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to preserve health by to
strict a regimen.” Our
body is the mirror of
whatever lifestyle we
have. It is the one who
suffers on what we put
inside.
Subdural hemorrhages may cause an increase
in intracranial pressure (ICP), which can cause
compression of and damage to delicate brain
tissue. Acute subdural hematoma (ASDH) has a
high mortality rate and is a severe
medical emergency. Subdural hematomas most
often affect people who are prone to falling.
Only a slight hit on the head or even a fall to the
ground without hitting the head may be enough
to tear veins in the brain, often without
fracturing the skull. There may be no external
evidence of the bruising on the brain's surface.
Head injuries account for
approximately 70% of these
traumatic deaths and most of the
persisting disabilities in accident
survivors. Many of these patients
are comatose on admission.
However, approximately 50% of
patients with head injuries who
require emergency neurosurgery
present with moderately severe or
mild head injuries (Glasgow Coma
Scale [GCS] scores 9-13 and 14-15,
respectively).
These patients may be more likely to benefit
from medical and surgical intervention when
instituted in a timely fashion.
hygiene she has a poor hygiene due
to self care deficit. The second one
was mood and manner not like those
patients that I handle she is not
cooperative, unable to speak
because the patient is having a
difficulty in doing so therefore affect
her movement and gesture. Third
was about distress, she has a poor
eye contact and it is usually seen in
depressed clients.
Temperature – 37c
Blood pressure-110/80 mmhg
Pulse Rate- 86 beats per min.
Respiratory Rate- 22 breaths per
minute
BODY PART METHOD FINDINGS ANALYSIS
Neck
>Inspection & >Neck is >Normal.
Palpation symmetrically
aligned
Reaction
>Inspection >Normal
>clear,moist
and smooth
>Conjuctiv underlying
a structures are
clearly visible
sclera is white
Ear >Inspection >Pinna recoils >Normal.
after being
folded
>Auricles are >Normal.
mobile, firm &
not tender.
>symmetrically >Normal.
aligned
>with >Abnormal,
discharge impacted
cerumen
blocking the
view of the
external
earcanal,
conductive
hearing loss
Nose >Inspection >symmetrically >Normal.
aligned.
Mouth
>Lips >Palpation >Not tender. >Normal
>dry with >Abnormal. Dry
cracks lips indicate
mouth
breathing or
dehydration.
>Teeth >Inspection
>with yellow >Abnormal.
cavities. Due to oral
hygiene
>Tongue >Inspection practice.
>dry, with
patches >Abnormal. It
indicates
dehydration.
>moves freely
>Normal.
>uvula >Inspection >Presence of >Normal.
uvula
Heart is magnified
No demonstrable pneumothorax or hemothorax
Visualized bony thorax is intact
Impression: clear lung fields
Magnified heart
PELVIS:
AP view of pelvis shows no demonstrable fracture or
dislocation
Puncture hyperdense foci are noted in both inferior frontal
lobes with associated undue hypodensity of the cerebral
hemisphere,bilaterally. Hyperdense called is also noted along
the frontal parasagittal cortical sulci.no midline shift is
noted.the posterior fossa and sellar structures are intact.
Impression:
Acute hemorrhagic contusion changes both frontal lobes
with associated edema of both cerebral hemispheres minimal
acute subarchnoid hemorrhage along the frontal sagittal sulci
negative for fracture.
RESULT NORMAL VALUES ANALYSIS
NORMAL
2) Hgb 124.2g/L F:120-140g/L
1.2-6.6 x 10 9/L
4) Leukocytes 17.23 x10 9/L Infection
0-0.7 x 10 9/L
5) Neutrophil 0.910% Neutrophenia
0.02-0.05 x 10 9/L
6) Eosinophil 0.0010% Eosinophilia
1.5-4.0 x 10 9/L
7) Basophil 0.003%
Basophenia
1) Lymphocyte 0.037% 1.5-4.0 x 10 9/L Lymphopenia
27-31
4) MCH 30.51 NORMAL
80-96
5) MCV 92.57 NORMAL
0.32-0.36
6) MCHC 0.33 NORMAL
1.5-4.0 x 10 9/L
7) Atyphical
Lymphocyte 0.002 Abnormal
lymphocytes,
can be also
associated with
viral infection
REMARK: Blood type (O+)
27-31pg
4) MCH 30.94 pg NORMAL
80-96 fl
5) MCV 93.95 fl NORMAL
0.32-0.36
6) MCHC 0.33 Abnormal
lymphocytes,
can be also
associated
with viral
infection
DATE TAKEN:
NOVEMBER
28,2008
DATE:Nov. RESULT NORMALVALUES ANALYSIS
28,2008
NON-MODIFIABLE FACTOR
Cerebral Infraction
Vascular Congestion
Cerebral Edema
S>:”Hindisiya
nakakakilos ng ayos
O>
Physical immobility
Restless
Facial grimace
While moving
Impaired physical mobility
related to decreased
muscle strength
Limitation in independent,
purposeful physical movement
of the body or of one or more
extremities
>After 6 hours of nursing
intervention, the client will
exhibit enhanced physical
mobility
>Evaluated >Identifies
patient’s ability impairments and
function and allows for
Injury identification of
appropriate
intervention
>Provides a baseline on
>Assessed patient which to base
intervention, patient may
for degree of only require minimal
immobility assistance or be
completely dependent on
caregiver’s for all body
needs
>Performed ROM >Helps to maintain
exercises every 4 mobility and
hours function of joints
Brand Name:
Dilantin
Anticonvulsants
To stabilize neuronal membranes and limit
seizure activity either by increasing efflux
or decreasing influx of sodium ions across
cell membranes in the motor cortex
during generation of nerve impulses
To control tonic clonic(grandmal) and
complex partial (temporal lobe)
seizures.
