Luz, Kathleen Mapili, Anjelika Marquez Rich Mendiola, Bessie Sadol, Bryan Santos, Raphael II Singh, Harmandeeep Zamora,

Miguel

On Completion of this Case Presentation, we will be able to: 1. Describe the nursing management of Bifrontal Contusions. 2. Discuss the Pathophysiology of Bifrontal Contusions and describe the appropriate nursing interventions.

3. Use the nursing process as a framework for care of patients with Bifrontal Contusions

Bifrontal Contusions 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 microhemorrhages, small blood vessel leaks into brain tissue. Contusion occurs in 20 30% of severe head injuries. A cerebral laceration is a similar injury except that, according to their respective definitions, the pia-arachnoid membranes are torn over the site of injury in laceration and are not torn in contusion. The injury can cause a decline in mental function in the long term and in the emergency setting may result in brain herniation, a life-threatening condition in which parts of the brain are squeezed past parts of the skull. Thus treatment aims to prevent dangerous rises in intracranial pressure, the pressure within the skull.

Health History: Name: E.A Age: 39 Address: Quezon City Hospital #: 351699 Attending Physician: Dr. Legaspi , Dr. Yeo Date Admitted: June 11,2012 Chief Complaint: Fall/ decreased sensation Final Diagnosis: Bifrontal Contusion Operation Performed: Bifrontal

Present history: Few minutes prior to admission, the client was just seen unconscious. Family History: (+) cancer mother (+) diabetes mellitus mother Personal/Social History: NON-smoker NON-alcohol drinker

Self-Care Deficit Nursing Theory of Dorothea Orem Orem developed the Self-Care Deficit Theory of Nursing, which is composed of three interrelated theories: (1) the theory of SelfCare, (2) the theory of Self-Care Deficit, and (3) the theory of Nursing System.

Pattern of Functioning Health Perception and Management

Before Hospitalization The patient is taking multivitamins

During Hospitalization the patients wife still provides him daily vitamins including the medication given to him.
The patient has decreased appetite due to his condition, though the wife makes sure that her husband eats his food.

Analysis/ Interpretation The patient is well aware of the medical diagnosis that was given to him.
Due to the patients condition it affects his eating pattern.

Nutritional and metabolic pattern

He usually eats times 6 a day including 3 snacks and drinks lots of water.

Elimination pattern

The patient does not experience pain during urination and does not feel any discomfort during defecation.

The patient does not feel any difficulty in urination and defecation. There was no change in his elimination pattern.

Patients condition did not affect his elimination pattern.

Activity and Exercise pattern

The patient has no particular exercise. But plays a lot outdoors. Like basketball,etc

Due to his condition patient usually sleeps and just watch tv.

Patient has no difficulty in moving but due to his condition he needs to rest.

Sleep and Rest pattern

The patient usually wakes up early around 6 am and has no trouble of sleeping. He has no nightmares.

Due to his condition patient has a disturbed sleeping. This is because of his vital signs needed to be checked by nurses.

Patient is having irregular sleep because of his condition checked regularly.

Role and Relationship Pattern

Patient is a 39 y/o man living with is wife only

Patient is Patient is well accompanied by his supported by his wife and sometimes wife. have visitors. They entertain him so that he will cooperate with any procedures that is being done.

Sexuality and Reproductive pattern

DID NOT ANSWER

Values and Beliefs pattern

Patient is roman catholic and goes church regularly with his wife.

Patient cannot go to church due to being hospitalized and his condition.

Due to his condition his the patient cannot go to church but pray.

Coping stress pattern

The patient does listen to music to cope up from stress.

The patient cooperates well with the nurses activities to cope up.

Patient does not show any signs of stress.

Cognitive and The patient doesnt Perceptual pattern wear glasses and doesnt have hearing impairment. And does not have any lesions and/or bruises.

During the interview patient was very cooperative and had interacted with us very well. He was aware of his surroundings and what was going on.

Patient is aware about his condition and the procedures that he had undergone.

Self perception and Self Concept

Patient is quiet but Patient gets more Patient has poor gets to be fun attention since his energy due to his wife is always there condition. around people. beside him.

