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LUKE’S COLLEGE OF NURSING
A. General: The main purpose of this study is to have the knowledge about intracranial hemorrhage, its causes and effects, signs and symptoms and treatment to be able to acquire and have hands on experience on the appropriate skills in helping the patient manage and recover from the said disease. B. Specific: 1. To have deeper understanding in: The causes and effects of intracranial hemorrhage The signs and symptoms and its corresponding treatment How to manage and prevent intracranial hemorrhage 2. To be able to improve our skills: In taking the accurate, thorough assessment to have appropriate nursing interventions In providing complete and needed care of the patient As an educator, by coaching the patient as well as his support person regarding home management of the disease of the patient, and the “do’s” and “don’ts” of the patient. 3. To build a good nurse-patient relationship through therapeutic communication so that the patient can express his thoughts and feelings for us to carry out the needed and accurate interventions with care.
A. Background of the study: This case will focus on the condition of Mr. NC. He was diagnosed with intracranial hemorrhage when he was admitted to Amang Rodriguez Memorial Medical Center last August 17, 2009 at 7:20 am with the chief complaint of left sided weakness. An intracranial hemorrhage is a severe condition requiring prompt medical attention. It may develop quickly into a life threatening situation for the patient which made our group chose this case. Another reason is that this study will give us deeper understanding and sufficient knowledge on the disease which will help us in our hands on experience in giving the appropriate nursing interventions. B. Definition of the case: An Intracranial hemorrhage is bleeding in the brain caused by breaking (rapture) of a blood vessel in the head. And this internal bleeding may occur any part of the brain. The blood may build up in the brain tissues or in the spaces between the brain and membranes that cover it. Hematomas (collections of blood) that develop within the cranial vault are most serious brain injuries. A hematoma may be epidural (above the dura), subdural (below the dura), and intra-cerebral (within the brain). Major symptoms are frequently delayed until the hematoma is large enough to cause distortion of the brain and increase intracranial pressure. The signs and symptoms of cerebral ischemia resulting from compression by a hematoma are variable and depend on the speed with which vital areas are affected and the area that is injured. In general, a rapidly developing hematoma, even if small, may be fatal whereas a larger but slowly developing one may allow compensation for the increase intracranial pressure.
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05
TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. LUKE’S COLLEGE OF NURSING C. General signs and symptoms: Symptoms vary depending on the location of the bleed and the amount of the brain tissue affected. The symptoms usually develop suddenly, without warning, often during activity. They may occasionally develop in a step wise pattern, or they may get worse over time. Signs and Symptoms include: Abnormal sense of taste Change in alertness (level of consciousness) o Apathetic, withdrawn o Sleepy, lethargic, stuporous o Unconscious, comatose Difficulty speaking or understanding speech Difficulty swallowing Difficulty writing or reading Headache o May occur when lay flat o May awaken patient from sleep o May increase with change in position o May increase with bending, straining, and coughing Loss of coordination Loss of balance Movement changes o Difficulty moving any body part o Hand tremor o Loss of fine motor skill o Weakness of any body part Nausea, vomiting Seizure Sensation changes o Abnormal sensations o Decreased sensation o Facial paralysis o Numbness or tingling Vision changes o Any change in vision o Decreased vision, loss of all part of vision o Double vision o Eyelid drooping o Pupils different size o Uncontrollable eye movement Signs and Symptoms seen in the patient: Left sided weakness Vomiting Slurring of speech Patient experienced blurring of vision
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05
TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. LUKE’S COLLEGE OF NURSING D. Etiology: The bleeding can occur in any part of the brain. It may be in one hemisphere (lobar intracerebral hemorrhage), in other brain structures, such as the thalamus, basal ganglia, pons, or cerebellum (deep intra-cerebral hemorrhage). Hemorrhage can be caused by: Abnormalities of the blood vessels (aneurysm or vascular malformation) High blood pressure (hypertensive intra-cerebral hemorrhage) Protein deposits along blood vessels (amyloid angiopathy) Traumatic brain injury In some cases, no cause could be found. Blood irritates brain tissues, causing swelling (cerebral edema). In can collect into a mass called hematoma. Either a hematoma or swelling will increase pressure on nearby tissues and can quickly destroy them. Other factors that raise the risk of ICH include the following: Blood and bleeding disorders o Decreased levels of blood platelets o Disseminated intravascular coagulation o Hemophilia o Leukemia o Sickle cell anemia Cerebral amlyloid or brain tumors Liver disease ( associated with increased bleeding risk in general Use of aspirin or blood thinners (anticoagulant medications such as warfarin) For the premature infants (born earlier than 35 weeks) will sometimes have bleeding into fluidfilled spaces (ventricles) in the brain. This type of bleed is called intra-ventricular hemorrhage (IVH). This occurs in the first day of life and is usually not preventable. E. Incidence: United States Each year, intracerebral hemorrhage affects approximately 12-15 per 100,000 individuals, including 350 hypertensive hemorrhages per 100,000 elderly individuals. The overall incidence of intracerebral hemorrhage has declined since the 1950s. International Asian countries have a higher incidence of intracerebral hemorrhage than other regions of the world. Mortality/Morbidity Annually, more than 20,000 individuals in the United States die of intracerebral hemorrhage. Intracerebral hemorrhage has a 30-day mortality rate of 44%. Pontine or other brainstem intracerebral hemorrhage has a mortality rate of 75% at 24 hours. Hallevi et al reviewed the charts and CT scans of patients with intraventricular hemorrhage (IVH) to determine if the extension of the hemorrhage could be measured. Clinical outcome was determined by the modified Rankin Scale (mRS). IVH was also classified with an IVH score. The IVH score allowed rapid estimate of IVH volume by the practitioner and increased predictability for outcome. Race Intracerebral hemorrhage has a higher incidence among populations with a higher frequency of hypertension, including African Americans. A higher incidence of intracerebral hemorrhage has been AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05
He used to be a shoemaker (retired at the age of 49 y/o). Usually he exercises as apart of keeping his body fit. possibly due to environmental factors (eg. a diet rich in fish oils) and/or genetic factors. Chief Complaint: The patient is complained of having a left sided weakness 10 hours prior to his admission.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Physical Examination: Health. and drinks alcohol often. NC’s condition was due to his vices (smoking and drinking). Demographic data: Name: Mr. Age Incidence of intracerebral hemorrhage increases in individuals older than 55 years and doubles with each decade until age 80 years. Dela Cruz B. His wife believed that Mr. 2009 Attending physician: Dr. Never he had accidents encountered or falls experienced. Sex Intracerebral hemorrhage has a slight male predominance. he was a smoker (more or less a pack per day as verbalized by his wife). Japanese. C. The relative risk of intracerebral hemorrhage is greater than 7 in individuals older than 70 years. Mr. 22 Bagong Nayon. Nutritional and Metabolic Pattern AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 4 . Phenylpropanolamine use has been associated with intracerebral hemorrhage in young women. NC Address: Blk. and other Asian populations. associated with slurring of speech and vomiting of previously eaten food. Cerebral amyloid angiopathy may be more common among women. PATIENT PROFILE A.Perception-Health –Management Pattern In the past Mr. lobar hemorrhage is the most common site of and frequently is associated with AVMs. NC often eats fatty and some salty food which could be a contributing factor in the development of the disease as perceived by his wife. 1952 Age: 57 Sex: Male Occupation: (retired shoemaker) Nationality: Filipino Religious orientation: Roman Catholic Admission date and time: August 17. for example while cooking or doing other household works sited by his behalf. NC is doing well according to his wife. AC Birthday: August 23. though study results have been conflicting. III. LUKE’S COLLEGE OF NURSING noted in Chinese. Subependymal hemorrhage or germinal matrix hemorrhage is primarily seen in premature infants. In individuals younger than 45 years. During his young adult life.
