CASE STUDY

BSN 3A-GROUP A3
Macam, Reya Eliza
Santiago, Joanna Marie
Soriano, Ciarra Gaspar
Tolentino, Andrea C.
Tadeo, Airan
LEARNING OBJECTIVES

 Describe how the few cells and molecules in the brain alter after a traumatic incident happens.
 Admire the common signs of TBI, such as post traumatic stupor, severe headache, vomiting and
focal neurological signs.
 Describe the clinical manifestations and diagnostic characteristics of: Except for minor head
injury, commonly referred to as concussion.
 Acquaint yourself on the first care and treatment of TBI that comprises of stabilization,
operations, and medications.
 Future rehab management of TBI patient brings you to the reason why patients with TBI need
rehabilitation during their recuperation period.
 Understand the kind of attention that one should be given depend on the chronic complications
such as seizure, memory problems, and mood swings.
 Understand more detail about the severity of the clinical case and apply learning to come up with
the plans of the treatment. 
 Enhance knowledge applied in the problem-solving category in the management of TBI patients.

BIOGRAPHIC DATA

Name: Patient M
Age: 25 years old
Address: La Paz, San Marcelino Zambales.
Chief Complaint: Loss of Consciousness
Admitting Diagnosis: Traumatic Brain Injury, Laceration Occipital secondary to Motor Vehicle
Accident.
History of Present Illness:
Past Health History:
Family History:

INTRODUCTION

Functional Health Problems ( Gordon’s Functional Patterns)

To avoid further difficulties, the patient understands the severity of TBI symptoms, seeks medical help
as soon as possible, and adheres to the prescribed therapies.

Nutrition - Metabolic Pattern

The patient follows a bland, easy-to-digest diet high in vitamin C, A, and zinc, which support healing
and immunological function.

Elimination Pattern
Due to potential limitations in mobility, the patient is urged to use the restroom with the supervision of
a guardian to avoid falls or injury.

Activity-Exercise Pattern.
The patient is mostly on bedrest, with mild walking during the day when tolerated to prevent muscular
atrophy and enhance circulation.

Cognitive-Perceptual Pattern
TBI-related cognitive impairment may demand the support of a guardian with memory, decision-
making, and problem-solving skills.

Sleep-Rest Pattern
The patient has a prolonged Sleep, which is typical during TBI recovery, helps brain regeneration and
reduces cognitive strain.

Self-perception - Self-concept Pattern

Lethargy and changes in energy levels can have an effect on the patient's self-concept, potentially
leading to frustration or a sense of helplessness.

Role Relationship Pattern

The patient communicates openly with family members about the impacts of TBI and seeks emotional
and physical assistance from them.

ACTIVITIES ON DAILY LIVING

Bathing: The patient was not able to bathe independently; assistance needed all the time.

Dressing: The patient was not able to get dressed and needed the assistance of a nurse

Toileting (getting on the toilet, using the toilet, and cleaning themselves): The patient was not able
to go to the toilet independently; assistance was needed.

Transferring (moving in and out of beds/chairs): The patient was unconscious all the time; if
conscious assistance of a nurse is needed

Continence (controlling bladder and bowel function): The patient was not able to poop since
admission.

Feeding (does not include meal preparation): The patient was not able to eat independently;
assistance was needed.

HEAD TO TOE ASSESSMENT

GENERAL Normal: Abnormal: Findings:

APPERANCE Alert and Cooperative Drowsy and Altered consciousness
Unresponsive
HEAD No trauma Swelling, skull fracture Depressed skull
fracture/ hematoma
EYES PERRLA Unequal pupils, Sluggish Fixed, dilated pupil
response
EARS No discharge Blood or CSF leak Clear fluid indicative
of basilar skull
fracture
NOSE AND No drainage CSF rhinorrhea Clear nasal discharge,
PARANASAL confirming CSF leak.
SINUSES
MOUTH AND Clear and no Obstruction requiring
PHARYNX obstruction Blood or vomit airway management
 NECK Supple, no tenderness Neck stiffness Muscle strain
CHEST Regular breath sounds Asymmetrical chest Pneumothorax or flail
movement chest
ABDOMEN Soft, non-tender Tenderness or rigidity Abdominal bleedings
EXTREMITIES Full movement and Weakness,paralysis Hemiplegia
sensation
SKIN Intact, warm Pale, clammy Shock/ bruising from
trauma

