During 3-4 hours of case presentation, the BSN4-Echo will be able to:

1. Review the anatomy and physiology of the brain

2.. Identify the subjective data collected from significant others while
gathering information for the nursing history.

3.. Identify the deviation from the normal using Inspection,

percussion, palpations and auscultation to elicit the objective data
while performing nursing assessment.

4.. State the normal values and interpret findings with significant
deviation of laboratory and diagnostic results.

5. Trace the pathophysiology of Traumatic Brain Injury.

6. Formulate nursing care plan as a framework of care according to

priority.

7. Tabulate the drugs given to the patient according to its name,

content, action, mechanism of action, indication contraindication,
adverse effect and nursing consideration

8.. Appreciate the role of the nurse in caring for patient with
Traumatic Brain Injury
 THE HUMAN BRAIN
Brain

The brain keeps the body in order. It helps to

control all of the body systems and organs,
keeping them working like they should. The
brain also allows us to think, feel, remember and
imagine. In general, the brain is what makes us
behave as human beings.
The brain communicates with the rest of the body
through the spinal cord and the nerves. They tell
the brain what is going on in the body at all
times. This system also gives instructions to all
parts of the body about what to do and when to
do it.
The central nervous system (CNS) represents the largest part of the nervous
system, including the brain and the spinal cord. Together with the peripheral
nervous system, it has a fundamental role in the control of behavior. The
CNS is contained within the dorsal cavity, with the brain within the cranial
subcavity, and the spinal cord in the spinal cavity. The CNS is covered by
the meninges. The brain is also protected by the skull, and the spinal cord is
also protected by the vertebrae. Peripheral nervous system

In humans, the brain consists of cerebrum (center for thought and memory
association); hypothalamus-thalamus (center for processing information),
cerebellum and brain stem (center for locomotion and coordination) and
the spinal cord, an extension of the brain consists of motor and sensory
nerves in the cervical, thoracic and lumber regions of the spine.
A. Embryological Development

• During the development stages, the brain starts out as a tube in most
mammals. The tube has three bulges or balloon-like structures at one end
of the third week of conception.
• The first part is prosencephalon (forebrain); mesencephalon (midbrain)
and rhobemencephalon (hindbrain).
• After 5wks, telencephalon and diencephalons form develop from the
forebrain (prosencephalon); the hind brain forms metencephalon
(afterbrain) and myelin-cephalon (form spinal cord).
• These structures form the brain and the other end forms the spinal cord.
• The cerebrum develop from telencephalon; diencephalons forms the
hypothalamus, thalamus and epithalamus.
• Mesencephalon, metencephalon and myelencephalon develop into
cerebellum and midbrain or brain stem (pons and medulla oblongata).
B. Characteristics of the CNS
The entire CNS is protected by a bony capsule – the cranium and the vertebral column
protects the spinal cord.
The cranium is covered with membrane called meninges of which there are three: dura
mater (out layer), arachnoid (middle) and pia mater (interior layer).
The surface of brain contains ridges called gyri (gyrus, singular) and are separated by
valleys called sulci and deeper valleys or grooves are called fissure.
There are five lobes: frontal, parietal, occipital, temporal and the insula lobe.
Two cerebral hemispheres exist which are mirrow images and are connected in the
middle by a bundle of nerves called corpus collasum.

C. Functions of the Brain

1. Cerebrum
Cerebrum is the center for control, thought and associations.
Command center: It serves as the command center of the brain. All information from the
periphery nervous system (PNS), motor functions and sensory activities are received,
processed, analyzed and relayed or commands are issued for their respective
responses.
Other functions include development, vision, speech, memory, thought, and association.
The cerebrum is divided into left and right hemispheres and these hemispheres contain
fibers or tracts, which cross over each half of the hemispheres
The association of the tract with each half of the cerebral hemispheres is very important.
During an accident or removal of tumor, the tracts can be cut accidentally. When the
cut is not repairable, it may leave permanent damage that could lead to loss of
function or paralysis of the functions related to that area.
2. Thalamus and hypothalamus

• Thalamus and hypothalamus are centers for processing information.