To prevent ant treat seizure accruing
during neurosurgery
Use cautiously in patient with hepatic
dysfunction, hypotension, myocardial
insufficiency, diabetes or respiratory
depression in elderly or rehabilitated
patient.
Elderly patient tend to metabolize drug
slowly and may need reduced dosages
CNS: Mental
confusion
Dizziness
Headache
GI: Nausea
Vomiting
Constipation
Don’t stop drug suddenly because
this may worsen seizures. Call
prescriber immediately if adverse
reaction develop
Monitor drug level
Monitor CBC and Calcium level every
6 months and periodically monitor
hepatic function.
May increase alkaline phosphatase, GGT
and glucose levels. May decrease urinary
17 hydroxysteroids, 17 ketosteroid and
Hgb and Hct level.
May increase urine 6 hydroxycortisol
excretions
May falsely bound iodine or free thyroxin
level test results.
Generic Name:
Mannitol
Brand Name:
Osmitrol
> Diuretics
Increase osmotic pressure of glomerular
filtrate inhibiting tubular reabsorption of
water and electrolytes. Drug elevates
plasma osmolality, increase water flow
into extracellular fluid
Oliguria
To prevent oliguria or acute
renal failure
To reduce intraocular or
intracranial pressure
Contraindicated in patient with
anuria, severe pulmonary
Congestion; frank pulmonary
edema, active intracranial
bleeding ; severe dehydration;
metabolic edema
CNS: Seizures
Dizziness
Headache
Fever
CV: Hypotension
Hypertension
Edema
Tachycardia
GI: Thirst
Drymouth
Nausea
Vomiting
Metabolic:
Dehydration
>Monitor vital signs including central
venous pressure and fluid input and
output hourly report oliguria.
Check weight ,renal function, fluid
balance and serum and urine sodium
and potassium levels daily
To relieve thirst, give frequent mouth
care or fluids
> Monitoring increasing or
decreasing electrolytes level
>May interfere with tests for
inorganic phosphorus and
ethylene glycol level.
METHODS
M: >Instructed the client to take his medication
such as phenytoin,co-amoxiclav and mefenamic
acid
Reinforced importance of medication compliance
to patient and his relatives: it’s time, route,
dosage, frequency and duration.
Advised to report unusual manifestations and
side effects of drug to physician.
E > Instructed the patients relative to provide calm
and non stressful environment.
Making things is a hard task. That's
why I would like to extend my
deepest gratitude to those who
patiently help me in fulfilling this
task and to whom who I owe this
success of our endeavor.
First and foremost, to our almighty God for
the knowledge and wisdom he showered
upon us; for His continuing guidance, for
giving us the strength to overcome our trials
and every little thing He’d done for us
To our dear parents,from assisting us in our
needs, finacially and emotionally; for being
there whenever we need them, for stating on
our side through ups and downs and most of all
for making us responsible individuals.
To our clinical Instructor, Dra. Iturralde for
sharing her knowledge to the best of her
ability; for guiding us the right way, we will
treasure all the learning's that she had taught
us.
To stuff of the IMC for letting I lend books and
assisting us in our needs without hesitations.
To the members of the group for giving extra
information even in the smallest thing that
they know.
To the entire person in our lives.For
suggestions they gave for the enrichment of
this work. THANK YOU
Delmar’s Pediatric Nursing Care Plans, 3rd edition,Luxner
Nursing Care Plan,7th edition, Doenges, et.al
Medical-surgical nursing, Smeltzer,et al.
Medical- Surgical Nursing Critical Thinking for collaborative
care, vol.1,5th edition,
Ignatius,
Delmar’s Manual of Laboratory and Diagnostic Test, Rick
Daniels
Health Assesment & Physical Examination, Estes
Health Assesment in Nursing 3rd edition, Janet Weber &
Jane Kelley
Medical-Surgical Nursing, Brunner and Suddharts,
Smeltzer,vol.1 & 2b
Nurse’s Pocket Guide, Doenges,et.al
Laboratory and diagnostic tests with nursing implications
Seventh Edition,Joyce Lefever Kee
Current Dignosis and treatment,Marcus A.Krupp and Milton
J. Chatton
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