DIAGNOSTIC TEST

Hematology Analysis Report

TEST LAST TEST RECENT TEST NORMAL VALUE
HEMOGLOBIN 142 139 140-180 g/L
HEMATOCRIT 0.43 0.40 0.42-0.55(male) L/L
0.36-0.46 (female) L/L
RBC COUNT 4.47 4.44 3.5-5.50x10²/L
WBC COUNT 13.45 12.35 5.0 - 10x10⁹/L
PLATELET COUNT 308 250 150-450x10⁹/L
NEUTROPHILS 85.0 83.0 50/70%
LYMPHOCYTES 8.0 7.0 20-40%
MONOCYTES 6.0 6.0 3-12%
EOSINOPHILS 1.0 1.0 1.5%
BASOPHILS 0.0 0.0 0.0
CLOTTING TIME
BLEEDING TIME
MCV 93.2 92.3 80-100 fL
MCH 31.9 32.1 27.0-34.0 pg

MCHC 342 324 320-360 g/L

CT SCAN
LIST OF PRIORITIZED PROBLEM

ACTUAL JUSTIFICATION
1. Neurological Assessment Monitor for changes in consciousness or cognition.
Assess for any new or worsening neurological
deficits.
2. Pain Management Address headaches or any other pain associated
with the injury.
Emotional and behavioral changes
3. Monitor for signs of anxiety, depression, Assess memory, attention, and executive function.
or irritability.
POTENTIAL JUSTIFICATION
1. Cognitive Rehabilitation Assess memory, attention, and executive function.
Develop strategies to aid cognitive recovery.
2. Sleep Disturbances Identify any issues with sleep patterns and provide
interventions.
3. Safety and Fall Risk Implement safety measures to prevent falls and
injuries due to impaired balance or coordination.
ANATOMY AND PHYSIOLOGY

The brain, which controls all bodily functions and regulates ideas, emotions, sensory data, and motor
abilities, is regarded as one of the most complicated organs in the body. The cerebrum, cerebellum, and
brainstem are the three primary sections. The main portion of the brain, the cerebrum, is split into two
hemispheres and has four lobes: frontal, parietal, temporal, and occipital. Higher cognitive activities
including reasoning, thinking, feeling, and voluntary movements are all performed by the cerebrum.
Directly beneath the cerebrum, the cerebellum controls fine motor function, balance, and
coordination. The brainstem controls vital involuntary processes like breathing, heart rate, and
digestion and connects the spinal cord to the brain. Together, these systems use a vast neuronal
network to direct and condense information in order to keep the body functioning as a single, cohesive
entity.

DRUG STUDY

Drug Name Mechanis Indications Contraindicatio Adverse Nursing

m of n Reaction Consideratio
Action n
BRAND: interferes Viral Contraindicated COMMON: Some forms
Cloxacillin with the infections in Gastrointesti of
THERAPEUTIC formation like chicken patients nal upset preparation
CLASS: of pox hypersensitive (nausea, may have to
Antibiotic bacterial and warts, to vomiting, be
PHARMACOLOG cell viral drug or other diarrhea). reconstitute
I walls by pneumonia, components. -Skin rash. d and should
CAL CLASS: forming a some -urticaria, be given as
Beta-lactam complex Fungal  angioedema. per the
antibiotic with infections, Known SERIOUS: recommendat
AVAILABLE penicillin parasitic hypersensitivity -Anaphylaxis. ion of the
FORMS: binding infections, or - preparation’s
Tablets-250 mg, proteins and other Pseudomemb manufacture
500 mg (PBPs) many others. penicillins. r r.
Capsules-250 mg, which Some anous colitis. 
500 mg are of the - Assess
Syrup- 125 mg/5 enzymes examples of Superinfectio symptoms of
mL that the bacterial n (overgrowth the
Intravenous-500 catalyze infections of non therapeutic
mg to 1 g the final include susceptible response,
steps in the the bacteria or such as
Intramuscular- formation following: fungi). lessening of
500 mg to 1 g of Streptococca the symptoms
ROUTE: bacterial l of an
Per Orem (PO), cell infection (for infection.
Intravenously wall. This instance, 
(IV) or leads to the pharyngitis, Specific
Intramuscularly laxing of skin effects
(IM). the infection include
DIALYZABLE cellulose among evaluating
DRUG: layer of the others). for ADR,
Yes. bacterial most
cell especially
wall and allergic
eventually reactions
the bacteria and
dies. gastrointesti
nal
intolerance.

