Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Patient Initials: A.H. Room #: 52## [Neuro ICU] Primary Language: English

Patient Data:
Age/Gender/Race/Religious Preference/HC Provider/etc.:
DATE OF CARE: 02/01-02/02 ADMIT: 01/27 - Patient Initials: A.H. Room: 52## [NEURO ICU] Primary Language: English
56yo / Male / Caucasian / Religious preference N/A / Dr. Chen - Neuro Surgical & Critical Team / NKA / FULL CODE / Wrist Restraints Bilaterally / 1:1 Sitter / Seizure precautions

Presents/Assessments (current data):

Vitals 0400: T98.6, HR100, RR28, BP (L cuff) 148/79 O2 Sat 99%
Neuro: GCS 14, Labile AOx1-3, usually disoriented to time and place; pupils 3.5mm, equal, round, reactive to light, slow&brisk; follows commands appropriately, able to move extremities
Resp: Shallowed breathing, coarse breath sounds in all lobes, symmetrical rise of chest bilaterally, on simple face mask 5L - dependent mouth breathing, naso&oro pharyngeal suctioning
3x - thick medium secretions w/ trace of non frothy blood, nonproductive cough. Possible pneumo aspiration - awaiting cultures. Has CPT.
Cardiac: NSR/ST occasionally, No murmurs, Cap refill <3 secs. Left A-Line pulled by pt - no more orders for ABG.
GI: Last BM 02/01 in AM; hyperactive bowel sounds, no abdominal pain/distention. NG Keofeed tube - diet restricted to Fibersource @65mL/hr, 0 residuals, pt tolerates well
GU: Incontinent -External device via condom cath; clear yellow urine
Skin: Appopriate to ethnicity; overall dry and intact. EVD on R remains clear, dry, intact with clean&dry transparent dressing. R groin puncture site clean and dry. PIV 20G R FA TKO - no
sign of ecchymosis; PICC IV double lumen R arm-no sign of ecchymosis.
Motor: 5/5 on all extremities, 5/5 grip strength
EVD drain @15 (q1h check): ICP 5-8mmHg [Goal <20], 2-10mL drainage serous, tan

Brief description of admission and problem list/plan:

Pt presented to the ED by EMS on 01/27 after family found him on the couch with a L side facial droop, not following commands, but able to move extremities spontaneously. CT showed diffusion of a subarachnoid hemorrhage (SAH) throughout the basal cisterns with
intraventricular hemorrhage (IVH) and hydrocephalus. Also found blood tracking down to spinal cord. Shortly after, pt decompensated and was emergently intubated in trauma bay before taken to IR for PICA aneurysm coiling with angiogram, and had EVD placed on R side. Pt
tolerated procedure well and placed on regular diet until found coughing during a meal. Pt was suctioned, but breath sounds became more diminished and coarse, fever of 100.1F, and can become sinus tachycardic. Possible aspiration pneumonia is suspected with urinalysis
finding trace bacteria. Still awaiting results from sputum [02/01] and CSF cultures [01/31]. Pt continues to be labile, AOx1-3, with subtle L facial droop.

Acute spontaneous intracranial hemorrhage is the event of bleeding from a ruptured vessel within the skull due to trauma or the rupture of an aneurysm in the vasculature of the brain or brain stem. Pertinent to this patient, the hemorrhage occurred from the rupture of the
posterior inferior cerebellar artery where bleeding has diffused into the subarachnoid space. Some factors that predispose this patient to the development of an aneurysm is his hx of smoking daily and having HTN. That increase in blood turbulence and narrowing of arteries
(the smoking) can lead to the pocket that develops within. Once that pocket bursts, the symptoms of sudden headache, mental changes, and cognitive function become impaired. In a case like this, the bleeding can be extensive to increase ICP that it can affect the cranial
nerves, such as the L facial droop in this patient. The hemorrhage is corrected through coiling and management of preventing rebleeds and draining the excess blood/fluids left in the brain. Management of BP is crucial in being high enough to promote blood flow to the brain,
while still not creating a high amount of blood flow to the brain. It is important to assess for a trend of increased ICP to be aware of the risk of the event of a rebleed or excessive ICP. Drastically altered mental status and inability to follow directions/appropriate answer response
would be evident. and MD should be alerted. This can be managed with dosing changes to antihypertensives, and anti-epileptic drugs for seizure control. A rupture or excess rebleed is a medical emergency and needs correction in IR/OR.

