CASE PRESENTATION IN

CONTUSION PARIETAL AREA (L)

CEREBRAL CONCUSSION

INTRODUCTION

CONCUSSION AND CONTUSION

Concussion

The term concussion describes an injury to the brain resulting from an impact to the head. By definition, a concussion is not a life-threatening injury, but it can cause both short-term and long-term problems. A concussion results from a closed-head type of injury and does not include injuries in which there is bleeding under the skull or into the brain. Another type of brain injury must be present if bleeding is visible on a CT scan (CAT scan) of the brain.

• A mild concussion may involve no loss of consciousness (feeling "dazed") or a very brief loss of consciousness (being "knocked out").

• A severe concussion may involve prolonged loss of consciousness with a delayed return to normal.

Concussion Causes

A concussion can be caused by any significant blunt force trauma to the head such as a fall, a car accident, or being struck on the head with an object.

Concussion Symptoms Loss of consciousness after any trauma to

the head Confusion Headache Nausea or vomiting Blurred vision Loss of short-term memory (you may not

remember the actual injury and the events some time before or after the impact)

Perseverating (repeating the same thing over and over, despite being told the answer each time, for example, "Was I in an accident?")

Cerebral contusion Latin contusio cerebri, a form of traumatic brain

injury, is a bruise of the brain tissue.Like bruises in other tissues, cerebral contusion can be associated with multiple micro hemorrhages, small blood vessel leaks into brain tissue. Contusion occurs in 20–30% of severe head injuries.

Contusions are likely to heal on their own without medical intervention.

Often caused by a blow to the head, contusions commonly occur in coup or contre-coup injuries. In coup injuries, the brain is injured directly under the area of impact, while in countercoup injuries it is injured on the side opposite the impact.

Contusions occur primarily in the cortical tissue, especially under the site of impact or in areas of the brain located near sharp ridges on the inside of the skull. The brain may be contused when it collides with bony protuberances on the inside surface of the skull. The protuberances are located on the inside of the skull under the frontal and temporal lobes and on the roof of the ocular orbit. Thus, the tips of the frontal and temporal lobes located near the bony ridges in the skull are areas where contusions frequently occur and are most severe. For this reason, attention, emotional and memory problems, which are associated with damage to frontal and temporal lobes, are much more common in head trauma survivors than are syndromes associated with damage to other areas of the brain.

Contusions, which are frequently associated with edema, are especially likely to cause increases in intracranial pressure (ICP) and concomitant crushing of delicate brain tissue.

Contusions typically form in a wedge-shape with the widest part in the outermost part of the brain.

The distinction between contusion and intracerebral hemorrhage is blurry because both involve bleeding within the brain tissue; however, an arbitrary cutoff exists that the injury is a contusion if two thirds or less of the tissue involved is blood and a hemorrhage otherwise.

The contusion may cause swelling of the surrounding brain tissue, which may be irritated by toxins released in the contusion. The swelling is worst at around four to six days after the injury.

Extensive contusion associated with subdural hematoma is called burst lobe.Cases of a burst frontal or temporal lobe are associated with high mortality and morbidity.

Old or remote contusions are associated with resorption of the injured tissue, resulting in various degrees of cavitation, in addition to the presence of a golden-yellow discoloration due to residual hemosiderin. These remote contusions are often referred to as plaque jaune or yellow plaque.

NURSING HEALTH HISTORY

‘’ You are the handicap you must face. You are the one who must choose your place’’

- James Lane Allen-

Demographic Data

NAME: PATIENT X AGE: 12 y/o ADDRESS: San Roque, Catbalogan City NAME OF FATHER: Noel O. Tipudan NAME OF MOTHER: Reanette Tipudan BIRTHDAY: December 18, 1992 BIRTHPLACE: Davao City NATIONALITY: Filipino RELIGION: Roman catholic

FAMILY PROFILE

PATIENT X IS A 12 YEAR OLD BOY FROM DAVAO CITY. HE ONLY CAME HERE IN

CATBALOGAN CITY TOGETHER WITH HIS SIBLINGS TO VISIT HIS RELATIVES HERE

AND AT THE SAME TIME, TO HAVE A VACATION. HIS MOTHER AND FATHER

WAS LEFT IN DAVAO. HE STATED THAT HIS MOTHER IS A HOUSEWIFE AND HIS FATHER IS A VENDOR AND HAS A SHOP

FOR WATCH REPAIR.