Warning
 patients on
drug
interactions
particularly
with other
antibiotics
and other
medication
that has an
ability to
alter the
gastrointesti
nal flora.

As for the
liver and the
kidneys, it is
necessary to
control the
tests in case
the drug is
not well
tolerated.

Drug Name Mechanism Indications Contraindication Adverse Nursing

of Action Reaction Consideratio
n
BRAND: May inhibit Short-term Contraindicated CNS: Alert:
Ketorolac prostagland management in headache, Watch for
Thromethamine in synthesis of patients dizziness, immediately
THERAPEUTIC to produce moderately hypersensitive to drowsiness. evaluate
CLASS: anti severe, ketorolac or CV: edema, sign and
Anti-inflammatory inflammato acute, pain for aspirin HTN. symptoms of
drugs r single -dose or other EENT: MI (chest
PHARMACOLOG y, treatment. NSAIDs. tinnitus. pain,
I analgesic,  Hypersensitivity Nasal shortness of
CAL and Short-term reactions , Spray breath,
CLASS: antipyretic management ranging only: or trouble
NSAID effects. of from increased breathing)
AVAILABLE moderately bronchospasm lacrimation, or stroke
FORMS: severe to anaphylactic nasall (weakness
Injection- acute pain for shock, have discomfort, in one part or
15mg/mL single multiple -dose occurred rhinalgia, side of
dose vials , 1- and treatment. and appropriate rhinitis, the body,
2-mL prefilled  counteractive throat slurred
syringes. Short-term measures must irritation. speech).
Nasal Spray - management be GI: Correct
15.75 mg/spray of available when abdominal hypovolemia
Tablets - 10mg moderately 1st pain, before giving
ROUTE: severe, dose of dyspepsia, drug.
Per Orem (PO), acute pain ketoroloc heartburn, Carefully
Intravenous when injection is nausea, observe
(IV),Intramuscula switching given. constipatio patients with
r ( IM), & from n, diarrhea, coagulopathi
Intranasal parenteral to Contraindicated flatuence, es and those
DIALYZABLE oral in GI fullness, taking
DRUG: administration children younger GI anticoagulan
Unlikely . . than age 17, as perforation ts, Drug
prophylactic , peptic inhibits
analgesics ulceration, platelet
before stomatitis, aggregation
major surgery, vomiting, and can
and GI prolong
intraoperatively hemmorhag bleeding
when hemostasis e. time.
is NSAIDs may
critical; in GU: renal mask sign
patients impairment and
with advanced . symptoms of
renal Hematolog infection
impairment; and ic: anemia, because of
in decreased their
those at risk for platelet antipyretic
renal failure adhesion, and anti
from prolonged inflammatory
volume bleeding actions.
depletion. time,
 purpura.
Contraindicated Hepatic:
in increased
patients with liver
suspected or enzyme
confirmed levels.
cerebrovascular Skin:
bleeding , diaphoresis,
hemmorhagic pruritus,
diathesis, or rash.
incomplete Other: pain
hemostasis, and at injection
in site.
those at high
risk
for bleeding
because
drug inhibits
platelet
function.

Drug isn't
indicated
for minor or
chronic
pain.

NSAIDs can
cause
peptic ulcers, GI
bleeding, or
perforation , and
a
history of peptic
ulcers disease
orGI
bleeding . Older
adults are at
greater risk for
serious GI
events.

Contraindicated
for
GU: renal
impairment.
Hematolog
ic: anemia,
decreased
platelet
adhesion,
prolonged
bleeding
time,
purpura.
Hepatic:
increased
liver
enzyme
levels.
Skin:
diaphoresis,
pruritus,
rash.
Other: pain
at injection
site.
and anti
inflammatory
actions.treatmen
t of
perioperative
pain in
patients
requiring
CABG surgery.

Contraindicated
in
patients
currently
receiving aspirin
,
probenecid or
other
NSAIDs
because of
the cumulative
risk
of inducing
serious
NSAID-related
adverse reaction.

