Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

In Partial Fulfillment
Of the Requirement in
________________________
Related Learning Experience (RLE)

A CASE STUDY ON

“Intracerebral Hemorrhage and Contusion Hematoma secondary to Vehicular Accident”

Presented by:
 Bea Flor Rapisura-Pegad
BSN III-A

Presented to:

Romeline A. Asanion, RN, MAN

Date:
November 30, 2019
I: Introduction

Intracerebral hemorrhage is focal bleeding from a blood vessel in the brain parenchyma. The cause is usually hypertension. Intracerebral hemorrhage usually
results from rupture of an arteriosclerotic small artery that has been weakened, primarily by chronic arterial hypertension. Such hemorrhages are usually large,
single, and catastrophic. Other modifiable risk factors that contribute to arteriosclerotic hypertensive intracerebral hemorr hages include cigarette smoking, obesity,
and a high-risk diet (eg, high in saturated fats, trans fats, and calories). Use of cocaine or, occasionally, other sympathomimetic drugs can cause transient severe
hypertension leading to hemorrhage.
Less often, intracerebral hemorrhage results from congenital aneurysm, arteriovenous or other vascular malformation (see Vascular Lesions in the
Brain), trauma, mycotic aneurysm, brain infarct (hemorrhagic infarction), primary or metastatic brain tumor, excessive anticoagulation, blo od dyscrasia,
intracranial arterial dissection, moyamoya disease, or a bleeding or vasculitic disorder.
Typical symptoms include focal neurologic deficits, often with abrupt onset of headache, nausea, and impairment of consciousn ess. Diagnosis is by CT or MRI.
Treatment includes BP control, supportive measures, and, for some patients, surgical evacuation.
Symptoms of intracerebral hemorrhage typically begin with sudden headache, often during activity. However, headache may be mil d or absent in the elderly.
Loss of consciousness is common, often within seconds or a few minutes. Nausea, vomiting, delirium, and focal or generalized seizures are also common.

Neurologic deficits are usually sudden and progressive. Large hemorrhages, when located in the hemispheres, cause hemiparesis ; when located in the posterior
fossa, they cause cerebellar or brain stem deficits (eg, conjugate eye deviation or ophthalmoplegia, stertorous breathing, pinpoint pupils, coma).

Large hemorrhages are fatal within a few days in about half of patients. In survivors, consciousness returns and neurologic d eficits gradually diminish to various
degrees as the extravasated blood is resorbed. Some patients have surprisingly few neurologic deficits because hemorrhage is less destructive to brain tissue than
infarction.

Small hemorrhages may cause focal deficits without impairment of consciousness and with minimal or no headache and nausea. Small hemorrhages may mimic
ischemic stroke.

A contusion happens when an injured capillary or blood vessel leaks blood into the surrounding area. Contusions are a type of hematoma, which refers to any
collection of blood outside of a blood vessel. While the term contusion might sound serious, it’s just a medical term for the common bruise.

Contusion is a medical term for a common bruise. While you likely think of bruises as splotchy areas of discoloration on your skin, they can also happen to your
bones and muscles. In most cases, both soft tissue and bone contusions heal on their own within a week or two, though bone contusions might take longer.

On a computed tomography (CT) scan, a contusion generally appears as a hemorrhagic lesion, although sometimes injured tissues or part of a contusive lesion can
appear normal (isodense) or as a hypodensity. A contusion is distinguished from a laceration by the fact that with a contusion, the pia mater remains intact. A
contusion is distinguished from a hematoma by the fact that with a contusion, blood is intermixed with brain tissue.
When head trauma results in a contusion, the hemorrhagic lesion often expands or a new hemorrhagic lesion may develop remotely from the original contusion
during the first several hours after impact.
II: Patient’s Profile

Name: Patient X44

Age: 59 years old
 Sex: Male
Civil Status: Married
Address: Barangay Baracbac, Sinait, Ilocos Sur
Birthday: August 12, 1960
Nationality: Filipino
Date of admission: 10-20-2019
Date of Death: 10-25-2019

Patient x44 was admitted at Ilocos Sur Provincial Hospital-Gabriela Silang on October 20, 2019 due to multiple injuries acquired on a vehicular accident.

The accident happened on the same day of admission.

The patient had driven the “kurong-kurong” together with neighbors when they were accidentally bumped by a 4 wheeled car as been detailed by the brother

of the patient. The other passengers of the “kurong-kurong” sustained only minor scratches and wounds, they were bought on the nearest hospital (Cabugao). While

patient X44 was directly bought to ISPH-GS due to major and serious injuries.

Upon receiving the patient on October 21,2019, a day after the accident, patient is still un-conversant and lying on bed. He has a skin traction on his left leg,

long leg posterior mold on the right.