Hydrocephalus is the buildup of fluid contained in the cerebral ventricles of the brain. The excess CSF found in the ventricles increases the ICP and can manifest symptoms of headache, lethargy, coordination loss, incontinence, memory loss, and altered cognitive function
depending on the affected area of the brain [see Encephalopathy]. A VP (ventriculoperitoneal) shunt or an EVD (external ventricular drain) is placed into the affected ventricle where it can drain the excess CSF or blood from a hemorrhage, reducing ICP. The goal for ICP is to
be at less than 20mmHg. Assessments for serum sodium levels also provide data on risks of fluid retention if levels are low. Interventions like 3% NaCl hypertonic solution would help increase sodium levels and promote osmolarity of increased fluid output and reducing the
fluid in the ventricles as well. In the event of fluid overload or another intracranial hemorrhage would lead to an increase in ICP or fluids in the ventricles would lead to a drastic shift in mental status. Immediate interventions would involve maintaining a 30 degree elevation of
HOB, with their neck remaining in neutral position. Priorities would focus on avoiding overhydration and maintaining normal temperature, while O2 and CO2 levels are within normal limits.

Encephalopathy refers to any damage, disease, or malfunction in the patient's brain and is symptomatic for altering the patient's mental state. Pertinent to this patient, some factors include his recent hemorrhagic event in the bleeding of a PICA aneurysm into the subarachnoid
space, as well as the increased pressure from the excess CSF found in the cerebral ventricles.The patient's altered mental state is evident in his confused and labile state, often disoriented to time and place with short term memory loss. This serves as his current baseline and
worsened alterations of mental status, like no longer following directions or not answering questions appropriately, can indicate an exacerbation of the mentioned problems listed or manifestation of a new problem. Precautions are taken, such as bilateral soft wrist restraints,
are used to prevent the pt from pulling on any wires in their confused state. Most forms of encephalopathy are reversible once the previous problems are corrected, while more severe cases are fatal in compromising systemic functions.

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Past Medical History:

Allergies
Drug: NKA → Reaction: NONE
Drug: " → Reaction: NONE
Drug: " → Reaction: NONE

Other Allergies (e.g. latex): NKA

Foods: NKA → Reaction: NONE

Environmental/Seasonal: NKA → Reaction: NONE

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 Current Medications
Drug Name Critical Care Name
Generic - Patient Care
Dose/Freq/Route – Emmanuel
Organizer (PCO)Mechanism Santuray, BSNSide
Patient-specific Student
effects

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student
Mucomyst Acetylcysteine 20% solution 400mg BID Mucolytic: Pt is presented with Bronchospasms, drowsiness, fever,
Amino acids that coarse, diminished increased bronchial secretions, nausea,
open disulfide breath sounds, while tracheal/bronchial irritation, runny/stuffy
bonds in mucus also having thick nose, vomiting, clamminess, wheezing,
to break it down, medium secretions SOB
allowing to thin when suctioning
mucus. nasopharynx.
Medication would
promote productive
coughs. Pt continues
to have a RR above 20
and reliant on mouth
breathing with coarse
breath sounds.
Rocephin Ceftriaxone 2000mg in sterile water Antibiotic: While sputum and Black, tarry stools, chest pain, chills, cough,
20mL ONCE IV Bactericidal CSF cultures are fever, painful urination/dysuria, SOB, sore
agent that trending, pt is placed throat, diarrhea
inhibits the on broad-spectrum
synthesis of the antibiotics d/t
bacterial cell infection sx. Pt
wall, leading to suspected of having
cell death aspiration pneumonia
or other form of
bacteria after
coughing when eating.
Pt developed a fever
of 100.1, HR
increased, and
urinalysis noted trace
levels of bacteria.
Colace Docusate Sodium 250mg q.day NGT Laxative: To encourage pt to Diarrhea, mild cramps, throat irritation,
Promotes the have a BM before the rashes
absorption of end of the next shift
water into the and to serve as a
stool, softening prophylaxis for fecal
the fecal matter impaction. Also
for greater ease allows for stool to
in passing. soften so the pt would
not exert excessive
pressure when having

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student
BM as it may alter
ICP. EVD drain is set
to 15 w/ drainage of 2-
10mL.
Folvite Folate 1mg tab q.day PO [AM] Nutriceutical: Though within normal Loss of appetite, nausea, confusion,
Supplemental limits, pt HGB (12.4) irritability, sleep pattern disturbance
folic acid that is and HCT (36.9) levels
converted into are on the lower end.
tetrahydrofolic Supplement would
acid necessary promote RBC
for the production and
production of oxygenation of blood
proteins for RBC to perfuse throughout
and HGB, Aids the body’s organs and
in metabolizing systems.
histidine
[Heparin] Heparin 5000units/1mL q8h SQ Anticoagulant: Prophylaxis for clot Bleeding, anemia, dizziness, headache,
Increases the development as pt insomnia, edema, constipation, pruritus,
inhibitory effect does not ambulate to rash, urticaria, thrombocytopenia,
of antithrombin use toilet and remains osteoporosis, pain at injection site
to reduce clotting at bed rest. Pt
factors. continues to have full
strength across all
extremities.
Keppra Levetiracetam 500mg in 0.9NaCl 100mL Anticonvulsant: Given for pt Appetites loss, vomiting, neck pain,
IVPB Inhibits synapses presenting after headache, irritability, change of behavior,
of plasma resolving an acute cough, nasopharyngitis, fatigue; S-J
membranes in the SAH. The risk for syndrome, decreased WBC, neutropenia,
CNS to prevent seizure is also thrombocytopenia
seizure activity increased in pt’s after
a SAH d/t the
common development
of hypovolemia post
IR. Hypovolemia
results in the
development of
seizure activity.
NicoDerm CQ Nicotine 14mg patch for 24h Autonomic / Indicated for pt whose Skin irritation, nicotine withdrawal,
transdermal [AM] cholinergic: pt hx involves dizziness, headache, insomnia, rare cases of
Binds nicotine to smoking every day. dysrhythmias, HTN, hypersensitivity rxn