NSAIDs can
increase
risk of serious
CV
thrombotic
 events,
including MI or
stroke. Risk of
MI or
stroke can occur
early in
treatment
and increase
with
duration of use.
Risk
appears greater
at
higher doses.
Use
lowest effective
dose for shortest
duration
possible.

Drug Name Mechanis Indication Contraindication Adverse Nursing

m of s Reaction Consideration
Action
BRAND: Decreased Relief of Contraindicated GI: Nausea, 
Paracetamol fever by mild-to inpatientshypersensiti vomiting, Monitor sign and
THERAPEUTI inhibiting moderate ve todrug or other and symptoms of
C the pain non- opoid analgesics abdominal hepatotoxicity,
CLASS: effects of treatment  Intolerance to pain even with
Antipyretic pyrogens of tartanine (yellow dye GU: Acute moderate are
PHARMACOL on the fever. #5), alcohol, table kidney tominophen
O hypothala sugar, saccharin.  injury doses, especially
GICAL mus heat Contraindicated Hematologi in individuals
CLASS: regulating withallergy to c: with poor
Non-opoid centers acetominophen Thrombocyt nutrition or who
analgesics and bya o have ingested
AVAILABLE hypothala penia and alcohol over
FORMS: mic action agranulocyt prolonged
Capsules- 500 leading to o periods;
mg, 650 mg sweating sis poisoning usually
Tablets- 500 and Skin: Rash from accidental
mg, 650 mg, vasodilati and ingestion stool,
1000 mg o urticaria. WBC
(extended n. Other: >10,000mm3,
release) hypersensiti earache, fever;
ROUTE: v obtain baseline
Per Orem (PO) ity information and
DIALYZABLE reactions. during
DRUG: treatment.
No. 
Obtain C&S
before beginning
product therapy
to identify if
correct
treatment has
been initiated.

 Assess for
anaphylaxis.

Identify urine
output.

Monitor blood
studies.

Monitorelectrolyt
es.

Assess bowel
pattern daily; if
severe diarrhea
occurs
discontinued.

Monitor for
bleeding.

Assess for
overgrowth of
infection.

NURSING CARE PLAN

Nursing Cues Analysis Goal Rationale Evaluation

Diagnosis
Risk for The patient has To maintain or Frequent Patient's
Decreased Subjective: hypothermia, improve monitoring of temperature
Cardiac "Wala na unresponsiveness, cardiac output vital signs, will stabilize
Output siyang malay and prolonged and promote neuro within 24
related to nung pumunta sleep, which patient assessments, hours,
altered dito (tulog ng indicates the risk responsiveness and remaining
metabolic tulog)" as of decreasing within 24-48 maintaining within normal
state verbalized by cardiac output. hours. active and range (36.5-
the patient The inability of passive range 37°C).
Objective: the body to of motion are Vital signs
Temperature: maintain normal essential for will remain
35.5°C body detecting early stable within
(hypothermia) temperature, as changes in a normal limits
Oxygen well as excessive patient's during the
Saturation weakness, can condition. next 48 hours.
(O₂ sat): 98% indicate altered Improvement
Respiratory metabolism, Regular neuro in
Rate (RR): 21 which, if not assessments consciousness
breaths/min handled can identify will be noted,
Pulse Rate promptly, can changes in with the
(PR): 81 lead to decreased mental patient
beats/min circulation and alertness and demonstrating
Blood cardiac output. neurological increased
Pressure (BP): decline, which responsiveness
120/70 mmHg could indicate or awakening
complications. more
frequently.
Maintaining The family
mobility is will verbalize
 crucial for understanding
preventing of symptoms
muscle to report and
stiffness, steps they can
contractures, take to support
or venous the patient's
stasis. care at home.

Providing a
warm
environment
helps
normalize
body
temperature
and prevents
additional
stress on the
cardiovascular
system.

Smart: The
patient's
temperature
will remain
stable between
36.5°C and
37°C for the
next 24 hours.
The patient's
temperature,
pulse rate, and
blood pressure
will be
measured
every four
hours.

With proper
nursing
treatments, the
patient's
temperature
will return to
normal.

The patient's
vital signs will
stay within
normal ranges,
and the patient
will be more
responsive.
Time-bound:
By 48 hours
the patient will
have improved
consciousness
and vital
signs,
particularly a
stable
temperature
and regular
cardiac output.