as observed by the wife. He is the main person that is involved in making decisions in the family. all are fine.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. For his skin. And now that he has an illness.Perception . Activity. For his urinary pattern.Concept Pattern The patient’s self esteem. Four of it is their children. when he cannot make a right or he is not sure he usually refers it to his family first before putting on the final decision. And up to the present he had not experienced any change in his memory. But aside from that he also eats vegetables and fruits. Usually weekends is their leisure time and spends it with his family. cooking their food and sometimes he helps in cleaning the surroundings. discomfort or in control. One of his sons in law is seaman who helps them sometimes in the expenses. Although he is drinks alcohol.Reproductive Pattern (The wife did not manage to answer the question…) AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 5 . Mr. NC has sufficient energy in performing in performing his daily activities. and there’s nothing wrong with his appetite. There a no known early awakenings and nightmares shared by his wife. Self. swallowing. such as getting some fire woods. NC started to wear eyeglasses.Self. LUKE’S COLLEGE OF NURSING Mr. and a slight dryness.Exercise Pattern Mr. He is not also experiencing any difficulty in eating (pain. no discomforts. NC rest first for a while then goes to sleep. Sexuality. and diet restrictions). Role –Relationship Pattern Their family is composed of 9 people. has noticeably decreased. His children who live with them are not totally dependent to him. But as to the characteristics his wife described it as fatty (steatoreic). some of his family members shared that they are hard up with what happened but what’s more important to them is to have their head of the family to recover. he drinks enough water as verbalized by his wife. some portion of his lower extremities has whitish spots near the bony prominences. Most of the time. It could be due to that he usually earns for the living of the family and now he is the one being cared for his recovery. and he can also perform a full care to his self before he was admitted to the hospital. He wakes up at 7:00 am and starts to do household works as his exercise. Sleep-Rest Pattern After their supper. increased in the frequency and other problems. he’s water intake is not affected. three are their grandchildren. Cognitive-Perceptual Pattern At the age of 40. Rest and relaxation periods are usually during the weekends with his family. he has no difficulties or problems as to the frequency. they are being entertained by their grandchildren and watch television shows together after lunch time and in the afternoon. Regarding the decision making. Elimination Pattern For his bowel elimination. Mr. NC likes to eat foods that are fatty and salty. Also there are n o dental problems.
nothing else was shared by the family members. Allergies: The patient has no known allergies. Other Other than those above mentioned. most often that he does is to sit back and relax. And during the times that he is out or sick. so he manage then to have some rest. E.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST.200 kcal (meds given and care requested) V/S taken and recorded Temp: 38⁰C. Then followed by blurring of his vision. If problems do come in along the way. there was no known signs and symptoms related top the illness aside from him being diagnosed with hypertension and rheumatism years ago. hence for referring to Amang Rodriguez Memorial Medical Center at 7:20 am and was diagnosed with intracranial hemorrhage. LUKE’S COLLEGE OF NURSING Coping-Stress –Tolerance Pattern When he feels tired. F. Present History of Illness: Mr. Past History: For the past days prior to the admission of the patient. Then after sometime the patient felt a left sided weakness. NC was doing a household chore when he experienced sudden dizziness after he stood up. but sometimes he drinks alcohol and smokes.2009 (Friday) 6:35 am V/S taken and recorded Refer for neurosurgery for further examination AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 6 . he refers it first to his family before laying out the final decision.2009 ( Thursday) 12:00 noon August 21. started on OF at 1. febrile Paracetamol 300 mg/ amp given Tepid sponge bath instructed August 20. Course in the ward: Date/ Time August 17. her wife or one of his sons in law is taking over the family. D. G.Belief Pattern According to his wife they do not have other beliefs aside from what it is traditionally done with their present orientation. Value. and con not make decisions alone.2009 (Monday) Remarks Referred for admission with PNSS 1L x 12 hr. Her wife applied a cold compress on his nape thinking that it was due to his hypertension.
