FATHER SATURNINO URIOS

UNIVERSITY
NURSING PROGRAM
Butuan City

An Individual Case Study

On

Hemorrhagic Contusion
Right Frontal Lobe
Subacute Subdural Hematoma
Right Convexity

Submitted by:

Bondoc, James Aurelle S.

N30

Submittted to:

Ms Michelle Donna A. Dulu, RN

Supervising Clinical Instructor
 INTRODUCTION

A subdural hematoma (SDH) is a common neurosurgical disorder that often requires

surgical intervention. SDH is a type of intracranial hemorrhage that occurs beneath the dura and
may be associated with other brain injuries. Essentially, it is a collection of blood over the
surface of the brain. SDHs are usually caused by trauma but can be spontaneous or caused by a
procedure, such as a lumbar puncture.

SDHs are usually characterized based on their size, location, and age (ie, whether they
are acute, subacute, or chronic). These factors, as well as the neurologic and medical condition of
the patient, determine the course of treatment and may also influence the outcome.

SDHs are often classified based on the period that has elapsed from the inciting event (if known)
to the diagnosis. When the inciting event is unknown, the appearance of the hematoma on CT scan or
MRI can help determine when the hematoma occurred.

Generally, acute SDHs are less than 72 hours old and are hyperdense compared with the brain on
CT scan. Subacute SDHs are 3-20 days old and are isodense or hypodense compared with the brain.
Chronic SDHs are 21 days (3 wk) or older and are hypodense compared with the brain. However, SDHs
may be mixed in nature, such as when acute bleeding has occurred into a chronic SDH.

The brain is covered by a membrane (layer of tissue) called the dura. If the veins located
below the dura (subdural area) leak blood, then pressure in this area may build up and injure the
brain. Head injuries may injure these veins, causing them to be torn and leak. This blood
collects into a mass called a hematoma.

` For the most part, this review discusses acute and chronic SDHs; less information is
available about the less common subacute SDHs.1 The entity of subdural hygroma is briefly
addressed with chronic SDH.Acute SDH is commonly associated with extensive primary brain
injury. In one study, 82% of comatose patients with acute SDH had parenchymal contusions.2
The severity of the diffuse parenchymal injury correlates strongly (inverse correlation) with the
outcome of the patient. In recognition of this fact, an SDH that is not associated with an
underlying brain injury is sometimes termed a simple or pure SDH, whereas the term
complicated has been applied to SDHs in which a significant injury of the underlying brain has
also been identified.

The practice of trephination of the head (ie, chipping or drilling a hole through the skull)
has been traced back to ancient times. The author Balzac, in 1840, described a case of chronic
subdural hematoma (SDH), including its traumatic origin and surgical treatment.3 In the late 19th
century, with the rise of medicine, development of aseptic technique and anesthesia, and
establishment of the basic principles of neurologic localization, surgery for intracranial lesions
(including SDH) became more common and, later, survival rates improved. In 1883, Hulke first
described successful neurosurgical treatment of chronic SDH. 4 Although cerebral angiography
could be used to localize SDH in the early–to–mid-20th century, the development of the CT scan
in the late 1970s represented another leap in patient care.

It is important that a patient receive medical assessment, including a complete

neurological examination, after any head trauma. A CT scan or MRI scan will usually detect
significant subdural hematomas.

Treatment of a subdural hematoma depends on its size and rate of growth. Some small
subdural hematomas can be managed by careful monitoring until the body heals itself. Other
small subdural hematomas can be managed by inserting a temporary small catheter through a
hole drilled through the skull and sucking out the hematoma; this procedure can be done at the
bedside. Large or symptomatic hematomas require a craniotomy, the surgical opening of the
skull. A surgeon then opens the dura, removes the blood clot with suction or irrigation, and
identifies and controls sites of bleeding. Postoperative complications include increased
intracranial pressure, brain edema, new or recurrent bleeding, infection, and seizure. The injured
vessels must be repaired.

I choose this case since it catches first my interest. Having Craniectomy operation as my
first major case assist really challenged me a lot to do my best during the operation. Efforts were
being given and it took 4 hours of long standing for me before the operation ended. Being a part
of that really means a lot to me indeed.

DEFINITION OF TERMS

Here are some of the terms that are being defined and could be
encountered as one gets along with this case study.

Autoregulation- is a specific form of homeostasis used to describe the tendency of the body to
keep blood flow constant when blood pressure varies

Brain Death- Irreversible brain damage and loss of brain function, as evidenced by cessation of
breathing and other vital reflexes, unresponsiveness to stimuli, absence of muscle activity, and a
flat electroencephalogram for a specific length of time.

Brain herniation- also known as cistern obliteration, is a deadly side effect of very high
intracranial pressure that occurs when the brain shifts across structures within the skull.

Cerebral blood flow- or CBF, is the blood supply to the brain in a given time.

Cerebral hypoxia- refers to deprivation of oxygen supply to brain tissue.

Cerebral perfusion pressure- or CPP, is the net pressure gradient causing blood flow to the
brain (brain perfusion).

Compression- A force squashing, squeezing, or pressing down on an object.

Contusion- A bruise that is usually produced by impact from a blunt object and that does not
cause a break in the skin.

Craniectomy- surgical removal of a portion of the cranium.

Effusion- the seeping of serous, purulent, or bloody fluid into a body cavity or tissue.

Hematoma- A mass of blood in the tissue as a result of trauma or other factors that cause the
rupture of blood vessels.

Intracranial Pressure- Pressure that occurs within the cranium. Trauma to the head,
inflammation, or infection of the linings of the brain may cause an increase in pressure within the
cranium, which is painful, dysfunctional, and may become life-threatening.
 NURSING HEALTH HISTORY

Nursing health history is the first part and one of the most significant aspects in
case studies. It is a systematic collection of subjective and objective data, ordering and step-
by-step process inculcating detailed information in determining client’s history, health status,
functional status and coping pattern. These vital informations provide a conceptual baseline
data utilized in developing nursing diagnosis, subsequent plans for individualized care and
for the nursing process application as a whole.

It was the 24th day of July, 2009 when our group was first exposed to the world of
sterility. Under the supervision of Ms. Michelle Donna A. Dulu, Rn, all of us practiced our
skills by applying the concepts we learned from school. Then we were told by our C.I to
make an individual case study regarding our major cases we were able to assist with. I
obtained my first major scrub assist last July 31,2009 that’s why I started gathering data
about my chosen patient’s case.

For the purpose of confidentiality and respect to the identity of my patient, I

decided to name him as Patient X.

Patient X is a native of Surigao City particularly Purok 1, San Juan. He first saw
the the light on August 30, 1960. He got married to a Surigaonon woman, a NFA rice
distributor here in Mindanao. Luckily, the couple was blessed with six beautiful children.
Three of them already graduated from their chosen courses with flying colors while the
remaining three are still studying respectively. He had just retired from his recent work. As a
means of making use of his time, he takes care of his grandchildren and helps his wife in
distributing the NFA rice instead.

It all happened last July 25, 2009. Patient X’s family and relatives gathered
together for a reunion at one of the beach of General Luna, Siargao City. Unfortunately, he
met an accident along the road causing him some minor wounds and abrasion. It was
believed that he was under the influence of alcoholic beverage as verbalized by his wife ,”
Nakainom man to siya gamay pero dili siya grabe kahubog.” He was rushed to the nearest
district hospital at Dapa, Siargao City. He stayed there for about two days for monitoring of
his case. He was then transferred to Caraga General Hospital at Surigao City. He spent three
days in the said hospital and given appropriate care. His condition got worsen so was referred
in Butuan City.