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student
receptors in order Administered for the
to elicit the reduction of pt
body’s response restlessness d/t
to it. withdrawal sx. This
would increase pt’s
comfort and improve
his rest.
Nimotop Nimodipine 3mg/mL 6mg oral Ca-Channel Pt is indicated for Hypotension, diarrhea, nausea, headache,
suspension q4h inhal Blocker: Prevents HTN with SBP CHF, GI hemorrhage, hematoma,
calcium ion entry reaching the early hemorrhage
into smooth 170s, but still
muscle cells maintains goal of
during <180. D/t pt’s recent
depolarization. SAH, the medication
Reduces HTN by would lower the pt’s
narrowing the HTN in order to
blood vessel to reduce bleeding and
stop excess blood fluid/blood in the
flow to the brain brain.
after SAH.
Zosyn Piperacillin/Tazobactam 3.375g in 50mL 0.9 NaCl Antibiotic: Pt presented w/ sx of Pruritus, rash, constipation, diarrhea,
100mL/hr q6h IVPB Provides a very an infection, suspected nausea, vomiting, headache, insomnia, fever
broad spectrum of aspiration
antibiotic that pneumonia. He
degrade gram+ displayed a high temp
and gram- strains reaching 100.1, is
(Piperacillin) sinus tachycardic, and
along w/ a beta
lactamase
inhibitor that
slows/halts the
breakdown of the
antibiotic
MiraLAX Polyethylene Glycol 17g powder q.day PO Laxative: Relies To encourage pt to Diarrhea, flatulence, nausea, stomach
on osmosis to have a BM before the cramps, swollen/distended abdomen
retain water in end of the next shift
the stool, leading and to serve as a
to softer stools prophylaxis for fecal
and more impaction. Pt has
frequent BMs. hyperactive BS with

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student
no abdominal
distention noted.
Reduces the exertion
of excessive pressure
when bearing down
during a BM as it may
alter ICP. EVD drain
is set to 15 w/
drainage of 2-10mL.
[Senna] Senna 2 tab – 17.2mg dose Laxative: The Important for Electrolyte imbalance, dehydration,
q.bedtime PO metabolite of the preventing fecal abdominal cramps, diarrhea, nausea,
medication acts impaction. Pt has not vomiting, urine discoloration, rashes
to irritate the had BM since the AM
colon, shift of 02/01, with
stimulating hyperactive bowel
peristalsis. The sounds. No abdominal
docusate distention noted.
promotes the Medication is also
absorption of important for reducing
water in the pt’s desire of bearing
stool, softening down extensively
it. when having a BM.
ICP continues to be 5-
8mmHg.
Hytrin Terazosin 1mg cap q.bedtime PO Alpha-1 Pt indicated for med Orthostatic hypotension, palpitations,
Adrenergic d/t the pertinent hx of peripheral edema, nausea, fatigue,
blocker: Blocks HTN with max SBP headache, somnolence, nasal congestion
receptors that reaching 171 (goal
would constrict <180). Important to
smooth muscles. prevent increased
Relaxation of pressure and fluid
these receptors in retention d/t
the bladder allow increasing ICP in pt
for increasing who had his PICA
urinary output aneurysm coiled. It
(corrects urinary allows pt to recover
retention) and from SAH by
reducing HTN restricting excess
(vasodilatory blood flow to the
effects). brain.

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student
Thiamin Vitamin B1 100mg inj q.day IV [AM] Nutriceutical: Thiamine deficiency is Injection site reaction (sx of infiltration,
Vitamin B is common in patients extravasation, ecchymosis, bruising or
essential in who are alcoholic d/t petechiae)
combining with poor nutrition and/or
ATP to form an the inability to absorb
enzyme that is vitamins
utilized in (inflammation of
carbohydrate stomach lining).
metabolism Though pt is ETOH
negative in his labs,
fiancé noted pt of
taking 6-7 shots of
alcohol each day.
DuoNeb Ipratropium PRN 3mL nebulizer Adrenergic/ Important for pt to Tachycardia, nausea, pharyngitis, vomiting,
bromide/albuterol sulfate solution q4h inh Anticholinergic: clear airway. These headache, nervousness, tremors,
Inhibits the meds were prescribed bitter/unpleasant taste, dry mouth,
production of for pt’s coarse, bronchitis, sinusitis
mucus and diminished breath
relaxes the sounds, labored/
bronchial shallow breathing
airways. AEB his RR reaching
past the 20s. Pt also
has an unproductive &
ineffective cough with
trace blood in thick
medium secretions
when suctioned.