tissues.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Regulating blood supply The adult heart is shaped like a blunt cone and is approximately the size of a closed fist. 2009 05:00 pm V/S taken and recorded Temp: 38⁰C. The Circulation The one-way circulatory system carries blood to all parts of the body. flat part at the opposite end of the cone is the base. This process of blood flow within the body is called circulation. The heart works as a pump that pushes blood to the organs. It is the pulmonary artery that brings oxygen-poor blood into the lungs and the pulmonary vein that brings oxygen-rich blood back to the heart. B. (Rod R. Routing blood 3. Essentials of Anatomy and Physiology 5th edition. Generating blood pressure 2. and capillaries. waste products and gases AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 7 . though. al. Arteries carry oxygen-rich blood away from the heart. and veins carry oxygen-poor blood back to the heart. McGraw-Hill Int. Seeley et. febrile Paracetamol 150 mg/ amp given Tepid sponge bath instructed IV. Blood is returned to the heart through venules and veins. and cells of the body. ANATOMY AND PHYSIOLOGY THE CARDIOVASCULAR SYSTEM The heart and circulatory system make up the cardiovascular system. Carry blood 2. and the larger. LUKE’S COLLEGE OF NURSING August 22. A. the roles are switched. arterioles. The Heart Functions of the Heart: 1. with its base directed posteriorly and slightly superiorly and the apex directed interiorly and slightly inferiorly. Blood is carried from the heart to the rest of the body through a complex network of arteries. The heart is located in the thoracic cavity between the two pleural cavities. The blunt point of the cone is the apex. It lies obliquely in the mediastinum. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. In pulmonary circulation. NY 10020 2005) Functions of the Peripheral Circulation: 1. Ensuring one-way blood flow 4. Exchange nutrients.
Elastic arteries are the largest diameter arteries and have the thickest walls. Classifications: 1. Seeley et. Regulate blood pressure 5. (Rod R. Capillaries Capillaries have thinner walls and it is where exchange occurs between the blood and tissue fluids. LUKE’S COLLEGE OF NURSING 3. Transport 4. There is no tension on the walls of the vessels therefore. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 8 . Direct blood flow Twenty major arteries make a path through the tissues. which deliver the blood back to the heart to pick up oxygen. The blood flows more slowly and its thin walls facilitate diffusion between the capillaries ad the surrounding cells. Most capillaries are thinner than a hair.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. they move the blood back through wider vessels called venules. Muscular arteries are the medium –sized and small-diameter arteries and are responsible for the regulation of blood flow to different regions of the body. Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and decrease in blood flow but an increase in pressure. the true deliverers of oxygen and nutrients to the cells. NY 10020 2005) Major Vessel Types C. Essentials of Anatomy and Physiology 5 th edition. Venules eventually join to form veins. McGraw-Hill Int. Arterioles further branch into capillaries. the lumen of the blood vessel increase in diameter thereby allowing increase in blood flow. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste. where they branch into smaller vessels called arterioles. al. The Arteries Arteries are blood vessels that carry blood away from the heart. Arterioles are the ones that transport bllod from small arteries to the capillaries and are the smallest arteries. 3. 2. In vasodilation. there is lower pressure. D.
3. 4. Large veins Various external factors also cause changes in blood pressure and pulse rate. Venules are tubes with a diameter slightly larger than that of capillaries and are composed of endothelium resting on a delicate connective tissue layer. Small Veins are slightly larger in diameter than that of the venules. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 9 . An elevation or decline may be detrimental to health. 2. LUKE’S COLLEGE OF NURSING E. Medium-sized veins collect blood from small veins and deliver it to large veins. blood flows into the veins.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Changes may also be caused or aggravated by other disease conditions existing in other parts of the body. Classifications: 1. The Veins From the capillaries. Veins are blood vessels that carry blood toward the heart.
TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. special proteins that recognize foreign materials and help the body destroy or neutralize them. the hemoglobin releases oxygen to the tissues. Each day. and sternum. although the body can increase production of white blood cells to fight infection. New cells are constantly being formed in the bone marrow. the body produces new red blood cells to replace those that die or are lost from the body. pelvis. al. and their life spans vary from a few days to months. They fight bacteria and viruses and may also attempt to destroy cells that have become infected or have changed into cancer cells. White blood cells (also called leukocytes) are a key part of the body's system for defending itself against infection. and waste products. (Rod R. the action of clotting factors is needed to produce a strong. These cells travel through the circulatory system suspended in a yellowish fluid called plasma. ribs. white blood cells and platelets. Functions of the blood: 1. Whole blood contains three types of blood cells. Blood gets its bright red color when hemoglobin in red blood cells picks up oxygen in the lungs. After the body has been challenged by some infections. NY 10020 2005) Certain types of white blood cells produce antibodies. Protection against foreign substances 7. Red blood cells contain an iron-rich protein called hemoglobin. As the blood travels through the body. Maintenance of body temperature 6. Seeley et. White blood cells called granulocytes and lymphocytes travel along the walls of blood vessels. Several different parts of blood are involved in fighting infection. Essentials of Anatomy and Physiology 5th edition. Clot formation These three types of blood cells are mostly manufactured in the bone marrow of the vertebrae. McGraw-Hill Int. Blood also contains important proteins called clotting factors. Transport of regulatory molecules 4. Regulation of pH and osmosis 5. stable clot. flattened disks. platelets gather in the area and help seal off the leak. The body contains more red blood cells than any other type of cell. The Blood The blood is part of the circulatory system. nutrients and waste products 2. hormones. Red blood cells (also called erythrocytes) are shaped like slightly indented. They can move in and out of the bloodstream to reach affected tissues. LUKE’S COLLEGE OF NURSING F. Plasma is 90% water and contains nutrients. and each red blood cell has a life span of about 4 months. proteins. Although platelets alone can plug small blood vessel leaks and temporarily stop or slow bleeding. his or her white cell count often is higher than when he or she is well because more white blood cells are being produced or are entering the bloodstream to battle the infection. They help in the clotting process. Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells. Whole blood is a mixture of blood cells and plasma. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 10 . which are critical to the clotting process. There are several types of white blood cells. skull. including: red blood cells. Transport of gases. The blood contains far fewer white blood cells than red cells. lymphocytes remember how to make the specific antibodies that will quickly attack the same germ if it enters the body again. Transport of processed molecules 3. When a blood vessel breaks. Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. When a person has an infection.
