to
improve
microcirculation
, and activation
of the
dopaminergic
system and
work s ant
Parkinson effect

(U) SURGICAL MANAGEMENT:

1. Craniotomy (Burr holes):
Craniotomy means making a hole or opening in the skull after complete investigation
surgeon will removes the hematoma or blood clot from the epidural side and also he
irrigate the inner side with normal saline or with antiseptic solution and placed the anti
hemorrhagic drugs to control internal hemorrhage and close it layer wise.

In head injury patient an epidural hematoma is considered an extreme emergency, as

marked neurological deficit or even cessation of breathing may occur within minutes. For
that reason the treatment consist of making opening through the skull, removing the clot
and controlling the bleeding point.

(V) NURSING MANAGEMENT:

1. Give Lateral or semi prone position to prevent tongue fall down.

2. Intubation and mechanical ventilation.

17
 3. First clear the airway, breathing , and circulation then
4. start oxygen therapy 100 % 15 liter /minute
5. Auscultation of chest for air entry every 8 hourly
6. Maintain i/o and u/o chart daily
7. Gave i/v fluids antibiotics, analgesics. anticonvulsive drugs as per doctors order
8. Vital signs taken and recorded(TPR and B.P.1 hourly)
9. Suction: Remove mucus, saliva, fluid and vomited material from mouth.
10. Maintain fluid and nutritional balance
Intravenous fluid
Blood transfusion if require
11. Elevate the head of the bed to a 30 degree angle.
12. NBM if patient is not able to eat or drink
13. Tracheostomy done so care of tracheostomy tube .
14. Suction done frequently
15. Oral hygiene (Mouth care).Maintain healthy oral mucus membrane.
16. Maintain corneal integrity
17. Preventing urinary retention by catheterization and do catheter care
18. Promoting bowel function.
19. Change the position frequently (Two hourly)
20. maintain safety by providing side rails
21. Promoting sensory stimulation by instructing patient daily once time about time,
place and person.
22. Supporting the family.
23. Attaining self care.
24. Monitoring and maintaining potential complication.
Medical treatment of the patient with a head injury may include diuretics to reduce
cerebral edema, which reaches maximum levels 3 to 5 days after cerebral infarction.
Anticoagulants may be prescribed to prevent further development or propagation of the
thrombosis or embolization from elsewhere in the cardiovascular system. Antiplatelate
18
medications may be prescribed because platelets play a major role in thrombus formation
and embolization.

NURSING CARE PLAN:

Application of Orem's Self-Care Deficit theory in Nursing Practice is done.
Dorthe Orem believed that people have a natural ability for self care and that nursing
should focus on affecting that ability (Orem, 1995). According to Orem's theory,
individuals whose needs for self care outweigh their ability to engage in self care are said
to be in a self care deficit (Isenberg, 2006). People in or at risk for self care deficit are
those in need of nursing intervention strategies to assist in becoming self sufficient in
managing their disease processes. This theory can act as a guide to nursing practice in
multiple settings and can involve patients throughout the life span in various stages of the
health-illness continuum.

OREM’S GENERAL THEORY OF NURSING

Orem’s general theory of nursing in three related parts:-

 Theory of self care

 Theory of self care deficit
 Theory of nursing system

OBJECTIVES OF THE OREMS THEORY IN APPNICATION OF NURSING

THEORY:

 To assess the patient condition by the various methods explained by the nursing
theory
 To identify the needs of the patient
 To demonstrate an effective communication and interaction with the patient.
 To select a theory for the application according to the need of the patient
 To apply the theory to solve the identified problems of the patient
 To evaluate the extent to which the process was fruitful.

REASON FOR THE APPLICATION OF THE THEORY :

Here the Orem’s theory of self care is used as the clients activities of normal self care are
only limited to a short span of the disease condition. There are no long term deficits that
the client will be facing. By giving adequate support the client will be able to deal with the
health needs herself. Here the term defined according to the clients condition is:

 Self care – Practices of activities that individual initiates and perform on their own
behalf in maintaining life, health and well being.

19
 -For the client: The normal grooming, bathing, maintenance of hygiene, breathing,
protecting from injuries of environment e.g. mosquitoes, unhygienic area etc. was
performed without help. But now client is unable to do it due to the deficit in
performing activities of daily living.