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Personal & Family Medical History Conditions

P F Detail Positive Remarks, Date, and Treatment
(personal) (family)

Neurologic/Epilepsy ✔ None prior to current pt care;

Thyroid Dysfunction NONE
Breast Disease/Breast Surgery NONE
Pulmonary (TB, Asthma) NONE
Heart Disease N/A
Hypertension ✔ Further details of hx N/A- presented in pt currently
Cancer ✔ Prostate CA- Further details N/A
Hematologic Disorders NONE
Anemia NONE
Gastrointestinal Disorders NONE
Hepatitis/Liver NONE
Kidney Disease/UTI NONE
Deep Vein Thrombosis NONE
Diabetes (Type 1 or Type 2) NONE
Autoimmune Disorders NONE
Dermatologic Disorders N/A
Operations/Hospitalizations ✔ Pertinent to care- IR Coiling of PICA aneurysm w/ EVD placed on 01/27
Gyn Surgery N/A
Anesthetic Complications NONE
History of Blood Transfusions N/A

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Personal & Family Medical History Conditions

P F Detail Positive Remarks, Date, and Treatment
(personal) (family)

Psychiatric Illness

Trauma/Violence

Tobacco (Smoked, Chewed, ENDS, Vaped) ✔ Reported to smoke everyday, amount of packs/day not documented
Alcohol (AMT/Wk) ✔ Per fiance @bedside pt drinks 6-8shots every night
Drug Use (Including Opioids)

Other

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Hospitalizations
Age Diagnosis
56 Current hospitalization: acute subarachnoid intracranial hemorrhage, hydrocephalus, encephalopathy

Surgeries
Age Procedure/Diagnosis Complications?
56 Coiling of PICA aneurysm from SAH No complications noted, pt tolerated procedure well

56 EVD placement for hydrocephalus secondary to SAH No complications noted, pt tolerated procedure well

N/A Surgical hx on pt's nose; Hx reported by fiance, no N/A

knowledge of details or when it was performed

Is blood transfusion acceptable?

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Social History
Substance Use
Yes No
Smoker? ✔ If yes, # of packs per day: Unknown

Drinker? ✔ If yes, # of drinks per day: 6-8 shots

per week: ~42-49 shots/week
Recreational drug use? ✔ If yes, name of drugs(s): Route of use:

Environment/Living Situation Check all that apply

lives alone ✔ with child boarding home
with spouse with friend homeless
with family with roommate ✔ other: Fiance & her children _

Interpersonal Relationship:
Composition of immediate family: Brother, no other immediate family documented; fiance and her children present
Composition of immediate family: "

Do you feel safe at home? UTA Is anyone hurting you at home? (kicking, hitting, verbal abuse?) UTA
Supportive others: Close support of fiance and her children; any biological children not documented
Yes No
Lifetime history of stress or trauma? ✔ If yes, describe (event/age of onset/duration):
Recent history of stress or trauma? ✔ If yes, describe (event/age of onset/duration):

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Evaluation of Health Status

Review the patient's medical history and admission/intake assessment form. Does the patient have Family, Medical or Social factors that put them at risk? List risk
factors and possible effect.
Effect on Patient's Health Nursing Intervention
Biophysical Factors
Pt work and home environment not assessed

Family History
No family hx available on pt records, UTA w/ pt labile

Infection History (Possible Exposure)

No infection hx available on pt records, UTA w/ pt labile

Psychosocial/Sociodemographic Factors
Smoker (daily) Studies show that there is a consistent and overwhelming relationship b/w smoking and strokes Pt education of titering off of smoking and recommending use of nicotine patches

ETOH (6-8 shots/day per fiance) Alcohol abuse places pt at greater risk for ischemic strokes Pt education to reduce alcohol consumption atoa minimum

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 Initial Labs Purpos Normal Values Patient's Results Interpretations & Nursing Implications
Critical Care
e - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Laboratory & Screening Tests

