30 mg Sub Q 1x day, enoxaparin Lovenox low molecular weight heparin with antithrombotic properties.

Indications - Prevents DVT and pulmonary. Side effects hemorrhage, anemia, and dyspnea. Pt. is on this drug to prevent clot formation due to intracranial traumatic injury, immobility r/t neurologic damage.

ocusate is a stool softener. It makes bowel movements softer and easier to eding or irritation;numbness or a rash around your rectum; severe s; or continued constipation.

straining and prevent increased ICP.

40 mg/IV/1 x day for 7-10 days Indication: reduces gastric acid astric mucus and bicarbonate production, creating protective

nt increase in intra thoracic pressure which can elevate ICP. inal pain,chest pain, rash, pruritus (itching skin) If pressure increases enough, it can cause displacement of the brain through or against the rigid structures of the skull. This causes restriction of blood flow to the brain, decreasing O2 delivery & waste removal. Cells in the brain become anoxic & can not metabolize properly, producing ischemia, infarction, irreversible brain damage & eventually brain death.

each nostril 1 x day. Side effects:Blood in the nasal e symptoms, dizziness, bronchitis. Indications: use inflammation, such as nasal symptoms such as -round allergies. Pt. is on this drug to CP is not elevated as a result of these symptoms.

Hemoglobin (Hgb) Purpose/definition: Hemoglobin is what gives the red color to your blood. It contains the iron, which carries the oxygen to the cells. The hemoglobin level indicates the amount of intracellular iron; hence, its value in determining anemia.Normal range: 14.0 to 15.0 g/dl Results: 14.5 g/dl Low Significance in patient & nursing implications: Low levels of Hgb would indicate anemia, or loss of blood, which will prevent adequate tissue perfusion and result in ischemia causing more damage to the brain tissue.

Hematocrit (Hct) Purpose/definition: The most precise methods of determining the degree of anemia or polycythemia (excessive amount of red blood cells). The hematocrit represents the volume of red blood cells in 100ml of blood and is therefore reported as a percentage. Normal range: 42.0 to 48.0% Results: 45% WNL Significance in patient & nursing implications: If Hct level decrease enough, ICP will increase causing decrease in tissue perfusion.

Ammonia test: is primarily used to help investigate the cause of changes in behavior and consciousness. Significantly increased concentrations of ammonia in the blood indicate that the body is not effectively metabolizing and eliminating ammonia but do not indicate the cause. Norma levels 10-40 mol/L, results 27 mol/L. If the ammonia levels increase significantly this affects the brain adversely.

RBC Purpose/definition:This test is a count of the number of circulating RBCs in 1mm3 of peripheral venous blood. RBCs act as the transport and exchange system for carrying oxygen to the tissues and carbon dioxide away from the tissues. Normal range: 4.70-5.25 million/mm3, Results: 4.87 million/mm3. If the RBC count is low, tissue perfusion is decreased and the brain tissue would become ischemic

Flonase fluticasone propionate)Nasal Spray, 1 spray in each nostril 1 x day. Side discharge. Runny nose, stomach pain, diarrhea, Flu-like symptoms, dizziness, br prevents the release of substances in the body that cause inflammation, such as congestion, sneezing, and runny nose caused by seasonal or year-round allergies prevent sneezing, congestion and runny nose so that ICP is not elevated as a res

Colace 100mg PO 1xday: Docusate is a stool softener pass. Side effects:rectal bleeding or irritation;numbn diarrhea or stomach cramps; or continued constipati

Pt. is on this med. to avoid straining and prevent incr

Protonix (Pantoprazole) 40 mg/IV/1 x day for 7 secretion and increases gastric mucus and bicarbon coating on gastric mucosa. Patient is on this to prevent increase in intra thorac Major side effects: Abdominal pain,chest pain, rash

the RBC count is low, tissue perfusion is decreased and the brain tissue would become ischemic

WBC Purpose/definition: The total number of WBCs (leukocytes) in 1 mm3 of periphe blood. The differential, which is the percentage of each type of leukocyte present in th specimen. The purpose of WBCs is to fight infection and respond immediately to forei Normal range: 4.5-10. mm3 Results: 5.3 mm3. The number of white blood cells is some find an infection. This helps identify early infection and prevent hyperthermia, hyperm and prevent further damage to brain.

