UNIVERSITY OF THE CORDILLERAS

College of Nursing
Governor Pack Road, Baguio City, Philippines 2600
(+6374) 442-3316, 442-2564, 442-8219, 442-8256
E-mail: webmaster@bcf.edu.ph
Website: www.bcf.edu.ph

CVD INTRACEREBRAL HEMORRHAGE LEFT THALAMOCAPSULAR AREA S/P FRONT TEMPORAL

CRANIOTOMY EVACUATION OF HEMATOMA

A Case Presented to the

College of Nursing

In Partial Fulfillment of the Requirements in the Course

Nursing Care Management 118A

Submitted By:

AWAN, Cherry Pearl A.

CAMPILIS, Glayssa S.
CANDO, Charlene S.
DAO-EY, Bryan C.
ESTARIS, Marl Nathaniel L.
MENDOZA, Yvette Marie L.
SERRAN, Abcde Zynmil Z.
TIGLAO, Kayla Marie D.
TUBAÑA, Faith Greyle Q.
WONG, Heather Shane A.

November 17, 2022

Noted and Approved for Presentation:

Milkhay Layco Imelda Payas

Signature of Panel/ Date Signature of Panel/ Date
 ABSTRACT

Title: CVD Intracerebral Hemorrhage Left Thalamocapsular Area S/P Front Temporal
Craniotomy Evacuation of Hematoma

BACKGROUND: Stroke is a life-threatening emergency situation that requires immediate

intervention, this happens due to a decrease or blockage in the brain’s blood supply
(McIntosh, 2020). There are two types of stroke, the ischemic and hemorrhagic stroke.
Ischemic stroke occurs when the blood flow in the brain is blocked causing the blood not to
distribute to other parts of the brain causing a damage on the parts of the brain that may
lead to stoke. On the other hand, hemorrhagic stroke occurs when there is a trauma inflicted
over the head or to the brain that causes bleeding to the brain thus causing brain damage
that may lead to stroke. The most common symptoms are numbness, confusion, trouble
seeing, trouble walking, and severe headache with no known cause. The cause of the stroke
in the case of the patient is poor lifestyle and diet which has most likely lead to atherosclerosis;
which is a major cause of having hypertension, and noncompliance to maintenance
medications. Genetics age, Diabetes mellitus and hypertension are the factors that increase
the possibility of stroke.

CASE DESCRIPTION: Patient X is a 69 years old female, a roman catholic and married. She is
currently residing at Sabangan Mt. Province. She came from a family with a history of
hypertension and diabetes mellitus. Patient X is known to be a hypertensive patient, she is
also diagnosed with diabetes mellitus and had no history of stroke and heart attack prior to
hospitalization. The significant other verbalized that her diet is more of meat and rice. She also
has no known vices; doesn't drink alcohol nor smoke a cigarette. She is not compliant with
her maintenance medications for hypertension and diabetes. She has a chief complaint of
loss of consciousness and with the admitting diagnosis of CVD ICH Left thalamocapsular area,
46cc, ICH 2, NIHSS21, HTN in etiology, HTN stage 2 uncontrolled then with a final diagnosis of
CVD ICH Left thalamocapsular area S/P front temporal craniotomy evacuation of
hematoma.

CONCLUSION: Unable to comply with maintenance medication can further cause a problem
thus it is important that the patient should take or have this during her treatment. Necessarily
giving appropriate information about stroke is needed so that the same incident may not
happen again.

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 TABLE OF CONTENTS

I. Introduction …………4

II. Statement of Objectives 4

A. General Objectives 4

B. Specific Objectives 4

III. Patient’s Profile 5

IV. Chief Complaint 5

V. Present History of Illness 5

VI. Past History of Illness 5

VII. Family Health History 5

VIII. Developmental History 5

IX. Social and Environmental History 5

X. Lifestyle and Health Practices 5

XI. Health Assessment 5

A. General Survey 5

B. Head to Toe Assessment 6

C. 13 Areas of Assessment 7

XII. Diagnostics 12

XIII. Comprehensive Pathophysiology 13

XIV. Treatment/Management 14

A. Drugs 14

B. IV Fluids 17

C. Surgery 19

XV. Nursing Care Plans 21

A. Prioritization of Problems 21

a.1. List of Problems 21

a.2. Basis for Prioritization 21

B. Nursing Care Plans 22

NCP 1 22

NCP 2 24

NCP 3 26

NCP 4 28

NCP 5 29

C. Discharged Plan 31

XVI. Learning Insights 32

XVII. List of References 34

XVIII. List of Appendices 35

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I. Introduction

Stroke is a life-threatening emergency situation that requires immediate

intervention, this happens due to a decrease or blockage in the brain’s blood supply
(McIntosh, 2020). Center for Disease Control and Prevention (2022) identified two
major types of stroke – Ischemic and Hemorrhagic stroke. Transient ischemic stroke
describes as “mini stroke” when blood flow to the brain is blocked for not more than 5
minutes and it is a warning sign for future stroke. Ischemic stroke is the most common
type of stroke that occurs when blood clots or other particles such as fatty deposits
block the blood vessels that carry blood supply to the brain that prevents brain tissue
from getting oxygen. American Stroke Association (2022) identifies the second
subtype of stroke which is the hemorrhagic stroke, it is caused by a weakened vessel
that ruptures and bleeds in or around the brain. The blood itself can damage the brain
tissue. Patel (2022) Furthermore, the extra blood in the brain may increase the pressure
within the skull (intracranial pressure (ICP)) to a point that further damages the brain.
Risk factors for stroke include smoking, diet, physical inactivity and the burden of
hypertensive disorders is greater (Fekadu, Chelkeba and Kebede. 2019).