• The thalamus and hypothalamus are collectively called diencephalons.
• These organs regulate bodily functions and motor activities (motion), therefore, process
information related to bodily functions and motor activities.
• The thalamus and hypothalamus are located immediately below the corpus callosum.
• The thalamus represents the last center where all sensory signals (except those associated with
the sense of smell) are processed before they are passed on to the cerebrum.
• The hypothalamus maintains homeostasis (that is maintenance of constant body temperature)
and contains centers for regulating hunger, sleep, thirst, temperature, water balance and blood
pressure.
• It also regulates the pituitary gland, which secretes hormones, thereby maintaining regulation of hormones.
3. Cerebellum
• Cerebellum coordinates motor functions.
• The cerebellum is located at the back of the brain below the cerebrum and appears partially
separated from the cerebrum by the fourth ventricle.
• The surface of the cerebellum is made of gray matter and the interior is white matter.
• It functions mainly in muscle coordination and integrating all motor activities.
• It also maintains normal muscle tone and posture and balance.
4. The brainstem
• The brainstem has centers for breathing (pneumatic center), digestive functions, heartbeat
(rhythmic center) and blood pressure.
• The brain stem consists of the midbrain, pons and medulla oblongata. These organs are
located in front of the cerebellum and below the hypothalamus and thalamus.
• The medulla oblongata contains centers which regulate breathing (Pneumonic center),
heartbeat and vasoconstriction. Other centers include vomiting, coughing, sneezing and hiccups.
• The pons functions in collaboration with the medulla, regulating breathing and reflex actions in
response to auditory and visual stimuli.
• It contains bundles of nerves that transmit information between the cerebellum and the CNS.
• The midbrain functions as a relay station. Nerve tracts pass between the spinal cord and
cerebrum or cerebellum. It also maintains centers for vision, auditory and tactile stimulations.
The nervous system is made up of nerve cells or neurons that are "wired"
together throughout the body, somewhat like communication system. Neurons
carry messages in the form of an electrical impulses. The messages move
from one neuron to another to keep the body functioning. Neurons have a
limited ability to repair themselves. Unlike other body tissues, nerve cells
cannot also be repaired if damaged due to injury or disease.
The PNS consists of all other nerves and neurons that do not lie within the
CNS. The large majority of what are commonly called nerves (which are
actually axonal processes of nerve cells) are considered to be PNS. The
peripheral nervous system can be further classified either by direction of
neurons and by function.

The peripheral nervous system uses special senses to connect the body to the
outside environment.
Spinal cord relays sensory and motor signals to the brain.
The spinal cord is the center for many reflex actions. It also functions as a
center providing communication between the brain and the spinal nerves that
leave the spinal cord.
It contains unmyelinated cell bodies and short fibers that give the gray
appearance inside.
The outside of the spinal cord contains bundles of myelinated long fibers of
interneurons. These tracts give the bundles a white color outside.
 FRONTAL LOBE
Located in front of the central sulcus.
Concerned with reasoning, planning, parts of speech and movement (motor
cortex), emotions, and problem-solving.
PARIETAL LOBE
Located behind the central sulcus.
Concerned with perception of stimuli related to touch, pressure, temperature
and pain.
TEMPORAL LOBE
Located below the lateral fissure.
Concerned with perception and recognition of auditory stimuli (hearing) and
memory (hippocampus).
OCCIPITAL LOBE
Located at the back of the brain, behind the parietal lobe and temporal lobe.
Concerned with many aspects of vision.
By direction
There are three types of directions of the neurons:
Sensory system by sensory neurons, which carry impulses from a receptor to the CNS
Efferent system by motor neurons, which carry impulses from the CNS to an effector
Relay system by relay neurons, which transmit impulses between the sensory and motor
neurons. However, there are relay neurons in the CNS as well.
The junction between two neurons is called a synapse. There is a very narrow gap
between the neurons - the synaptic cleft.
By function
By function, the peripheral nervous system is divided into the somatic nervous system and
the autonomic nervous system.
The somatic nervous system is responsible for coordinating the body's movements, and
also for receiving external stimuli. It is the system that regulates activities that are under
conscious control.
The autonomic nervous system is then split into the sympathetic division,
parasympathetic division, and enteric division. The sympathetic nervous system responds
to impending danger or stress, and is responsible for the increase of one's heartbeat and
blood pressure, among other physiological changes, along with the sense of excitement
one feels due to the increase of adrenaline in the system. The parasympathetic nervous
system, on the other hand, is evident when a person is resting and feels relaxed, and is
responsible for such things as the constriction of the pupil, the slowing of the heart, the
dilation of the blood vessels, and the stimulation of the digestive and genitourinary
systems. The role of the enteric nervous system is to manage every aspect of digestion,
from the esophagus to the stomach, small intestine and colon.
Name: Captain Hook
Age: 6 years old
Address: Canetown Subdivision Victorias, City Negros Occidental
Religion: Roman Catholic
Citizen: Filipino citizen
Birthday: August 27,2001
Fathers name: Peterpan
Mothers name: Tinkerbell
Chief Complaint: Vehicular Accident

