Bifrontal Contusions Ppt

Bifrontal ContusionsLuz, Kathleen

Mapili, AnjelikaMarquez Rich

Mendiola, BessieSadol, Bryan

Santos, Raphael IISingh, 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

Objectives

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.

Introduction

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

DEMOGRAPHIC DATA

Present history:Few minutes prior to admission, the

client was just seen unconscious. Family History:

(+) cancer – mother(+) diabetes mellitus – mother

Personal/Social History:NON-smokerNON-alcohol drinker

HISTORY

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 Self-Care, (2) the theory of Self-Care Deficit, and (3) the theory of Nursing System.

Theoretical Framework

Pattern of Functioning

Before Hospitalization

During Hospitalization

Analysis/ Interpretation

Health Perception and Management

The patient is taking multivitamins

the patient’s wife still provides him daily vitamins including the medication given to him.

The patient is well aware of the medical diagnosis that was given to him.

Nutritional and metabolic pattern

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

The patient has decreased appetite due to his condition, though the wife makes sure that her husband eats his food.

Due to the patient’s condition it affects his eating pattern.

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.

Gordon’s Pattern of Functioning

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

Patient is well supported by his wife.

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 Perceptual pattern

The patient doesn’t wear glasses and doesn’t 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 gets to be fun around people.

Patient gets more attention since his wife is always there beside him.

Patient has poor energy due to his condition.

Physical Assessment:

Parts of the

body

Normal

Findings

Findings

Analysis

A. Upper

Extremities

Arms Warm to touch and tenderness

Warm to touch, no lesions

normal

Palms and dorsal surface

Pinkish and slightly rough

Pinkish, slightly rough

normal

Nails Transparent, convex and five fingers each

Transparent, convex and five fingers each hand

Normal

Shoulders Perform w/o any difficulty

Can move without difficulty and have a tattoo of his wife on left shoulder

Normal

Elbows Perform without any difficulty

Can bend without difficulty

Normal

1.skull

Generally round

Not semmetrical

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 part where in

its hairless

Because his head is been

incised therefore the hair

haven’t grown yet.

B.Eyes

Non

protruding

Visual acuity

: 20/20

Normal

1.eyelashes

Evenly

distributed

Evenly

distributed

Normal

2.eyelids

No ptosis

No signs of

ptosis

Normal

3.lacrimal

gland

Non-palpabale

Non-palpable;

no

regurgitation

Normal

4.conjunctiva

Pink-palpebral

Pink-palpebral

conjunctiva

Normal

5.sclera Anicteric sclera

(white in color)

Anicteric sclera Normal

C. Ears

Bean-shaped

earlobes, no

lesions or open

wounds

No lesions or any

discharges

Normal

D. Nose Nose in the

midline; no

discharges; no

bone or cartilage

deviation noted.

No tenderness

noted; no signs of

any discharges

Normal

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;

non-tender

IF

PALPABLE;

less than

1cm in size.

Firm; non-

tender and

less than

1cm in size

Normal

2.thyroid

Normally

non-palpable;

no nodules

palpable

No nodules

present

Normal

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

orange peel skin

present; no

presence of

obvious masses

No retractions

or any dimpling;

no obvious

masses

Normal

I. Abdomen

Skin color is

uniform, no

lesions;

some may

have

presence of

striae or

scars

No venous

engorgemen

t; no

tenderness

noted; no

muscles

guarding

Normal

K. Lower

extremities

Equal in size;

no edema; no

crepitus

Asymmetrical

in size.

Normal

Anatomy and Physiolgy

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.

LABORATORY AND DIAGNOSTIC TESTS:

CT Scan Result Date: June 11, 2012

CT of the HeadMultiple 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

Test Result Unit Normal Value

Remarks

Sodium 136 mmol/L 136-145 Normal

Biochemistry:Date of Examination-June 15, 2012


Remarks

FT4 (RIA) 29.46 Pmol/L 11-5-23 high

TSH(IRMA) .84 ul/ml .27-3.75 normal

Nuclear Medicine TestDate of examination-June 25, 1012

• 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


Remarks

Hemoglobin*

120 g/dl 135-160 Low

Hematocrit**

.37 .40-.48 Low

Eryhtrocyte***

3.91 10^12/l 4.5-5 low

MCV 93.90 fl 80-96 Normal

MCH 30.70 pg 27.33 Normal

MCHC 32.70 g/dl 33-36 Normal

Total WBC****

15.7 10^g/l 5-10 High

Complete Blood Count

*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.