Seeley et. Seeley et. When large blood vessels are cut the body may not be able to repair itself through clotting alone. The process of clotting is like a puzzle with interlocking parts. al. When the last part is in place. blood contains other important substances. dressings or stitches are used to help control bleeding. (Rod R. It is composed of neurons and other specialized cells called glia. kidneys. McGraw-Hill Int. Blood also carries carbon dioxide and other waste materials to the lungs. LUKE’S COLLEGE OF NURSING Platelets and clotting factors work together to form solid lumps to seal leaks. al. and scratches and to prevent bleeding inside and on the surfaces of our bodies. wounds. In these cases. such as nutrients from the food that has been processed by the digestive system. NY 10020 2005) THE NERVOUS SYSTEM The nervous system is a network of specialized cells that communicate information about an animals surroundings and its self. that aid in the function of the neurons. it processes this information and causes reactions in other parts of the body. cuts. Control of muscle and glands AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 11 . Homeostasis 4. Integration 3. from where they are removed from the body. (Rod R. In addition to the cells and clotting factors. McGraw-Hill Int. Essentials of Anatomy and Physiology 5th edition. Essentials of Anatomy and Physiology 5th edition. NY 10020 2005) Blood is essential for good health because the body depends on a steady supply of fuel and oxygen to reach its billions of cells. Functions of the Nervous system: 1. and digestive system.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Even the heart couldn't survive without blood flowing through the vessels that bring nourishment to its muscular walls. Sensory input 2. Blood also carries hormones released by the endocrine glands and carries them to the body parts that need them. Mental activity 5. the clot is formed.
The Brain Brain is a part of the Central Nervous System. while the head contains and protects the brain. Ependymal cells line the fluid filled cavities within the CNS and some produce CSF and help it move through the CNS. Oligodendrocytes produce myelin sheath around the CNS 5. Each neuron consists of a cell body and two types of processes: Dendrites – receive information from sensory receptor and transmit it toward the cell body. Essentials of Anatomy and Physiology 5th edition. speech.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. the peripheral nervous system and the central nervous system. (Rod R. Seeley et. and axons – receive information from the motor receptor and conduct impulses away from the CNS. Schwann cells form myelin sheath around the PNS The nervous system is divided broadly into two categories. thus regulating its behavior. and the spinal cord is also protected by the vertebrae. Microglia help remove bacteria and cell debris from the CNS 4. Essentials of Anatomy and Physiology 5th edition. 3. The brain is also protected by the skull. al. McGraw-Hill Int. and memory. Seeley et. McGraw-Hill Int. al. and memory. speech. senses. LUKE’S COLLEGE OF NURSING A. In response to stimuli. Some reflex movements can occur via spinal cord pathways without the participation of brain structures. Types: 1. McGrawHill Int. NY 10020 2005) The neurons of the nervous systems of animals are interconnected in complex arrangements and use electrochemical signals and neurotransmitters to transmit impulses from one neuron to the next. The peripheral nervous system is composed of sensory neurons and the neurons that connect them to the nerve cord. al. a three layered protective coat. movements. Nervous systems are found in many multicellular animals but differ greatly in complexity between species The central nervous system (CNS) is the largest part of the nervous system. The surface of the cerebral cortex has AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 12 . thoughts. Seeley et. which make up the central nervous system. sensations. Neuralgia Neuralgia or the glial cells are the nonneuronal cells of the CNS and PNS. and includes the brain and spinal cord. (Rod R. it plays a central role in the control of most bodily functions. The CNS is covered by the meninges. Essentials of Anatomy and Physiology 5th edition. NY 10020 2005) The cerebrum is the largest part of the brain and controls voluntary actions. Neurons generate and conduct impulses between and within the two systems. NY 10020 2005) B. Astrocytes serve as the major supporting tissue in the CNS and form the blood brain barrier. The interaction of the different neurons form neural circuits that regulate an organism’s perception of the world and what is going on with its body. 2. The Neurons Neurons or nerve cells receive stimuli and transmit action potential to other neurons or to effector organs. (Rod R. thought. sensory neurons generate and propagate signals to the central nervous system which then process and conduct back signals to the muscles and glands. spinal cord and brain. The spinal cavity holds and protects the spinal cord. including awareness.
Atrial fibrillation –pulling of blood from poorly emptying atrial which leads to formation of tiny clots in Left atrium which can move on the cerebral circulation. Almost every person has one dominant hemisphere. Sedentary lifestyle –increase of having DM and Obesity which one of the factors of having CVA (Joyce M. via their connections with other lobes. hypertension. The cerebrum is divided into two halves. Seeley et. Each hemisphere is divided into four lobes. hypercoagulability and cerebral eschemia which may cause CVA. The frontal lobes are located in the front of the brain and are responsible for voluntary movement and. pain. Each convolution is delimited by two sulci and is also called a gyrus (gyri in plural). The temporal lobes are located on each side of the brain. h. i. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) f. c. Hyperlipidemia –too much lipid in the blood may cause increase plaque formation which may cause thrombus formation. al. They process memory and auditory (hearing) information and speech and language functions. The occipital lobes are located at the back of the brain. The convolutions of the cortex give it a wormy appearance. e. In addition. which are interconnected. light or moderate alcohol may protect against ischemic stroke. LUKE’S COLLEGE OF NURSING grooves or infoldings (called sulci). the space around one’s body. d. attentiveness to the position of one’s body parts. and touch. There is an increase viscousity of blood which may cause formation of thrombus formation. Modifiable a. (Joyce M. and one's relationship to this space. NY 10020 2005) THE PATIENT AND HIS ILLNESS Modifiable and Non Modifiable Factors (Book Based) 1. McGraw-Hill Int. Hypertension –this is due to plaque deposits on the wall of the arteries which causes narrowing of the blood vessel thereby causing hypertension which may lead to hemorrhagic stroke. Excessive alcohol consumption –heavy alcohol consumption increases one’s risk of a stroke.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. They process sensory information such as temperature. speech output. and the left hemisphere controls voluntary limb movements on the right side of the body. The right hemisphere controls voluntary limb movements on the left side of the body. Essentials of Anatomy and Physiology 5th edition. the largest of which are termed fissures. organizational skills. They receive and process visual information (Rod R. and memory. A mass of fibers called the corpus callosum links the hemispheres. Drug addiction –This may cause vasopasm. Smoking –nicotine content of cigarettes causes vasoconstriction there by resulting hypertension which may lead to CVA. Type A personality –stress causes hypertension thereby increasing chance of having hemorrhagic stroke. Some fissures separate lobes. taste. participate in the execution of sequential tasks. g. the processing includes information about numbers. known as the right and left hemispheres. and certain aspects of behavior. Diabetes Mellitus –The mechanism is related to macrovascular changes in people with diabetes mellitus. mood. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 13 . b. or areas. The parietal lobes are located behind the frontal lobes and in front of the occipital lobes.