 Self care agency – is a human ability which is "the ability for engaging in self care"
-conditioned by age developmental state, life experience sociocultural orientation
health and available resources.

-The client has attained the role of a father. She is taking care of family.

Therapeutic self care demand – "totality of self care actions to be performed for
some duration in order to meet self care requisites by using valid methods and
related sets of operations and actions"

- For the client: he is suffering from unconciousness, weakness, unable to carry out
activities of daily living. These needs are temporary and have to be met by the
nurse.

 Self care requisites-action directed towards provision of self care. 3 categories of

self care requisites are:--

1. Universal

 Developmental
 Health deviation

2. Universal self care requisites

 Associated with life processes and the maintenance of the integrity of human
structure and functioning
 Common to all , ADL
 Identifies these requisites as:
 Maintenance of sufficient intake of air ,water, food
 Provision of care associated with elimination process
 Balance between activity and rest, between solitude and social interaction
 Prevention of hazards to human life well being and
 Promotion of human functioning

3. Developmental self care requisites

 Associated with developmental processes/ derived from a condition…. Or

associated with an event

20
The client: he needs assistance in two fields of universal self care requisites and
developmental self care needs.
 Health deviation self care of the client:
 Requires being aware of the pathological condition of head injury
 Adjusting to the role of the head of family
 To maintain good immunity level .

21
 (X) NURSING PROCESS OF HEAD INJURY PATIENT

ASSESSMENT NURSING GOAL INTEVENTION EVALUATION

DIAGNOSIS
.
• Reports 1. Administer fibrinil • Reports relief of
Severe pain and Reduce edema
(paracetamol) or injection Pain.
frequent
discomfort related pain and diclofenic sodium • Moves and turns
episodes of intramuscularly frequently, as without increasing
to edema, and discomfort
pain, prescribed, based on patient's Pain and discomfort.
discomfort, and scalp injury as well level of pain and discomfort. • Rests comfortably
and sleeps for
cramping as head injury.
2. Assess pain level before and increasing periods of
• Moves and after administration of Time.
turns with analgesic. •Reports less frequent
increasing pain episodes of pain,
3. Report unrelieved pain or
and discomfort increasing intensity of pain. discomfort, and
Patient Assist the patient to assume
Cramping.
complaints of positions of comfort; turn and
pain Reposition q2h.
Observed pts
feeling pain
during change
of position

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Taken vital signs Ineffective airway The gal of the One of the most important nursing Attains/maintain effective
Which was clearance and patients may goal in the management of the airway clearance,
Pulse 88/ minute ventilation related include patient with a head injury is to ventilation and brain
Resp.Rate to hypoxia attainment of a establish and maintain an oxygenation.
20/minute patent airway adequate airway  Achieve normal
B.P.120/80 mm Keep unconscious patient in a blood gas values.
of hg position that Facilitates drainage of  Has normal breath
Spo2 90 % oral secretion , with the head of sounds on
Checked the bed elevated about 30 auscultation.
breathing degrees to decrease venous  Mobilizes and clears
patrerns pressure secretions.
Which shows Establish effective suctioning
difficulties and Guard against aspiration and
also fluid respiratory insufficiency.
secretion also Monitor arterial blood assess to
present . assess adequate of ventilation
Monitor the patient on mechanical
ventilator.

Restlessness High risk for Prevention of The patient is assessed to ensure Avoids injury
due to hypoxia, violence related to injury that the airway is adequate and Shows lessening agitation
fever and pain or disorientation, the bladder is not distended and restlessness.

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full bladder. restlessness and .Likewise , bandages and casts Is oriented to time place
Observed the brain damage. should be checked for and person.
signs of head constriction.
injury, Bleeding Protect the patient from self injury
from ear GCSis and dislodging of body tubes side
7/15 and revised rails are rapped and the patients
trauma hands may be wrapped in mitts.
score10/12. Allowed freedom of movement and
promotes patients safety.
Environmental stimuli should be
kept to minimum by keeping the
room quite, limiting visitors
,speaking calmly
Provide adequate lighting facility to
minimize hallucination.
The skin is lubricated with oil or
emollient lotion to prevent irritation
due to rubbing against the sheet.
If incontinence is the problem do
catheterization.