He was rushed to Butuan City via an ambulance and admitted at Manuel J. Santos
Hospital for further management of his condition. They arrived at the hospital around 1:59
a.m of July 30, accompanied by his relative, lying flat on the stretcher. He was admitted
because of hematoma on his subdural space. He was then managed by Dr. Marlowe S. Indo.
Vital signs were obtained initially as follows,

BP: 120/80 mmHg Oxygen Saturation:98%

Temp: 38 C Pulse Rate: 87 beats/min

He was then referred to Dr. Neil Oliver Camonggol for further management
around 2:35 a.m. He was seen by Dr. Camonggol at the Emergency Room and orders were
given. At 2:45 a.m , doctors orders were carried out as follows:

> given Mannitol 20 %, 100cc

> requested watcher to secure out PRBC type.
> scheduled patient for Craniectomy and evacuation of hematoma at 2p.m of
same day
> informed Dr. Oclarit through text for follow- up anesthesia

At 2: 18 in the afternoon, patient X was wheeled in into the operating room with
IVF hooked at right metacarpal vein, infusing well. Then the consent for the craniectomy
operation was obtained. He was then attached to the cardiac monitor and pulse monitor as
well.

Plain NSS was started as venoclysis at left arm at just drip around 2:45 p.m.
Around 2:28 p.m, general anesthesia was started with KVO( keep vein open) instruction and
intubation was also done. Then venocylsis was started with KVO instruction now at the right
arm along with the shaving and skin preparation done simultaneously. Erythromycin was
instilled on both eyes at 3 p.m together with the initial counting of the sponges and
instruments pre-operatively.

The operation/ procedure namely “Craniectomy Right Frontotemporoparietal,

Evacuation of Hematoma Expansion, Duraplexy, Bone Transplant to Right Hemiabdomen”
started around 3:05 p.m with Dr. Neil Oliver Camonggol as the head surgeon, Dr. Sheree Lim
as the assistant surgeon, Dr. Castulo P. Oclarit as the anesthesiologist, Ms. Vanessa P. Orboc,
R.N as the instrument nurse, Ms. Micthel P. Calo, RN as the circulating nurse, me as the
scrub student nurse and Ms Ruby Grace N. Insong, as the circulating student nurse. The pre
operative diagnosis was “Hemorrhagic Contusion Right Frontal Lobe, Subdural Subacute
Hematoma Right Convexity.” Major instruments were used, prepared in the mayo table and
draping was done accordingly. Incision of body tissue was done carefully and cauterization
of bleeders followed afterwards. Opening og the skull was done using power drill, an
specialized instrument for cutting owned by Dr. Camonggol himself. Bone flap was then
removed and placed carefully in the kidney basin filled with sterile water. Washing of the
bone flap was also done carefully. Hgt results were then referred to Dr. Camonggol.

At 4:15 p.m, the initial counting of the sponges, instruments, sutures and
cottonoids were checked and complete. I was given the chance to report the outcome of the
said counting among the doctors and the rest of the surgical team. Then the 1st unit of PRBC
with serial number of 09.231 with blood type O positive was transfused to patient X obtained
from proper cross- matching. Dr. Oclarit continuously monitored the vital signs seeing to it
all of them were at normal level.

Around 5:25 p.m, suturing of the head was done while DLR 1L was then well
infused. The final counting of instruments, sutures, sponges and cottonoids was done
afterwards. Patient X’s abdomen was then incised around 5:28 p.m. Bleeders were also
cauterized respectively. Bone flap was then implanted at right lower abdomen after the
incision was being made. Suturing then ended, betadinizing was done and Jackson Pratt was
attached accordingly.

The operation ended exactly 5:45 p.m with post diagnosis same with that of that
of the pre operative diagnosis. Post operative care was given. Patient X’s blood pressure was
obtained with 126/90 mmHg reading. At 6: 05 p.m, suctioning was done and he was brought
back to the CCU with post operative orders to be carried out by the nurse on duty.

According to Eric Erickson’s Psychosocial Theory, patient X belongs to the Middle

Adulthood with the central task of Generativity v.s Stagnation. Positive crisis resolution
results in creativity, productivity, and concern for others. Stagnation results in selfishness and
lack of interest and commitments. Generativity means concern for establishing and guiding
the next generation. People turn from self- and- family centered focus of young adulthood
toward more altruistic activities like community involvement, charitable work and political
and social endeavor. Stagnation results if the need for sharing, giving, and contributing to the
growth of others is not meet. Patient X was able to share his skills and attributes for the good
of others like becoming a good father to his children and a responsible husband to his wife.
Somehow his concern for the people around him was appreciated by his loved ones as well.
 PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the cephalocaudal

assessment. This is done systematically using the techniques of inspection, palpation, percussion
and auscultation with the use of materials and investments such as the penlight, thermometer,
sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, I
made every effort to recognize and respect the patient’s feelings as well as to provide comfort
measures and follow appropriate safety precautions.

Physical assessment is a systematic, comprehensive, continuous collection, validation and

communication of the patient’s data using a variety of methods. The purposes of the physical
assessment are as follows:

-to collect data and establish a need for continued physical assessment;
-to ascertain patient’s level of health condition and physiological functioning;
-to identify factors facing the patient at risk; and
-to determine the areas of preventive nursing.

The physical assessment of patient X was done last August 22, 2009 at one of the private
rooms of MJ Santos Hospital. The student nurses used the cepholocaudal approach in assessing
the patient. The student brought with him bp apparatus, temperature, stethoscope, wristwatch,
ballpen, and notebook

General Survey:
The patient’s general appearance seemed he was responding to treatment. He was
relaxed, lying on bed with left knee flexed. Left hand was moved, flexed during interaction. He
was wearing white comfortable sleeveless shirt and a diaper, bandages for both legs. He was
conscious, right eye closed left eye semi-open, nods when acknowledged.

Vital Signs:
BP: 120/80 mmHg
TEMPERATURE: 37. 2 C
HEART RATE: 87 beats/ min
RESPIRATORY RATE: 18 breaths/ min

Skin:
The skin was brown in color. Muscle tone present. Few abrasions are noted but
nevertheless, the skin was not dry.

Head:
The head was slightly sunken on the right side due to removal of bone flap. Hair was
starting to grow.

Ears:
Ears were symmetrical, free of abrasions. Color was good, same with the rest of the body
with no pale manifestations.

Eyes:
Eyebrows and eyelashes are evenly distributed. The scleras of both eyes were clear,
equally round and reactive to light accommodation .Right eye can’t be opened by himself. Left is
in good condition, can be opened by himself. Right eye secretions are noted.

Nose:
No discharges or flaring.
Lips:
Lips are dry but with no pale manifestations.

Mouth:
Teeth are symmetrical. Plaques are noted.
Upper Extremities:
Right upper arm can’t be hyperextended. Pain is verbalized by patient. Right hand has
healed wound but not cyanotic, has abrasions om right shoulder. Left hand flexed and moved
freely. Fingers are symmetrical with no abrasions. Nails are not trimmed, manifested with dirt.

Chest:
Presence of tracheo tubing in the neck noted which is suctioned two times a day. Rest of
the chest is with no abrasions. Color is brown, the same with the rest of the body.

Abdomen:
Presence of incision on right upper quadrant is noted due to transplant of bone flap. The
rest of the abdomen is of the same color and with no abrasions.

Back:
No abrasions are noted.

Lower Extremities:
Abrasions present on left knee. Right foot, just above the ankle is manifested with slight
abrasions. Both feet until the lower part of the thighs are covered with bandage-like socks. Toes
are symmetrical, nails are not trimmed.

Bowel and Urine Excretion:

Bowel movement is two times a day. Urine is collected through a diaper.

Neurologic Status:
He can speak but not fluently due to the presence of the tracheo tubing, nods when
acknowledged, raises left hand as we said goodbye. He was conscious with calm behavior.

