Faculty of Nursing and Midwifery

Bachelor of Science (Honours) Nursing- Post Registration

Academic Writing NBNS 1234

Student Name: Sia Ching Hung

Student Matrix Number: BNP 18046418
Course Title: Health Assessment In Nursing
Course Code: NBNS 1234
Essay Title: Health Assessment
Subject Leader: Dr Shaharuddin Mohd Yasin
Word Count:
Date of Submission: 20 December 2018

Introduction
I am a registered nurse with 5 years working experience and graduated with diploma in nursing. I

have been posted to intensive care unit in government hospital in my state. Following my years of

working experience in the area, therefore I decided to go deeper into my profession. Currently I am

attached to 17 bedded with 5 isolation room department. My Hospital is one of the major specialist

hospitals in Ministry of Health and is the second largest hospital in Sarawak. My hospital serves as

the secondary referral centre for Central Sarawak. In addition, some urgent cases from other

Hospital are also transferred to here for further assessment and management due to its convenient

geographical location.

In this assignment I am going to talk about health assessment of patient with basal ganglia bleed as it

is very common though regarded as one of the emergencies of brain injury. A stroke is a medical

emergency that can occur when the blood supply to part of the brain is cut off or when a blood

vessel in the brain bursts and releases blood into the brain tissue. Sometimes, a stroke can affect the

basal ganglia, which not only helps to control motor movement but is also the message center of the

brain. Intracerebral haemorrhage is a neurologic emergency that requires immediate neuroimaging

to differentiate it from acute ischemic stroke. Patients presenting within the first few hours have a

high risk of haemorrhage expansion and neurologic deterioration.

Approximately 33% of all stroke cases are deadly. Prognosis depends on the underlying cause, how

extensive it is, how soon it was medically treated, size and location of the lesion, degree of deficit,

and age of the patient. The chance of death for patients with hemorrhagic stroke is 70% while for

ischemic stroke, mortality is lower which is 25%. However, reoccurrence of ischemic stroke is 5-15%

every year. Patients who had stroke confined to the basal ganglia have smaller lesions but slower

initial recovery time compared to those who had stroke on the cerebral cortex. Although the
recovery was gradual during early rehabilitation stage, it significantly progresses towards the end.

Compared to patients who had stroke on cerebral cortex, those who had stroke on basal ganglia had

a greater overall recovery. The earlier the stroke was recognized and treated, the better the

prognosis. The greater the Glasgow coma scale (GCS) score of the patient, the better the prognosis.

Health assessment

A 46-year-old indonesian lady, was brought in by paramedics accompanied by family members to

the emergency room with history of sudden onset right side upper limb and lower limb motor

weakness of the body at home associated with slurred speech and changed in behaviour. She did

not respond to call since then she was then brought to the emergency department where she was

given initial and further management.

The nursing health assessment is an incredibly valuable tool nurses have in their arsenal of skills. A

thorough and skilled assessment allows you, the nurse, to obtain descriptions about your patient’s

symptoms, how the symptoms developed, and a process to discover any associated physical findings

that will aid in the development of differential diagnoses. Assessment uses both subjective and

objective data. Subjective assessment factors are those that are reported by the patient. Objective

assessment data includes that which is observable and measurable (Jarvis, 2012).
Subjective data

On assessment, patient was intubated for airway protection and keep sedated. According to family

members, patient had sudden onset of right side body weakness, which occurred during at rest,

associated with slurred speech and changed in behaviour as history taken from her son. Patient also

complained of headache and numbness over right side of body, which symptoms was progressively

worsened. She also had multiple times of vomiting at home, food particles were seen in the vomitus.

Subsequently her son noted she was not responsive to call. However, family members deny any

jerky movement; fall prior to that; or previous trauma. Intracerebral hemorrhage in the basal ganglia

is usually caused by hypertension (Steven R Levine MD 2018).

Upon further history taking, patient has underlying hypertension but defaulted treatment. She was

previously on tab amlodipine for her hypertension. However, her compliance to medication was

poor. Other risks factors such as smoker and alcoholic are excluded. She has no known allergy, no

previous hospital stays or surgery done before. She worked at farm as fruit collector together with

her family. She had 2 son with age 15 and 18. Unsure her last menstrual .

It is important to ask questions about your patient’s past health history. The past health history

should elicit information about the patient’s childhood illnesses and immunizations, accidents or

traumatic injuries, hospitalizations, surgeries, psychiatric or mental illnesses, allergies and chronic

illnesses. For women, include history of menstrual cycle, how many pregnancies and how many

births (Jarvis, 2012).