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student
CBC (02/01) Provides a general screening of WBC - 4.5-13.5 WBC- 9.5 Within normal limits.
the blood to reflect the indication HGB – 11.5-17.5 HGB- 12.4
of any possible, infections, HCT – 35-45 HCT-36.9
bleeding/clotting issues, anemia, PLT- 140-400 PLT-228
or general need for hemodynamic
interventions.
BMP (02/01) Provides the status of the patient’s Na-135-145 Cl-95-105 Na-135 Cl-103 Glucose is elevated. Hyperglycemic levels puts pt
kidneys in their ability to K-3.5-5 HCO3-22-29 K-4.1 HCO3 - 27 at risk for infections, but more likely an indicator
metabolize the body’s BUN-7-18 Cr-0.6-1.2 BUN-12 Cr-0.6 of a current infection that is supplying a bacterial
electrolytes. Glu-70-110 Glu-128* strain. Continue to wait for culture results and
administer the antibiotics per MD order. Assess an
increase in temp and sinus tachycardia. Notify MD
if feeding should be altered.
Na Screens the concentration of 135-145 139 (02/01 2155) Within normal limits.
sodium in the pt’s blood. 138 (02/01 1603)
Pertaining to the pt, it asses 135 (02/01)
ETOH (01/27) Labs done to assess pt for alcohol Negative (<100) Negative Within normal limits.
abuse/alcoholism. Pt was
suspected for having withdrawal
symptoms after he appeared to be
agitated on the unit and fiancé
reported hx of drinking 6-8
shots/day.
Urine Analysis To analyze any indications of RBC – 0-5 RBC – 8 Elevated RBC and WBC levels with presence of
possible infections or renal WBC – 0-3 WBC – 22 some bacteria can indicate the development of an
complications. No Bact. Present Few Bact. Present infection. Administer the Rocephin and Zosyn per
MD order and continue to assess for basic vitals,
especially TEMP and HR, while waiting for results
from sputum and CSF culture.
Sputum Pt indicated for developing an No Bact. Present Awaiting Results Information not yet available to interpret. Await
Culture (2/1) infection from urine analysis. for results and continue to administer antibiotics
Culture done to narrow down per MD order.
source of infection to possible
aspiration pneumonia when pt
coughed during a meal when on
regular diet.

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student
CSF Culture w/ Pt indicated for developing an No Bact. Present Awaiting Results Information not yet available to interpret. Await
Gram Stain infection. CSF culture is done to for results and continue to administer antibiotics
(1/31) assess for any possible CNS per MD order.
infections pertinent to post IR
coiling procedure. Infection may
also be r/t blood tracing in spinal
cord upon admission.
Chest X-Ray To assess for proper placement of No anomalies. No distinction of Within normal limits.
(2/1) lines/tubing in pt, as well as to aspiration pneumonia.
provide a general screen for any PICC line stable and
anomalies in pt’s lungs after Keofeed tube in Stable PICC line and
suspected aspiration pneumonia. appropriate place Keofeed tube.
CTA – Brain To assess status of brain No anomalies. Edema in R upper internal EVD has been placed in area of edema, continue
(1/31) compromise in increased ICP due lobe monitoring for dramatic increase in ICP and assess
to possible edema, excess CSF, for drainage. Line can be flushed away from pt.
hemorrhagic event, or presence of Expecting another CTA brain scan to assess for
aneurysm. Indicated for pt to additional changes. Assess for altered mental status
assess status of coiled PICA as well.
aneurysm.

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Physical Assessment
Time Findings
Physical Exam q4h - Recent @0400 Vitals baseline with improved temp of 98.6, BP within goal of <180SBP (148/79) O2 Sat 99% on simple face mask 5L

Neuro assessment q1h - Recent @0600 Via pupilometer: round, equal, brisk response to light, 3.5mm bilaterally; GCS 14, 2+ grip strength, labile AOx1-3, follows commands

Cardiac assessment q4h - Recent @0600 NSR/ST rhythm, cap refill <3 secs, murmurs absent
Respiratory assessment q4h - Recent @0600 no Coarse breath sounds heard in all lobes bilaterally w/ unproductive cough, tolerates well w/ simple face mask d/t mouth br eathing, thick Naso/Oropharynx secretions with trace blood, non frothy

GI Assessment q4h - Recent @0600 Last BM prev shift [02/01 AM], hyperactive BS, no abdominal pain, no abdominal distention
GU Assessment q4h - Recent @0600 Incontinent - on external condom cath: clear, yellow, urine; no signs of skin breakdown, petechiae, ecchymosis in

Integumentary Assessment q4h - Recent @0600 Appopriate to ethnicity; overall dry and intact. EVD on R remains clear, dry, intact with clean&dry transparent dressing. R groin puncture site clean and dry.

Musculoskeletal Assessment q4h - Recent @0600 5/5 on all extremities, 5/5 grip strength
IV sites(s) check 0400 No signs of infiltration, ecchymosis, petechiae, and swelling found on insertion site of PICC and R PIV

Wound care Assessment q1h w/ Neuro EVD site clean, dry, and intact with no purulent drainage or sx of ecchymosis, petechiae, or breakdown. R groin puncture site is clean, dry, and intact w/ no purulent drainage.

Dressing change Assessment q1h w/ Neuro Wound dressings for EVD and R groin puncture site clean, dry, intact - dressing not changed
Oral care 2300, 0100, 0500 No CHG mouth wash, oral suctioning only. Pt tolerated well, O2 saturations did not decline below 95%
Bath 0400 Pt tolerated well to care, no signs of skin breakdown. CHG batch applied to all extremities, trunk, and inguinal area

Cough deep breathe 0500 Difficulty in instructing pt for deep breathing d/t being labile and sleepy. Produced weak, nonproductive cough when suctioni ng.