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General physical Altered thought Improved Neurologist plans a program and Shows cognitive
examination process related to cognitive initiates therapy or counseling that progression.
done .in which result of head functioning is design to help the patient reach Demonstrate lessoning of
patient is not injury maximum potential. inappropriate behaviours.
conscious. Cognitive rehabilitation activities  Shows improve
He got injury to are directed at redeveloping the memory.
brain and also patient’s ability to devise new  Verbalizes realistic
skull fracture problem solving strategies. plans.
present . The retraining is carried out over
an extended period and includes
the use of computer training
programme, video game, sensory
stimulations and reinforcement.

Observe d that Altered nutrition

patient is less than body
unconscious and requirement
not able to take related to
foo or liquid metabolic
orally. changes, fluid
restriction and
inadequate intake.

25
Patient is Fluid volume Fluid and Serial study of blood and urine Achieves satisfactory fluid
unconscious and deficit related to electrolyte electrolytes and osmolarities are and electrolyte balance.
not able to take disturbances of balance carried out because head injury Demonstrate serum
fluid orally. consciousness may be accompanied by disorders electrolytes within normal
He is not able to and hormonal of sodium regulation. Sodium range.
talk not able to dysfunction. retention may last several days, Has no clinical sign of
walk & not able followed by sodium diuretics. dehydrations or over
to open eye. Endocrine dysfunctions are hydration.
evaluated by monitoring serum
electrolyte, glucose values, and
intake and out put.
Urine is tested regularly for
acetone..
A record of daily weight is kept
,especially if the patient has
hypothalamic involvement and
must be observed for the
development of diabetes incipidus

26
27
NURSING CARE REPORT OF CLIENT:
6/2/2014
Checked Client’s vital signs
Client given medications, oral hygiene maintained, all nursing care
Functional test is normal
7/2/2014
Checked Vital Signs
Provided care of hygiene
T’stomy suctioning was done
Oxygenation is been given.
8/2/2014
Checked Vital signs
Oral care is given.
Backcare.
10/2/2014
Checked Vital signs
Intake-output chart maintained
Medications were continued
11/2/2014
Checked Vital signs
Intake-output chart maintained
Range of motion exercises
HEALTH EDUCATION
Injury prevention

Doing for/Enabling

Being with

Knowing

Maintaining Belief
Maintaining Belief

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 Helped the parents of child to understand the disease condition, holding themselves in
high esteem, maintaining a hope. Helping to final solution
Expressed being with child.
Knowing
Encouraging parents and child in the process of knowing. Explanation about disease
condition, Personal hygiene etc.
Being with
Being with the parents and sharing their feelings, psychological support and clarifying
doubts
Doing for
Checking the vital signs, providing bath, changing dressing, protecting the child from
complication.
Enabling
Helping to cope the situation and Encouraged early ambulation and resoring health as
much as possible.

(Y) CONCLUSION:-

Injury to the head involve trauma to the scalp, skull, and brain. Head injuries are
among the most frequent and serious neurologic disorders, and have reached
epidemic proportions as a result of traffic accident. As estimated 1000,000 persons
die annually from head injury and more than 700,000 have injuries severe enough
to require hospitalization.
At the time of admission the condition of patient is not good. Patient was
unconscious and GCS was 7/15 Revised trauma score 10/12 .Ct brain s/o
contusion in brain at various two side, also depressed skull fracture was present ,
bleeding from ear was present . So my patient Mr.KUKESHBHAI’S general
condition is poor.

BIBLIOGRAPHY

29
1. Lillian sholtis Brunner and Doris smith suddarth;”The Lippincott manual of
Nursing practice;”3rd edition, J.B.Lippincott Company,
Philadelphia: 1982, Page no. 712-714, 745-747.

2. Suzanne C. Smeltzer and Brenda G. Bare;” Bruner and suddarths text

Book of medical surgical nursing;” Eighth edition, Lippincott
Company, Philadelphia: 1996, page no. 1011-1015.

3. Joyce M. Black and Esther Matassarin-Jacob;”Medical surgical nursing

Clinical management for continuity of care;” 5th edition, W.B.Saunders
Company, New Delhi-India: 1997, Page no. 1522-1524.

4. Patricia A. Potter and Anne Griffin Perry;” Fundamentals of nursing;”6th

Edition Mosby Inc., Saint Louis: 2005, Page no. 745-746..

5. R.S. Satoskar,”Pharmecology and pharmecotheraputic” !3 th Edition, !993: Popular

Prakashan, Bombay, page No.121-130.

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