Diagnosis:
1. Multi-system trauma with Brain Injury Acute Subdural
Hematoma right fronto temporo- parietal and multiple
hemorrhagic concussions severe diffuse cerebral edema;
diffuse subarachnoid hemorrhage.
2. Fracture midshaft right femur.
3. Multiple contusion/ abrasion in faces and extremities
4. Post craniotomy evacuation of subdural hematoma right
temporal.
>Post decompression craniotomy,
dural entry, evacuation of acute
subdural hematoma.
>Post application of long leg posterior
mold.
>Post IV cutdown at right arm.
>Post application of skeletal traction.
>Post suturing of 7cm lacerated
wound at right temporal area.
At 6 am, 2 hours prior to admission, patient was riding in a
vehicle (Toyota revo) driven by his father from Victorias going
to Bacolod to fetch his sister. He was sleeping at the back
passenger seat, with no seatbelt on, when another 4 wheeled
vehicle (land cruiser) hit them head on at EB Magalona.
Luckily, one of there neighbor was passing by on the time of
the accident and with the help of the bystander patient and his
father was rushed to the nearest Hospital (Teresita Lopez
Jalandoni Provincial Hospital).Patient was unconscious and
suffered bleeding and multiple abrasion, he was immediately
given first aid, was intubated and transferred to Dr. Pablo O.
Torre Memorial Hospital for further evaluation and
management together with his father.
Patient’s mother verbalized that patient was delivered
via caesarian section secondary to transverse.Mother
had gestational diabetes during pregnancy.Patient had
complete immunizations, no history of hospitalizations
and no known allergy.

Paternal side Maternal side

X √
Diabetes mellitus
√ √
Hypertension
X √
Cancer
X X
Asthma
Captain Hook is a grade 1 student in Jack
and Jill Victorias He is the only boy and the
youngest among the 2 siblings. His father
and mother are businessmen. On the time of
the accident, his mother was in the USA for
some business matter. Tinkerbell verbalized
that her son is a normal active school grader
before the accident happen.
As a child , captain hooks usual activity is playing on their
school and at there house together with his neighbors. He and
his dad love to drive everywhere. They usually practice safety
measures such as wearing of seatbelts. But during the time of
the accident, his dad was the only one who was able to wear a
seatbelt because he was sleeping at the backseat of there car.
Eating/drinking √

Bathing √

Dressing/groo √
ming

toileting √

Bed Mobility √

StairClimbing √

Ambulating √
Normal appetite
No swallowing difficulty
Ate a well balance diet
Loves to eat chicken

Prior to accident patient

has a normal bowel
(once a day ) and
bladder pattern ( 5-6
times a day)
Presently, with an
indwelling catheter
attached to drainage bag
and a diaper