HISTORY OF FAMILY ILLNESS THE PATIENT HAS A FAMILY HISTORY OF CHICKEN POX AND ASTHMA. NO

FAMILY HISTORY REPORTED ON DIABETES MELLITUS WITH NO

PATHOLOGICAL SIGNS PRESENT ON HIS OTHER SIBLINGS. PAST HEALTH HISTORY

HE STATED THAT PRIOR TO THE ACCIDENT HAPPENED HE HAD COUGH AND WAS TREATED. HE ALSO STATED

THAT HE HAS DIARRHEA.

HISTORY OF PRESENT ILLNES

THIS IS THE CASE OF A MALE CLIENT FROM DAVAO CITY BUT CURRENTLY STAYING IN SAN ROQUE CATBALOGAN CITY WHO WAS ADMITTED AT SAMAR PROVINCIAL HOSPITAL LAST APRIL 27,2010 AROUND 1:45 O’CLOCK IN THE AFTERNOON WITH CHIEF COMPLAIN OF LOSS OF CONSCIOUSNESS WITH DIAGNOSIS OF CONTUSION PARIETAL AREA (L) CEREBRAL CONCUSSION. THE PRESENT CONDITION STARTED PRIOR TO ADMISSION WHEN HE WAS ACCIDENTALLY HIT BY A MOTORCYCLE. HE WAS RUSHED TO THE HOSPITAL FOR PROPER MEDICAL TREATMENT AND WAS ASSESSED TO HAVE EDEMA IN LEFT PARIETAL AREA OF THE HEAD, ABRASIONS AND HEMATOMA ON ARMS AND RIGHT LEG UPON ADMISSION, HE HAD THE FOLLOWING VS:

T = 36°CWT = 26KG

 

 LIFESTYLE

 UPON INTERVIEW, HE STATED THAT HE IS FOND OF PLAYING

COMPUTER GAMES ESPECIALLY DOTA. AND BASKETBALL. HE EATS VEGETABLES, MEAT AND FISH AND NO KNOWN ALLERGIES.

ADMITTING HISTORY: 

DATE ADMITTED: APRIL 27, 2010TIME ADMITTED: 1:45PM

TYPE OF ADMISSION: NEWADMITTING PHYSICIAN: DR. CATALAN

TENTATIVE DIAGNOSIS: CONTUSION PARIETAL AREA (L) CEREBRAL CONCUSSION

CHIEF COMPLAINT: LOSS OF CONSCIOUSNESS 

 

PHYSICAL ASSESSME

NT

Body ParAreArts Normal Findings Actual Findings Interpretation

Skin - Color varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive; generally uniform except in areas exposed to the sun; no edema; no abrasions or other lesions; moisture in skin folds and axillae; temp. uniform w/n normal range; good skin turgor.- Convex curvature of nail plate; smooth texture; highly vascular and pink in light-skinned clients; intact epidermis; prompt capillary refill.

>positiveabrasions in botharms>positive bruisesin left arm>pale coloredskin>positive freckles

Deviation from normal.Indicatestissue trauma

Head - Rounded; smooth skull contour; absence of nodules or masses; symmetric facial features and movements

(+) bruises on parietal area(+) abrasions in the parietal area of the head

Deviation from normal. May due to the trauma from being hit by a motorcycle

Eyes - Hair evenly distributed; skin intact; eyebrows symmetrically aligned; equal movement; eyelashes curled slightly outward; no discharge; no discoloration; lids close symmetrically; sclera appears white; capillaries sometimes evident; shiny, smooth, and pink or red palpebral conjunctiva; no edema over lacrimal gland; transparent, flat, round, shiny and smooth iris; trigeminal nerve intact; no shadows of light on iris; pupils black in color, equal, round, smooth border and constricts when illuminated; pupils accommodation is normal; eyes are coordinated, parallel alignment and move in unison; able to read newsprint;

>uncoordinatedextra ocularmovement>slightly paleconjunctiva

Deviation from normal. May be due no loss of consciousness

Ears - Color same as facial skin, symmetrical; auricle aligned w/ outer canthus of eye; mobile, firm, not tender and pinna recoils after folding; dry or sticky, wet cerumen; normal voice tones audible.

Normal

Nose - Symmetric and straight; no discharge or flaring; uniform color; no tender and lesions; air moves freely when breathing; mucosa pink; nasal septum intact; sinuses are not tender.

