Sweetie B.

Palconit 2012 Emergency Room (CCMC)

Group 1 BSN 3B Mr. Arnold Daclan, R.N
CNU- CI

CASE STUDY

A. INTRODUCTION

A case of Ramil Pagar, 42 years old, Male, was admitted on November 19, 2010,
unconscious, unresponsive, comatose and was initially diagnosed with intracerebral
hemorrhage secondary to head trauma. The patient’s mother reported that the he
usually drinks alcohol everyday and that he does not take drugs at all. She also said that
4 days ago she saw the patient lying on the floor on his room probably hitting on the wall
one night when he arrived home drank. The day after that, the patient experienced
several episodes of seizures. And the family decided to seek hospital aid 2 days after.

Intracerebral hemorrhage is bleeding into the substance of the brain. It is

commonly seen in head injuries in which force is exerted to the head over a small area.
These hemorrhages within the brain may also result from systemic hypertension, which
causes degeneration and rupture of a vessel; from systemic causes, including bleeding
disorders.

B. PHYSICAL ASSESSMENT

The client’s pulse rate is 110 beats per minute upon receiving and respiratory rate is 28
breaths per minute, temperature is 36.8°c. The client is in medium frame with stooped posture.
He wears worn out clothes and has a foul alcoholic smell. He doesn’t have any deformity. The
client is stupor and unconscious. The client’s skin is of normal racial tone which is brown. It is
dry and slightly rough. The skin turgor is wrinkled and loss of elasticity. The body hair is evenly
distributed. He doesn’t have any edema. But he has a skin lesion on his right elbow. The client’s
nail shape is convex clubbing, the nail is rough and the nail bed is pallor. The capillary refill is
less than 3 seconds and these is an absence of beau’s line. The client’s skull is proportionate to
the body size; there were tenderness in the scalp. There were no presence of nodules, and
infestation. His hair is evenly distributed and the strands are thin and brittle. The color of his hair
is black. His head is round and symmetrical its consistency is hard. The condition of his eyes is;
the eye brows are evenly distributed. Eyelids have effectively closure. The blink response is not
seen, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pallor
and the sclera is white. The palpebral slant is aligning with the tip of the pinna. The corneal
sensitivity reflex is not present. Pupils are equal in size. Pupils are equally round and does not
react to light and accommodation. He cannot execute the occular movements. The lacrimal
apparatus are moist. The color of the ear is of normal racial tone which is brown, it is
symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic and recoil when
folded.. The auditory canal contains some cerumen, the color is brown and there is an absent of
discharges. The color of the client’s nose is of racial tone which is brown. His septum is in the
midline. The mucosa is pale; nostrils are both patent, nasal flaring is present. Landmarks are
visible. Sinuses are non-tender. There is an NGT in his left nostrils. The lips is symmetrical and
pale, the consistency is smooth, buccal mucosa is pale, the gum is slightly pale, the tongue is in
the midline, the color is pale pink and it is smooth. The tongue movements are not that smooth.
Its texture is rough. The color of the hard and soft palate is pink. And it is intact. The tonsils are
inflamed grade of + 2. There is presence of mucous. Uvula is in the midline, gag reflex is
absent. The teeth are incomplete. The neck has involuntary movement and with resistance, the
muscle strength 1/5. The trachea is in the midline, thyroid is in the midline and it is smooth.
Maxillary lymph nodes are palpable. The breasts are symmetrical with flat contour. Shape is flat,
the skin surface is smooth. Lympnodes are not palpable. The areola is color brown, shape is
round and the nipple is everted, there are no discharges and there are no Lymph nodes and no
tenderness. The color of the chest is of normal racial tone which is brown, the shape is AP to
lateral ratio 1:2. There are presences of intercoastal retraction, costal angle is 45° chest wall are
symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90. Respiratory
rhythm is irregular. The respiratory depth is shallow. Respiratory pattern is abnormal changing
from time to time. When percussed the sound is crackles. No adventitious sounds heard.
Respiratory rate is 28 breaths per minute. Heart rhythm is irregular. PMI is located in the apical
pulse. ECG reading yields a supraventricular tachycardia. Heart rate is 110 beats per minute.
Abdominal skin is of normal racial tone which is brown, the contour is flat. Peristalsis is non-
visible. When percussed the sound is tympany. When palpated he doesn’t have any tenderness
and when light palpation is done muscle guarding is absent. The liver is palpable. The client
cannot resist force when asked to resist. Muscle strength is 1/5. He has a skin lesion in his right
elbow. The peripheral pulses are non-equal. Lympnodes are not palpable. The IV site is in his
left arm. The client is circumcised and his genitals are fully developed

C. SCHEMATIC DIAGRAM

PATHOPHYSIOLOGY
Predisposing Factor:

- Age (42 years old)

- Cigarette smoking

- Alcohol consumption

- Trauma on head

Direct impact to the head or direct invasion

of the object to the brain (PRIMARY
INJURY)
 Bleeding or hemorrhage on at the
affected area
No opening to the skull and
close dura ( close brain injury)