4. e. Excessive alcohol consumption 4. LUKE’S COLLEGE OF NURSING 2. Hypertension 3. Family history of CVA – Family history of stroke increase one’s risk c. d. b. Family history of DM –Family which has history of DM especially type 2 is high risk of having stroke due to accelerated atherosclerosis.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Age 2. 3. Race – (more prevalent among African Americans than whites or Hispanics) (Joyce M. Age –Intracranial hemorrhage is most often secondary to hypertension and is most common after age 50 years. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) PATHOPHYSIOLOGY Modifiable Factors: 1. Smoking 2. Edema Increase blood pressure Weakness Decreased/limited body movements Visual deficits AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 14 . Sedentary lifestyle Non modifiable Factors: 1. Sex (Male) –Incidence of stroke in men is slightly higher than that of women. Non-Modifiable a. Gender Hypertension Basal Ganglia Thalamus Brainstem Cerebellum Rupture of an arteriosclerotic small artery in the brainstem Hemorrhage accumulates as a mass Neuronal dysfunction Large hematoma leading to increase ICP Pressure from supratentorial hematoma 1. 2.
b.95mmol/L 1. Assess patient for signs and symptoms of presence of disease. Cholesterol 3.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Triglycerides 0. c.2 mmol/L 2.8 mmol/L 4.95 To determine undiagnosed diabetes mellitus. Teach patient on proper nutritional intake to increase abnormal cholesterol levels by eating: a. Used to estimate risk of developing a disease.76 d. Refer to physician. LABORATORY EXAMINATION/DIAGNOSTIC PROCEDURES Date/ Laboratory Test August 18’2009 BLOOD CHEMISTRY: a.46-1. HDL 0. LUKE’S COLLEGE OF NURSING V.7 mmol/L 0. Check the level of cholesterol in the AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 15 . Meat or animal products at moderate amounts.6-6. Drinking pineapple juice c.78-1.8-5. Eating eggs. FBS Normal Value Client Result Reason for the test Nursing Intervention for Abnormal Result 3.29 Used as part of the lipid profile to determine risk of heart disease (for elevated levels) and brain infarction (for low levels).98 b.
Severe restriction on fatty acids to 15 g per day.26mmol/L 1. Monitor patient’s BP Health teaching– b.3 mmol/ L 3. LDL 2. Teach the patient on proper nutritional intake focusing on: a. BUN 1. Refer to the physician Take patient’s Blood pressure Assess for presence of hypertension.08-5. Creatinine 53-115 mmol/L 148 AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 16 . Vitamin E Supplementatio n. b. Random Blood Sugar (HGT) <11. DM August 17 ‘2009 BLOOD CHEMISTRY: a. Refer to physician Assess for signs and symptoms of renal impairment. e.80 To determine presence of kidney or renal failure (decreased levels) Evaluate renal function.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST.81 Refer to the physician.7-8. LUKE’S COLLEGE OF NURSING blood and to determine the risk of disease.1 mmol/L 12 Measures blood glucose regardless of when you last ate. Used to check the level of cholesterol in the blood and the probable risk of acquiring a disease. August 17’ 2009 CHEMISTRY: a.
1 10^3/ uL Used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders.64 To evaluate fluid and electrolyte status. limit alcohol intake. Maintain Na balance/ water restriction as ordered by the physician. b. Hemoglobin 4. d. Refer to physician. aerobic exercise.5 -18. 5-10 10^3/ uL 9.0 To evaluate fluid and electrolyte status.5-5.5 mmol/L 3. WBC count 3.2 10^6/uL 13. limit sodium intake (low salt diet) Provide medicationaspirin and lipid lowering therapy as prescribed by physician.18 10^6/uL 17. Potassium August 17’ 2009 HEMATOLOGY REPORT: a. Assess for signs and symptoms of hyponatremia.0 g/dl 5. weight loss. Sodium 136-148 mmol/L 133. LUKE’S COLLEGE OF NURSING smoking cessation. RBC count c.8 g/dL AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 17 .TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST.6 -6. c.
acute infection etc. Hematocrit 40.7 g/dL h. MCH 27-32 pg 34. f. Refer the result to the physician. Platelet Count DIFFERENTIAL COUNT: a. Lymphocyte 20-40% 10. Health teaching – slowly decrease alcohol consumption. LUKE’S COLLEGE OF NURSING d. Assess for signs and symptoms of physical and emotional stress. Assess for signs and symptoms of immunodeficiency disease. Segmenters 150-450 10^3/uL 228 10^3/uL 40-60% 84. Assess for presence of liver disease.1% b.9% AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 18 .4 pg Assess for presence of anemia. Refer the result to the e.4% Refer to physician Assess the patient for signs of chronic obstructive pulmonary disease.0-36 g/dl 32. cushing’s syndrome. pernicious anemia and alcoholism. MCHC 32.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Refer the result to the physician.0-54.0% 54. MCV 80-100 fL 105 fL g.
0-6.5-7. Microscopic a. e. Assess for signs and symptoms of allergic reactions.7% 0. c.5-1. Assess for signs and symptoms of anemia or bone marrow failure to infection.5% 0. Retic Count August 17’2009 URINALYSIS: I. Basophil 2.0 f. Urates/ phosphates a.Epithelial cells b. Macroscopic a. Pus Cells: b. Transparency II. Few Few Few Few AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 19 .Mucus threads 0. RBC A.3% Refer result to the physician. Refer result to the physician.0% 4.0% 1. Hyperthyroidism and Stress reactions. Monocyte d.0-8.5% - Straw like Clear Hazy Yellow Clear 0-3 Negative or rare 1-3/hpf 0-1 Refer result to the physician Assess for signs and symptoms of renal dysfunction or urinary tract infection. Assess for signs and symptoms of acute or chronic inflammation. Eosinophil 2. Color b. LUKE’S COLLEGE OF NURSING physician.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST.