> Symmetric and straight > No discharge or flaring> Uniform color> No tender and lesions> Air moves freely when breathing> Nasal septum intact> Sinuses are not tender.

Normal

Mouth - Uniform pink color, soft, smooth, moist texture, elastic and symmetry of contour; ability to purse lips; 32 adult teeth; smooth, white, shiny tooth enamel; pink, moist, no retraction, firm texture to gums; central tongue position, pink, smooth, lateral margins, raised papillae, moves freely; no lesions; no tenderness; smooth tongue base w/ prominent veins; no palpable nodules; salivary duct same color as buccal mucosa; light pink, smooth, soft and hard palate; uvula positioned on midline of soft palate; pink and smooth posterior wall; tonsils no discharge and of normal size; elicit gag reflex.

> Slightly dry, cracked lips and pale Deviation from Normal. This may also due to dehydration or because of loss of consciousness

Neck - Muscles equal in size, head centered; head movement coordinated, smooth and no discomfort; head flexes 45°; head hyperextends 60°; head laterally flexes 40°; head laterally rotates 70°; equal muscle strength; lymph nodes not palpable; central placement of trachea in midline of neck; thyroid gland not visible on inspection, ascends during swallowing but not visible; lobes may not be palpable; absence of bruit.

> Muscles equal in size> Hhead centered> Head movement coordinated, smooth and no discomfort> Lymph nodes not palpable> Central placement of trachea in midline of neck> Thyroid gland not visible on inspection, ascends during swallowing but not visible

Normal

Thorax and Lungs - AP to transverse diameter in 1:2; chest symmetric; skin intact, uniform temperature; chest wall intact; no tenderness; no masses; full and symmetric chest expansion; bilateral symmetry of vocal fremitus; diaphragm slightly higher on the right side; chest vesicular and bronchovesicular breath sounds; quiet, rhythmic and effortless respirations; costal angle is less than 90°; full symmetric excursion; trachea bronchial and tubular breath sounds.

> RR = 31cpm > Deviation from Normal.Slightly elevated due to head trauma and pain

Heart - Precordium no abnormal pulsations, lifts or heaves; pulsations visible in most PMI in 5th LICS at or medial to MCL; symmetric pulse volumes; full pulsations, thrusting quality; Carotid artery no sound heard on auscultation; jugular veins not visible; peripheral pulses symmetric and full; veins symmetric in size; skin color pink, skin temperature not excessively warm or cold; no edema; skin texture resilient and moist; capillary refill test: immediate return of color.

> PR = 109BPM Increaesd. Deviation from normal and may due to the effects of the head traume

Abdomen - Unblemished skin, uniform color; flat, rounded or scaphoid abdominal contour; no evidence of enlargement of liver or spleen; symmetric contour; symmetric abdominal movements caused by respirations; no visible vascular pattern; audible bowel sounds; absence of arterial bruits; absence of friction rub; tympany over the stomach; dullness over the liver and spleen or a full bladder; no tenderness, relaxed w/ smooth consistent tension; tenderness may be present near xiphoid process, over cecum, over sigmoid colon; liver may not be palpable, border feels smooth; bladder not palpable.

Abdominal movement as with

respiration. >negativeabdominaldistention>negative abrasions>negative swelling

Normal

Musculoskeletal - Muscles equal size on both sides of the body; no contractures, fasciculation or tremors; normally firm; smooth coordinated movements; equal strength on each body side; skeleton no deformities, tenderness or swelling; joints move smoothly, no swelling, tenderness, crepitation or nodules.

>unable to move accordingly

> unable to extend arms in front or push them out to the side.

>unable to stand or walk slowly

>(+)deformities, tenderness or swelling; joints move slowly, swelling, tenderness, crepitation or nodules.

Deviation from Normal.

ANATOMY AND

PHYSIOLOGY

Anatomy of the Brain

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>midbrain>hindbrain.

The forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function.

Two Major Division of forebrain:

> Diencephalon - contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions

> Telencephalon - contains the largest part of the brain, the cerebral cortex. Most of the actual information processing in the brain takes place in the cerebral cortex.

The midbrain and the hindbrain together make up the brainstem.

The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain.

This region of the brain is involved in auditory and visual responses as well as motor function.

The hindbrain - extends from the spinal cord and is composed of the metencephalon and myelencephalon.

The metencephalon contains structures such as the pons and cerebellum. These regions assists in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information.

The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion.