Has a normal sleep and rest

pattern, he usually sleeps
more than 8 hours a day.
A. General Appearance

Patient lies in a supine position, head of bed is slightly elevated

with a decerebrate posture;, attached to cardiac monitor, with
endotracheal tube to mechanical ventilator. Tidal volume of
400, FIO2 of 60%, BUR of 20, with NGT in placed, with IVF via
IV cutdown at right arm, with IVF set B cycle 33 D5NSS 1L + 2
meq KCL @ 43 cc/hr , with skeletal traction attach to 8 lbs.wt
elevated right lower extremities, with pulse oximeter, with
foley catheter attach to drainage bag, with suction machine
on bedside, with hematoma right temporal area, punctured
left cheek, hematoma left cheek, dried bloody ear discharges
is presence on the right ear. Hematoma on the left auricle,
disproportionate head shape, presence of white dressing in
the head, positive for ptosis, eyelids are taped, non pitting
edema is present in left upper extremities.
 Level IV- light coma
Glasgow Coma Scale of 6

Cranial nerve I cannot be assess

Cranial nerve II cannot be assess

Cranial nerve III, IV, VI Anisocoria (left pupil-2mm. right pupil-

4mm )
Presence of ptosis
Cranial nerve V sensory: cannot be assess
Motor: positive corneal reflex
Lacks facial sensation

Cranial Nerve VII sensory: cannot be assess

Motor- Mask-like face

Cranial nerve VIII Patient follows some command

Cranial nerve IX and X presence of gag reflex upon suctioning

Cranial nerve XI cannot be assess

Cranial nerve XII cannot be assess

Asymmetrical- left upper extremities has presence of
non-pitting edema

3/5- lower extremities

1/5- upper extremities

Hypotonicity (flaccidity)
a.Pupillary reflexes – pupils round, unequal L- 2mm R-
4mm, reactive to light, don’t accommodate

b.Positive corneal reflex

c.Positive abdominal reflex

d. Negative cremasteric reflex

e. Negative babinski reflex

f. Deep tendon reflex

1. Biceps- 1/5
2. Triceps- 3/5
3. Brachioradialis- 1/5
4. patellar reflex-2/5
5. Achilles Tendon Reflex- 1/5
g. negative meningeal irritation

h. negative oculovestibular reflex

 1. EENT
☺presence of white dressing in
the head
☺ disproportionate head shape
☺ presence of ptosis
☺ eyelid is tape
☺ dry eyes
☺ no movement of eyeballs
☺ Anisocoria- pupils round,
unequal L- 2mm R- 4mm,
reactive to light, don’t
accommodate
☺ Pale conjunctiva
☺ White sclera
☺ Comminuted right cheek
☺ Presence of endotracheal
tube attach to mechanical
ventilator
☺ Dry lips
☺ Hematoma right temporal area
☺ Punctured wound in left cheek
☺ Hematoma on left cheek
☺ Hematoma on the left auricle
☺ Dried bloody ear discharges
☺ Mask like face
2.Circulatory
☺ Blood pressure of 150/100 mmHg
☺ Pulse pressure of 40 mmHg
☺ Pulse rate of 160 beats/min.
☺ Temperature of 38.5
☺ Capillary refill of 4 seconds
☺ Non-pitting edema is presence on the
left upper extremities
☺ Dry lips
☺ Pale conjunctiva
☺ White sclera
☺ Skin is warm to touch
3. Respiration
☺ Presence of endotracheal
tube attach to mechanical
ventilator
☺ Respiratory rate of 20
breaths/min-assisted
ventilation
4.Musculoskeletal
☺ Increase muscle size in left
upper extremities due to
non pitting edema
☺ Absent range of motion
☺ Weak muscle strength 6.Integumentary
☺ Hypotonicity ( flaccidity )
☺ Presence of hematoma on the face
☺ Presence of skeletal traction
☺ Presence of broken skin on the groin area
attach to 8 lbs. wt
☺ Multiple abrasions and bruises on the face
☺ Redness on the skeletal and extremities
traction area
☺ Skin is warm to touch

5.Elimination ☺ Presence of redness on the skeletal traction

area
☺ Laxative use: none
☺ Character of stool: mushy
☺ With foley catheter attach to
drainage bag
☺ Color of urine: light yellow
☺ Has a normal urine output
7. Neurosensory
☺ Decrease level of consciousness
☺ Patient is in light coma
☺ pupils round, unequal L- 2mm R-
4mm, reactive to light, don’t
☺ accommodate
☺ weak handgrasp
☺ decerebrate posture
JULY 07 2007
July 07 2007 10 : 27 am Results Normal value