-round allergies. Pt. is on this drug to CP is not elevated as a result of these symptoms.

Medications

tablet/ 2 tabs PO every 4 hour as needed lerant patients who require higher doses dation, nausea, vomiting, sweating, ent is on this drug due to incisional pain r/t

sulin that is slightly different from other forms of insulin lling in your hands or feet; or rate, extreme thirst,increased urination, leg discomfort, n this medication to lower glucose levels R/T tube feedings,

Pt. sustained an IVH, large parenchyma hemorrhage, SAH, depressed skull fracture, a midline shift and an uncal herniation.

Psychosocial

Intracranial Traumatic Injury

Often cause: damage to the brain which results in Increased In

congestion, sneezing, and runny nose caused by seasonal or year-round allergies prevent sneezing, congestion and runny nose so that ICP is not elevated as a res

Norco:hydrocodone bitartrate and acetaminophen 325mg/tablet/ 2 tabs PO every 4 Indication: For the management of severe pain in opioid-tolerant patients who requir of opioids. Major side effects:lightheadedness, dizziness, sedation, nausea, vomiting, flushing, dysphoria, euphoria, dry mouth, and pruritus. Patient is on this drug due to i craniotomy procedure, and help to decrease ICP.

Insulin detemir is a long-acting form of insulin that is slightly differ that are not man-made. side effect swelling in your hands or feet low potassium (confusion, uneven heart rate, extreme thirst,incre muscle weakness or limp feeling). Pt. is on this medication to lowe which also helps to not elevate ICP.

Diet: Eat a healthy variety of foods: fruits, vegetables, breads, meats and fish, and dairy products. Aim to consume at least on fruit and on vegetable with eac meal. (1 cup of fruit or 100% fruit juice, or cup of dried fruit can be considered as 1 cup from the fruit group, 1 cup of raw or cooked vegetables or vegeta juice, or 2 cups of raw leafy greens can be considere as 1 cup from the vegetable group.) the red meat in your diet with leaner cuts, such as chicken and turkey (three ounces of cooked chicken turkey, or other poultry) these contain protein and iron to help rebuild the iron stores you may have lo during bleeding episodes (1 ounce of meat, poultry fish, cup cooked dry beans, 1 egg, 1 tablespoon o peanut butter, is for the maintenance of tissue (suc as skin, blood cells, muscles, etc.) in adulthood.) Eat foods high in vitamin C is the same as foods high in iron increases iron absorption. plus three snacks per day. Eat regularly to avoid periods of hunger. Drink six to eight (8 ounce) cups liquid each day (follow your caregiver's advice if you must limit the amount of liquid you drink).

Diagnostic Tests

olor to your globin level nemia.Normal sing implications: nt adequate tissue

ining the degree of anemia resents the volume of red rmal range: 42.0 to 48.0% l decrease enough, ICP will

Medication: The patient will be instructed on an medication he will be sent home with, their side he needs to do if there is any changes while on t regimen. Keep a written list of the medicines yo when and why you take them. aspirin, naproxen, or ibuprofen in it without first caregivers. Always take your medicine as direct Call your caregiver if you think your medicines a if you feel you are having side effects. medicines until you discuss it with your caregive antibiotics, take them until they are all gone eve better.

investigate the cause of Significantly increased d indicate that the body is not g ammonia but do not indicate results 27 mol/L. If the is affects the brain adversely.

Med list: Lovenox 30 mg Sub Q 1 x day Colace 100mg PO 1 x day Flonase 1 spray in each nostril 1 x Protonix 40 mg PO PRN Norco 325mg PO every 4 hrs. Levemir 12 units 1 x day

n 1mm3 of peripheral en to the tissues and 4.87 million/mm3. If come ischemic

come ischemic

BCs (leukocytes) in 1 mm3 of peripheral venous f each type of leukocyte present in the same on and respond immediately to foreign invaders. e number of white blood cells is sometimes used to n and prevent hyperthermia, hypermetabolic state

Blood sugar levels should be tightly controlled by using a sliding scale for normal levels. Hyperglycemia also adversely affects the ischemic brain by promoting cerebral edema. Hyperglycemia has been associated with incre brain tissue acidosis, increasing infarct size. normal blood sugar levels are 98mg/dL.