Environment:
The room was clean and well-ventilated.
 ANATOMY AND PHYSIOLOGY OF THE BRAIN

The scarecrow needed it, Einstein had an excellent one, and it can store a whole lot of
information. What is it you say? Why, the brain of course. The brain is the control center of the
body. Think of a telephone operator who answers incoming calls and directs them to where they
need to go. Similarly, your brain acts as an operator by sending messages from all over the body
to their proper destination.

The brain is one of the largest and most important organs of the human body. Weighing in
at about three pounds, this organ has a wide range of responsibilities. From coordinating our
movement to managing our emotions, the brain does it all. The brain is made up of three parts:
the forebrain, the brainstem, and the hindbrain.

The anatomy of the brain is complex due its intricate structure and function. This
amazing organ acts as a control center by receiving, interpreting, and directing sensory
information throughout the body. There are three major divisions of the brain. They are the
forebrain, the midbrain, and the hindbrain.

The brain serves many important functions. It gives meaning to things that happen in the
world surrounding us. Through the five senses of sight, smell, hearing, touch and taste, the brain
receives messages, often many at the same time.

The brain controls thoughts, memory and speech, arm and leg movements, and the
function of many organs within the body. It also determines how people respond to stressful
situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.) by regulating heart
and breathing rates. The brain is an organized structure, divided into many components that serve
specific and important functions.

The weight of the brain changes from birth through adulthood. At birth, the average brain
weighs about one pound, and grows to about two pounds during childhood. The average weight
of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three
pounds.

The Nervous System

The nervous system is commonly divided into the central nervous system and the
peripheral nervous system. The central nervous system is made up of the brain, its cranial nerves
and the spinal cord. The peripheral nervous system is composed of the spinal nerves that branch
from the spinal cord and the autonomous nervous system (divided into the sympathetic and
parasympathetic nervous system).

The Cell Structure of the Brain

The brain is made up of two types of cells: neurons and glial cells, also known as
neuroglia or glia. The neuron is responsible for sending and receiving nerve impulses or signals.
Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form
myelin, and facilitate signal transmission in the nervous system. In the human brain, glial cells
outnumber neurons by about 50 to one. Glial cells are the most common cells found in primary
brain tumors.

When a person is diagnosed with a brain tumor, a biopsy may be done, in which tissue is
removed from the tumor for identification purposes by a pathologist. Pathologists identify the
type of cells that are present in this brain tissue, and brain tumors are named based on this
association. The type of brain tumor and cells involved impact patient prognosis and treatment.
The Meninges

The brain is housed inside the bony covering called the cranium. The cranium protects the brain
from injury. Together, the cranium and bones that protect the face are called the skull. Between
the skull and brain is the meninges, which consist of three layers of tissue that cover and protect
the brain and spinal cord. From the outermost layer inward they are: the dura mater, arachnoid
and pia mater.

In the brain, the dura mater is made up of two layers of whitish, nonelastic film or membrane.
The outer layer is called the periosteum. An inner layer, the dura, lines the inside of the entire
skull and creates little folds or compartments in which parts of the brain are protected and
secured. The two special folds of the dura in the brain are called the falx and the tentorium. The
falx separates the right and left half of the brain and the tentorium separates the upper and lower
parts of the brain.

The second layer of the meninges is the arachnoid. This membrane is thin and delicate and
covers the entire brain. There is a space between the dura and the arachnoid membranes that is
called the subdural space. The arachnoid is made up of delicate, elastic tissue and blood vessels
of varying sizes.

The layer of meninges closest to the surface of the brain is called the pia mater. The pia mater
has many blood vessels that reach deep into the surface of the brain. The pia, which covers the
entire surface of the brain, follows the folds of the brain. The major arteries supplying the brain
provide the pia with its blood vessels. The space that separates the arachnoid and the pia is called
the subarachnoid space. It is within this area that cerebrospinal fluid flows.

Cerebrospinal Fluid

Cerebrospinal fluid (CSF) is found within the brain and surrounds the brain and the spinal cord.
It is a clear, watery substance that helps to cushion the brain and spinal cord from injury. This
fluid circulates through channels around the spinal cord and brain, constantly being absorbed and
replenished. It is within hollow channels in the brain, called ventricles, that the fluid is produced.
A specialized structure within each ventricle, called the choroid plexus, is responsible for the
majority of CSF production. The brain normally maintains a balance between the amount of CSF
that is absorbed and the amount that is produced. However, disruptions in this system may occur.

The Ventricular System

The ventricular system is divided into four cavities called ventricles, which are connected
by a series of holes called foramen, and tubes.

Two ventricles enclosed in the cerebral hemispheres are called the lateral ventricles (first
and second). They each communicate with the third ventricle through a separate opening called
the Foramen of Munro. The third ventricle is in the center of the brain, and its walls are made up
of the thalamus and hypothalamus.

The third ventricle connects with the fourth ventricle through a long tube called the
Aqueduct of Sylvius.

CSF flowing through the fourth ventricle flows around the brain and spinal cord by
passing through another series of openings.

Brain Components and Functions

Brainstem
 The brainstem is the lower extension of the brain, located in front of the cerebellum and
connected to the spinal cord. It consists of three structures: the midbrain, pons and medulla
oblongata. It serves as a relay station, passing messages back and forth between various parts of
the body and the cerebral cortex. Many simple or primitive functions that are essential for
survival are located here.

The midbrain is an important center for ocular motion while the pons is involved with
coordinating eye and facial movements, facial sensation, hearing and balance.

The medulla oblongata controls breathing, blood pressure, heart rhythms and swallowing.
Messages from the cortex to the spinal cord and nerves that branch from the spinal cord are sent
through the pons and the brainstem. Destruction of these regions of the brain will cause "brain
death." Without these key functions, humans cannot survive.

The reticular activating system is found in the midbrain, pons, medulla and part of the
thalamus. It controls levels of wakefulness, enables people to pay attention to their environments,
and is involved in sleep patterns.

Originating in the brainstem are 10 of the 12 cranial nerves that control hearing, eye
movement, facial sensations, taste, swallowing and movements of the face, neck, shoulder and
tongue muscles. The cranial nerves for smell and vision originate in the cerebrum. Four pairs of
cranial nerves originate from the pons: nerves 5 through 8.

Cerebellum

The cerebellum is located at the back of the brain beneath the occipital lobes. It is
separated from the cerebrum by the tentorium (fold of dura). The cerebellum fine tunes motor
activity or movement, e.g. the fine movements of fingers as they perform surgery or paint a
picture. It helps one maintain posture, sense of balance or equilibrium, by controlling the tone of
muscles and the position of limbs. The cerebellum is important in one's ability to perform rapid
and repetitive actions such as playing a video game. In the cerebellum, right-sided abnormalities
produce symptoms on the same side of the body.

Cerebrum

The cerebrum, which forms the major portion of the brain, is divided into two major
parts: the right and left cerebral hemispheres. The cerebrum is a term often used to describe the
entire brain. A fissure or groove that separates the two hemispheres is called the great
longitudinal fissure. The two sides of the brain are joined at the bottom by the corpus callosum.
The corpus callosum connects the two halves of the brain and delivers messages from one half of
the brain to the other. The surface of the cerebrum contains billions of neurons and glia that
together form the cerebral cortex.

The cerebral cortex appears grayish brown in color and is called the "gray matter." The
surface of the brain appears wrinkled. The cerebral cortex has sulci (small grooves), fissures
(larger grooves) and bulges between the grooves called gyri. Scientists have specific names for
the bulges and grooves on the surface of the brain. Decades of scientific research have revealed
the specific functions of the various regions of the brain. Beneath the cerebral cortex or surface
of the brain, connecting fibers between neurons form a white-colored area called the "white
matter."