Hemoglobin 59 ( 120- 170 g/l)

Hematocrit .20 ( .40-.54)
Red blood cell 2.28 ( 4.60-6.00 x 10 12/L
White blood cell 26.6 ( 5.00-10.00 x 10 9/L
Segmenters .72 ( .50-.70 )
Lymphocytes .21 ( .20-.40 )
Eosinophils .01 ( .00-.05 )
Monocytes .06 ( .00-.09 )
Platelet Adequate
Arterial Blood Gas 10: 50 am
Results Normal value

pH 7.01 ( 7.35-7.45 )
PCO2 49.6 ( 35-45 mmHg )
PO2 362.1 ( 80- 100 mmHg )
HCO3 12.5 ( 22- 26 meq/L )
BE 18.5 ( ± 2 meq/L )
O2 sat 99.5 ( 97 % )
Multiple axial tomographic sections of the head were obtained without
intravenous contrast material due to craniocerebral trauma secondary to
vehicular accident.

CT image reveal the following findings:

1. there is DIFFUSE CEREBRAL EDEMA with “ white cerebellum” signs for
which HYPOXIC ISCHEMIC ENCEPHALOPATHY is considered. The sulci and
fissure are effaced. The supracellular cisterns are likewise slightly effaced.
2.ACUTE SUBDURAL HEMATOMA is noted in the right fronto-temporo parietal
convexity a widest transverse diameter of 0.7 cm. there is midline shift of 0.9 cm
to the left.
3. A few small hyper dense foci are seen in the right temporal likely CORTICAL
CONTUSION HEMATOMAS.
4,MINIMAL SUBARACHNOID HEMMORRHAGE is also noted.
5. A COMMINUTED FRACTURE is seen in the right temporal bone extending
into the upper portion of the right mastoid. A linear fracture is also seen in the
right side of the occipital bone.
6. SCALP SOFT TISSUE SWELLING AND HEMATOMA is seen in the right
temporo-parietal regions.
7. VERY MINIMAL INTERSTITIAL EMPHYSEMA is seen in the right temporal
extracalvarial soft tissue.
NO OTHER REMARKABLE FINDING
 Results Normal value
pH 7.35 ( 7.35-7.45 )
PCO2 23.9 ( 35-45 mmHg )
PO2 218.5 ( 80- 100mmHg )
HCO3 13.1 ( 22- 26 meq/L )
BE -12.4 ( ± 2 meq/L )
O2 sat 99.4 ( 97 % )

Metabolic acidosis compensated

Overcorrected hypoxemia @ 60% FIO2
EXAMINATION-CHEST BUCKY

CHEST BUCKY-negative for fracture or subluxation in the ribs and thoracic spine
No evidence of pneumothorax or pulmonary contusions.

FEMUR APL/THIGH APL

Right thigh APL shows complete fracture with tiny comminuted in the
midshaft femur with overriding as the distal fragment slipped posterior.

Hip and knee joint are intact

PELVIS OR BOTH HIPS AP

Pelvis AP shows no fracture or synchronal dehiscence. Sacrum and hip

joints are unremarkable as well as the included upper femora.

CERVICAL SPINE APL OR BOTH OBL

Cervical spine APL shows no abnormal curvatures. Normal weight and contour
of the vertebral bodies and disc spaces
Pedicles and spinous processes are intact
Prevertal soft tissue thickness is with in normal

REMARKS: no remarkable finding in the cervical spine

July 08 2007 Results Normal value Results Normal value
9: 58 am
Calcium 1.90 ( 2.10-2.60 ) 7.60 (8.40-10.40)

Potassium 4.20 ( 3.50-5.50) 4.20 (3.50-5.50)

sodium 145 ( 136.00- 145.00 ( 136.00-

145.00) 145.00)

COMPLETE BLOOD COUNT

July 08 2007 10:48am Results Normal value

Hemoglobin 114 ( 120- 170 g/l)