Patient X44 was a Barangay Tanod on their Brgy and he was doing his duty when the accident happened.

CT Scan and series of X-rays were done with the patient due to the injuries he have sustained with accident.
III: NURSING HISTORY OF PAST AND PRESENT ILLNESS

The patient has no history of serious illnesses.

He was admitted last October 20, 2019. He was under IVF of 0.9 NaCl 1000 ml, 41-42 gtts/min on his right arm. He has also IFC with a level of 150 ml

upon receiving the patient. He is un conversant. He only opens his eyes for a while and closes it again and return to sleep. He is with a skin traction on his left leg

and a long leg posterior mold on the right . He was given Tranexamic acid 500 mg via IV Q8 for the superficial bleeding of the brain on the frontal area. He was on

NPO As ordered by the admitting Physician. Cefuroxime was also given via IV Q8.
IV: PEARSON ASSESSMENT
ASSESSMENT Hospital Hospital Hospital Home Visit
Date: 10-21-19 Date Date Date
Patient Felipe who was 59 10-21-19
yrs of age was un
conversant. Pain could be
Physiological seen on his face.
For his family,particularly
his brother who was with
him. Talking to him even
though he cannot talked
back. Assuring him that he
can make it through.
10-21-19
Has excessive perspiration
because of the hot
weather. He’s on IFC and
Elimination at 350 ml upon receiving
the patient.

10-21-19
 He is on bed . we have
difficulty of turning him
Activity and Rest side or repositioning him
because of the posterior
mold and skin traction.

Initial vital signs taken as 10-21-19

follows:
BT= 36.5 ‘C
Safety and PR= 131 bpm
Security RR= 21 cpm
BP= 120/90 mmHg
IV site intact and patent
Skin traction is intact.

10-21-19
No o2 supplement
RR= 21 cpm

Oxygenation

NPO for 8 hrs for the 10-21-19

ABD UTZ
Un conversant
Nutrition With poor appetite
With 0.9 NaCl 1L at 1L
for 41-42 gtts/min
V. DIAGNOSTIC PROCEDURE

A. IDEAL

 CT Scan - A CT scan or computed tomography scan makes use of computer-processed combinations of many X-ray measurements taken from different angles to
produce cross-sectional images of specific areas of a scanned object, allowing the user to see inside the object without cutting.
 X-Ray- A CT scan or computed tomography scan makes use of computer-processed combinations of many X-ray measurements taken from different angles to
produce cross-sectional images of specific areas of a scanned object, allowing the user to see inside the object without cutting.
 Urinalysis- used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves
checking the appearance, concentration and content of urine.
 ABD UTZ- Abdominal ultrasonography is a form of medical ultrasonography to visualize abdominal anatomical structures. It uses transmission and reflection of
ultrasound waves to visualize internal organs through the abdominal wall.
 COMPLETE BLOOD COUNT with BLOOD TYPE- The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete
blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the
different components of blood in less than a minute. major portion of the complete blood count is the measure of the concentration of white blood cells, red
blood cells, and platelets in the blood.

B: ACTUAL

 All Ideal Diagnostic procedures are done to the patient. The ff. are the results.
CT Scan:
VI. ANATOMY AND PHYSIOLOGY
The magnitude of damage to cerebral tissues following head trauma is determined by the primary injury, caused by the kinetic energy delivered at the time of
impact, plus numerous secondary injury responses that almost inevitably worsen the primary injury. When head trauma results in a cerebral contusion, the
hemorrhagic lesion often progresses during the first several hours after impact, either expanding or developing new, non-contiguous hemorrhagic lesions, a
phenomenon termed hemorrhagic progression of a contusion (HPC). Because a hemorrhagic contusion marks tissues with essentially total unrecoverable loss of
function, and because blood is one of the most toxic substances to which the brain can be exposed, HPC is one of the most severe types of secondary injury
encountered following traumatic brain injury (TBI). Historically, HPC has been attributed to continued bleeding of microvessels fractured at the time of primary
injury. This concept has given rise to the notion that continued bleeding might be due to overt or latent coagulopathy, prompting attempts to normalize coagulation
with agents such as recombinant factor VIIa. Recently, a novel mechanism was postulated to account for HPC that involves delayed, progressive microvascular
failure initiated by the impact. Here we review the topic of HPC, we examine data relevant to the concept of a coagulopathy, and we detail emerging data
elucidating the mechanism of progressive microvascular failure that predisposes to HPC after head trauma.
The illustration also shows how can we treat hemorrhage.

Anatomy of the Brain

The brain serves many important functions. It gives meaning to things that happen in the world surrounding us. Through the five senses of sight, smell, hearing,
touch and taste, the brain receives messages, often many at the same time.

