Sunday, March 27, 2011

Cerebral Contusion is a Head injury that More serious than a concussion, a cerebral contusion is an ecchymosed of brain tissue that results from a severe blow to the head. When the head is abruptly brought to a stop against a solid object, the brain continues to move for an instant, hitting the inside the now stationary skull. The soft brain is easily contused and lacerated by the hard bony ridges at the base of the skull or by the tentorium cerebelli and falx cerebri. A contusion disrupts normal nerve functions in the bruised area and may cause loss of consciousness, hemorrhage, edema, and even death.
Causes For Cerebral Contusion
Cerebral contusion can happen to anyone, at any time. The most common causes of contusion include a blow to the head from a motor vehicle crash, fall or assault. People at higher risk are those who have difficulty walking and fall often, those who are active in high impact contact sports. It is also seen in child, spouse, and elder abuse. A cerebral contusion results from acceleration-deceleration or coup countercoup injuries. Contusions may correspond to the site of impact or develop opposite the impact (“coup” contusions- contre coup” contusions). Cerebral contusion that occur directly beneath the site of impact (coup) when the brain rebounds against the skull from the force of a blow (a beating with a blunt instrument, for example), when the force of the blow drives the brain against the opposite side of the skull (counter coup), or when the head is hurled forward and stopped abruptly (as in a motor vehicle accident when the driver’s head strikes the windshield). The brain continues moving, slaps against the skull (acceleration), and then rebounds (deceleration). A cerebral contusion can be distinguished from a cerebral infarct because, in the infarct, the superficial cortex is usually preserved, whereas in the contusion, it is the first to be damaged.

Complications for Cerebral Contusion
When injuries cause the brain to strike against bony prominences inside the skull (especially to the sphenoidal ridges), intracranial hemorrhage or hematoma can occur. The patient may also suffer tentorial herniation. Residual headache and vertigo may complicate recovery. Secondary effects, such as cerebral edema, may accompany serious contusions, resulting in increased intracranial pressure (ICP) and herniation.

Treatment for Cerebral Contusion
Contusions usually involve the surface of the brain, especially the crowns of gyri, and are more frequent in the orbital surfaces of the frontal lobes and the tips of the temporal lobes. Acute contusions show hemorrhagic necrosis and brain swelling. Gradually, macrophages remove necrotic brain tissue and blood. Eventually, the contusion evolves into a yellowish plaque characterized by loss and atrophy of brain tissue, glial scarring, hemosiderin deposition, and loss of axons in the underlying white matter. Immediate treatment may include establishing a patent airway and, if necessary, tracheotomy or endotracheal intubation. Treatment may also consist of careful administration of I.V. fluids I.V. mannitol to reduce ICP, and restricted fluid intake to decrease intracerebral edema. Dexamethasone may be given I.M. or I.V. for several days to control cerebral edema. An intracranial hemorrhage may require a craniotomy to locate and control bleeding and to aspirate blood. Epidural and subdural hematomas usually are drained by aspiration through burr holes in the skull. Increased ICP which can occur in hemorrhage, hematoma, and tentorial herniation may be controlled with mannitol I.V, steroids, or diuretics, but emergency surgery is usually required.

Nursing Assessment
The patient’s history reveals a severe traumatic impact to the head, commonly against a blunt surface such as a car dashboard. Signs and symptoms vary, depending on the location of the contusion and the extent of damage. A period of unconsciousness, possibly lasting 6 hours or more, may follow the trauma. An unconscious patient may appear pale and motionless, whereas a conscious patient may appear drowsy or easily disturbed by any form of stimulation, such as noise or light. A conscious patient may become agitated or violent. Assessment of an unconscious patient may reveal below-normal blood pressure and temperature. His pulse rate may be within normal levels but feeble, and his respirations may be shallow. In a conscious patient, temperature, pulse rate, and respiratory status vary, depending on his physical and emotional status.
  • Inspection may reveal severe scalp wounds, labored respirations and, possibly, involuntary evacuation of the bowels and bladder. Palpation may disclose less obvious head injuries such as hematoma. On palpation, the unconscious patient’s skin will feel cold. 
  • Neurologic findings may include hemiparesis, decorticate or decerebrate posturing, and unequal pupillary response. With effort, you may be able to temporarily rouse an unconscious patient. If you’re performing a neurologic examination after the acute stage of the injury, you may find that the patient has returned to a relatively alert state, perhaps with temporary aphasia, slight hemiparesis, or unilateral numbness. 

