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°C
WT = 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, 2010
TIME ADMITTED: 1:45PM
TYPE OF ADMISSION: NEW
ADMITTING PHYSICIAN: DR. CATALAN
TENTATIVE DIAGNOSIS: CONTUSION PARIETAL AREA (L)
CEREBRAL CONCUSSION
CHIEF COMPLAINT: LOSS OF CONSCIOUSNESS
 
 
 PHYSICAL
ASSESSMEN
T
 Body ParAreArts Normal Findings Actual Findings Interpretation

Skin - Color varies from light to deep >positive Deviation from normal.
brown; from ruddy pink to light pink; abrasions in both Indicates
from yellow overtones to olive; arms tissue trauma
>positive bruises
generally uniform except in areas in left arm
exposed to the sun; no edema; no >pale colored
abrasions or other lesions; moisture in skin
skin folds and axillae; temp. uniform >positive freckles
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.
Head - Rounded; smooth skull contour; (+) bruises on parietal area Deviation from normal. May due to the
absence of nodules or masses; (+) abrasions in the parietal area of the trauma from being hit by a motorcycle
symmetric facial features and head
movements

Eyes - Hair evenly distributed; skin intact; >uncoordinated Deviation from normal. May be due no
eyebrows symmetrically aligned; extra ocular loss of consciousness
equal movement; eyelashes curled movement
>slightly pale
slightly outward; no discharge; no conjunctiva
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
Ears - Color same as facial skin, Normal
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.
Nose - Symmetric and straight; no discharge or > Symmetric and straight Normal
flaring; uniform color; no tender and > No discharge or flaring
lesions; air moves freely when breathing; > Uniform color
mucosa pink; nasal septum intact; sinuses > No tender and lesions
are not tender. > Air moves freely when breathing
> Nasal septum intact
> Sinuses are not tender.
Mouth - Uniform pink color, soft, smooth, moist > Slightly dry, cracked lips and pale Deviation from Normal.
texture, elastic and symmetry of contour; This may also due to dehydration or
ability to purse lips; 32 adult teeth; because of loss of consciousness
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.

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 Normal
> 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
Thorax and Lungs - AP to transverse diameter in 1:2; > RR = 31cpm > Deviation from Normal.
chest symmetric; skin intact, uniform Slightly elevated due to head trauma
temperature; chest wall intact; no and pain
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.
Heart - Precordium no abnormal pulsations, > PR = 109BPM Increaesd.
lifts or heaves; pulsations visible in most Deviation from normal and may due to
PMI in 5th LICS at or medial to MCL; the effects of the head traume
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.
Abdomen - Unblemished skin, uniform color; flat, Abdominal movement as with Normal
rounded or scaphoid abdominal contour;
no evidence of enlargement of liver or respiration.
>negative
spleen; symmetric contour; symmetric abdominal
abdominal movements caused by distention
respirations; no visible vascular pattern; >negative abrasions
audible bowel sounds; absence of arterial >negative swelling
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.
 >unable to move Deviation from Normal.
Musculoskeletal - Muscles equal size on both accordingly
sides of the body; no > unable to extend arms
contractures, fasciculation or in front or push
tremors; normally firm; smooth them out to the
coordinated movements; equal side.
strength on each body side; >unable to stand or walk
skeleton no deformities, slowly
tenderness or swelling; joints >(+)deformities,
move smoothly, no swelling, tenderness or
tenderness, crepitation or swelling; joints
nodules. move slowly,
swelling,
tenderness,
crepitation or
nodules.
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 Change in level of responsiveness, lethargy,

Rising of BP or widening pulse
quietness to restlessness, confusion , stupor,
Between systolic and diastolic
drowsiness, coma & progressive deterioration
Increased pulse rate as ICP

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 7.7 5-10x10/L Normal

Count

Eosinophil 0.01 0.01-0.03 Normal

Segmenter 0.45 0.40-0.60 Normal

Chronic
Lymphocytes 0.18 0.20-0.35 decreased Infection; Viral
Infection
* A lymphocyte count is
usually a pary of a
peripheral complete
blood cell count and is
expressed as
percentage of
lymphocytes to total
white blood cells
counted.
DRUG ANALYSIS
 DRUG MECHANISM INDICATION SIDE DRUG PREPARATIO NURSING
OF ACTION EFFECTS INTERACTION N AVAILABLE CONSIDER
ATIONS

Ranitidine Inhibits the Short term Headache, Cimetidine ½ amp  Assess for
Hydrochl epigastric
oride action of treatment dizziness, inhibits drug- every8 hour or
Brand histamine at of active drowsiness, metabolizing s abdominal
Name:
the h2 duodenal hallucinatio enzymes pain and
Zantac ns, (cytochrome frank or
receptors ulcers and constipatio 450 pathway)
occult
blood in the
site located benign n, diarrhea. the liver, may stool,
primarily in gastric lead to emesis or
ulcers. gastric
gastric increased aspirate.
parietal Prophylaxi levels and  Instruct
cells, s of toxicity with patient to
the following- take
resulting in duodenal medication
ulcers ( at some
inhibition of benzodiazepin
as directed
for the full
gastric acid lower course of
es especially
secretion. doses). chlordiazepox the therapy
even if
ide, some beta feeling
blockers better.
( metoprolol,
propanolol).
DRUG MECHANISM INDICATION SIDE DRUG PREPARATION NURSING
OF ACTION EFFECTS INTERACTION AVAILABLE CONSIDERA
TIONS

