Mrs Theresa Ngozi Tuan.


Full code.

MR: Q0000999667

Location: Trauma unit

Room 3042NorthEast.

Admitted: 09/14/2012.

Diagnosis: Intracranial Hemorrhage and Skull Fracture. Due to Car accident. SAH,Skull fracture. Bruises bilateral eyes, especially right eye.Frontal bone fracture with pneumocephaly. Right orbital wall fractures. Headache. Facial lacerations. Suture right upper eyelid. Patient said to the nurse I don’t like asking for pain medication because I get nauseated. The nurse asks which medication make you nauseous?.Patient replied they both made me nauseated but the dilaudid works better.

02 2Liter NC.

Live alone since her husband died one year ago.

PT/OT for home evaluation safety.


K. = 3.9

H/H 12.4/ 38.0

Diet : Regular diet.

Poor appetite.


Allergy: NKDA

Activity: Ambulates.


Dilaudid 0.5mg IV Q4hours prn pain.

Norco 10/325mg po Q6hours prn pain.

Zofran 4mg IV Q4hours prn nausea/Vomiting.

PLAN: Discharge to Rehabilitation center ( short term).

Case manager consulted.


(1)Why is the patient nauseated?.Answer: Her nausea is associated with her headache and pain medication.

(2)Patient is able to ambulate.Why is she discharged to rehabilitation center?.Answer : patient is discharged to Rehabilitation for short term care because she live by herself and still need help.

(3)Do patient need nutrition consult before discharge to SNF?.

Answer :need nutrition consultant because of poor appetite.

(4 )Is the pain medication effective?.

Answer :Pain medication is effective but it contributed to her nausea.

(5)A 34 years old woman is diagnosed with a malignant brain tumor focused in her left frontal lobe.She undergoes a craniotomy for removal of the tumor. In caring for the patient postoperatively ,the nurse would expect which of the following neurologic changes resulting from frontal lobe surgery.

Answer: Personality changes.

Craniotomy is a surgical opening into the skull . Complications of craniotomy include atelectasis,pneumonia, cardiac dysthymia, increased intracranial pressure, fluid and electrolyte imbalance.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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