Hematocrit .34 ( .40-.54)
Red blood cell 3.78 ( 4.60-6.00 x 10 12/L
White blood cell 11.9 ( 5.00-10.00 x 10 9/L
Segmenters .74 ( .50-.70 )
Lymphocytes .16 ( .20-.40 )
Eosinophils ( .00-.05 )
Monocytes .09 ( .00-.09 )
Platelet 109 ( 150-400 )
Platelet: decreased
RBC: Normal
JULY 09 2007
July 092007 Results Normal Results Normal
7:19 PM value value

Calcium 2.01 ( 2.10-2.60 ) 8.04 (8.40-10.40)

CHEST PA OR AP ( CONVENTIONAL )

CHEST PA PORTABLE: Essentially normal chest

findings.Endotracheal tube in place and tip straddling
the carina

RIGHT FEMUR APL PORTABLE shows it is in position mold. There

is complete transverse fracture in the midshaft with tiny
comminutions. There is mild over riding as the distal fragment is
isplace posterior. Pin across the tibia is for traction.
July 10 2007 9:53 am Results Normal value

Potassium 3.19 ( 3.50-5.50)

July 10 2007 12:22 pm Results Normal Value

Sodium 164.00 ( 136.00-145.00)

July 10 2007 7:19 pm Results Normal value

Calcium 2.01 ( 2.10-2.60 )

July 10 2007 Results

Urine specific Gravity 1.010
COMPLETE BLOOD COUNT
July 11 2007 9:21 am Results Normal value

Hemoglobin 66 ( 120- 170 g/l)

Hematocrit .23 ( .40-.54)
Red blood cell 2.3 ( 4.60-6.00 x 10 12/L
White blood cell 11.1 ( 5.00-10.00 x 10 9/L
stabs .04 (.03-0.05)
Segmenters ..64 ( .50-.70 )
Lymphocytes .31 ( .00-.05 )
Monocytes .02 ( .00-.09 )
Platelet 129 ( 150-400 )

July 11 2007 7:47 am Results Normal value

Calcium 3.19 (3.20-5.50 mmol/L)

July 11 2007 3.21 pm Results

Urine specific Gravity 1.010

July 11 2007 6:25 pm Results

Urine specific Gravity 1.020
July 12 2007 9:37 am Results Normal value
Potassium 2.92 ( 3.50-5.50)

July 12 2007 9.38 Am Results Normal Value

Sodium 144.6 ( 136.00-145.00)

July 12 2007 9:38 am Results Normal value

Albumin 20.8 ( 37.00- 53.00 g/l
COMPLETE BLOOD COUNT
July 12 2007 10:37 am Results Normal value

Hemoglobin 84 ( 120- 170 g/l)

Hematocrit .28 ( .40-.54)
Red blood cell 2.8 ( 4.60-6.00 x 10 12/L
White blood cell 13.3 ( 5.00-10.00 x 10 9/L
Segmenters .72 ( .50-.70 )
Lymphocytes .19 ( .00-.05 )
Monocytes .08 ( .00-.09 )
Platelet 146 ( 150-400 )
PLATELET:DECREASED
RED BLOOD CELL: NORMAL
July 13 2007 8:45 am Results Normal Value
Sodium 134 ( 136.00-145.00)

July 13 2007 9:38 am results Normal value

Glucose RBS 6.82 ( 00-00 )

COMPLETE BLOOD COUNT

July 13 2007 11:04 am Results Normal value

Hemoglobin 103 ( 120- 170 g/l)

Hematocrit 31 ( .40-.54)
Red blood cell 3.4 ( 4.60-6.00 x 10 12/L
White blood cell 18.8 ( 5.00-10.00 x 10 9/L
Metamyelocytes .02 ( .00-.01)
Segmenters .79 ( .50-.70 )
Lymphocytes .16 ( .00-.05 )
Monocytes .02 ( .00-.09 )
Atypical .01 (.00-.00)
Platelet 156 ( 150-400 )

July 13 2007 Results

Urine specific Gravity 1.010
July 14 2007 8:25 am Results

Urine specific Gravity 1.005