Test Result Normal Value Remarks

Neutrophils* .74 .55-.65 High

Lympocytes** .14 .25-.40 Low

Monocytes .06 .02-.06 Normal

Stabs .06 .01-.06 Normal

Platelet Increased

Differential Count:Date of Examination June 21, 2012

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


Remarks

Creatinine 80 umol/L 53-115 Normal

Sodium* 134 mmol/L 146-145 Low

Potassium 4.3 3.5-5.1 Normal

Biochemistry:Date of Examination-June 21, 2012

*Low Sodium may indicate dehydration

Test Result Unit Normal Value Remarks

HPLC, Glycosated Hemoglobin

5.4 % % 4.3-6.4 Normal

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


Remarks

Testosterone*

20.16 ng/dl (62-593ng/dl

low

LH** .99 1.9-9.4mlu/ml

low

Nuclear Medicine ResultDate of Examination

*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

UrinalysisAppearance Result and remarksColor Dark Yellow – indicative that the patient

is not drinking enough water

Transparency Cloudy-sign of health issues, caused by blood in urine, UTI and kidney stone

Specific Gravity 1.025g/ml - normalPh 6.0 (5-7 acid urine) predisposition to uric

acid calculi or kidney stone

Sugar Negative Protein +3 ( trace of protein, indicative of

infection)RBC Numerous (0-2 hpf)- bacteria builds up in

the bladder and kidneys more likely to develop infection

WBC 0-3 (0-4 hpf) -NormalBacteria FewCast Crystal

Test Result Normal Value

Remarks

Bleeding Time

2 minutes 1-3 normal

Clotting Time

8 minutes 5-15 normal

Hematology

Blood Type- “B” RH Positive

Test Result Unit Normal value

Remarks

BUN 4.2 mmol/L 2.5-6.4 Normal

Creatinine*

119 mmol/L 53-115 High

Uric Acid 357 mmol/L 155-485 Normal

Amylase 52 u/L 30-110 Normal

Package Real II

*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

Medical/surgical interventions:

Drug Study

Brand name

Generic name

Indication

Drug classification

Mechanism of action

Dosage

Adverse Reaction

Contraindications

Nursing responsibilities

Biogesic

Paracetamol

Relief of fever, minor aches and pain

Analgesic and Antipyretic

Produce analgesia by blocking pain impulses by inhibiting prostaglandin synthesis in the CNS or of other substances that sensitize pain receptors to stimulation . the drug mayrelief fever through central action in the hypothalamic heat regulating center

Tab adult and children >12YO 1-2 tablet every 4-6 hours as needed. Max: 8 tabs in 24hrs

Allergic skin reactions and Gastro intestinal disturbances

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

>Use liquid form for children and patients w/ difficulty in swallowing>In children, don’t 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 use.

Brand name

Generic name

Indications

Drug classification

Mechanism of action

Dosage

Contraindication


Bactidol hexetidine

Minor sore throat; halitosis, general oral hygiene, improves appearance of mouth tissue, protects tooth surfaces afaints formation of decay acids.

Oral anti septic

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 long lasting protection.

½ mouthful should be held in the mouth, swished and gargles for 30second in the morning 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

Generic name

Drug classification

Dosage Therapeutic effects

Drug interactions

Side effects


Cephulac, chronulac

lactulose Gastrointestinal agent, hyperostomic laxative

10mg/15ml solution, syrup

Acidifies colon contents, osmotic effect of organic acids causes laxative action

Laxatives may incorrectly suggest therapeutic action of lactulose

Diarrhea

Mix with half a 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. Evaluate therapeutic response; decrease constipation or blood ammonia level.