The cerebral hemispheres have several distinct fissures. By locating these landmarks on
the surface of the brain, it can effectively be divided into pairs of "lobes." Lobes are simply
broad regions of the brain. The cerebrum or brain can be divided into pairs of frontal, temporal,
parietal and occipital lobes. Each hemisphere has a frontal, temporal, parietal and occipital lobe.
Each lobe may be divided, once again, into areas that serve very specific functions. The lobes of
the brain do not function alone – they function through very complex relationships with one
another.
 Messages within the brain are delivered in many ways. The signals are transported along
routes called pathways. Any destruction of brain tissue by a tumor can disrupt the
communication between different parts of the brain. The result will be a loss of function such as
speech, the ability to read, or the ability to follow simple spoken commands. Messages can travel
from one bulge on the brain to another (gyri to gyri), from one lobe to another, from one side of
the brain to the other, from one lobe of the brain to structures that are found deep in the brain,
e.g. thalamus, or from the deep structures of the brain to another region in the central nervous
system.

Research has determined that touching one side of the brain sends electrical signals to the
other side of the body. Touching the motor region on the right side of the brain, would cause the
opposite side or the left side of the body to move. Stimulating the left primary motor cortex
would cause the right side of the body to move. The messages for movement and sensation cross
to the other side of the brain and cause the opposite limb to move or feel a sensation. The right
side of the brain controls the left side of the body and vice versa. So if a brain tumor occurs on
the right side of the brain that controls the movement of the arm, the left arm may be weak or
paralyzed.

Cranial Nerves – There are 12 pairs of nerves that originate from the brain itself. These nerves
are responsible for very specific activities and are named and numbered as follows:

1. Olfactory: Smell
2. Optic: Visual fields and ability to see
3. Oculomotor: Eye movements; eyelid opening
4. Trochlear: Eye movements
5. Trigeminal: Facial sensation
6. Abducens: Eye movements
7. Facial: Eyelid closing; facial expression; taste sensation
8. Auditory/vestibular: Hearing; sense of balance
9. Glossopharyngeal: Taste sensation; swallowing
10. Vagus: Swallowing; taste sensation
11. Accessory: Control of neck and shoulder muscles
12. Hypoglossal: Tongue movement

Hypothalamus – The hypothalamus is a small structure that contains nerve connections that
send messages to the pituitary gland. The hypothalamus handles information that comes from the
autonomic nervous system. It plays a role in controlling functions such as eating, sexual behavior
and sleeping; and regulates body temperature, emotions, secretion of hormones and movement.
The pituitary gland develops from an extension of the hypothalamus downwards and from a
second component extending upward from the roof of the mouth.

The Lobes

Frontal Lobes – The frontal lobes are the largest of the four lobes responsible for many different
functions. These include motor skills such as voluntary movement, speech, intellectual and
behavioral functions. The areas that produce movement in parts of the body are found in the
primary motor cortex or precentral gyrus. The prefrontal cortex plays an important part in
memory, intelligence, concentration, temper and personality.

The premotor cortex is a region found beside the primary motor cortex. It guides eye and
head movements and a person’s sense of orientation. Broca's area, important in language
production, is found in the frontal lobe, usually on the left side.

Occipital Lobes

These lobes are located at the back of the brain and enable humans to receive and
process visual information. They influence how humans process colors and shapes. The occipital
lobe on the right interprets visual signals from the left visual space, while the left occipital lobe
performs the same function for the right visual space.

Parietal Lobes

These lobes interpret simultaneously, signals received from other areas of the brain such
as vision, hearing, motor, sensory and memory. A person’s memory and the new sensory
information received, give meaning to objects.

Temporal Lobes

These lobes are located on each side of the brain at about ear level, and can be divided
into two parts. One part is on the bottom (ventral) of each hemisphere, and the other part is on
the side (lateral) of each hemisphere. An area on the right side is involved in visual memory and
helps humans recognize objects and peoples' faces. An area on the left side is involved in verbal
memory and helps humans remember and understand language. The rear of the temporal lobe
enables humans to interpret other people’s emotions and reactions.

Limbic System

This system is involved in emotions. Included in this system are the hypothalamus, part
of the thalamus, amygdala (active in producing aggressive behavior) and hippocampus (plays a
role in the ability to remember new information).

Pineal Gland

This gland is an outgrowth from the posterior or back portion of the third ventricle. In
some mammals, it controls the response to darkness and light. In humans, it has some role in
sexual maturation, although the exact function of the pineal gland in humans is unclear.

Pituitary Gland

The pituitary is a small gland attached to the base of the brain (behind the nose) in an
area called the pituitary fossa or sella turcica. The pituitary is often called the "master gland"
because it controls the secretion of hormones. The pituitary is responsible for controlling and
coordinating the following:

• Growth and development

• The function of various body organs (i.e. kidneys, breasts and uterus)
• The function of other glands (i.e. thyroid, gonads, and adrenal glands)

Posterior Fossa
This is a cavity in the back part of the skull which contains the cerebellum, brainstem,
and cranial nerves 5-12.

Thalamus

The thalamus serves as a relay station for almost all information that comes and goes to
the cortex. It plays a role in pain sensation, attention and alertness. It consists of four parts: the
hypothalamus, the epythalamus, the ventral thalamus, and the dorsal thalamus. The basal ganglia
are clusters of nerve cells surrounding the thalamus.

Language and Speech Functions

 In general, the left hemisphere or side of the brain is responsible for language and speech.
Because of this, it has been called the "dominant" hemisphere. The right hemisphere plays a
large part in interpreting visual information and spatial processing. In about one third of
individuals who are left-handed, speech function may be located on the right side of the brain.
Left-handed individuals may need specialized testing to determine if their speech center is on the
left or right side prior to any surgery in that area.

Many neuroscientists believe that the left hemisphere and perhaps other portions of the
brain are important in language. Aphasia is simply a disturbance of language. Certain parts of the
brain are responsible for specific functions in language production. There are many types of
aphasias, each depending upon the brain area that is affected, and the role that area plays in
language production.

There is an area in the frontal lobe of the left hemisphere called Broca’s area. It is next to
the region that controls the movement of facial muscles, tongue, jaw and throat. If this area is
destroyed, a person will have difficulty producing the sounds of speech, because of the inability
to move the tongue or facial muscles to form words. A person with Broca's aphasia can still read
and understand spoken language, but has difficulty speaking and writing.

There is a region in the left temporal lobe called Wernicke's area. Damage to this area
causes Wernicke's aphasia. An individual can make speech sounds, but they are meaningless
(receptive aphasia) because they do not make any sense.
 LABORATORY RESULTS

Hematology Complete Blood Count

Test Definition Result Reference Interpretation Clinical significance

Range
Hemoglobin It is the main 151 (137-167 g/ml) Normal Elevated level denotes
component of red for
blood cells. Its hematoconcentration
main function is to and polycythemia.
carry oxygen from
the lungs to the Decreased level
body tissues and denotes for
to transport hemorrhage, anemia or
Carbon Dioxide, hemodilution
the product of ( overhydartion).
cellular
metabolism, back
to the lungs.
Hematocrit It is the 0.45 (0.40- 0.50) Normal Elevated level may
measurement of account for
the percentage of hemoconcentration
red blood cells in and polycythemia
the total volume vera.
of blood. It is
expressed as the Decreased level may
percentage of red account for anemia,
cells in the total acute blood loss or
blood volume. hemodilution.
Leukocytes The total white 13.20 (5.0- 10.0) Increased Elevated level
(WBC) blood count accounts for anemia.
(WBC) is the
absolute number Decreased level may
of white blood account for anemia or
cells (leukocytes) bone marrow
circulating in a transplant.
cubic millimeter
of blood.
Platelet Count Also called (205) x 10 ˆ 150-390 Normal Elevated level
thrombocytes, are g/L signifies
large, non- thrombocytosis
nucleated cells resulting from
derived from the hemorrhage, surgery,
megakaryotes chronic inflammatory
produced in the disease.
bone marrow.
They promote
coagulation.

