Cerebral Contusion
Cerebral Contusion
Cerebral Contusion
PRESENTATION
ROTATION 1
(When did July 28, 2017 July 28,2017 July 28,2017 July 29,2017
it begin)
Location
Pattern It does not make It does not make It does not make It makes better after
better according better according better according to 6 days. Its not
(What makes it to him to him him. But last August 4, painful anymore.
better or 2017 , the swollen Patient is taking
worse?) eyes got better, he Cefuroxime to avoid
can now open his infection in the
both eyes. wounds.
Associated Body Body Body weakness, Body weakness
factors/how weakness weakness and Headache,
it affects the and pain swollen distal Periorbital pain,
client end of the Swollen red eyes,
right arm cant open both
eyes
Past Health History
Problems at birth No problems at birth.
When he was in 3rd year high school, he had suicidal thought and cut his left
Accidents hand ; ulnar portion of the hand
N/A
Prolonged pain or pain
patterns
Allergies No allergies.
The patient does not share his problems to his parents and according to his mother, he
Physical, emotional, was bewitched.
social, or spiritual
weaknesses
N/A
Physical, emotional,
social, or spiritual
strengths
Family Health History
None
Parents Illness and
longevity
Patient doesnt remember their ages but they died due to katigulangon
Grandparents Illness
and longevity
Lifestyle and Health Practices Profile
Naa ra sa balay magtan-aw ug TV, usahay rani siya mugawas ug balay, naa
Description of Typical day rajud ni siya sa sulod, magtuon usahay, brayt maning bataa, siya galiy
manlaba sa iyang sanina as verbalized by the patients mother
None
Substance use
Kuan kaning responsible bitaw sa tanan, pero dili lang jud ni siya mu-storya kung
Self-concept and Self-care unsay iyang problema sa amoa, as verbalized by the patients mother
responsibilities
system
Stress levels and Coping styles Patients mother did not comment
Chief Complaint(s): PTA, the patient complaints of pain @ right leg, deformed right
arm and lacerated wound in face area.
Admission Dx: Cerebral contusion with multiple lacerations and abrasions probably
secondary to vehicular accident.
Health Perception and Management
History:
A. absences from work/school, colds in past year, general health, important things you do
to keep healthy, use of cigarettes/ alcohol/drugs, self-
examination, accidents at home/work/school/driving.
None.
B. Has it been easy to find ways to carry our doctors or nurses suggestions?
Yes, as stated by the patients mother. Even though
at times its hard to easily find a way to by the
prescriptions given due to financial incapability.
1. Abdominal Assessment
Observe the color of the The skin color is lighter The skin color is lighter The skin color is lighter
skin than the skin color. No than the skin color. No than the skin color. No
Inspect for scars and striae scars and striae noted. scars and striae noted. scars and striae noted.
Assess for lesions and No lesions and rashes No lesions and rashes The umbilicus is located
rashes noted. Umbilicus is noted. Umbilicus is midline. No lesions and
Inspect the umbilicus, its located in the left lower located in the left lower rashes noted. Client
appearance and location quadrant due to quadrant due to defecates only once
Assess abdominal abdominal enlargement. abdominal enlargement. with black brown in
symmetry The client was able to Client wasnt able to color. No masses and
Inspect abdominal able to defecate once, defecate. No masses tenderness upon
movement black brown in color. No and tenderness upon palpation.
Check bowel sounds masses and tenderness palpation.
Check internal organs upon palpation.
Check for masses and
abdominal tenderness
1. Heart and neck vessels
Observe and evaluate Jugular vein is not Jugular vein is not Jugular vein is not
jugular venous pulse distended. No extra heart distended. No extra heart distended. No extra heart
Check the carotid arteries sound. No visible sound. No visible sound. No visible
Check the apical pulse pulsations in the aortic pulsations in the aortic pulsations in the aortic
Check for the extra heart and pulmonic areas. A and pulmonic areas. A and pulmonic areas. A
sounds blood pressure of - blood pressure of - blood pressure of
Check blood pressure 110/70mmHg. 110/70mmHg. 110/60mmHg.