Objective data
Upon arrival at intensive care unit, vital sign taken. Blood pressure was 161/93mmhg, heart rate 76

beat per minute, temperature 37.2 degree Celsius, oxygenation 100% under intubated. Blood

glucose level :6.6mm0/l. Hypoglycaemia can mimic a stroke and must be excluded in those with

sudden onset of neurological symptoms. Neurologically, her Glasgow coma scale (GCS) was 2+T/15

not obeying command. Both pupil 3mm reactive bilaterally to light. Pupillary assessment is an

important part of neurological assessment because changes in the size, equality and reactivity of the

pupils can provide vital diagnostic information in the critically ill patient (Smith, 2003). Noted facial

asymmetry and weakness over right side.

Her head of bed was prop up 30 degrees. She had a regular heart rate with normal S1 and S2. No

appreciable murmurs, rubs or gallops. Her abdomen was soft, nontender, and nondistended with

positive bowel sounds. Fair hydration looked, warm peripheries capillary return less than 2 seconds,

good pulse volume palpable, not tachypneic, gag reflex present. She has no lower extremity

oedema. The physical examination revealed the patient’s weight to be 65 kg, with a height of 162 cm

(body mass index = 20 kg/m2), and her neck circumference of 40 cm (15.75 inch). Nasogastric tube

and uninary catheter inserted. On electrocardiogram, normal sinus rhythm with sinus arrhythmia,

non-specific T wave abnormality, and prolonged QT were observed. No abnormality in the chest was

found by chest X-ray examination. Babinski’s sign was absent.

Upon blood chemistry examination, she had higher levels of prothrombin time 15.1 seconds, Partial

thromboplastin time 19.9 seconds , international normalised ratio 1.19 seconds . Haemoglobin 13.5

grams/L, white blood cell 13.1 billion cells/L, platelet 233 billion/L. Sodium143 mmol/L, potassium

3.2 mmol/L, urea 99 mmol/L ,creatinine 2.3 µmol/L . Computed tomography (CT) brain , shown

hyperdensity over left basal ganglia region with mass effect, clot volume about 30cm,midline shift

0.7cm to right, with ipsilateral sulci and gyri effacement and patient diagnosed with left basal ganglia
bleed secondary to hypertensive emergency by a neurosurgical team . CT scanning of the head is

typically used to detect a blood clot or bleeding within the brain shortly after a patient exhibits

symptoms of a stroke.

The assessment in patients with possible hemorrhagic stroke includes vital signs; a general physical

examination that focuses on the head, heart, lungs, abdomen, and extremities; and a thorough but

expeditious neurologic examination. Morgenstern LB et.al.(2010).Blood pressure checking is vital

because it is a barometer of health. It is the baseline to all diagnosis and treatment and there are

often no symptom to alert one of the presence of high pressure. In this case, Hypertension is

commonly a prominent finding in hemorrhagic stroke. Higher initial blood pressure is associated

with early neurologic deterioration, as is fever. The GCS is a reliable and objective way of recording

the initial and subsequent level of consciousness in a person after a stroke. In this measure, three

aspects of behaviour are independently measured: motor responsiveness, verbal performance, and

eye opening.

Management and outcomes

Management begins with stabilization of vital signs. Perform endotracheal intubation for patients

with a decreased level of consciousness and poor airway protection. Intubate and hyperventilate if

intracranial pressure is elevated, and initiate administration of mannitol for further ICP control.

Rapidly stabilize vital signs, and simultaneously acquire an emergent computed tomography (CT)

scan. Glucose levels should be monitored, with normoglycemia recommended. Antacids are used to

prevent associated gastric ulcers. . Patient was planned admit to intensive care unit while awaiting

for operation theatre call for operation left decompressive craniectomy and clot evacuation and

bone bury. A decompressive craniectomy is brain surgery that removes a portion of the skull. When
the brain swells following an injury, the pressure in the brain can build inside the skull, causing

further damage. The body's natural healing response to injury is to swell. Swelling in the brain, can

be dangerous because the skull restricts the swelling and pushes on the brain. Removing a portion of

the skull can reduce the risk of severe brain damage, and may even be life-saving. Clot was

evacuated to help in reduce intracranial pressure and to correct midline shift.

Nursing care plan and evaluation

Nursing diagnosis for this patient is ineffective cerebral tissue perfusion related to brain

haemorrhage evidenced by altered level of consciousness, restlessness, changes in motor/sensory

responses. Desired outcomes is to maintain usual or improved level of consciousness, cognition, and

motor/sensory function. Nursing intervention is to assess for nuchal rigidity, twitching, increased

restlessness, irritability, onset of seizure activity to indicative of meningeal irritation, especially in

hemorrhage disorders. Seizures may reflect increased ICP or cerebral injury, requiring further

evaluation and intervention. Besides, nurses have to evaluate pupils, noting size, shape, equality,

light reactivity because pupil reactions are regulated by the oculomotor (III) cranial nerve and are

useful in determining whether the brain stem is intact. Pupil size and equality is determined by

balance between parasympathetic and sympathetic innervation. Response to light reflects combined

function of the optic (II) and oculomotor (III) cranial nerves. Position with head slightly elevated and

in neutral position to reduces arterial pressure by promoting venous drainage and may improve

cerebral perfusion. Nurses also have to administer medications as indicated. Example

antihypertensive. Chronic hypertension requires cautious treatment because aggressive

management increases the risk of extension of tissue damage.