Psychosocial

23y/o male transported to the ED by EMS on 8/30/11 with a head injury as a result of an assault with a tire iron.

Often cause: damage to the brain from bleeding or swelling which results in Increased Intra Cranial Pressure.

Cause

acranial Traumatic Injury

Nsg. Dx.

Ineffective airway clearance R/T accumulation of secretions & decreased LOC

At risk for aspiration (for entry of gastrointestinal secretions, oropharyngeal secretions, solids or fluids into tracheobronchial passages due to dysfunction or absence of normal protective mechanisms).

Altered cerebral tissue perfusion R/T increased ICP

Discharge Planning

Discharge teachings:Discuss the im

ariety of foods: fruits, vegetables, and fish, and dairy products. Aim to ast on fruit and on vegetable with each f fruit or 100% fruit juice, or cup of be considered as 1 cup from the fruit f raw or cooked vegetables or vegetable s of raw leafy greens can be considered the vegetable group.) replace most of n your diet with leaner cuts, such as rkey (three ounces of cooked chicken, er poultry) these contain protein and build the iron stores you may have lost g episodes (1 ounce of meat, poultry or ked dry beans, 1 egg, 1 tablespoon of is for the maintenance of tissue (such cells, muscles, etc.) in adulthood.) Eating itamin C is the same as foods high in iron absorption. Eat three small meals cks per day. Eat regularly to avoid ger. Drink six to eight (8 ounce) cups of y (follow your caregiver's advice if you amount of liquid you drink).

Discharge teachings:Discuss the im benefits the different food groups medications and administration te subcutaneous injections. Review s plan of action if one is suspected. dressing changing technique

Follow up: This patient is currently rehabilitation hospital. Family wil scheduled home visits from nurse. all appointments and has the mea needed. Instruct patient to call Dr 9627, neurosurgery, 711 W 38th S of an emergency, call 911.

Where is the patient being discharged and who discharged to a rehabilitation hospital with his fa be providing his transportation.

n: The patient will be instructed on any of the he will be sent home with, their side effects and what o do if there is any changes while on the medication eep a written list of the medicines you take, the dose, why you take them. Do not take any medicine that has proxen, or ibuprofen in it without first asking your Always take your medicine as directed by caregivers. aregiver if you think your medicines are not helping, or you are having side effects. Do not quit taking your until you discuss it with your caregiver. If you are taking take them until they are all gone even if you feel

Activity: Set limits. There are only so many hours in the day and only so many things you can do. Some things can wait. Learn relaxation techniques such as breathing exercises, meditation or progressive muscle relaxation. Wear a helmet if participating in sports or activities for which a helmet is available

Med list: Lovenox 30 mg Sub Q 1 x day Colace 100mg PO 1 x day Flonase 1 spray in each nostril 1 x day Protonix 40 mg PO PRN Norco 325mg PO every 4 hrs. Levemir 12 units 1 x day

Wound care: This pt has a temporal to frontal lobe incision. Review proper technique for cleaning and taking care of the incision with the family, teach them the signs and symptoms of possible infection, including redness, warmth at site, swelling of tissues, and drainage from wound. Also teach the patient and their caregiver about the effects of anemia on the immune system and how it will also delay wound healing. Skin should be inspected daily for breakdown or areas of redness that do not blanch as this may be a sign of breakdown and

redness that do not blanch as this may be a sign of breakdown and possible decubitus ulcer formation.

controlled by using a sliding scale for insulin or an insulin infusion to maintain dversely affects the ischemic brain by disrupting the blood-brain barrier and ycemia has been associated with increased cerebral lactate resulting in local ct size. normal blood sugar levels are between 70 and 150 mg, results

Monitor pt. LOC frequently to maintain patent airway, LOC will be at or above 13 in a Glasgow Coma Scale. AEB: Pt. maintained a Glasgow score of 15.