Sugar d. Basal cisterns. 20 . LUKE’S COLLEGE OF NURSING III. No hydrocephalus seen. Reason for Test Used to determine small nodules or tumors in a person’s body not usually seen with the use of an x-ray. right upper lobe of undetermined activity. Chemical Strip a. Reaction b. sella. Focal perilesional edema noted.003-1. right brainstem and right thalamo – ganglionic areas with intraventricular dissection. Heart is normal in size. Diaphragm and bony thorax are unremarkable. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 Used to study the images of the human body using radiant energy. There is mild leftward boning of midline structures.010 Negative Negative Date/ Diagnostic Procedure August 17’ 2009 CT SCAN EXAMINATION: Plain Cranial Client Result There is a connection of acute intraparenchymal hemorrhage seen in the right brainstem and right thalamo ganglionic areas with intraventricular dissection.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. CT or CAT scans are special x-ray tests that produce cross-sectional images of the body using x-rays and a computer. petromastoids and bony calvarium are intact. visualized paranasal sinuses. IMPRESSION: Acute intraparenchymal hemorrhage. Protein pH 4. Specific Gravity c.030 Negative Negative Acidic 1.6-8 1. August 17’ 2009 RADIOLOGY REPORT Chest Sup: Fibrohazed densities in the right upper lobe. IMPRESSION: Mild PTB.
headache.severe renal disease. Nursing implications: 1. insert indwelling catheter as ordered to monitor urine output. heart failure. What do you need to check or do prior to drug administration: Assess ocular condition and record pretreatment intraocular pressures. Document baseline VS & ECG Assess pt’s & family’s knowledge on drug therapy. mild to moderate dehydration .TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. MANNITOL (OSMOFUNDIN) Drug: Mannitol Appropriate dosage (Osmofundin) for 24 hrs drug computation: Dosage: 150 cc 900 cc/day (average dose) Route: IV Frequency: q4hrs (every 4 hours) Drug classification: Osmotic diuretic Action: Increases osmotic pressure of plasma in glomerular filtrate.pregnant or breastfeeding pts 2. major side effects of drug: CNS: dizziness. central venous pressure. Nursing intervention/ Consideration related to effects of drug: Monitor IV site carefully to avoid extravasation and tissue necrosis. lower ICP. This condition can be predisposed by uncontrolled hypertension and can cause increased intracranial pressure. inhibiting tubular reabsorption of water & electrolytes (including K & Na) . In comatose patient. seizures CV: chest pain. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 21 . Giving osmotic dieresis can decrease BP & at the same time. Assess for evidence Why client is receiving the drug based on history of present illness: The pt is diagnosed with Intracerebral Hemorrhage. urinary output. Use cautiously in: . DRUG STUDY 1.these actions enhance water flow from various tissues and ultimately decrease intracranial and intraocular pressures. Watch for excessive fluid loss and s/sy of hypovolemia and dehydration. hypotension. fluid balance. Monitor for the possible druginduced adverse reactions. LUKE’S COLLEGE OF NURSING VI. and electrolyte levels (especially Na & K). Monitor renal function tests. serum Na level rises while K and blood urea levels fall Protects kidneys by preventing toxins from forming and blocking tubules.
Advice pt to report pain at infusion site as well as adverse reactions. hyperkalemia. review all other significant & lifethreatening adverse reactions and interactions AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 22 . heart failure. including pulmonary edema. As appropriate. extravasation with edema and tissue necrosis of circulatory overload. thirst. Teach pt about importance of monitoring exact urine output. LUKE’S COLLEGE OF NURSING hypertension. fever. water intoxication. diarrhea. osmotic nephrosis Metabolic: dehydration. legs or chest. Emphasize that fluid restrictions are necessary. thromboplebitis. dry mouth GU: polyuria. edema. but that frequent mouth care should ease these symptoms. hypernatremia. and heart failure. hyponatremia. urticaria Other: chills. tachycardia. rhinitis GI: nausea. water intoxication.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. metabolic acidosis Respiratory: pulmonary congestion Skin: rash. urinary retention. vomiting. Tell pt drug may cause thirst or dry mouth. such as increased shortness of breath or pain in back. vascular overload EENT: blurred vision.
adequate pulses & skin turgor Monitor liver function: ALT. Advise pt to avoid hazardous activities until stabilized on drug and dizziness is no longer a problem. BP. AST. altered vision. bilirubin 2. respiration. irregular pulse. distended neck veins. drug is usually discontinued & another drug started Teach pt to use as directed even if feeling better. hepatic impairment Assess cardiorespiratory status: angina pain. ECG Assess hydration and fluid volume status: I&O ratio.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. AMLOPIDINE MALEATE (STAMLO-M) Drug: Amlopidine Appropriate dosage Maleate (Stamlo-M) for 24 hrs drug computation: Dosage: 5mg x 1 tab 5 mg/day Route: Oral Frequency: OD (once a day) Drug classification: Calcium Antagonist Action: Inhibits influx of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle (dilatation of coronary arteries) Decrease peripheral vascular resistance of smooth muscle (decrease blood pressure) Increases myocardial oxygen delivery in patients with vasospastic angina Nursing implications: 1. What do you need to check or do prior to drug administration: Use cautiously in pts with: CHF.000/mm3. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 23 . Why client is receiving the drug based on history of present illness: Since pt has constant hypertension. pulse. may be taken with other cardiovascular drugs (nitrate. beta-blockers). LUKE’S COLLEGE OF NURSING 2. the drug is given to decrease the BP. presence of edema. food helps decrease stomach upset. swelling of extremities. major side effects of drug: Palpitations Peripheral edema Syncope Tachycardia Bradycardia Nursing intervention/ Consideration related to effects of drug: Monitor if platelet count is <150. lung crackles. Report symptoms of chest pain.
& drug therapy AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 24 . stress reduction.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. exercise. LUKE’S COLLEGE OF NURSING Arrhythmias Ventricular asystoles Headache Dizziness Fatigue Lethargy Somnolence Dermatitis Rash Pruritis Urticaria Nausea Abdominal discomfort Cramps Dyspepsia Shortness of breath Dyspnea Wheezing Flushing Sexual difficulties Muscle cramps Pain Inflammation shortness of breath or hypotension Advise pt to comply in all areas of medical regimen: diet. smoking cessation.