Second nursing diagnosis for this patient is impaired physical mobility related to neuromuscular

involvement like weakness, paresthesia; flaccid or hypotonic paralysis; spastic paralysis evidenced by

inability to purposefully move within the physical environment; impaired coordination; limited range

of motion; decreased muscle strength or control. The desired outcome is to maintain and increase

strength and function of affected or compensatory body part, maintain optimal position of function

as evidenced by absence of contractures, foot drop. Nursing intervention is begin active or passive

room of motion to all extremities including splinted on admission. Encourage exercises such as

quadriceps and gluteal exercise, squeezing rubber ball, extension of fingers and legs to minimizes

muscle atrophy, promotes circulation, helps prevent contractures and also reduces risk of

hypercalciuria and osteoporosis if underlying problem is haemorrhage. Change positions at least

every 2 hour (supine, side lying) and possibly more often if placed on affected side to reduces risk of

tissue injury because affected side has poorer circulation and reduced sensation and is more

predisposed to skin breakdown. Nurse also have to inspect skin regularly, particularly over bony

prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as

necessary. Pressure points over bony prominences are most at risk for decreased perfusion.

Circulatory stimulation and padding help prevent skin breakdown and decubitus development.

Another nursing diagnosis is potential for impaired gas exchange related to elevated blood pressure

hypoventilation, and immobility. By 6-8 hours, patient will maintains optimal gas exchange as

evidenced by usual mental status, unlaboured respirations at 12-20 per minute, oximetry results

within normal range, blood gases within normal range, and baseline heart rate for patient. Nurse

should position patient with head of bed 45 degrees if tolerated to promotes better lung expansion

and improved gas exchange. Suction patient as needed to remove secretions from the airway and

optimizes gas exchange. Hyperoxygenate patient with 100% before and after suctioning. Keep
suctioning to 10-15seconds to prevents alteration in oxygenation during suctioning. Monitor vital

signs. Initially with hypoxia and hypercapnia blood pressure, heart rate and respiratory rate all

increase. As the condition becomes more severe blood pressure may drop, heart rate continuous to

be rapid with arrhythmias and respiratory failure may ensue.

Conclusion

Health assessment is important and often first step in identifying the patient’s problem. Health

assessment helps to identify the medical need of patients. Patients health is assessed by conducting

physical examination of patient.it is also a plan of care that identifies the specific needs of a person

and how those needs will be addressed by the healthcare system or skilled nursing facility. Health

assessment is the evaluation of the health status by performing a physical exam after taking a health

history. There are different from diagnostic tests which are done when someone is already showing

signs and/or symptoms of a disease. The major health assessments are Initial Assessment in which

determine the nature of the problem and prepares the way for the ensuing assessment stages.

Nursing care plans are an important part of providing quality patient care. They help to define the

nurses' role in the patient's treatment, provide consistency of care and allow the nursing team to

customize its interventions for each patient. Additionally, it promotes holistic treatment of the

patient and helps define specific goals for the patient.

References
Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al. (2010)

‘Guidelines for the management of spontaneous intracerebral hemorrhage’, a guideline for

healthcare professionals from the American Heart Association/American Stroke Association, 41(9),

pp. 2108-2019.

Nadine Salmon(2014). Overview of Nursing Health Assessment. Available at:

https://lms.rn.com/getpdf.php/2051.pdf (Accessed: 6 November 2018).

Phil Jevon, et al (2008) Neurological assessment Part 2 - Pupillary assessment. Available at:

https://www.nursingtimes.net/clinical-archive/neurology/neurological-assessment-part-2-pupillary-

assessment/1732244.article (Accessed: 15 November 2018).

Rinta rajan. (2015) Nursing diagnosis list – neurological disorders. Available at:

https://fromthenursingstation.wordpress.com/2015/05/06/nursing-diagnosis-list-neurological-

disorders/ (Accessed at: 16 November 2018)

Steven, R.( 2018) basal ganglia bleed. Available at: http://www.medlink.com/ (Accessed:15

October 2018).

Zawn Villines. (2017) What is a decompressive craniectomy?. Available at:

https://www.medicalnewstoday.com/articles/319755.php (Accessed: 15 November 2018).