The cerebral cortex is the part of the brain that functions to make human beings unique. Distinctly human traits including higher thought, language, human consciousness, as well as the ability to think, reason, and imagine all originate in the cerebral cortex.

The cerebral cortex is what we see when we look at the brain. It is the outermost portion that can be divided into the four lobes of the brain. Each bump on the surface of the brain is known as a gyrus, while each groove is known as a sulcus.

The cerebral cortex can be divided into four sections, which are known as lobes. The frontal lobe, parietal lobe, occipital lobe and temporal lobe have been associated with different functions ranging from reasoning to auditory perception.

The frontal lobe is located at the front of the brain and is associated with reasoning, motor skills, higher lever cognition, and expressive language. At the back of the frontal lobe, near the central sulcus, lies the motor cortex. This area of the brain receives information from various lobes of the brain and utilizes this information to carry out body movements.

The parietal lobe is located in the middle section of the brain and is associated with processing tactile sensory information such as pressure, touch, and pain. A portion of the brain known as the somatosensory cortex is located in this lobe and is essential to the processing of the body's senses.

The temporal lobe is located on the bottom section of the brain. This lobe is also the location of the primary auditory cortex, which is important for interpreting sounds and the language we hear. The hippocampus is also located in the temporal lobe, which is why this portion of the brain is also heavily associated with the formation of memories.

The occipital lobe is located at the back portion of the brain and is associated with interpreting visual stimuli and information.

The primary visual cortex, which receives and interprets information from the retinas of the eyes, is located in the occipital lobe.

PATHOPHYSIOLOGY

Vehicular accident

Direct and indirect head trauma

Brain strikes the skull

Cortical Injury ( especially under the site of impact or in areas of the brain located near sharp ridges on the inside

of the skull)

Acute traumatic damage to the brain

Blood extent bidirectionally to white matter, subdural and subarachnoid spaces

Tissue injury

Vascular response

Edema

Increased ICP

Change in vital signs Crushing of brain tissue

slowing of speech, Headache

Rising of BP or widening pulse

Between systolic and diastolic

Increased pulse rate as ICP

Change in level of responsiveness, lethargy, quietness to restlessness, confusion , stupor,

drowsiness, coma & progressive deterioration

Constant/increasing intensity by movement

LABORATORY RESULTS

Result

Normal Values

Interpretation

Significance

Hgb 141 140-180gms/L Normal

Hematocrit 0.40 0.40-0.54 Normal

White Cell Count

7.7 5-10x10/L Normal

Eosinophil 0.01 0.01-0.03 Normal

Segmenter 0.45 0.40-0.60 Normal

Lymphocytes

0.18 0.20-0.35 decreased ChronicInfection; ViralInfection* A lymphocyte count is usually a pary of aperipheral completeblood cell count and isexpressed aspercentage oflymphocytes to totalwhite blood cellscounted.

DRUG ANALYSIS

DRUG MECHANISM

OF ACTION INDICATION

SIDE

EFFECTS

DRUG

INTERACTIONPREPARATION AVAILABLE

NURSING CONSIDER

ATIONS

RanitidineHydrochlorideBrand Name: Zantac

Inhibits the action of histamine at the h2

receptors site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion.

Short term treatment of active duodenal ulcers and benign gastric ulcers. Prophylaxis of duodenal ulcers ( at lower doses).

Headache, dizziness, drowsiness, hallucinations, constipation, diarrhea.

Cimetidine inhibits drug-metabolizing enzymes (cytochrome 450 pathway) the liver, may lead to increased levels and toxicity with the following- some benzodiazepines especially chlordiazepoxide, some beta blockers ( metoprolol, propanolol).

½ amp every8 hour s

Assess for epigastric or abdominal pain and frank or occult blood in the stool, emesis or gastric aspirate.

Instruct patient to take medication as directed for the full course of the therapy even if feeling better.

DRUG MECHANISM

OF ACTION INDICATION

SIDE

EFFECTS

DRUG

INTERACTIONPREPARATION

AVAILABLE NURSING

CONSIDERATIONS

Advise patients taking OTC preparations not to take the maximum dose continuously for more than 2 week without consulting health care professional.

DRUG MECHANISM

OF ACTION INDICATION

SIDE

EFFECTS

DRUG

INTERACTIONPREPARATION

AVAILABLE NURSING

CONSIDERATIONS

DEXAMETHASONEBrand name: Decadron, Deronil, Dexone, HexadrolDrug Classification: Steroid

Decreases the inflammation, mainly bystabilizing leukocyte lysosomal membranes. Also suppresses theimmune response, stimulates bone marrow and influences protein, fatand carbohydrate metabolism.