Diagnostic tests for Cerebral Contusion
Cerebral angiography outlines vasculature, and a Computed tomography (CT) scan CT scan MRI (magnetic resonance imaging)

Nursing diagnosis
Common Nursing diagnosis found in Nursing care plans for Cerebral Contusion

  • Acute pain 
  • Anxiety 
  • Decreased intracranial adaptive capacity 
  • Disturbed sensory perception: Kinesthetic, tactile 
  • Disturbed thought processes 
  • Impaired verbal communication 
  • Ineffective coping 
  • Risk for deficient fluid volume 
  • Risk for infection 
  • Risk for injury 
  • Risk for post trauma syndrome

Nursing Intervention and Rationale
Acute pain Related factors injuring agents (Cerebral Contusion)
Nursing Interventions: Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain Environmental Management Manipulation of the patient’s surroundings for promotion of optimal comfort

Nursing diagnosis Anxiety Related to Threat to or change in health status progressive debilitating disease, illness, interaction patterns, role function/status
Nursing Interventions:
Anxiety Reduction minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger Provision of a modified environment for the patient who is experiencing a confusional state Calming Technique: Reducing anxiety in patient experiencing acute distress

Nursing diagnosis Ineffective cerebral tissue Perfusion Related to Interruption of blood flow by space-occupying lesions (hemorrhage, hematoma), cerebral edema
Nursing Interventions Neurologic Monitoring Cerebral Perfusion Promotion Collaborative oxygen, Prepare for surgical intervention, such as craniotomy or insertion of ventricular drain or ICP pressure monitor, if indicated, and transfer to higher level of care.

Nursing diagnosis Disturbed sensory perception: Kinesthetic, tactile Related to Altered sensory reception, transmission, and/or integration: Neurologic disease, trauma
Nursing Interventions
Communication Enhancement: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit Peripheral Sensation Management: Prevention or minimization of injury or discomfort in the patient with altered sensation

Nursing diagnosis Disturbed thought processes 

Nursing diagnosis Impaired verbal communication Related to decrease in circulation to brain, Cerebral Contusion 
Nursing Interventions: Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech Communication Enhancement: Hearing Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing Active Listening: Attending closely to and attaching significance to a patient’s verbal and nonverbal messages 

Nursing diagnosis 
Ineffective coping Related to Impairment of nervous system cognitive, sensory, perceptual impairment, memory loss, Severe/chronic pain. 
Nursing Interventions: Coping Enhancement Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles Decision-Making Support Providing information and support for a person who is making a decision regarding healthcare Impulse Control Training Assisting the patient to mediate impulsive behavior through application of problem-solving strategies to social and interpersonal situations 

Nursing diagnosis 
Risk for deficient fluid volume 
Nursing Interventions: Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility Bleeding Precautions: Reduction of stimuli that may indicate bleeding or hemorrhage in at-risk patients 

Nursing diagnosis 
Risk for infection Risk factor inadequate primary defenses broken skin, traumatized tissue 
Nursing Interventions: Infection Protection Prevention and early detection of infection in a patient at risk Infection Control Minimizing the acquisition and transmission of infectious agents Surveillance Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making 

Nursing diagnosis
Risk for injury 
Nursing Interventions: Safety Behavior: Personal: Individual or caregiver efforts to control behaviors that might cause physical injury Risk Actions to eliminate or reduce actual, personal, and modifiable health threats Safety Status: Physical Injury: Severity of injuries from accidents and trauma 

Nursing diagnosis 
Risk for post trauma syndrome Risk factors, serious injury or threat to self, criminal victimization. Tragic occurrence involving violent and/or multiple deaths; disasters; epidemics 
Nursing Interventions: Crisis Intervention Use of short-term counseling to help the patient cope with a crisis and resume a state of functioning comparable to or better than the pre-crisis state Coping Enhancement Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles Support System Enhancement Facilitation of support to patient by family, friends, and community 

Patient Teaching And Home Healthcare Guidance For Patient With Cerebral Contusion
Be sure the patient understands all medications, including the dosage, route, action, adverse effects, and the need for routine laboratory monitoring for convulsants. Teach the patient and caregiver the signs and symptoms that necessitate a return to the hospital. Teach the patient to recognize the symptoms and signs of post injury syndrome, which may last for several weeks. Explain that mild cognitive changes do not always resolve immediately. Provide the patient and significant others with information about the trauma clinic and the phone number of a clinical nurse specialist in case referrals are needed. Stress the importance of follow-up visits to the physician’s office. Patient with cerebral contusion may present with a variety of physical and cognitive disabilities, depending on the severity of the injury. Individuals may need treatment by physical, occupational, or speech therapists; neuropsychologists; vocational counselors; and/or social workers. Care for those experiencing moderate to severe Cerebral Contusion progresses along a continuum of care, beginning with acute hospital care and inpatient rehabilitation to sub acute and outpatient rehabilitation, as well as home- and community-based services. 
Patient teaching and home healthcare guidance for patient with Cerebral Contusion 

  • Tell the patient not to cough, sneeze, or blow his nose because these activities can increase ICP. 
  • Instruct the patient to observe for CSF drainage and to be alert for signs of infection. 
  • Teach the patient and his family how to observe for mental status changes and to return to the facility or to call the physician if such changes occur.

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