What do you need to check or do prior to drug administration: Use cautiously in persistent ICH. increases cerebral metabolism and increases the level of various neurotransmitters. 2.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. CITICOLINE (ZYNAPSE) Drug: Citicoline Appropriate dosage (Zynapse) for 24 hrs drug computation: Dosage: 1 gm 2 gm/day Route: IV Frequency: q12hrs (every 12 hours) Drug classification: Cerebroprotective/ Neurotropic/CNS Stimulant Action: Citicoline activates the biosynthesis of structural phospholipids in the neuronal membrane. administer very slowly. as well as improved learning and memory performance in animal models of brain aging. Citicoline has shown neuroprotective effects in situations of hypoxia and ischemia. it has been demonstrated Nursing implications: 1. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 25 . LUKE’S COLLEGE OF NURSING 3. Use with caution in pregnant and lactating women. Furthermore. Why client is receiving the drug based on history of present illness: Citicoline accelerates the recovery of consciousness and overcoming motor deficit in stroke patients. including acetylcholine and dopamine. major side effects of drug: Increased parasympathetic effects fleeting & discrete hypotensor effect Nursing intervention/ Consideration related to effects of drug: Contraindicated in patients with hypertonia of the parasympathetic.
inhibits the activation of phospholipase A2 and accelerates the reabsorption of cerebral edema in various experimental models. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 26 . nausea. 4. Assess pt’s condition before therapy and reassess regularly thereafter to monitor drug’s Nursing intervention/ Consideration related to effects of drug: Do not use if in the presence of abdominal pain. Should not be taken for more than 1 wk w/o the advice of physician. hour of sleep) Drug classification: Laxative Action: Causes an influx of fluid in the intestinal tract by increasing the osmotic pressure within the intestinal lumen Bacterial metabolism of the drug to lactate and other acids which are only partially absorbed in the distal ileum and Nursing implications: 1. Why client is receiving the drug based on history of present illness: Forceful bowel expulsion or constipation can cause increased intracranial pressure and increase in blood pressure. LACTULOSE (RILAX) Drug: Lactulose Appropriate dosage (Rilax) for 24 hrs drug computation: Dosage: 30 cc 30 cc/day Route: Oral Frequency: OD HS (once a day. Advice pt to dilute drug with juice or water or take with food to improve taste. LUKE’S COLLEGE OF NURSING that citicoline restores the activity of mitochondrial ATPase and of membrane Na+/K+ ATPase. Laxative administration aids in decreasing risk for increased ICP and BP.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. fever or vomiting. debilitated. elderly. What do you need to check or do prior to drug administration: Use cautiously in pts with lactose intolerance & diabetes. and pregnant & lactating women.
Monitor fluid & electrolyte status: urine output. major side effects of drug: Abdominal discomfort associated w/ flatulence and intestinal cramps Nausea Vomiting Diarrhea on prolonged use Teach pt that normal bowel mov’ts do not always occur daily and that adequate fluid consumption is necessary Inform pt of possible adverse effects and the need to notify physician immediately if these occurs. nausea. The distention of the colon due to increased fluid enhances intestinal motility and secretion. effectiveness. and vomiting Instruct pt that bowel tone may be lost if used as laxative for long tern therapy. Identify cause of constipation: Assess lifestyle in relation to fluids.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 27 . Do not give at bedtime because it may interfere with sleep. LUKE’S COLLEGE OF NURSING colon augments the osmotic effect of lactulose. Remind pt not to use in presence of abdominal pain. hypokalemia and hypernatremia. These result to the passage of soft stools. Decrease in the lumenal pH (due to bacterial metabolism) further increase motility and secretion. bulk and exercise. I&O ratio to identify fluid loss. 2. Assess pt’s and family’s knowledge of drug therapy. Inform pt that diarrhea may indicate overdosage.
TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Provides calming effect. and promotes rest to maintain/ lower ICP. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 28 . the patient with the help of the support person was able to maintain absence of signs of increased intracranial pressure. Avoid placing head on large pillows. 3. 4. After 3 hours of nursing interventions. After 2 days of nursing interventions. Turning head to one side compresses the jugular veins and inhibits cerebral venous drainage. Objective cues: Altered mental status Speech abnormalities Restlessness Changes in motor response Nursing Diagnosis Ineffective cerebral tissue perfusion related to interruption of blood flow by a space-occupying hemorrhage as evidenced by altered level of consciousness and changes in motor responses. Monitor intake and output. Increased metabolic needs and oxygen consumption occur. 2. quiet environment and gentle touch. the patient with the help of the support person will be able to demonstrate techniques and behaviors to prevent further aggravation of intracranial pressure. Administer tepid sponge bath in presence of fever. thereby increasing ICP. Interventions Independent: 1. Rationale Fever may reflect damage to hypothalamus. Maintain head and neck in midline or neutral position. the patient with the help of the support person will be able to maintain absence of signs of increased intracranial pressure. LUKE’S COLLEGE OF NURSING VII. Planning Short term goal: After 3 hours of nursing interventions." as stammered by the patient. reduces adverse physiologic response. Useful indicator of total body water. Monitor temperature and regulate environmental temperature. which can further increase ICP. the patient with the help of the support person wias able to demonstrate techniques and behaviors to prevent further aggravation of intracranial pressure. NURSING CARE PLAN Assessment Subjective cues: " Ang sakit ng ulo ko. which is an integral part of tissue perfusion. Goal met. Decrease extraneous tissue stimuli and provide comfort measures like back massage. Evaluation Goal met. Long term goal: After 2 days of nursing interventions.
2. IV. These nonverbal cues may indicate increasing ICP or reflect presence of pain when client is unable to verbalize complaints. Antipyretics 150 mg. Dependent: 1. 6. IV. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 Reduces hypoxemia. 150 ml. elevating ICP Diuretics are used to draw water from brain cells. moaning and guarding behaviors. which is known to increase cerebral vasodilation and blood volume. Reduces/ controls fever and its 29 . reducing ICP. Promotes venous drainage from head. therby reducing cerebral congestion and risk of increased ICP. Administer supplemental oxygen at 2-3 LPM thru nasal cannula as ordered by the physician. Investigate increasing restlessness.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Position the patient in moderate high back rest. LUKE’S COLLEGE OF NURSING 5. Administer medications as ordered by the physician: Diuretics Mannitol(IV).