Alteration in the cerebral Hematoma Presence of free blood in the

-ABG, Cerebral component formation interstitial areas
Angiography, MRI, CT
SCAN,Subarachoid Screw,
Ventriculostomy, Epidural
ICP Monitoring.
Thrombus Cell membrane
-Restlessness, Increase in the formation destruction
Continuation………..
drowsiness,confusion, Intracranial pressure
headache

CT SCAN
and MRI

Decrease
Compression Compensatory
oxygen
of the brain mechanism
supply
components

Stimulates Seizures
further
swelling and Cellular
inflammation edema Vasospasm Electrolyte Acidosis
imbalance

-projectile
vomiting,
Ischemia Stimulation of
numbness of
vasomotor
extremiities ,
centers
visual
disturbances -SERUM
Scar ELECTROLYTE TEST
Formation (decrease Mg, K),
ABG(Respiratory
Alteration in Increase
alkalosis)
the frontal systemic
lobe function pressure
X RAY, -changes in the v/s
CT
scan,
MRI

-Broca’s aphasia,
hemiparesis,
- Increase
hemianopsia,
BP
dysarthria,
incapable of
abstract thinking
 Without Medical With Medical
intervention Intervention
Management:

SURGICAL: craniectomy, craniotomy

Brain stem
herniation MEDICAL: Pharmacologic Therapy
(citicholine, mannitol, dilatin, captopril,
Nitroglycerin, furosemide, remopain,
Comatose stupor Kalium Durule, MgSO4)

Worsening of the Bad Prognosis

condition

DEATH

D. EXPLANATION

Predisposing factors include that the patient is 42 years old, a cigarette smoker, takes
in alcohol at least everyday, and had head trauma 4 days ago. There was a direct impact to
the head that results to a primary injury to the brain but it was noted that there are no
opening of the brain, therefore making it an internal injury. These will contribute to bleeding
tendencies that result to alterations of cerebral components of the brain and the escape of
blood to the interstitial areas. As expected, there will be increase intracranial pressure that
results from the compression of the brain components, decrease in oxygen supply, thus
stimulating further swelling and inflammation. Seizure attacks usually occur due to constant
increase in intracranial pressure. Signs and Symptoms would include projectile vomiting,
numbness of the extremities, and visual disturbances. Furthermore, the presence of free
blood in the interstitial area will cause cell membrane destruction leading to edema,
vasospasms, electrolyte imbalances and possible acidosis. Changes in brain function will
lead to primary brain areas such as the frontal lobe, affecting several motor and speech
functions. At the event of no medical interventions given, brain herniation will occur the
patient will be in a comatose state and worst conditions such as death.

E. NURSING DIAGNOSIS WITH INTERVENTIONS

1. Nursing Diagnosis: Ineffective airway clearance and ventilation related to hypoxia

a. Establish and maintain an adequate airway, respiratory exchange, and

circulation.

b. Place the patient in a three-fourths prone position or in a lateral position with his
head turned to one side. (The event of increased intracranial pressure, thehead
of the bed may be elevated as prescribed.)

c. Note the respiratory rate and pattern.

d. Insert oral airway if tongue is paralyzed or is obstructing the airway.

e. Provide oxygen and other therapies as prescribed.

f. Keep the airway free of secretions by efficient suctioning.

g. Prepare for insertion of the cuffed endotracheal tube if the patient’s condition
requires.

h. Use humidified oxygen; positive pressure assisted breathing techniques or

mechanical ventilation when there is indication of impending respiratory failure.

i. Evaluate pulses: measure blood pressure.

j. Assist with passage of nasogastric tube.

2. Nursing Diagnosis: Altered in cerebral tissue perfusion related to unconscious state.

a. Maintain a constant assessment of patient’s level of consciousness and changes

in responsiveness.

b. Record the patient’s exact reactions: eye opening, verbal response, movements,
and quality of speech.

c. Examine pupils of eyes for size, shape and reaction to light.

d. Know the patient’s baseline vital signs and alert the physician if there are
significant fluctuations of blood pressure and instability of the pulse and
respiratory cycles.

e. Obtain blood pressure readings, pulses, respiratory rate patterns and

temperature at frequently specified intervals until there are clinical evidences of
stabilization.

f. Assess movements of extremities in response to verbal commands or painful

stimulations.

g. Pad side rails, apply mitts or boxing gloves.

 h. Have adequate lighting in the room to prevent hallucinations in the patient who is
regaining conscious.

i. Avoid oversedating the patient.

j. Observe the patient during seizure and record observations.

3. Nursing Diagnosis: High risk for impaired skin integrity related to immobility or
restlessness

a. Keep the skin clean, dry, and free of pressure.

b. Turn the patient frequently.

c. Lubricate the skin with emollient lotions.

d. Inspect pressure areas for evidence of skin redness and breakdown.

e. Clip patient’s fingernails to prevent skin excoriation by accidental or reflex

scratching.

f. Protect the eyes from corneal irritation.

g. Irrigate the eyes with prescription solution and instill sterile ophthalmic drops or
ointment in each eye.

h. Prevent irritation from sheetd, dryness, chafting and cracking.

i. Monitor the patient for any changes in skin texture and or rigidity development.

j. Administer nursing support as the patient’s changing condition indicates. Be

aware of the varying phases of restlessness.