1. Peripheral vascular
Assessment The clients hands, finger The clients hands, finger The clients hands, finger
Inspect the fingers, hands, and arms are cold to and arms are cold to and arms are warm to
arms, and temperature touch. Inability to do ROM touch. Inability to do ROM touch. Can now extend
Inspect the capillary refill and his right arm has and his right arm has his both legs. But still his
time transverse fracture. The transverse fracture. The right arm has transverse
Check the brachial pulses, capillary refill time is within capillary refill time is within fracture.
femoral pulses, popliteal 2 second. No varicosities 1 second. No varicosities The capillary refill time is
pulse, posterior tibial pulse noted. noted. within 1 second. No
and dorsalis pedis pulse varicosities noted.
Perform Allen test
Inspect the superficial
inguinal lymph nodes
Inspect for varicosities and
thrombophlebitits
1. Male/Female Genitalia
Male:
Inspect the base of the penis N/A N/A N/A
and pubic hair
Inspect the skin of the shaft
Inspect the foreskin
Inspect the size, shape an
position of the scrotum
Check urethral discharges
Check for inguinal lymph nodes
and hernia
Female:
Inspect for mons pubis
Observe and palpate inguinal
nodes
Inspect the labia majora and
perineum
Inspect the labia minora, clitoris,
urethral meatus and vaginal
opening inspect the size of the
vaginal opening of the angle of
the vagina
Inspect the cervix
Inspect the vaginal wall
1. Anus and rectum Assessment
Inspect for the peri-anal No masses in the peri-anal No masses in the peri-anal No masses in the peri-anal
area(Note for lumps, ulcers, area. Defecate once with area. Wasnt able to area. Defecate once. No
lesions, rashes and redness) black brown in color. No other defecate. No other other discharges noted.
Check the rectum discharges noted. discharges noted.
Inspect for the stool
characteristic
Inspect for any other discharges
1. Musculoskeletal
Assessment The extremities are not The extremities are not The extremities are not
Inspect size, shape, color symmetrical in color and symmetrical in color and symmetrical in color and
and symmetry size. Edema noted in right size. Edema noted in right size. Edema noted in right
Check for edema, heat, posterior thigh (violet red posterior thigh (violet red posterior thigh (violet red
tenderness, pain and in color), tenderness or in color), tenderness or in color), tenderness or
nodules pain upon palpation. Also pain upon palpation. Also pain upon palpation. Also
Check for ROM in the right knee, it is in the right knee, it is in the right knee, it is
Observe and assess gait painful to touch. Has a painful to touch. Has a painful to touch. Has a
Observe the cervical, bad good posture. bad good posture. bad good posture.
thoracic and lumbar Patient can stand with Patient can stand with Patient can stand with
curves from the side, then assistance but feel dizzy assistance but feel dizzy assistance but feel dizzy
from behind when standing, can sit when standing, can sit when standing, can sit
Check ROM of cervical and cannot walk on his and cannot walk on his and cannot walk on his
spine, thoracic and lumbar own. Transverse fracture own. Transverse fracture own. Transverse fracture
spine in the right hand with in the right hand with in the right hand with
Check ROM of elbows, bandage on it. bandage on it. bandage on it.
wrist, hands, fingers, hips,
ankles and feet
1. Neurologic Assessment
Assess GCS A GCS scoring of 14. A GCS scoring of 14. A GCS scoring of 14.
Check 12 cranial nerves Having an inadequate Having an inadequate Having an inadequate
Assess movement, sense of balance, sense of balance, sense of balance,
balance, coordination, incoordination and incoordination and incoordination and
sensation and reflexes reflexes with no reflexes with no reflexes with no
Check involuntary involuntary movements. involuntary movements. involuntary movements.
movements Patient felt restlessness Patient felt restlessness Patient felt restlessness
Evaluate gait and balance sometimes. Hes still sometimes. Hes still sometimes. Hes still
Assess for sensory system oriented. Patient always oriented. Patient is oriented. Patient is
sleeps. awake. awake.