Differential Count

Test Definition Result Reference Interpretation Clinical

Range significance
Eosinophil They play a role in 0.00 (0.00-0.06) Normal Elevated level on
allergic reactions, eosinophil count
possibly may be caused by
inactivating hyperimmune or
histamine. more or allergic
reaction where
there is antigen-
antibody response.

Decreased
eosinophil count
may be associated
 with congestive
heart failure or
anemia.
Lymphocyte They play a role in 0.09 (0.20-0.50) Decreased Elevated level may
our immune be associated with
response. presence of viral
infection and
hormonal disorders.

Decreased level
may account for
burns, trauma and
the administration o
corticosteroids.
Basophil They contain 0.00 (0.0-0.1) Normal Elevated level
histamine and accounts for
heparin and appear inflammatory
to be involved in process, leukemia,
immediate healing stage of
hypersensitivity infection.
reactions.
Decreased level
accounts for stress
or hypersensitivity
reactions.
Monocyte They are the second 0.06 (0.08-0.14) Decreased Elevated level
line of defense accounts or viral
against bacterial diseases or
infections and monocytic
foreign substance. leukemia.

Decreased level
accounts for
lymphocytic
leukemia and
aplastic anemia.
Neutrophils Most numerous 0.85 (0.37-0.72) Increased Increased level
circulating WBC’s denotes presence of
and they respond a bacterial or
more rapidly to the aplastic infectious
inflammatory and process.
tissue injury sites
than other types of Decreased levels
WBCs. may be caused by
hamatoloic diseases
and acute viral
infecrion.

Microscopic Examination of Urinary Sediment

Constituents Definition Result Reference Value Interpretation Clinical significance
WBC and WBC Casts are formed 6-10/1pf > 4 per lower Increased Accumulation of red
casts within the kidney power field cells and white cells
tubules from indicates an infection
agglutination of o the urinary tract.
protein cells, of
red and white Accumulation of
cells of epithelial white cells casts
cells. occurs in
glumerolonephritis,
pyelonephritis,and
Rickey inflammation.
RBC and WBC Casts are formed 8-10/ lpf >2/11 pf Increased Accumulation of red
casts within the kidney cells indicates
tubules from bleeding in the
agglutination of glomeruli or tubules
protein cells, of of presence of calculi.
red and white Accumulation of red
cells of epithelial cell casts indicates
cells. glumerolonephritis.
Epithelial Cells Casts are formed Occasional Occasional Normal Epithelial cells
within the kidney accumulate from
tubules from casts of tubular cells
 agglutination of damaged by
protein cells, of nephrosis, eclampsia
red and white and poisoning from
cells of epithelial heavy metals and
cells. toxins.

URINALYSIS

Property/Constituents Definition Result Reference Value Interpretation Clinical

significance
Color Yellow Light straw to Normal A pale color
dark amber usually indicates
yellow diluted urine and
dark yellow or
amber indicates
concentrated
urine.
Transparency Clear Clear Normal
PH It is the hydrogen 5.0 4.5-8.0 Normal Acid urine is
concentration of associated with
the urine. It is a diabetes mellitus,
measurement of diarrhea and
the acid or dehydration.
alkaline status of
he urine. Alkaline urine is
found in patients
with UTI and
chronic renal
failure.
Specific Gravity it is the 1.025 1.005-1.030 Normal Increased urine
measurement of specific gravity
the concentration are caused by
of urine increased
concentration of
various
substances
contributing to
urine
concentration and
increased water
loss in the body
Protein Protein found in Negative Qualitative Normal Proteinuria is a
the urine albumin, Analysis sensitive indicator
a serum protein > negative of kidney
that normally dysfunction.
does not leak into Quantitative
the glomerular Analysis
filtrate > 10-100 mg/24
h
Sodium It is the principal 135.3 mEq/l 135-1487 mEq/l Normal Deviations that
cation of the result in
extracelluar fluids concentrated
and is the most body fluid state is
important referred to as
antelectrolyte in hypertonic that is
the maintenance caused by either a
of fluid balance in sodium excess or
the body. body water.
Excess of body
water or a
decrease sodium
intake and is
reflected by
hyponatremia
with serum
sodium level
below 120 mEq/l
Potassium It is one of the 4.30 mEq/l 3.5-5.5 mEq/l Normal Excess signifies
major electrolytes hyperkalemia that
in the body fluid occurs when a
that is responsible serum level of
for maintaining accumulated
life-sustaining potassium rises
neuromuscular above 5.5 mEq/1.
functioning. It is caused by
kidney disease,
such as renal
shutdown.

Deficit signifies
hypokalemia that
is caused by
administration of
thiazide diuretics
without
potassium
replacements.
 DRUG STUDY

Name of Drug: Tramadol

Brand Name: Ultram
Classification: Opioid analgesic
Dosage/ Frequency: Tablets 50 mg, 1 cap every 6 hours

Mechanism of Action:
Binds to certain opioid receptors and inhibits reuptake of norepinephrine and serotonin; exact
mechanism of action unknown.

Indications:
Relief of moderate to moderately severe pain (immediate-release); relief of moderate to
moderately severe chronic pain for patients who require around-the-clock treatment for an
extended period of time (ER).

Contraindications:
Acute intoxication with alcohol, hypnotics, centrally acting analgesics, narcotics, opioids, or
psychotropic agents; hypersensitivity.

Adverse Reactions:

Nursing Considerations:

• Instruct patient to take the prescribed dose at the recommended intervals.

• Advise patient to swallow the ER tablet whole and not to break, cut, or crush the tablet.
• Instruct patient to report any serious adverse reactions to health care provider.
• Advise patient not to wait until pain level is high to self-medicate; drug will not be as
effective.
• Advise patient to avoid using alcohol or other CNS depressants (eg, sleeping pills).
• Advise patient that this medication may cause drowsiness and to use caution while
driving or using heavy equipment, or performing other tasks requiring mental alertness.
• Advise patient not to abruptly discontinue this medication; when discontinuing treatment,
taper the dose.
• Advise patient to notify health care provider if pain is not relieved by the medication at
prescribed dosage.

Name of Drug: Phenytoin

Brand Name: Dilantin
Classification: Anticonvulsant
Dosage/ Frequency: 100mg 1cap QID

Mechanism of Action:
It works by slowing down impulses in the brain that cause seizures.

Indications:
Treating certain types of seizures (eg, status epilepticus). It is also used to prevent and treat
seizures that may occur during or after brain or nervous system surgery. It may also be used for
other conditions as determined by your doctor.

Contraindications:

• you are allergic to any ingredient in Phenytoin or to another hydantoin (eg, fosphenytoin)
• you have certain types of heart problems (eg, very slow heart beat, certain types of heart
block, Adams-Stokes syndrome)

Adverse Reactions:
Constipation; dizziness; headache; mild nervousness; nausea; trouble sleeping; vomiting.

Nursing Considerations:
Phenytoin may cause dizziness. This effect may be worse if you take it with alcohol or
certain medicines. Use Phenytoin with caution. Do not drive or perform other possibly unsafe
tasks until you know how you react to it.
Check with your doctor before you drink alcohol while you are taking Phenytoin . Alcohol
may increase or decrease the amount of medicine in your blood.
Do not change brands or dose forms (eg, tablets, suspension, injection) of Phenytoin without
talking with your doctor.
Do NOT take more than the recommended dose without checking with your doctor.
Proper dental care is important while you are taking Phenytoin . Brush and floss your teeth
and visit the dentist regularly.
Phenytoin may raise your blood sugar. High blood sugar may make you feel confused,
drowsy, or thirsty. It can also make you flush, breathe faster, or have a fruit-like breath odor. If
these symptoms occur, tell your doctor right away.