Incentive spirometry q 2 hrs 2100 RT performed when administering inhalant medications to pt. Pt tolerated well, no complications

SCD 2300 Removed @0400 d/t pt preference. Pt tolerated well prior to removal. No sx of bruising, redness, blanching on LEs.

TED hose - Not applicable, pt used SCD.

Education Other 0800/0900/0000/0400 Described medications pt would receive when administering it

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

Care Coordination/Consultations/Discharge Planning

Case Management Consult
Social Work
Out-patient Appointment
Depressions Screen
Primary Medical Doctor
Family Support
With improved sx, discuss plan for pt staying in unit or transferring out.
Notify AM shift to f/u on consult request regarding pt disability forms
Clamping of EVD and future appointments not yet disclosed.
Possible psych consult when pt is more oriented, less confused.
Discuss plan of care regarding updates of R side cranial edema, outlook for discharge,
Education for pt care in reducing stressful activities, needing assistance for ambulating when home, low sodium diet.

Nutrition I&O
NG Keofeed Restricted Diet – Fibersource 65mL/hr
Amount
ype of diet:
Meal 780mL total feed intake (12h)
Meal Percent Taken / Time Breakfast -
Breakfast / Lunch -
AM snack / Dinner -
Lunch / Output
PM snack / Urine ~250mL* [partial data, end of shift total unable to record]

Dinner / Stool 0
HS snack / Emesis 0
TOTAL ~+530*

IV Fluids Solution Rate per Hour Total Intake

NaCl [Normal Saline] 3% (hypertonic) 30mL/hr TKO 360mL

TOTAL 360mL

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 Critical Care - Patient Care Organizer (PCO) – Emmanuel Santuray, BSN Student

EVIDENCE BASED ARTICLE

Discuss article selected for PCO and explain why you chose the article. Provide citation in APA format.
ARTICLE: Bautista, C. (2012). Unresolved issues in the management of aneurysmal subarachnoid hemorrhage. AACN Advanced Critical
Care, 23(2), 175-185. DOI: 10.1097/NCI.0b013e31824ebcfa

Though the patient's HTN is still managed with a beta-blocker, the allowance of a higher BP is so that the brain will not be ischemic, but it
can increase the risk of a rebleed if it's so extensive. At first I was confused why the reference range for SBP is so high, especially when the
patient is hypertensive and would be at a great risk of a rebleed. This article I chose is a review of numerous evidence based studies that
discusses the effects and purpose of different complications that can arise with a patient who recently suffered a SAH and the therapeutic
measures taken for the prevention or management of these issues. It was insightful for explaining that the induction of hypertension is
desired to promote blood perfusion to the brain, especially after an even of heavy blood loss with the aneurysm hemorrhage. This is why our
goal for the patient in SBP is as high as the 180s is that it is enough to promote blood flow to the brain, while considering the patient's
longstanding history of HTN. This, however, does not mean that the risk of rebleed is no longer a concern. There is an extent at which the
patient's ICP and BP is excessive that the vast amount of pressure can create bleeding again. The article describes how hyponatremia is a
concern in patient's ICP since serum sodium plays a role in the retention or wasting of fluids as well as the amount of pressure that goes to
the brain. The low sodium levels from the hemorrhage would promote water retention and thus increased ICP. A hypertonic solution would
help replenish the sodium and promote fluid output to decrease pressure. For our patient continuously infuse hypertonic 3% NaCl to our
patient ever since he became more hypertensive with an SBP in the 170s. Though the maximum SBP range for the patient is still limited to
180, Na was not low, and the ICP was normal, we still wanted to be more cautious of the SBP reaching the max goal and eventually lead to
an increased ICP. By administering the hypertonic fluid continuously, there would be consistent maintenance of the desired volemic pressure
that can be influenced by the sodium, making ICP also decrease. A hypertonic solution in this patient ensures that his induced HTN does not
exceed dangerously.
The following are resources to help you find EBP articles to attach to your PCOs to examine the Evidence Base for your Care Plan. You must indicate on your PCO
where you have utilized the research to manage your patient's care with a clear APA citation. Remember that you must attach ONE article to EACH PCO submitted and
be prepared to discuss in post-conference. In addition, you must include ONE paragraph summarizing your article, and clearly applying to your present and future
nursing care.
http://grunigen.lib.uci.edu
- AccessMedicine - STAT!RefNursing

- CINAHL - PubMed@UCI - Mosby's Nursing Consult

- Cochrane Library - UpToDate - PsycINFO

- Micormedex - National Guideline Clearinghouse (for clinical guidelines)