Parts of the body A. Upper Extremities Arms

Normal Findings

Findings

Analysis

Palms and dorsal surface Nails

Warm to touch Warm to and tenderness touch, no lesions Pinkish and Pinkish, slightly rough slightly rough Transparent, convex and five fingers each Perform w/o any difficulty Transparent, convex and five fingers each hand Can move without difficulty and have a tattoo of his wife on

normal

normal

Normal

Shoulders

Normal

Elbows

Perform without any difficulty

Can bend without difficulty

Normal

1.skull

Because of the surgery head is not symmetrical

2.scalp

Lighter in color, moist, free from lice

Moist or oily, free from lice and flakes. There is an incision

Because of the procedure done it marked or made a scar

3.hair

Can be black, brown, depending on the race; evenly distributed

Not evenly distributed because an incision was made. It was there is a

Because his head is been incised therefore the hair havent grown yet.

B.Eyes

Non protruding Visual acuity :

Normal

20/20
1.eyelashes Evenly distributed 2.eyelids Evenly distributed No signs of Normal

No ptosis

Normal

ptosis
3.lacrimal gland Non-palpable; no regurgitation

Non-palpabale

Normal

4.conjunctiva

Pink-palpebral

Pink-palpebral
conjunctiva

Normal

5.sclera

Anicteric sclera

Anicteric sclera

Normal

(white in color)
C. Ears Bean-shaped No lesions or any Normal

earlobes, no lesions discharges

or open wounds
D. Nose Nose in the midline; No tenderness no discharges; no noted; no signs of Normal

bone or cartilage
deviation noted.

any discharges

E. Neck

No visible mass or lumps; symmetrical; no jugular venous distention

No mass or lumps; symmetrical

Normal

1.lymph nodes

May not be palpable; PALPABLE; less than 1cm in size.

Firm; nontender and 1cm in size

Normal

non-tender IF less than

2.thyroid

Normally

No nodules

Normal

non-palpable; present

no nodules
palpable

F. Thorax
1.lungs Illustrate voluntary sound Voluntary sounds present Normal

G. Cardiovascular Pulse visible; no lift or heaves.

apical pulsations is present

Normal

H. Breast

May or may not be completely symmetrical; no

No retractions or any dimpling; no obvious

Normal

orange peel skin

masses

I. Abdomen

Skin color is uniform, no lesions; some may have presence of striae or scars

No venous engorgement; no tenderness noted; no muscles guarding

Normal

K. Lower extremities

Equal in size; no edema; no

Asymmetrical in size.

Normal

crepitus

Frontal Lobe - Front part of the brain; involved in planning, organizing, problem solving, selective attention, personality and a variety of "higher cognitive functions" including behavior and emotions. The posterior (back) of the frontal lobe consists of the premotor and motor areas. Nerve cells that produce movement are located in the motor areas. The premotor areas serve to modify movements.

CT Scan Result Date: June 11, 2012

CT of the Head Multiple axial images of the head were obtained without intravenous contrast Cerebral contusion hematoma with perilesional edema is noted in both frontal lobes. This causes slight posterior compression of the adjacent unaffected frontal lobes and anterior horns of the lateral ventricle. Extraaxial hemorrhagic collection is also seen in the fronto temporal region extending into parietal region in both region. The ventricles and cisterns are normal in size and shape. The rest of the parenchymal gray-white pattern is intact. Subgaleal hematoma is seen in the parietooccipital region and mucoperiosteal thickening is also noted in the ethnoid and sphenoid sinuses. Polypoid densities are seen in the left maxillary sinus. The mastoids and the rest of parangeal sinus are well-aerated and intact. Linear fractures are seen in the frontal bones as well as in the occipital bone extending down the margin of the foramen magnum. The rest of the visualized osseous structures are normal.

IMPRESSION: Contusion hematoma, bilateral frontal lobe Acute subdural hemorrhage with subarachnoid component, bilateral protemporal region extending into parietal region, as well as epidural focus in the left and right parietal region. Subgaleal hematoma, frontal and occipital bones Polysinusitis Mucus retention cysts or polyps, left maxillary sinus Polysinusitis

Biochemistry: Date of Examination-June 15, 2012

Test

Result

Unit

Normal Value 136-145

Remarks

Sodium

136

mmol/L

Normal

Nuclear Medicine Test Date of examination-June 25, 1012

Test FT4 (RIA) TSH(IRMA)