Name of Drug: Mannitol

Brand Name: Osmitrol
Classification: Diuretic
Dosage/ Frequency: 100cc q8h IV Bolus

Mechanism of Action:
It works by increasing the amount of fluid excreted by the kidneys and helps the body to
decrease pressure in the brain and eyes.

Indications:
Mannitol is used to force urine production in people with acute (sudden) kidney failure.
Increased urine production helps prevent the kidneys from shutting down, and also speeds up
elimination of certain toxic substances in the body. Mannitol is also used to reduce swelling and
pressure inside the eye or around the brain.

Contraindications:

• you are allergic to any ingredient in Mannitol

• you have a history of heart failure
• you have decreased or absent production of urine due to severe kidney disease, certain
severe lung problems (eg, pulmonary congestion or pulmonary edema), bleeding in the
brain, or severe dehydration

Adverse Reactions:

• dry mouth, increased thirst, blurred vision, or seizure (convulsions);

• swelling, pain, or skin changes where the medicine was injected;
• chest pain, fast heart rate;
 • feeling like you might pass out;
• feeling short of breath, even with mild exertion;
• swelling, rapid weight gain; or
• if you stop urinating.

Nursing Considerations:

Mannitol may cause dizziness. These effects may be worse if you take it with alcohol or
certain medicines. Use Mannitol with caution. Do not drive or perform other possibly unsafe
tasks until you know how you react to it.

Use Mannitol with caution in the ELDERLY; they may be more sensitive to its effects.

Mannitol should be used with extreme caution in CHILDREN younger than 12 years old;
safety and effectiveness in these children have not been confirmed.

Name of Drug: Sevoflurane

Brand Name: Sevorane
Classification: Anesthetic, general
Dosage/ Frequency: Inhalation
Mechanism of Action:

Sevoflurane is used to cause general anesthesia (loss of consciousness) before and during
surgery. It is inhaled (breathed in)

Indications:

Contraindications:
Diseases that can cause muscle weakness, such as familial periodic paralysis, muscular
dystrophy, myasthenia gravis, or myasthenic syndrome, Head injury, kidney disease, liver
disease, malignant hyperthermia and portwine stain.

Adverse Reactions:
Cough; dizziness; drowsiness; increased amount of saliva; nausea; shivering; vomiting and
headache

Nursing Considerations:

• Sevoflurane may cause some people to feel drowsy, tired, or weak for a while after they
receive it. It may also cause problems with coordination and ability to think. Therefore,
for about 24 hours (or longer if necessary) after receiving sevoflurane, do not drive,
operate moving machinery, or do anything else that could be dangerous if you are not
alert.
• Unless otherwise directed by your doctor or dentist, do not drink alcoholic beverages or
take other central nervous system (CNS) depressants (medicines that may make you
drowsy or less alert) for about 24 hours after you have received sevoflurane. Taking these
medicines or drinking alcoholic beverages may add to the effects of sevoflurane. Some
examples of CNS depressants are antihistamines or medicine for hay fever, other
allergies, or colds; other sedatives, tranquilizers, or sleeping medicine, prescription pain
medicine or narcotics; barbiturates; medicine for seizures; and muscle relaxants.

Name of Drug: Silver Sulfadiazine

Brand Name: Flamazine
Class: Broad spectrum Sulfonamide
Dosage/ Frequency: cream 1%

Mechanism of Action:
Acts on cell membrane and cell wall: it’s bactericidal for many gram-positive and gram- negative
organisms

Indications:
Used to prevent or treat wound infection in second- and- third degree burns.

Contraindications:
- hypersensitivity
- pregnant women or near term and in premature or full term neonates
- increase possibility of kernicterus

Adverse Reactions:
Interstitial; nephritis, leukopenia, altered serum osmolality, erythema multiforme, pain, burning,
rash, pruritus, skin necrosis and skin discoloration.

Nursing Considerations:
.Wash, rinse, dry affected areas before application.
. Prolonged used may be needed when treating acne vulgaris, which result in overgrowth of
nonsusceptible organisms.
. Tell patient to stop using drug and notify prescriber if no improvements occur or if condition
worsens in 3 to 12 weeks.
. Caution patient to keep drug away from the heat and open flame.

Name of Drug: Abscorbic Acid

Brand Name: Cecon
Class: Vitamin
Dosage/ Frequency: 500mg 1tab OD

Mechanism of Action:
Stimulates collagen formation and tissue repair: involved in oxidation- reduction reactions
throughout body.

Indications:
Extensive burns, delayed fracture or wound healing, post operative wound healing, severe febrile
or chronic disease states.

Contraindications:
Use cautiously among pregnant women, give only if clearly needed.

Adverse Reactions:
Dizziness with rapid I.V delivery, faintness, diarrhea, acid urine, oxaluria, renal calculi,
discomfort at infection site.

Nursing Considerations:
. Assess patient's condition before starting therapy and regularly thereafter to monitor drug's
effectiveness.
. When giving for urine acidification, check urine pH to ensure effectiveness.
. Be alert for adverse reactions and drug interactions.
. Assess patient's and family’s knowledge of drug therapy.

Name of Drug: Acetaminophen

Classification: Non-opioid analgesic, anti-pyretic

Dose and Frequency: 325 to 650 mg PO every 4 hours prn

Mechanism of Action: Blocks pain impulses, probably inhibiting prostaglandin or pain receptor
sensitizers. May relieve fever by acting on hypothalamic heat-regulating center.

Indications: Mild pain or fever

Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in

patients with a history of chronic alcohol abuse because hepatotoxicity may occur.

Adverse Reactions:
Hematologic: hemolytic anemia, leukopenia
Hepatic: liver damage, jaundice
Metabolic: hypoglycemia
Skin: rash, urticaria

Nursing Considerations:
• Assess patient’s pain and temperature before giving any drugs.
• Assess patient’s drug history and calculate daily dosage accofdingly.
• Be alert for adverse reactions and drug interactions.
• Assess patient and family’s knowledge of drug use.
• Tell patient not to use drug for fever higher than 103 degrees Fahrenheit or
lasts longer than 3 days or recurs.
• Tell patient to keep track of daily acetaminophen intake.

Name of Drug: Baclofen

Classification: Chlorophenyl derivative
Brands: Kemstro, Lioresal
Dose and Frequency: Initially 5 mg PO TID for 3 days. Based on response, increase dosageat 3-
day intervalsby 15 mg daily up to maximum of 80 mg daily.
Mechanism of Action: Appears to reduce transmission of impulses from spinal cord to skeletal
muscles.
Indications: Spasticity in multiple sclerosis, spinal cord injury
Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in
patients with impaired renal function or seizure disorder.
Adverse Reactions:

Metabolic: hyperglycemia
Skin: pruritus
CNS: confusion, dizziness, headache, paresthesia
CV: ankle edema, hypotension
GI: constipation, nausea and vomiting
GU: sexual dysfunction
RESPIRATORY: dsypnea
EENT: blurred vision, nasal congestion

Nursing Considerations:
• Obtain history of patient’s pain and muscle spasms.
• Be alert for adverse reactions and drug interactions.
 • Tell patient to avoid activities that require alertness.
• Tell patient to avoid alcohol while taking drug.
• Advise patient to follow prescriber’s orders about rest and physical therapy.
• Advise patient to take drug with food or milk to prevent GI disorders.