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NURSING CARE PLAN (SOAPE Charting)
Subjective:
Pt had no complaints of
headache, nausea, or desire to
vomit
Grimaced only when
repositioning: "That hurts"
Objective:
SBP reached up to 150s-170
ICP 5-8mmHg
2-10mL drainage q1h - serous, tan
Occasionally sinus tach HR up to
101-104
Na levels in the mid-late 130s
Brain CTA noted new edema in R
upper internal lobe
Please note for references: Textbook; Peer-reviewed journal articles; Reference materials; or Professional Association guidelines are acceptable. Use APA for citations
References
Ackley, B., Ladwig, G., & Makic, M.B. (2016). Nursing Diagnosis Handbook: An Evidence Based Guide to Nursing Care (11th edition).
Bautista, C. (2012). Unresolved issues in the management of aneurysmal subarachnoid hemorrhage. AACN Advanced Critical Care, 23(2),
175-185.
Goldstein, L.B., Bushnell, C.D., Adams, R.J., et al. (2011). Guidelines for the primary prevention of stroke: a guideline for healthcare
professionals from AHA/ASA. Stroke; a Journal of Cerebral Circulation, 42, 517-584.
Critical Care - Patient Care Organizer (PCO)
Nursing DX Assessment Intervention Plan Rationale/Expected Outcomes Evaluation
1. 1. 1.
RISK FOR It is important to ensure that pt Pt tolerated new bag and fluids well. ICP
Prepare new IV fluid bag
INEFFECTIVE (3% NaCl) prior to maintains euvolemia in order to sustain remained within normal limits, but CPP is in
the upper 80s-90s d/t pt HTN. Notify MD for
CEREBRAL TISSUE completion of the current
a normal cerebral blood flow. 3% NaCl
possible changes to fluids and/or rate.
is used to reduce fluid retention that Continue to monitor carefully for worsening
PERFUSION bag for replacement occurs in pt having increased CSF in edema like changes in LOC, nausea,
(Bautista, 2012). the cerebral ventricles. vomiting, headache.
r/t to recent event of 2. 2. 2.
SAH, coiling of Regularly monitoring pt's BP Pt has hx of HTN presented during Pt did not exceed an SBP
cerebral aneurysm, and being alert for shift reaching an SBP of 171. SBP
max goal of 140 is expanded to 180 to of 180 and was not given
HTN, and excess CSF increasing trend of BP [MD promote cerebral tissue perfusion, but a PRN beta-blocker
intraventricularly AEB goal <180SBP] (Goldstein et exceeding it places risk of another during shift.
SBP reaching 170, up al, 2011). hemorrhagic event and increased ICP.
to 10mL of CSF 3. 3. 3.
drainage in 1h via Draw labs for sodium (Na) levels Hyponatremia is the most common electrolyte
imbalance in 50% of pt's after SAH. Low Na
Pt Na levels remain within
q6h while observing for sx of normal levels, but in the lower
EVD, and brain CTA hyponatremia like nausea,
levels would exacerbate intracranial edema
and increase ICP through the retention of fluid, end. Did not display any
showing development vomiting, headache, & muscle worsening pt sx and developing a poor outlook.
weakness or spasms (Bautista, The goal is to remove the excess fluid in the significant sx of hyponatremia
of new edema in R 2012). ventricle to maintain an ICP within normal limits beyond baseline.
upper internal lobe
4. 4. 4.
When appropriate, repeat Pt is a daily smoker who is currently given Determined no appropriate
nicotine patches for cessation. It is pertinent
educate pt in the importance for pt awareness of the high correlation b/w time for pt to receive education
of smoking cessation smoking and strokes. Plan is to reduce risk as he had greater desire to
practices for long-term of future event of hemorrhagic or ischemic rest and can be agitated.
strokes (Goldstein et al, 2011).
health and post-discharge.
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NURSING CARE PLAN (SOAPE Charting)

Subjective:
Fiance: "His breathing sounds a
little worse. Is there something
we can do about that?"
Nursing DX Assessment Intervention Plan Rationale/Expected Outcomes Evaluation
1. 1. 1.
INEFFECTIVE
Provide nasopharyngeal Suctioning pt will create a more Pt did not desaturate during
BREATHING suctioning as needed (worsening patent airway with the removal of suctioning and tolerated being
PATTERN coarse breaths, increased mucus secretions, allowing for on room air during the process.
shallow breathing) for less than Coarse breath sounds were
decreased labored breathing and
10 seconds at a time.
r/t mouth-dependent reduced RR. (Ackley et al, 2016) improved w/ pt speaking clearer.
ventilation and reduced 2. 2. 2.
airway patency AEB Follow up with pt after Mucomyst inhalation promotes mucus Pt could not perform a productive cough
breakdown, thinning the pt's secretions to independently and was suctioned. Pt instructed
coarse breath sounds, Mucomyst and DuoNeb to allow for clearance of airway through to cough during suctioning, displayed only quiet,