Result 29.46 .84

Unit Pmol/L ul/ml

Normal Value Remarks 11-5-23 .27-3.75 high normal

FT4-It avoid any change the proteins could have, giving us the real value of T4 (thyroid function test) TSH- use to diagnose a thyroid disorder in a person with symptoms

Complete Blood Count

Hemoglobin* 120 Hematocrit** .37

Eryhtrocyte** 3.91 * MCV MCH 93.90 30.70

fl pg

80-96 27.33

Normal Normal

MCHC
Total WBC****

32.70
15.7

g/dl
10^g/l

33-36
5-10

Normal
High

*Low hemoglobin level indicates anemia. ** Low hematocrit indicates anemia, over hydration, malnutrition, bleeding and destruction of RBC. ***Low erythrocyte indicates anemia, bleeding, kidney disease and malnutrition ****High WBC is not a disease but could indicate other underlying problem, indicative of infection, inflammation, allergy, severe physical or emotional stress and others.

Differential Count: Date of Examination June 21, 2012

Platelet

Increased

*High neutrophils indicate infection. **Low lymphocytes indicate susceptibility to infection.

Biochemistry: Date of Examination-June 21, 2012 Test Creatinine Sodium* Potassium Result 80 134 4.3 Unit umol/L mmol/L Normal Value 53-115 146-145 3.5-5.1 Remarks Normal Low Normal

*Low Sodium may indicate dehydration

HPLC/HBAL (Hemoglobinopathies) Date of Examination-June 21, 2012

Test

Result

Unit

Normal Value

Remarks

HPLC, 5.4 % Glycosated Hemoglobin

4.3-6.4

Normal

Nuclear Medicine Result Date of Examination

Testostero 20.16 ne* LH** .99

1.9low 9.4mlu/ml

*Low testosterone level indicates that the body is unable to produce sufficient amount of testosterone **Low LH indicates low testosterone concentration.

ECG: Date of Examination

Interpretation: Sinus tachycardia Probable old inferior wall myocardial infaction R in V1 maybe in normal variant Clockwise rotation

Urinalysis
Appearance Color Transparency Result and remarks Dark Yellow indicative that the patient is not drinking enough water Cloudy-sign of health issues, caused by blood in urine, UTI and kidney stone

Specific Gravity Ph
Sugar Protein RBC

1.025g/ml - normal 6.0 (5-7 acid urine) predisposition to uric acid calculi or kidney stone
Negative +3 ( trace of protein, indicative of infection) Numerous (0-2 hpf)- bacteria builds up in the bladder and kidneys more likely to develop infection 0-3 (0-4 hpf) -Normal Few

WBC Bacteria Cast Crystal

Hematology
Test Result Normal Value 1-3 5-15 Remarks normal normal

Bleeding Time 2 minutes Clotting Time 8 minutes

Blood Type- B RH Positive

Package Real II
Test BUN Result 4.2 Unit mmol/L mmol/L Normal value 2.5-6.4 53-115 Remarks Normal High

Creatinine* 119

Uric Acid
Amylase

357
52

mmol/L
u/L

155-485
30-110

Normal
Normal

*High Creatinine indicates renal insufficiency or renal failure.

There are several intervention that could be able to relieve our patients condition. Craniectomy Monitor Vital Signs : to monitor the current health status of our patient Provide psychosocial support and a restful environment : to reduce anxiety and promote rest Plan for adequate rest

Brand name

Generic name

Indication

Drug classification

Mechanism of action

Dosage

Adverse Reaction

Contraindications

Nursing responsibilitie s

Biogesic

Paraceta mol

Relief of fever, minor aches and pain

Analgesic and Antipyreti c

Produce analgesia by blocking pain impulses by inhibiting prostaglan din synthesis in the CNS or of other substances that sensitize pain receptors to stimulatio n . the drug mayrelief fever through central action in the hypothala

Tab adult and childr en >12Y O 1-2 tablet every 4-6 hours as neede d. Max: 8 tabs in 24hrs

Allergic skin reactions and Gastro intestinal disturban ces

Anemia, cardiac and pulmonary disease. Hepatic and severe renal disease.