The brain controls thoughts, memory and speech, arm and leg movements and the function of many organs within the body. It also determines how people respond
to stressful situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.) by regulating heart and breathing rates. The brain is an organized structure,
divided into many components that serve specific and important functions.

The weight of the brain changes from birth through adulthood. At birth, the average brain weighs about one pound, and grows to about two pounds during
childhood. The average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three pounds.

A brain hemorrhage is a type of stroke. It's caused by an artery in the brain bursting and causing localized bleeding in the surrounding tissues. This bleeding
kills brain cells.
The Greek root for blood is hemo. Hemorrhage literally means "blood bursting forth." Brain hemorrhages are also called cerebral hemorrhages, intracranial
hemorrhages, or intracerebral hemorrhages.
When blood from trauma irritates brain tissues, it causes swelling. This is known as cerebral edema. The pooled blood collects into a mass called a hematoma. These
conditions increase pressure on nearby brain tissue, and that reduces vital blood flow and kills brain cells.
Bleeding can occur inside the brain, between the brain and the membranes that cover it, between the layers of the brain's covering or between the skull and the covering of
the brain.

Traumatic brain injury usually results from a violent blow or jolt to the head or body. An object that penetrates brain tissue, such as a bullet or shattered piece of
skull, also can cause traumatic brain injury.

Mild traumatic brain injury may affect your brain cells temporarily. More-serious traumatic brain injury can result in bruising, torn tissues, bleeding and other
physical damage to the brain. These injuries can result in long-term complications or death.
VIII. MANAGEMENT
A. MEDICAL
a.Ideal

The patient was already on a long leg posterior mold upon receiving. On the other leg theres a skin traction which indicates that he needed another surgery for the fractured leg.
But the main problem is, the patient is un conversant. The significant others have already talked about the surgery and later decided to transfer the patient into another surgeon
for unknown reason. And both parties agreed to schedule the operation once the materials that would be needing is already available.

On the pharmacological management, he was given Manitol 75mg IV to reduce swelling and pressure inside around the brain, Tranexemic Acid 500 mg via IV Q8 , this
works by slowing the breakdown of blood clots, which helps to prevent prolonged bleeding. It belongs to a class of drugs known as antifibrinolytics. Cefuroxime
750mg IV Q8 treat a wide variety of bacterial infections. This medication is known as a cephalosporin antibiotic. It works by stopping the growth of bacteria.
The client was put on NPO for the ABD UTZ. He is with IVF of 0.9 NaCL 1000 ml ,41-42 gtts/min. and on IFC with level of 150ml upon receiving.

Base on my assessment with my patient, he should be at the Intensive Care Unit. He barely woke up. Cannot even talk nor ask for food or drink. The whole duration of staying
with my patient for two days, I can say that he is at a critical condition. After the ABD UTZ he must be on NGT to receive nutrients and gain strength.
 b.Actual

The patient was given medications as per physicians order. He was still at the Surgical ward. Was given antipyretics due to his fever. Applied TSB to reduce the
fever. The ABD UTZ shows no sign of any abnormalities nor bleeding on the abdominal area. Series of Xray were done for the multiple injuries.

B .SURGICAL

a.Ideal

The patient was already on a long-leg posterior mold on the left leg. Another surgery which is Hip Pinning needs to be done with him on his right hip and leg. He
still has the skin traction on the right leg. Due to unknown reason he was transferred into another surgeon that caused the delay of his operation.

b.Actual

Hip Pinning was not done due to the patient have already died prior to the operation.
 B. NURSING CARE PLAN

DATA NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impared physical After 8 hours of nursing  Provide rapport with  To gain trust and After 8 hours of nursing care
“the patient is mobility related to care, the client will be the patient full cooperation intervention the patient was able to:
unconversant, very pain/discomfort as able to:  vital signs altered
low LOC. evidenced by  monitor vital signs during pain  Perform physical activity
limited range of  Performs physical  to aid in independently (such as walking,
Objective: motion, slowed activity independently  provide a therapeutic alleviation of taking a bath, etc.) or with
-Difficulty of turning movements and (such as walking, environment assistance as needed.
pain and to avoid
-no movement resistance to taking a bath, etc.) or
further injuries
-febrile attempt movement. with assistance as  encourage
 to assist in  Was not able to maintain mobility
needed. verbalization of
VS taken as follows: evaluation at highest possible level
feelings
BT= 38.1‘C  to alleviate pain
 regain or maintain and reduce
PR= 141 bpm  encourage to do light  knew different techniques in
RR= 22 cpm strength and mobility fatigue
diversional / alleviating pain
BP= 120/90 mmHg at the highest possible  to reduce fatigue
recreational activities
level
 to reduce fatigue
 encourage rest and
 to know different sleep
techniques in
alleviating pain  schedule activities
with adequate rest
periods