Objective:
RR of 22-28
Diminished, coarse breath sounds
Ineffective/unproductive cough
O2 sat. 99-100% when 5L O2
administered through simple face
mask (decreased when on 2L
N.C.)
thick pink-like coughing or suctioning. The intervention also nonproductive coughs. Difficult to educate pt in
promote coughing along assesses improvement in developing a
deep breathing while sleepy and labile.
Maintained high RR. Did not desire for pt to exert
secretions upon with deep breathing productive cough / independent clearance of excessive pressure d/t risk of increasing ICP.
airway.(Parshall et al, 2012).
suctioning, and
tachypnic respiratory 3. 3. 3.
rate above 20 w/ Continue to administer 5L of Pt already responding well to MD Pt continues to tolerate the O2
shallow breathing. O2 via simple face mask per order of O2 therapy, and is important via simple face mask, no
to maintain continuous O2 supply for
MD order, limiting removal of respirations and sustain a high O2 sat. drastic decrease during neuro
it when pt desires to speak Prolonged removal can result to assessments and suctioning.
or for neuro assessments. desaturation . (Campbell, 2011). O2 sat. remained above 95%.
4. 4. 4.
Adjust pt's HOB to an Per Campbell, most pts would find Pt felt uncomfortable and compromised
greater comfort and increased to be in high fowler's position. Continued
upright position as to have coarse breath sounds that
capacity to effectively breath in a more
tolerated (Campbell, upright position. It can be an optimal improved with suctioning. No significant
changes noted. O2 sat. remained above
position to reduce dyspnea (2012).
2012). 95% w/ simple face mask

Please note for references: Textbook; Peer-reviewed journal articles; Reference materials; or Professional Association guidelines are acceptable. Use APA for citations
References
Ackley, B., Ladwig, G., & Makic, M.B. (2016). Nursing Diagnosis Handbook: An Evidence Based Guide to Nursing Care (11th edition).
Campbell, M.L. (2012). Dyspnea. AACN Advanced Critical Care, 22(3), 257-264.
Parshall, M.B., Schwartzstein, R.M., Adams, L., et al. (2012). An official American Thoracic Society statement: update on the mechanisms,
assessment, and management of dyspnea. American Journal of Respiratory and Critical Care Medicine, 185(4) 435-452.

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NURSING CARE PLAN (SOAPE Charting)

Subjective:
Pt said he was in "La Palma"
once during shift
Learned to get year and month
correct, but still confused of day
Objective:
Sleepy, labile, AOx1-3, usually
disoriented to time and place
Responds to noxious stimuli
Follows commands, but eye
opening varies (GCS 12-14)
Nursing DX Assessment
ACUTE CONFUSION
r/t excess CSF in
cerebral ventricles and
admit of SAH bleeds
AEB labile mood with 2.
disorientation to time Ensure pt has a new bag of IV fluids and Pt is restricted to a Keofeed diet with
Fibersource keofeed ready for
and place replacement within the last 15 min of
Intervention Plan
1.
Perform neuro assessment
q1h for any distinct changes
in pupils, facial symmetry,
AO/LOC, and sensation &
strength in all extremities.
2.
hypertonic fluids infusing. Important that were administered appropriately w/
infusion in previous bag. Assess for pt
tolerance. Prioritize assessment of
Keofeed residuals, and line patency
(flush).
3.
Encourage and educate family visitors at
bedside to engage with pt and to notify
nurses if there is a distinct shift in pt's
mental status that is not r/t delirium,
such as not responding to directions and
responses to questions/conversations
less appropriate.
4.
Rationale/Expected Outcomes
1.
Important to assess for any
neurological changes that are
drastic or distinct from pt's current
baseline that it is not r/t to delirium
in the ICU. (Ackley et al, 2016).
2.
New bags for fluids and Keofeed
all pumps are not stopped for prolonged
periods of time. Malnourishment and
fluids can exacerbate delirium and
confusion (Ahmed et al, 2014).
3.
Family of pt are now more intuitive of some delirium
that is part of his baseline behavior and education
of drastic mood changes d/t pathophysio alterations
allow for quicker diagnoses and interventions.
Increased interaction when pt is available helps
reduce delirium and allow pt to be more oriented
(Keyser et al., 2012).
4.
Evaluation
1.
Pt became irritated with hourly
neuro checks in the evening and
desired rest. Pt remained baseline
in being labile with varied AO. No
change in sensation and strength.
pumps stopped for less than 5 min.
Pt tolerated the bag changes w/
tubes flushed, lines primed. 0
residuals in Keofeed tube.
3.
Family @bedside was attentive and did
not display a lot of needs
psychosocially - aware of some
delirium/confusion in pt baseline. Slept
in room for the night. Pt responses are
appropriate and follows directions.
4.

Please note for references: Textbook; Peer-reviewed journal articles; Reference materials; or Professional Association guidelines are acceptable. Use APA for citations
References
Ackley, B., Ladwig, G., & Makic, M.B. (2016). Nursing Diagnosis Handbook: An Evidence Based Guide to Nursing Care (11th edition).
Ahmed, S., Leurent, B., & Sampson, E.L. (2014). Interventions for preventing delirium in older people in institutional long-term care. The Cochrane Database of
Systematic Reviews, (1), CD009537.
Keyser, S.E., Buchanan, D., & Edge, D. (2012). Providing delirium education for family caregivers of older adults. Journal of Gerontological Nursing, 38(8), 24-31.

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