Laboratory Results
Name of lab Result Normal value Interpretation Impression / analysis
Hematocrit 40.1 % 42.0 52. 0 % Below the normal Indicates bleeding
range
Hemoglobin 13.6 g/dl 13.5 18.0 g/dl Within normal -
range
WBC 18.1 10^ 9/L 5.0 10.0 10^9/L Above the normal Indicates inflammation
range
RBC 4.52 10 ^12/L 4.7 6.1 10^12/L Below the normal Indicates bleeding
range
Platelet count 258 10^g/L 150-450 10^g/L Within normal -
range
MCV 89 fl 80 94 fl Within normal -
range
MCH 30 pg 27- 31 pg Within normal -
range
MCHC 33.8 g/L 33- 36 g/L Within normal -
range
Differential -
count:
Impressions:
Impression:
X-ray of right knee for APL views negative for fracture-dislocation as far as visualized.
X-RAY Wrist
Impression:
Reveals transverse fracture involving the distal end of the right radius.
Pathophysiology
Predisposing Factors: Precipitating Factors:
Age 18 Attempting suicide
Vehicular accident
Increased ICP
Severe Cerebral
Ischemia Cerebral Ischemia
Increased Systemic
Vasoconstriction
COMPENSTORY MECHANISMS
Decreased CPP
DEATH
DOCTORS ORDER
DATE DOCTORS ORDER
07/28/17 Please admit
Secure consent to care
Diet: NPO-Temporarily
IVF- PLD 1 liter @30 gtts/min; 08:05 pm.
Labs:
CBC with BT
X-Ray for right wrist APO
CT Scan: Brain Plain
Meds
1. Mannitol 150 cc IV q8H ;8:10 pm now then 100 cc q4H
2. Ketorolac 30 mg IVTT q6H PRN for pain
3. Tetanus toxoid 0.5 ml IM
4. Tetanus Immune Globulin 250 ml IM
5. Cefuroxime 750 mg IVTT q8H ANST(-)
Monitor v/s every 4h
I&O every shift
Refer accordingly
07/29/17 DAT
CXR-PA
07/30/17 X-RAY RIGHT KNEE APL
07/31/17 Follow up for CT Scan
08/01/17 Follow up for referral to Dr. Bombeo
08/02/17 Citicoline 1 gm IV q12H
Please refer to Dr. Bombeo for collaborative management
08/03/17 Follow up referral to Dr. Bombeo
08/04/17 Follow up referral to Dr. Bombeo
08/05/17 Please follow up Dr. Bombeo
Refer to ortho. Dept. regarding fracture of distal end of the right radius
08/06/17 For referral ortho.
08/07/17 Still for follow up ortho. Dept.
Please follow up referral CT Scan result to Dr. Bombeo
08/08/17 Still for ortho. Dept.
Continue meds.
Please refer CT Scan result to Dr. Bombeo
08/09/17 CT Scan noted
Plan: Non-surgical
Medical management
Management Date General Description Indication Clients Response
Ordered
PLR 07-28-2017 1 liter 30 gtts/mmin Fluid & Electrolyte Rehydrated
replenishment
MOA: restores fluid and electrolyte balances,
produces diuresis, and acts as alkalizing agent
CBC 07-28-17 A complete blood count (CBC) gives important Bleeding and HCT: 40.1 %
information about the kinds and numbers of cells in Inflammation RBC: 4.52 10^12/L
the blood, especially red blood cells , white blood WBC: 18.1 10^9/L
Neutrophils: 82.8 %
cells , and platelets.
Lymphocytes: 5.6 %
Mannitol 07-28-2017 150 cc IV Soln Adjunct in the Edema subsided and the
treatment of edema intraocular pressure
Therapeutic Class: Osmotic Diuretic and intraocular decreases.
pressure.
Ketorolac 07-28-2017 30 mg IVTT q6H for pain Short term Patient reports no pain.
management for
Therapeutic class: NSAIDs pain.
Cefuroxime 07-28- 750 mn IVTT q8h ANST Skin structures/ Reports no skin infection.
2017 infections
Therapeutic Class: Anti-infective
X-RAY WRIST 07-28- Diagnostic x rays are useful in detecting To identify Reveals transverse
2017 abnormalities within the body. They are a fracture.
fracture involving the distal
painless, non-invasive way to help diagnose
problems such as broken bones, tumors, end of the right radius.
dental decay, and the presence of foreign
bodies.
CXR RIGHT KNEE 07-29-2017 The purpose of knee radiographs is to assess the To identify fracture. X-ray of right knee for APL
APL bony structure of the knee and specifically to define
views negative for fracture-
the presence of fractures and also to assess for
degenerative disease within the joint. dislocation as far as
visualized.