Elevate the HOB to at least 30 degrees to promote venous return and check frequently to make sure the head is not lower than the body. AEB: Pt. in a semi fowlers position through out the day.
Pt. airway will be maintained patent by careful suctioning. AEB: pt. & family using suction apparatus to clear secretion as needed.maintained patent by careful suctioning.

Pt. will experience no aspiration and both pt. & family will demonstrate techniques to prevent and/or correct aspiration, suctioning as needed to clear secretions.

AEB: Pt. respiration was noiseless and unlabore breath sounds were clear, and no secretions th needed to be suctioned.

Pt. will avoid washing solids down with liquids, and will eat slowly, while chewing slowly and thoroughly, to prevent aspiration.

AEB: After eating dinner, the pt. d aspiration such as coughing, tachy Pt. will not experience coughing, tachypnea, or dyspnea, which are signs of aspiration after eating, or drinking when he is advance to a soft/solid foods at the end of the day.

Monitor pt. BP frequently to maintain the BP WNL, noting onset of and continuing systolic hypertension and widening pulse pressure.

Pt. will maintain a HR & Rhythm WDL, monitor HR & Rhythm, frequently, noting bradycardia,alternating bradycardia & tachycardia, to prevent dehydration, fever or hypermetabolic state which may increase ICP. Position the pt. with head slightly elevated and in a neutral position to reduce arterial pressure and promote venous drainage which will promote

AEB: Pt & family verbalized the imp head elevated, the HOB was at a 30 elevation throughout the day, pt. d uncomfortable with HOB elevated.

Discharge teachings:Discuss the importance of a healthy diet and the

Discharge teachings:Discuss the importance of a healthy diet and the benefits the different food groups has on wound healing. Review medications and administration technique for both PO's and subcutaneous injections. Review signs and symptoms of infection and plan of action if one is suspected. Review proper wound care and dressing changing technique

Follow up: This patient is currently awaiting placement in a rehabilitation hospital. Family will be instructed to maintain any scheduled home visits from nurse. Ensure that the family maintains all appointments and has the means to transport the patient if needed. Instruct patient to call Dr. Thomas Bragg III, (512) 4549627, neurosurgery, 711 W 38th St, Austin, TX 78705. In the event of an emergency, call 911.

he patient being discharged and who will assist? Patient will be to a rehabilitation hospital with his family; mother and father will ng his transportation.

Goal met: Pt. airway maintained patent by using suction as needed, his LOC remained at a Glasgow score of 15, and pt. and family verbalized the understanding of keeping the HOB at a 30 degree angle or higher.

espiration was noiseless and unlabored, his unds were clear, and no secretions that be suctioned.

Goal Met: Pt. respiration was noisless & unlabored, with brea pt. was advance to soft/solid foods which he demonstrated ho slowly avoiding liquids to wash his food down, pt did not show aspiration such as coughing, tachypnea or dyspnea.

AEB: Pt. was advanced to soft/solid foods, he was able to demonstrated how to chew his food slowly and thoroughly, he verbalized that to prevent aspiration he would have to avoid washing his foods down with liquids.

AEB: After eating dinner, the pt. did not experience any signs of aspiration such as coughing, tachypnea or dyspnea.

AEB: BP 8 am: 121/69 12pm: 119/42 5pm: 132/77

Goal Met:Pt. BP remained WNL, there was no signs of bradycardia, alternating bradycardia & tachycardia, the HOB remained at a 30 degree elevation throughout day and night which was confirmed by pt. and family.

AEB: HR 8am: 88 12pm: 84 5pm: 82

AEB: Pt & family verbalized the importance of keeping his head elevated, the HOB was at a 30 dgeree or high elevation throughout the day, pt. did not appear to be uncomfortable with HOB elevated.

n as needed,

was noisless & unlabored, with breath sounds clear; solid foods which he demonstrated how to chew o wash his food down, pt did not show any signs of ing, tachypnea or dyspnea.

NL, there was no signs of ycardia & tachycardia, the HOB ation throughout day and night