Goal met. Monitor therapeutic effectiveness of interventions. Assessment Subjective cue: “Ang sakit ng ulo ko. the patient was able to achieve normal body temperature level within normal range. Maintain cool environment by using room fan. Long term goal: After 1 day of nursing interventions. 3. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 30 . After 4 hours of nursing interventions. Monitor body temperature. 2. Heat loss by convection. Evaluation Goal met. the client was able to maintain body temperature within normal range. Advise mother to promote surface cooling by means of undressing and reducing the use of bed linens. Provide surface cooling by means of continuous tepid sponge bath (TSB). 5.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Reduce metabolic demands and oxygen consumption. the patient will be able to achieve normal body temperature within normal range Interventions Independent: 1.” as stammered by the patient. Planning Short term goal: After 4 hours of nursing interventions. Advise patient to maintain bedrest. After 1 day of nursing interventions. Objective cues: T= 38. 4. LUKE’S COLLEGE OF NURSING deleterious effect on cerebral metabolism/ oxygen needs and insensible fluid losses. the client will be able to maintain body temperature within normal range.6°C RR = 22 breaths per minute Warm to touch Nursing Diagnosis Elevated body temperature related to a disease and exposure to hot environment as evidenced by increase in body temperature higher than normal range and increased repiratory rate. Heat loss by evaporation and conduction. Rationale Heat loss by radiation and conduction.
150 mg. lagi siyang pinagpapawisan. thru IV as ordered by the physician." as the wife of the patient verbalized. Goal met. the patient with help of the support person will be able to demonstrate behaviors and techniques to prevent skin breakdown.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Anticipate and use preventive measures to prevent skin breakdown by repositioning the patient every 2 hours. the patient with help of the support person was able to demonstrate behaviors and techniques to prevent skin breakdown. Long term goal: 2. Objective cues: Immobility Presence of foley cathether Nursing Diagnosis Risk for impaired skin integrity related to reduced mobility. Hirap din akong ibahin ang posisyon nya. Rationale Provides opportunity for early intervention of the patient who have thin. Pharmacologic intervention. altered circulation. Support circulating volume and tissue perfusion. Positioning Evaluation Goal met. and prevention is the best treatment. motor deficits. Administer paracetamol. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 31 . Interventions Independent: 1. Inspect skin. Planning Short term goal: After 3 hours of nursing interventions. Assessment Subjective cues: " Mainit kasi dito. tissues. and problems with self-care. less elastic. antipyretics are used to reduce fever by its central action on the hypothalamus. After 3 hours of nursing interventions. and more fragile skin and tissues. bladder excretions. Administer replacement IV fluids and electrolytes as ordered by the physician. 2. LUKE’S COLLEGE OF NURSING Dependent: 1. Decubitus ulcers are difficult to heal. and mucous membranes routinely.
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 32 . the patient with the help of the psupport person was able to maintain intact skin. Cleansing is needed to keep skin soft and protect susceptible skin from breakdown. Keep bed sheets and bedclothes clean. drying gently and thoroughly.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. Avoids friction of skin. the patient with the help of the support person will be able to maintain intact skin. LUKE’S COLLEGE OF NURSING After 2 days of nursing interventions. 3. Maintain skin hygiene. After 2 days of nursing interventions. 4. and joint motion and promotes client participation. muscle tone. using mild soap. dry and free from wrinkles. improves circulation.
LUKE’S COLLEGE OF NURSING NURSING THEORY Orem’s General Theory of Nursing For Dorothea E. Spiritual Encourage the family the need for prayers and great faith to God. a person other than himself who provides care. Provide for him a place where he could rest and get away from the hassles. NC. Diet Advise family that it is good to provide healthy food to the patient. The self care demands are greater than the self care activities. People can be assisted through the 5 methods of helping: acting. and carbohydrates are necessary for the patient’s faster recovery. Health teaching Instruct the family to initiate providing proper hygienic care to the patient. A balanced diet of fruits. guiding. supporting and providing an environment that promotes the patient’s abilities to meet current and future demands. VIII.TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 33 . Mr. There are contributing factors affecting the self care agent and demand of the patient. teaching. In the case of Mr. vegetables. he cannot provide care for himself. Orem. Self care deficit resulted because the self care agency is not adequate to meet the known self care demand. Health deviation self care are the needs that are required for the patient due to his condition. A wholly compensatory system is required because the patient is unable to control and monitor the environment and process information. DISCHARGE PLANNING Medication Emphasize necessity of compliance to taking medications as directed by the physician. self care refers to those activities an individual performs independently throughout life to promote and maintain personal well-being. Out Patient Follow up check up regarding the patient’s condition. Environment Encourage family to promote an environment conducive to recovery. NC needs a dependent care agent.
IMPLICATIONS OF THE CASE STUDY TO THE FOLLOWING Nursing Research The study can help in further improving researches related to the disease and could help provide more information regarding its manifestations and prevalence among the geriatric patients in the Philippines. pathophysiology and the prevalence of the disease among geriatric patients. This research could provide more knowledge for future researchers in the said disease and could provide more in depth solutions to the problem so that such diseases could be prevented in the society. Nursing Education The research would be of much help in the nursing profession because it will be able to provide more information on the importance of managing the disease of the patients by providing proper care and treatment to the patients. This study will help student nurses in understanding the disease better and help improve their skills and knowledge when it comes to dealing with the patient and other members of the health care team that will allow them to become better nurses in the future. Nursing Practice The research could help as a guide for the health care team most especially for nurses to further improve on their nursing interventions when it comes to dealing with the patient and his/ her needs. LUKE’S COLLEGE OF NURSING IX. Also. AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER | Group 1 of 3NU05 34 .TRINITY UNIVERSITY OF ASIA [CASE PRESENTATION: INTRACEREBRAL HEMORRHAGE] ST. it gives a more descriptive characteristic of the clinical manifestations of the geriatric patients with the said disease and a deeper understanding of its etiology.
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