Generic Name

Brand Name

Classification

Dosage

Action

Indication

Contraindication


Midazolam

Dormicum

ANXIOLYTICS, HYPNOTICS, SEDATIVES

15mg/ 2 tablets HS

May potentiate the effect of GABA, depress the CNS, and suppress the spread of seizure activity.

Disturbances of sleep rhythm, insomnia especially difficulty in falling asleep either initially or after premature awakening.

Known hypersensitivity to benzodiazepines or to any component of Dormicum. Severe respiratory and hepatic insufficiency, sleep apnea syndrome, myasthenia gravis. Those with acute angle closure glaucoma, shock, coma, or acute alcohol intoxication.

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. Warn patient to avoid hazardous activities that require alertness or good coordination until effects of drug 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

Mechanism of action

Indication

Contraindication

Side effects Nursing responsibility

Prednisone Classification: anti-inflammatory

10mg/5ml OD on full stomach 8am

Inhibition of leukocyte infiltration at the site of inflammation, interference in the function of mediators of inflammatory response, and suppression of humoral immune responses.

Pneumonia

Prednisone is contraindicated in patients with systemic fungal infection, but many clinicians believed that corticosteroids can be administered to ptx with any type of known infection as long as appropriate anti fungal therapy is administered simultaneously.

Bloody or black, tarry stools Confusion, excitement, restlessness, a false sense of well being Eye pain, decreased or blurred vision, or bulging eyes Fever, sore throat, sneezing, cough, or other sings of infection, wounds that will not heal Frequent passing of urine Increase thirst Irregular heartbeatMenstrual problemsNausea, vomiting

Establish baseline and continuing data regarding BP, INO ratio and pattern, weight, and sleep pattern.Start flow chart as reference for planning individualize pharmacotherapeutic patient care Check and record BP during dose stabilization period at least 2 times daily.Report an ascending pattern. Monitor patient for evidence of HPA axis suppression during long term therapy by determining plasma cortisol levels at weekly intervals.

Nursing Care Plan

ASSESSMENT DIAGNOSIS PALNNING Subjective“ nahilo at nawalan siya ng malay nung nalaglag siya” as verbalized by the patient’s wife Objectivedizziness unconsciousloss of sensation VS 140/100

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

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 patient’s LOC will be increased and will not feel dizziness.

INTERVENTION RATIONALE EVALUATIO NINDEPENDENT-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 -Wound dressing

-Baseline data -to promote venous drainage -to prevent internal bleeding-to prevent blood clots -to assist in evaluating impact of pain on client’s life -to decrease environmental factors which contribute to migraine and promote rest -By using side rails

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 patient’s LOC will be increased and will not feel dizziness. Goal was met.

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective: “Parang nagiba nga itchura ko eh tignan mo yung noo ko flat parang nagmukha akong napanot tignan” Objective:-Flat forehead-continuous touching of hair and forehead.-high hair line

Disturbed body image related to altered physical appearance, neurologic deficits or alteration in personality and thought processes.

After 5 hours of effective nursing interventionsThe patient will verbalize feelings of self-worth and demonstrate an interest in occupational therapy, activities of daily living, and a rehabilitation program, if appropriate.

Independent: -Encourage the patient to express feelings, beliefs, and concerns about changes resulting from the Diagnosis and craniotomy. - Assess the patient's feeling toward hair loss and postoperative incision. Provide measures, such as a surgical cap or scarf to provide comfort. -Encourage participation in occupational and physical therapy. Reinforce exercises and activities that the patient learns. Provide emotional support. Encourage family participation and support.

-Expression of feelings and concerns may decrease the patient's anxiety, and help clear Misconceptions. - Specific interventions to minimize the body image changes may make the patient feel less Self-conscious. - Participation in therapy promotes recovery and gives the patient a feeling of independence and accomplishment. Family involvement gives the patient support and a feeling of acceptance.

After 5 hours of effective nursing interventionsThe 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.

DISCHARGE PLANNING

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 follow-up 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 Doctor- If you experience the following:

-A temperature that exceeds 101º 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.

RecoveryThe 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. It’s 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.

HAPPY BIRTHDAY :)

FROM, GROUP 6 :

Bifrontal Contusions Ppt

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