Name of Drug: Cefixime

Brand: Tergecef
Classification: Third-generation cerhalosporin, amtibiotics
Dose and Frequency: 200 mg 1 tab BID
Mechanism of Action: Inhibits cell wall synthesis promoting osmotic instability, usually
bactericidal.
Indications: Infections of lung, skin, soft tissue, bones, joints, urinary and respiratory tracts,
blood, abdomen and heart. Infections develop after surgical procedures classified as potentially
contaminated.
Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in
patients with renal or hepatic impairment.
Adverse Reactions:

Hepatic: hepatitis, jaundice

Skin: pruritus
CNS: dizziness, fatigue
GI: abdominal pain, diarrhea and vomiting
GU: genital pruritus

Nursing Considerations:
• Review patient’s history of allergies.
• Monitor patient for adverse reactions.
• Obtain culture and sensitivity of specimen.
• Monitor renal function, PT and platelet count.

Name of Drug: Clindamycin

Brand: Cleocin
Classification: Lincomycin derivative
Dose and Frequency: 150 – 450 mg PO every 6 hours
Mechanism of Action: Inhibits bacterial protein synthesis by binding 50s subunit of ribosome.
Indications: Infections caused by sensitive staphylococci, streptococci, pnuemococci,
bacteroides, and other sensitive anaerobic and aerobic organisms.
Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in
patients with renal or hepatic disease, asthma and a history of GI disease or significant allergies.
Adverse Reactions:
Hematologic: thrombocytopenia, leukopenia
Skin: urticaria
CV: thrombophlebitis
GI: abdominal pain
RESPIRATORY:
EENT: pharyngitis
Nursing Considerations:
• Assess patient’s infection before and regularly throughout therapy.
• Obtain specimen for culture and sensitivity.
• Monitor renal and hepatic functions.
• Be alert for adverse reactions and drug interactions.
• Tell patient how to store oral solutions.
• Instruct patient to report diarrhea and avoid self-treatment because of the
threatening pseudomemebranous colitis.

Name of Drug: Ranitidine

Brand: Zantac
Classification: Histamine-receptor antagonist
Dose and Frequency: 150 mg PO BID or 300 mg at bedtime
Mechanism of Action: Competitively inhibits action of histamine2 receptor sites of parietal cells,
decreasing gastric acid secretion.
Indications: Acute duodenal or gastric ulcer and gastroesophageal reflux
Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in
patients with impaired renal and hepatic function.
Adverse Reactions:
Hepatic: jaundice
Skin: rash
CNS: malaise
GI: abdominal discomfort
EENT: blurred vision

Nursing Considerations:
• Monitor patient for adverse reactions, especially hypotension and
arrhythmias.
• Peridically monitor lab tests, such as cbc and renal and hepatic studies.

Name of Drug: Epinephrine

Brand: Adrenalin chloride
Classification: Adrenergic
Dose and Frequency: 0.1 to 0.5 ml of 1: 1000, subcutaneously or IM
Mechanism of Action: Stimulates alpha and beta receptors an sympathetic nervous system.
Indications: Bronchospasm, prolonging local anesthetic effect
Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in
patients with angle-closure glaucoma, shock, organic brain damage.
Adverse Reactions:

Metabolic: glycosuria
Skin: urticaria
CNS: cerebral hemorrhage
CV: anginal pain
 GI: nausea and vomiting
RESPIRATORY: dsypnea

Nursing Considerations:
• Obtain history of patient’s underlying condition before starting therapy, assess
regularly.
• Be alert for adverse reactions and drug interaction.
• Tell patient to take drug exactly as prescribed and to take it around the clock.
• Tell patient to reduce intake of foods containing caffeine such as coffee.
• Tell patient to obtain approval from physician before taking OTC drugs and
herbal medicines.

Name of Drug: Lidocaine

Brand: Lidopen
Classification: Amide derivatives
Dose and frequency: 50-100 mg by IV bolus at 25-50mg per minute
Mechanism: Decrease depolarization, automaticity and excitability in ventricles during diastolic
phase by direct actions on tissues.
Indication: Ventricular arrythmias resulting from MI, cardiac manipulation or digoxin toxicity.
Contraindication: contraindicated to patients hypersensitive to the drug, use cautiously and
reduce dosage in patients with complete or second-degree heart block or sinus, and to patients
with renal and hepatic disease.
Adverse reactions:
CNS: confusion
CV: bradycardia
EENT: blurred vision
RESPIRATORY: respiratory arrest
Skin: diaphoresis

Nursing Considerations:
• Assess patient condition before starting therapy and regularly thereafter to
monitor drug effectiveness.
• Monitor patient’s response especially ECG, BP, electrolytes, BUN, and
creatinine levels.
• Be alert for adverse reactions and drug interactions.
 NURSING CARE PLANS

Nursing Care Plan

Pre Operative Phase

Problem Identified: Impaired Physical Mobility

Date Identified: July 30, 2009
Date evaluated:

Subjective Cues:

Objective Cues:
 limited range of motion
 inability to perform gross motor skills
 difficulty upon turning
 unable to transfer to bed
 decreased muscle strength

Assessment: Impaired Physical Mobility r/t Sensoriperceptual Impairment secondary to

injury, bedrest and unresponsive state

Planning: Within the pre operative phase of nursing interventions, the patient will be able to
maintain/ increase strength and function of affected and/or compensatory body part and regain
optimal position function as evidenced by absence of contractures and footdrop.

Interventions:
1. Review functional ability and reasons for impairment.
R: Identifies probable functional impairments and influences choices of interventions
2. Assess the degree of immobility, using a scale to rate dependence(0-4)
R: The client may be completely independent (0), may require minimal assistance/equipment
(1), moderate assistance/ supervision/ teachings (2), extensive assistance / equipment and
devices (3),or be completely dependent on caregivers (4)
3. Provide/ assist with range of motion exercises.
R: Maintains mobility and function of joints/functional alignment of extremities and reduces
venous stasis.
4. Place the client in designated therapeutic position.
R: Designated therapeutic position should cause no undue stress on muscles or joint.
5. Apply a foot board to the bed.
R: A foot board will prevent foot drop.
6. Elevate the head of bed, as appropriate.
R: The head of the bed may be elevated to provide counteraction of for comfort if permitted.
7. Place frequently used objects within reach.
R: Placing frequently used objects within reach permits the client safe and convenient access.
8. Provide meticulous skin care, remove wet linen/clothing and keep bedding free from
wrinkles.
R: Promotes circulation and skin elasticity and reduces risk of skin excoriation.
9. Monitor bowel elimination and provide for/ assist with a regular bowel routine.\
R: A regular bowel routine requires simple but diligent measures to prevent complications.
10. Provide air/ water mattress, kinetic therapy as appropriate.
R: Equalizes tissue pressure, enhances circulation, and helps reduce venous stasis to decrease
risk of tissue injury.
Evaluation
 Nursing Care Plan
Intra Operative Phase

Problem Identified: Ineffective Cerebral Tissue Perfusion

Date Identified: July 30, 2009
Date evaluated:

Subjective Cues:
Objective Cues:
 changes in vital signs
 altered level of consciousness
 disproportionate increase in ICP

Assessment: Ineffective tissue perfusion r/t interruption of blood flow by space- occupying
lesions as evidenced by hemorrhage and hematoma.

Planning: Within the intra operative phase of nursing interventions, the patient will be able to
demonstrate stable vital signs and absence of signs of increased intracranial pressure (ICP).