CT SCAN: Brain 07-31-2017 A computerized tomography (CT) scan combines a To identify head injury 1. Multifocal Contusion
Plain series of X-ray images taken from different angles and and bleeding.
Hemorrhage, left occipital
uses computer processing to create cross-sectional
images, or slices, of the bones, blood vessels and soft and bilateral posterior
tissues inside your body. CT scan images provide more parietal cortical area.
detailed information than plain X-rays do.
2. Minimal subarachnoid
hemorrhage.
3. Mild cerebral edema.
4. Pneumocephalus
5. Linear fractures left side of
nasal bone, superior wall
of the left orbit.
6. Frontal, ethmoid, maxillary
sinuses hemoantra.
7. Adjacent soft tissue
swelling along the frontal
scalp area
Cefuroxime (Zinacef) 750 mg IVTT Every 8 hours Bind to bacterial cell wall membrane causing cell
ANST death.
15. Hyperkalemia
Renal functions should be monitored.
16. Hypernatremia
17. Hyponatremia
18. Hypokalemia
19. Phlebitis @ IV
site.
DRUG NAME ROUTE/DOSAGE INDICATION MECHANISM OF CONTRAINDICA SIDE EFFECTS NURSING
/FREQUENCY ACTION TION RESPONSIBILTY
/ PT TEACHING
GENERIC NAME: 250 ml IM Transient Directly Hypersensiti 1. Difficulty of Assess
Tetanus Immuno protection against neutralized toxins vity breathing previous
Globulin tetanus in any excreted by Caution: 2. Hives immunizatio
person that may Clostridium Bleeding 3. Itching n history.
BRAND NAME: be contaminated tetanae, causing 4. Swelling Inform
Baytet with tetanus tetanus. 5. Tiredness patient of
spores when 6. Weakness potential and
patients history of 7. Convulsion reportable
PHARMACOLOG immunization is side effect of
IC CLASS: unknown. the TIG.
Immune Globulin
THERAPEUTIC
CLASS:
Vaccine
DRUG NAME ROUTE/D INDICATIO MECHANI CONTRAIN SIDE EFFECTS NURSING
OSAGE/F N SM OF DICATION RESPONSIBILTY/
REQUEN ACTION PT TEACHING
CY
GENERIC 0.5 ml IM Prevention Tetanus Hyperse 1. Redness Monitor vital
NAME: against toxoid nsitivity 2. Swelling signs.
Tetanus tetanus. absorbed Patient 3. Lymphadenop Educated patient
Toxoid induces with low athy to increase fluid
active immune 4. Tachycardia intake.
BRAND immunity system 5. Hypotension Educate patient
NAME: of tetanus 6. Flushing that pain and
Tetanus antigen by 7. Muscle pain tenderness in the
Toxoid activating 8. Thrombocytop injection site may
the enia occur.
immune Monitor patient
PHARMACO system to for complication.
LOGIC produce
CLASS: specific
EPI Vaccine anti-toxin.
THERAPEUT
IC CLASS:
Anti-tetanus
DRUG ROUTE/D INDICATION MECHANIS CONTRAINDI SIDE EFFECTS NURSING RESPONSIBILTY/ PT
NAME OSAGE/F M OF CATION TEACHING
REQUENC ACTION
Y
GENERIC 1g IV Head trauma Promotes Hypersen 1. Fleeting and Instruct patient to take
NAME: brain sitivity discrete medications as directed.
Citicoline metabolism Patient hypotension Assess vital signs especially
by restoring with effect the blood pressure.
BRAND phospholipid hypertoni 2. Increase Monitor adverse effects.
NAME: content in the c of the parasympathe Report directly if the patient
Cholinerv brain and parasymp tic effect experience chest tightness,
regulation of athetic 3. Hypotension headache, tingling
PHARMAC neuronal Cautions: 4. Itching sensation, and blurring of
OLOGIC membrane pregnanc 5. Hives vision.
CLASS: excitability. y and 6. Swelling in the Monitor neurologic function.
Nootropics lactation face and Advise to report any
hands complications.