 Advise
patients
taking
OTC
preparati
ons not
to take
the
maximu
m dose
continuo
usly for
more
than 2
week
without
consultin
g health
care
professio
nal.
 DRUG MECHANISM INDICATION SIDE DRUG PREPARATION NURSING
OF ACTION EFFECTS INTERACTION AVAILABLE CONSIDERATI
ONS
DEXAMET Decreases Cerebral CNS: Aminoglutethi 4mg IV Gradually reduce
HASONE the Psychotic mide: drug dosage after
Brand
Edema, Behavior, Aminoglutethi
every 6 long term therapy.
inflammatio Inflammat hours Tell
name: Euphoria mide may
n, mainly patient not to
Decadron ory CV: diminish
, Deronil, by Congestiv adrenal
discontinue drug
stabilizing Conditions abruptly or
Dexone, e hart suppression by
Hexadrol leukocyte , failure, corticosteroids.
without doctor’s
consent.
Drug lysosomal Shock Hyperten Amphotericin • Monitor patient’s
Classifica membranes sion, B injection weight, blood
tion: . Also Edema and pressure and
Steroid Skin: potassium- serum
suppresses electrolytes.
Delayed depleting
the wound agents: When • Watch for
immune healing, corticosteroids depression or
response, various are psychotic
episodes,
stimulates skin administered
especially in
bone eruptions concomitantly highdose
marrow and Other: with therapy.
Muscle potassium- • Inspect patient’s
influences
weakness depleting skin for petechiae
protein, fat , agents (e. g. , • Not used for
and susceptibi amphotericin alternate day
carbohydrat lity to B, diuretics), therapy
e infections patients should
metabolism . be observed
. closely for
development of
hypokalemia
 DRUG MECHANISM OF INDICATION SIDE DRUG PREPARATION NURSING
ACTION EFFECTS INTERACTION AVAILABLE CONSIDERATI
ONS

Cefazolin is 500mg IVTT every 6 Instruct patient not

Cefazolin Like other
cephalosporins mainly used to
Possible
side effects
Probenecid may
decrease renal hours ANST use cefazolin if you
and penicillins, treat bacterial include tubular secretion have ever had an
infections of the allergic reaction to
cefazolin binds diarrhea, of cephalosporins another
skin. It can also
to stomach when used cephalosporin or to a
be used to treat
penicillin-bindin moderately
pain or concurrently, penicillin without
g proteins upset resulting in first talking to her
severe bacterial
thus interfering infections stomach, increased and doctoe. Imnstruct
with the final involving the vomiting, more prolonged patient Before using
stage of cefazolin, to tell the
lung, bone, joint, and rash. cephalosporin
bacterial cell doctor if you are
stomach, blood, blood allergic to any drugs
wall synthesis, heart valve, and concentrations. (especially
the urinary tract. It penicillins), or if you
peptidoglycan is clinically have kidney disease,
layer, and effective against liver disease, or a
causing autolysis infections caused stomach or intestinal
of the cells by by staphylococci disorder such as
and streptococci colitis.
autolysins
of Gram positive Teach the patient nt
enzymes. bacteria. These that Cefazolin will
organisms are not treat a viral
common on infection such as the
normal human common cold or flu.
skin. Resistance
to cefazolin is
seen in several
species of
bacteria.
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: Self care deficit At the end of my Independent: Goal met as

Subjective: related to loss of Impaired ability to nursing intervention 1. Assess abilities 1. Aids in evidenced by the
“ Deri ko pa kaya muscle perform or complete the client will be able and level of anticipating client is able to
magliwan kay control/coordination feeding, to: deficit (0- planning for perform self-care
masakit an akon as evidenced by: bathing/hygiene, 1. Perform self- 4)scale for meeting activities with in level
kamot a.impaired ability to dressing and care activities performing individual’s of his own ability.
pagnauunat”as put on/take off grooming or toileting with in level of ADL’s. needs.
verbalized by the clothing. activities for oneself. own ability.
client. b. difficulty 2. Demonstrate Therapeutic:
“ Deri pa ak completing toileting techniques/lifes
nakakalakat tasks. Reference: tyle changes. 2. Assist client to 2. May provide
maupay kay c. inability to perform Nurses Pocket Guide 3. Perform ROM. find position of relaxation or
masakit tak pasa ROM 11th edition Pg 575 comfort. redirect
ha tiil”as verbalized Doenges, Moorhouse, attention and
by the client. Murr. reduces
“ Deri ko pa kaya analgesic and
kumarigo anxa needs
gintatrapuhan la frequency.
anay ako ni lola”as 2.Provide positive 3. Enhances sense
verbalized by the feedback for of self-worth,
client. efforts and promotes
Objective: accomplishmen independence
 (+)Weakness ts. and encourages
 Decreased patient to
motivation continue
 Fatigue endeavors.
 (+)
Discomfort
 Temp= 36c
 Weight=26kg