>Use liquid form for children and patients w/ difficulty in swallowing >In children, dont exceed 5 doses in 24 hours. >Tell patient to consult doctor before giving the drug to children below 2y/o. >Advise patient that drug is only for short term

Brand name Bactidol

Generic name

Indication Drug Mechanis Dosage Contraindicat Nursing classificati m of responsibiliti s ion on action es
Protection against oral bacterial and fungal infection to give fast release from sore throat and mouth ulcers. First, bactidol quicly reduces bacteria in the affected areas to help relieve and prevent soreness, then hexetidine contains adheres to affected areas for extended period of time, giving

Oral anti hexetidi Minor septic sore ne throat; halitosis, general oral hygiene, improves appearan ce of mouth tissue, protects tooth surfaces afaints formation of decay acids.

mouthf ul should be held in the mouth, swished and gargles for 30seco nd in the mornin g and evening .

Lesions and ulceration of oral/buccal mucosa.

Instruct patient not to swallow the medication Caution the patient that the solution may be to harsh to taste Assess for any lesions in the mouth of the patient

Brand name

Drug classificatio n Cephulac lactulose Gastrointes , tinal agent, chronula hyperostom c ic laxative

Generic name

Therapeu tic effects 10mg/15 Acidifies ml colon solution, contents, syrup osmotic effect of organic acids causes laxative action Dosage

Drug interacti ons Laxative s may incorrec tly suggest therape utic action of lactulos e

Side Nursing effects responsib ilities Diarrh Mix with half a ea glass of water, milk or fruit juice to improve taste.

May take up to 48 hours to act. Diarrhea may indicate the dose is too high.

Generic Brand Name Name Midazolam Dormic um

Classificati on ANXIOLYTI CS, HYPNOTIC S, SEDATIVES

Dosag e 15mg /2 tablet s HS

Action Indicati on May Disturb potenti ances ate the of sleep effect rhythm, of insomni GABA, a depres especial s the ly CNS, difficult and y in suppre falling ss the asleep spread either of initially seizur or after e premat activity ure awaken . ing.

Contraindica Nursing tion responsibilities

Tell patient to take drug with or without food. If patient is taking it as sleeping pill, take drug before going to bed. Advise patient to avoid alcohol and grapefruit juice while taking the drug. Tell patient if he misses a dose take it at his next scheduled dose.

Severe respiratory and hepatic insufficiency, sleep apnea syndrome, myasthenia gravis.

Those with acute angle Warn patient to closure avoid hazardous glaucoma, activities that shock, coma, or require alertness or acute alcohol good coordination until effects of drug intoxication. are known. Tell patient to store the drug in a cool, dry place away from the reach of children

Name of drug

Dosage, route and frequency Prednison 10mg/5m e l OD on full Classificat stomach ion: anti- 8am inflammat ory

Mechanis m of action Inhibition of leukocyte infiltration at the site of inflammati on, interferen ce in the function of mediators of inflammat ory response, and suppressi on of humoral immune responses.

Indicatio Contraindicati Side effects n on Pneumo Prednisone is contraindicate nia d in patients with systemic fungal infection, but many clinicians believed that corticosteroid s can be administered to ptx with any type of known infection as long as appropriate anti fungal therapy is administered simultaneousl y.
Bloody or black, tarry stools

Nursing responsibility

Establish baseline and continuing data regarding BP, Confusion, INO ratio and excitement, pattern, weight, restlessness, a and sleep pattern. false sense of Start flow chart as well being reference for planning Eye pain, individualize decreased or pharmacotherapeut blurred vision, or ic patient care bulging eyes Check and record Fever, sore BP during dose throat, sneezing, stabilization period cough, or other at least 2 times sings of daily. infection, wounds Report an that will not heal ascending pattern. Frequent passing Monitor patient for of urine evidence of HPA axis suppression Increase thirst during long term therapy by Irregular heartbeat determining Menstrual plasma cortisol problems levels at weekly Nausea, vomiting intervals.

ASSESSMENT Subjective nahilo at nawalan siya ng malay nung nalaglag siya as verbalized by the patients wife Objective dizziness unconscious loss of sensation VS 140/100

DIAGNOSIS Risk for ineffective cerebral tissue perfusion related to head trauma as manifested by loss of sensation and consciousness

PALNNING Short term: After 2 days of effective nursing intervention the patient will be able to feel sensation and will be comfortable and conscious. Long term: After 4 days of effective nursing interventions the patients LOC will be increased and will not feel dizziness.