Cerebral Edema,Inflammatory Conditions, Shock

CNS: Psychotic Behavior, EuphoriaCV: Congestive hart failure, Hypertension, EdemaSkin: Delayed wound healing, various skin eruptionsOther: Muscle weakness, susceptibility to infections.

Aminoglutethimide: Aminoglutethimide may diminish adrenal suppression by corticosteroids.Amphotericin B injection and potassium-depleting agents: When corticosteroids are administered concomitantly with potassium-depleting agents (e. g. , amphotericin B, diuretics), patients should be observed closely for development of hypokalemia

4mg IV every 6 hours

Gradually reduce drug dosage after long term therapy. Tellpatient not to discontinue drug abruptly or without doctor’s consent.• Monitor patient’s weight, blood pressure and serum electrolytes.• Watch for depression or psychotic episodes, especially in highdosetherapy.• Inspect patient’s skin for petechiae• Not used for alternate day therapy

DRUG MECHANISM

OF ACTION INDICATION

SIDE

EFFECTS

DRUG

INTERACTIONPREPARATION

AVAILABLE NURSING

CONSIDERATIONS

Cefazolin

Like other cephalosporins and penicillins, cefazolin binds to penicillin-binding proteins thus interfering with the final stage of bacterial cell wall synthesis, the peptidoglycan layer, and causing autolysis of the cells by autolysins

enzymes.

Cefazolin is mainly used to treat bacterial infections of the skin. It can also be used to treat moderately severe bacterial infections involving the lung, bone, joint, stomach, blood, heart valve, and urinary tract. It is clinically effective against infections caused by staphylococci and streptococci of Gram positive bacteria. These organisms are common on normal human skin. Resistance to cefazolin is seen in several species of bacteria.

Possible side effects include diarrhea, stomach pain or upset stomach, vomiting, and rash.

Probenecid may decrease renal tubular secretion of cephalosporins when used concurrently, resulting in increased and more prolonged cephalosporin blood concentrations.

500mg IVTT every 6 hours ANST

Instruct patient not use cefazolin if you have ever had an allergic reaction to another cephalosporin or to a penicillin without first talking to her doctoe. Imnstruct patient Before using cefazolin, to tell the doctor if you are allergic to any drugs (especially penicillins), or if you have kidney disease, liver disease, or a stomach or intestinal disorder such as colitis.Teach the patient nt that Cefazolin will not treat a viral infection such as the common cold or flu.

NURSING CARE PLAN

‘’Where there is great love, there are always miracles’’

-Willa Cather-

Assessment Nursing Diagnosis Background Study Goals and Objectives Nursing Intervention Rationale Evaluation

Cues:Subjective:“ Deri ko pa kaya magliwan kay masakit an akon kamot pagnauunat”as verbalized by the client.“ Deri pa ak nakakalakat maupay kay masakit tak pasa ha tiil”as verbalized by the client.“ Deri ko pa kaya kumarigo anxa gintatrapuhan la anay ako ni lola”as verbalized by the client.Objective: (+)Weakness Decreased

motivation Fatigue (+)

Discomfort Temp= 36c Weight=26kg

Self care deficit related to loss of muscle control/coordination as evidenced by: a.impaired ability to put on/take off clothing.b. difficulty completing toileting tasks.c. inability to perform ROM

Impaired ability to perform or complete feeding, bathing/hygiene, dressing and grooming or toileting activities for oneself.

Reference:Nurses Pocket Guide 11th edition Pg 575Doenges, Moorhouse, Murr.

At the end of my nursing intervention the client will be able to:1. Perform self-

care activities with in level of own ability.

2. Demonstrate techniques/lifestyle changes.

3. Perform ROM.

Independent:1. Assess abilities

and level of deficit (0-4)scale for performing ADL’s.

Therapeutic:

2. Assist client to find position of comfort.

2.Provide positive feedback for efforts and accomplishments.

1. Aids in anticipating planning for meeting individual’s needs.

2. May provide relaxation or redirect attention and reduces analgesic and needs frequency.

3. Enhances sense of self-worth, promotes independence and encourages patient to continue endeavors.

Goal met as evidenced by the client is able to perform self-care activities with in level of his own ability.