Case study: Nursing care of the patient with Mild Traumatic Brain Injury

Abstract

     This study was a case study aimed to study the illness conditions of head injury patients and to study nursing care for head injury patients with brain hemorrhage in moderate head injury patients: 2 case studies by comparing nursing care for injured patients. in the head with intracerebral hemorrhage in a patient with a moderate head injury Somdej Phra Yupparat Kuchinarai Hospital The tools used in the study include: Data recording form Data were collected from inpatient medical records. Interviews with patients and relatives, observation, comparative data analysis and nursing planning using the nursing process Comprehensive care plan up to discharge planning.

     The results of the study found that Case Study 1 was a Thai male patient aged 74 years with no underlying diseases. Motorcycle accident Admitted on September 13, 2023 with symptoms of bleeding from the left ear.Diagnosed: Traumatic along bilateral cerebral sulci, right sylvian fissure and tentorial cerebelli. SDH along right cerebral convexity with Fracture Lt 3rd - 6th ribs, Fracture distal Lt. Shoulder. The patient had vital signs measured and his level of consciousness assessed. According to the standard, vital signs are measured every 15 minutes x 2 hours, every 30 minutes x 6 hours, and every 2-4 hours until 72 hours have passed. No abnormal vital signs were found. The patient stayed in the hospital for 5 days and was discharged home. Use your rights to maintain the Act. A follow-up appointment was made 2 weeks after discharge. Case study 2: Thai male patient, age 73 years, with no history of congenital disease. Motorcycle accident Admitted for treatment on September 22, 2023 with symptoms of abrasions on the body. Diagnosed: Traumatic SAH with Right zygomatic bone Fracture with Right greater wing sphenoid. The patient received vital signs and assessed the level of consciousness continuously according to the standard, namely measuring vital signs every 15 minutes x 2 hours, every 30 minutes x 6. hours, every 2-4 hours until 72 hours, no abnormal vital signs found The patient stayed in the hospital for 3 days and was discharged home. Use your rights to maintain the Act. There is a follow-up appointment 2 weeks after discharge, along with a plan to refer for treatment to a plastic surgeon at a provincial hospital for another 2 weeks.