INTERVENTION INDEPENDENT -Monitor Vital signs -Position head in neutral position -check for bleeding -ask client to rate pain on 0-10 scale -provide calm and quiet environment(adjust lights, temperature and eliminate offensive odors which may contribute to headache -Protect the patient for further injury COLLABORATIVE -Pain management

RATIONALE -Baseline data -to promote venous drainage -to prevent internal bleeding -to prevent blood clots -to assist in evaluating impact of pain on clients life

EVALUATIO N Short term: After 2 days of effective nursing intervention the patient will be able to feel sensation and will be comfortable and conscious. Goal was met. Long term: After 4 days of effective nursing interventions the patients LOC will be increased and will not feel dizziness. Goal was met.

-to decrease environmental factors which contribute to migraine and promote rest

-By using side rails

-Wound dressing

Assessment Subjective: Parang nagiba nga itchura ko eh tignan mo yung noo ko flat parang nagmukha akong napanot tignan

Diagnosis Planning Intervention Rationale After 5 hours Independent: Disturbed of effective body image nursing -Encourage the -Expression of related to interventions patient to express feelings and The patient feelings, beliefs, and concerns may altered will verbalize concerns decrease the physical feelings of about changes patient's anxiety, and appearance, self-worth and resulting from the help clear Misconceptions. neurologic demonstrate Diagnosis and an interest in craniotomy. deficits or occupational alteration in therapy, - Assess the patient's - Specific feeling toward interventions to personality activities of daily living, hair loss and minimize Objective: and thought and a postoperative the body image -Flat forehead processes. rehabilitation incision. Provide changes may program, if measures, such make the patient feel -continuous as a surgical cap or less appropriate. touching of scarf to Self-conscious. hair and provide comfort. -Encourage forehead. participation in - Participation in -high hair line occupational and therapy promotes
physical therapy. Reinforce exercises and activities that the patient learns. Provide emotional support. Encourage family participation recovery and gives the patient a feeling of independence and accomplishment. Family involvement gives the patient support and a feeling

Evaluation After 5 hours of effective nursing interventions The patient had verbalized the feelings of self worth and he has demonstrated an interest in occupational therapy and activities of daily living. Goal was met.

Discomforts After surgery, headache pain is managed with narcotic medication. Because narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks). Their regular use may also cause constipation, so drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought without a prescription. Thereafter, pain is managed with acetaminophen as prescribed by the doctor.

Follow-up care Make sure all follow-up appointments are scheduled in the computer and give your patient a copy of her schedule. Explain the reason for each appointment. If she is seeing someone in the community outside your facility, make sure she knows how to obtain a copy of her medical file. You can also give her the phone numbers to your nursing unit and to her physician's office so she can call if questions arise once she is home.

Restrictions-Do not drive after surgery until discussed with your surgeon and avoid sitting for long periods of time. -Do not lift anything heavier than 5 pounds (e.g., 2-liter bottle of soda), including children. -Housework and yardwork are not permitted until the first followup office visit. This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer. -Do not drink alcoholic beverages.

Activity -Encourage adequate rest periods to prevent fatigue -Gradually return to your normal activities. Fatigue is common. -An early exercise program to gently stretch the neck and back may be advised -Walking is encouraged; start with short walks and gradually increase the distance. -Wait to participate in other forms of exercise until discussed with your surgeon.

Bathing/Incision care -You may shower and shampoo 3 to 4 days after surgery unless otherwise directed by your surgeon. -Sutures or staples, which remain in place when you go home, will need to be removed 7 to 14 days after surgery. Ask your surgeon or call the office to find out when.

When to call your DoctorIf you experience the following: -A temperature that exceeds 101 F -An incision that shows signs of infection, such as redness, swelling, pain, or drainage. -If you are taking an anticonvulsant, and notice drowsiness, balance problems, or rashes. -Decreased alertness, increased drowsiness, weakness of arms or legs, increased headaches, vomiting, or severe neck pain that prevents lowering your chin toward the chest.

Recovery The recovery time varies from 1 to 4 weeks depending on the underlying disease being treated and your general health. Full recovery may take up to 8 weeks. Walking is a good way to begin increasing your activity level. Start with short, frequent walks within the house and gradually try walks outside. Its important not to overdo it, especially if you are continuing treatment with radiation or chemotherapy. Ask your surgeon when you can expect to return to work.