THERAPE 7. Chest
UTIC tightness
CLASS: 8. Tingling in the
Central mouth and
nervous throat
system 9. Headache
stimulant 10. NV
11. Diarrhea
12. Blurred vision
DRUG NAME ROUTE/DOS INDICATION MECHANISM CONTRAINDICAT SIDE EFFECTS NURSING RESPONSIBILTY/ PT
AGE/FREQU OF ACTION ION TEACHING
ENCY
Bind to bacterial
GENERIC 750 mg IVTT Skin structure Hypersensiti 1. Seizure Arrange for culture and sensitivity
NAME: q8H infections. vity. 2. Pseudomembr tests before beginning therapy.
Cefuroxime ANST cell wall Cross- anous colitis
Assess for skin infections.
membrane sensitivity 3. Diarrhea
among 4. Cramps Assess for vital signs.
BRAND causing cell agents within 5. NV
Continue therapy for 2 days after
NAME: death. class may 6. Rashes
signs and symptoms of infection are
Zinacef occur. 7. Urticarial gone.
8. Bleeding
PHARMACOL 9. Hemolytic Ensure that patient is well hydrated.
OGIC CLASS: Cautions anemia
Give antacids at least 2 hr after
2nd Pregnancy 10. Phlebitis @ IV
dosing.
generation Lactation site
Cephalospori Renal 11. Pain @ IM site Monitor clinical response; if no
ns impairment 12. anaphylaxis improvement is seen or a relapse
occurs, repeat culture and sensitivity.
THERAPEUTI Encourage patient to complete full
C CLASS: course of therapy.
Anti-infective
Drink plenty of fluids while you are
taking this drug.
ADMITTING DIAGNOSIS: Cerebral contusion with multiple lacerations and abrasions probably
secondary to vehicular accident.
FINAL DIAGNOSIS:
CHIEF COMPLAINT Prior to admission, the patient complaints of pain @ right leg, deformed right arm,
and lacerated wound in face area.
Discharge Planning
Medicine:
Continue medication
Treatment
Medication as prescribed:
Health Teaching
Prognosis
The prognosis of the patient is getting better because there are visible signs
that the swelling, bruises and lacerations are healing.
Recommendation:
The students recommend the following for the patient:
WOUND CARE/ LACERATION
1) If you have stitches, do not wet the area for the first 24 hours. After 24
hours, you can wash the area with mild soap and water and pat dry. Do
not scrub the wound.
2) If you have a bandage, do not touch it for the first 24 hours. If it becomes
stained with blood, make the bandage thicker by adding more gauze. You
can remove the bandage after 24 hours.
3) Do not pick at the sutures, tape or glue. It may cause the wound to open
or get infected.
4) Do not wet the area for the first 24 hours.
5) Have the stitches or sutures removed when instructed. Do not remove
them yourself. They will be removed at different times depending on the
type and location on your body. If they are removed too late, they can
cause scars or lead to an infection. If you have absorbable sutures, they
do not have to be removed and will break down on their own. If the
injury is over a joint, avoid stretching the joint so the wound does not
open.
BROKEN ARM
1. If the doctor gave you a sedative:
o For 24 hours, don't do anything that requires attention to detail. It takes time for
the medicine's effects to completely wear off.
o For your safety, do not drive or operate any machinery that could be dangerous.
Wait until the medicine wears off and you can think clearly and react easily.
2. Put ice or a cold pack on your arm for 10 to 20 minutes at a time. Try to do this every
1 to 2 hours for the next 3 days (when you are awake). Put a thin cloth between the
ice and your cast or splint. Keep the cast or splint dry.
3. Follow the cast care instructions your doctor gives you. If you have a splint, do not
take it off unless your doctor tells you to.
4. Be safe with medicines. Take pain medicines exactly as directed.
o If the doctor gave you a prescription medicine for pain, take it as prescribed.
o If you are not taking a prescription pain medicine, ask your doctor if you can
take an over-the-counter medicine.
5. Prop up your arm on pillows when you sit or lie down in the first few days after the
injury. Keep the arm higher than the level of your heart. This will help reduce
swelling.
6. Follow instructions for exercises to keep your arm strong.
7. Wiggle your fingers and wrist often to reduce swelling and stiffness
QUESTIONS ?
THANK YOU
FOR LISTENING
!!!