Interventions:
1. Monitor patient’s vital signs.
R: To provide baseline data.
2. Determine factors related to individual situation, cause for coma/decreased cerebral
perfusion and potential for increased ICP.
R: Influences choices of intervention. Deterioration in neurological signs/ symptoms may
reflect decreased intracranial adaptive capacity requiring client be transferred to critical care
unit for ICP monitoring and/or surgical intervention.
3. Calculate and monitor cerebral perfusion pressure (CPP).
R: A CPP equal to or greater than 60-70 mmHg is needed to provide adequate oxygenation
and nutrition to brain tissue.
4. Monitor respiratory status like rate, rhythm and depth of respirations.
R: Adequate gas exchange is required for tissue oxygenation.
5. Evaluate eye opening (e.g spontaneous (awake), opens only to painful stimuli, keeps eyes
closed (coma).
R: Determines arousal ability/ level of consciousness.
6. Note presence/ absence of reflexes like blink, cough or gag reflex.
R: Altered reflexes reflect injury at level of midbrain or brainstem and have direct
implications for client safety
7. Monitor temperature and regulate environmental temperature as indicated.
R: Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen
consumption occur (especially with fever and shivering) which can further increase ICP.
8. Monitor I & O and note skin turgor, status of mucous membrane.
R: Useful indications of total body weight, which is an integral part of tissue perfusion.
Alterations may lead to hypovolemia, or vascular engorgement, either which can negatively
affect cerebral pressure.
9. Provide rest periods between care activities and limit duration of procedures.
R: Continual activity can increase ICP by producing a cumulative stimulation effect.
10. Observe for seizure activity and protect client from injury.
R: Seizures can occur as a result of cerebral irritation, hypoxia, or increased ICP that further
elevate ICP, compounding cerebral damage.
11. Administer medications as indicated such as diuretics like Mannitol and Furosemide.
R: Diuretics may be used in acute phase to drain water from blood cells, reducing cerebral
edema and ICP.
12. Initiate cooling measures, as indicated.
R: May be needed to regain or maintain normal core body temperature.

Evaluation
 Nursing Care Plan
Post Operative Phase

Problem Identified: Risk for Infection

Date Identified: July 31, 2009
Date evaluated:

Subjective Cues:

Objective Cues:
 Touches operative wound with bare hands
 Slight increase in vital signs
 diaphoresis

Assessment: Risk for Infection r/t traumatized tissue secondary to post- craniectomy.

Planning: Within 2 days of nursing interventions, the patient will be able to maintain free signs
of infection and achieve stable vital signs.

Interventions:
1. Monitor patient’s vital signs.
R: To provide baseline data.
2. Monitor for systemic & localized signs and symptoms of infection.
R: Elevated temperature, pulse, respirations, and fever indicate systemic infection. Redness,
heat, swelling and pain indicate localized infection.
3. Provide meticulous, aseptic care, maintaining good handwashing technique.
R: First line of defense against nosocomial infection.
4. Inspect the condition of any surgical incision/ wound.
R: Early identification of developing infections permits prompt intervention and prevention
of further complications.
5. Monitor temperature routinely. Note presence of chills, diaphoresis and changes in
mentation.
R: May indicate developing sepsis requiring further evaluation/ intervention.
6. Encourage deep breathing and coughing, as appropriate.
R: Coughing and deep breathing clear the lungs of secretions that may encourage the growth
of pathogenic microbes.
7. Encourage sufficient nutritional intake.
R: Adequate nutrition is essential for immune system formation and for the repair of
damaged body tissues to provide protection against external pathogens.
8. Promote rest periods and encourage fluid intake.
R: Mending tissues requires energy. Adequate fluid intake provides for renal clearance of
toxins produced by pathogens.
9. Administer antibiotic therapy, as ordered/ appropriate.
R: Antibiotic therapy should assist the body to destroy pathogens.
10. Screen/ restrict of visitors or caregiver, with upper respiratory infections (URI).
R: Reduces exposure of “compromised host”.

Evaluation:
 DISCHARGE PLANNING

M – Medication
- Advise patient to take home medications following right drug, frequency, dosage
and timing as prescribed by the Physician such as follows:

> Tramadol, 50 mg 1 cap q6h

> Cecon, 500mg 1 tab OD

> Flamazine

E – Environment
- Instructed patient to stay in calm, quiet environment

- Home environment must be free from slipping or accident hazards

T – Treatment
- Informed patient to have a follow-up check up after 1- 2 weeks

H – Health Teachings
- Inform patient to avoid lifting heavy objects for 1-2 weeks

- Stress the importance of proper hygiene like handwashing, toileting, toothbrushing

and bathing.

- Encourage client to engage to range of motion exercises.

- Instruct patient to increase intake of protein-rich foods to promote faster wound

healing

- Advise patient to increase adequate fluid intake for hydration purposes.

- Discourage patient to participate in strenuous activities that might precipitate stress

and trauma to the wound.

- Tell patient not to hesitate to ask for assistance when waking up in bed or when
going to comfort room.

- Promote rest periods among the client but also encourage ambulation.

- Advise patient to avoid touching the operative wound with hands dirty that may
cause infection.
 - Encourage deep breathing and coughing exercises among the client.

O – Observable Signs and Symptoms

- Instruct patient to report signs and symptoms of increased intra cranial pressure
like seizures, vomiting or headache to nearest hospital to avoid further
complications.

- Instruct patient to report to physician any signs of infection like inflammation,

redness or swelling

- Instruct patient to report any case of hemorrhage or abnormal bleeding

D – Diet
- Encourage client to increase intake of fiber to avoid constipation

- Instruct to increase fluid intake

- Instruct to increase intake of nutritious foods such as fruits and vegetables

S- Spirituality

- Advise patient to keep believing on God’s holy will so that he could be spiritually
motivated.
- Tell patient to constantly participate to religious activities so that his faith could
be more strengthened.
 LEARNING OUTCOMES

Life is indeed full of surprises. Things happen as what expected to them to happen.
No one ever travels the highway of success without ever crossing the road of failures instead.
All we need to is to follow path that leads us to the unknown road. But we should always be
glad that as we get stumbled along the road, we learn to stand on our own feet putting our
heads up. From those experiences, we learn to grow as a person accountable for every action
we take. That’s how learning process takes place. It comes naturally as it may seem.

How could I ever forget the experience I have acquired upon exposure to
operating/delivery room of Manuel J. Santos Hospital. It was the 24th day of July, when I first
heard during our NCM 100 RLE concept last summer classes. I have to admit on my part that
I got anxious and nervous as I found out that our group was assigned to OR/DR area for the
2nd rotation, as early as that. Preparations were being made. I also reviewed my OR/DR
lecture notes within that short span of time, if that would be possible.

As day progressed, I have gained new learnings and insights most especially during
exposure to surgical operations. It’s just that in OR/DR area, there is no room for mistakes
perhaps. Principle of sterility should strictly be observed. For being a part of surgical team
means being a part of a battle we need to win. It entails cooperation and presence of mind as
one engages to the world of sterility. Imagine yourself standing for about 4-6 hours during an
operation, I bet it’s going to be hard perhaps. But patience and dedication area somewhat the
virtues to keep, so one should keep the fire burning.

When it comes to operation, one should be fully prepared. One must be assertive
enough to do all things needed to be carried out. One must be fully equipped with the
knowledge, skills and attitude before exposing to the area so that one could be productive and
useful during operations/delivery. One should really pay attention so that things would run
smoothly.

Upon exposure, I was able to appreciate the organs of the body. It somehow made me
appreciate myself and lot more becoming a part of the team. Things could be much more
appreciated if one puts it into practice. It’s a great feeling being part of a team, trying to save
a life of a person. No one can ever replace that happiness I felt for the successful operations I
had assisted with may it be major or minor operation instead. What a great relief seeing my
patient lying flat on bed, well and normally breathing after a risky procedure.

“Life is uncertain, treasure every moment”-a quotation on worth to lived for. As for
now, I should live my life doing good things not just for myself but also for others. I should
bear in mind that I should not count the number of times I felt better just because I made
them happy. Twelve days of exposure may be short enough yet with the experiences and
learnings I gained, the hardships were all worth it. The experience was truly superb and
remarkable indeed.