The stroke treatments that work best are available only if the stroke is
recognized and diagnosed within 3 hours of the first symptoms. Stroke patients may
not be eligible for these if they don’t arrive at the hospital in time. Use the letters F.A.S.T
to identify the warning sign of stroke F- facial droop, A-arm weakness, S-slurred speech,
and T-Time to call for help (CDC, 2022). Other stroke symptoms to watch for includes
numbness, confusion, trouble seeing, trouble walking, and severe headache with no
known cause (ASA, 2022).

World Health Organization (WHO, 2022) reports that Stroke is the leading cause
of disability worldwide and the second leading cause of death. The Global Stroke
Factsheet released in 2022 reveals that lifetime risk of developing a stroke has
increased by 50% over the last 17 years and now 1 in 4 people is estimated to have a
stroke in their lifetime. (Collantes, et. Al., 2021) In the Philippines, from 2009 to 2019,
stroke remains the second leading cause of death and one of the top five leading
causes of disability in the Philippines. The true stroke prevalence is uncertain, but
reported estimates vary between 0.9% (2005) to 2.6% (2017) of the population. Based
on types of stroke, seven out of 10 cases are diagnosed as ischemic while the other
three are considered hemorrhagic. Thirty-six percent (36%) of the total stroke deaths
are not attended by any medical personnel.

II. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of

student nurses on how to care for patients with CVD-Intracerebral Hemorrhage
effectively and efficiently.

B. Specific Objectives

Specifically, this case analysis aims to:

1. Define CVD-Intracerebral Hemorrhage and its effects to the body as a whole.

2. Tabulate present a thorough general assessment of the client which includes
physical assessment and family history taking.
3. Illustrate the pathophysiology and etiology of CVD-Intracerebral Hemorrhage in
relation to the signs and symptoms specifically observed in the patients.
4. Discuss the medical and surgical interventions for the management of CVD-
Intracerebral Hemorrhage.
5. Efficiently formulate appropriate and proper nursing diagnosis in line with the client’s
medical condition and skillfully formulate nursing care plans for the problems
identified.
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 6. Identify nursing interventions necessary for the patient and family to promote
continuity of care and independence after discharge.

III. Patient’s Profile

Name: Patient X
Sex: Female
Age: 69 years old
Religion: Roman Catholic
Address: Sabangan Mt. Province
Admitting Diagnosis: CVD ICH Left thalamocapsular area, 46cc, ICH 2,
NIHSS21, HTN in etiology, HTN stage 2 uncontrolled.
Final Diagnosis: CVD ICH Left thalamocapsular area S/P front
temporal craniotomy evacuation of hematoma

IV. Chief Compliant

Loss of consciousness

V. Present History of Illness

Mrs. X was a transfer patient from Luis Hora Memorial Hospital, it was reported
initially that the patient was seen on the floor unconscious by their neighbor, since
patient X lives alone. Patient X was then bought to the emergency room of their local
hospital and her CT scan revealed an acute hemorrhage in the capsulothalamic area
about 46 cc volume and was advised to have further neurologic examination and for
this reason, transferred to BGHMC.

VI. Past History of illness

Patient X is known to be a hypertensive patient, she is also diagnosed with
diabetes mellitus, she had no history of stroke and heart attack prior to hospitalization.

VII. Family Health history

The significant other verbalized that hypertension and Diabetes mellitus runs in
their family.

VIII. Developmental History

Patient X is a 69 years old female; she falls under the integrity vs. Despair on
the Erik Erikson’s psychosocial theory of development.

IX. Social and Environmental History

Patient X lives alone in her house located at Sabangan Mt. Province.

X. Lifestyle and Health Practices

The significant other verbalized that patient lacks physical activity, and that
patient X’s diet consists more of meat and more rice. SO also confirmed that the
patient does not drink alcohol or smoke cigarettes. The patient is not compliant with
her maintenance medications for hypertension and also stopped taking metformin for
her Diabetes.

XI. Health Assessment

A. General Survey
The client was seen lying on bed with a pale appearance. She wears a
neat gown and her hair is oily. Client has ETT connected to a mechanical
ventilator, NGT on the left nare, and an ongoing IV fluid of PNSS 1L x 16hrs,
with a side drip of Nicardipine, Tranexamic acid 1g + 90ml, PNSS x 8hrs,
and Totillac 250ml x 40cc/hr. Patient has also IFC connected to a urine
bag.

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B. Head to Toe Assessment

1. Head The client’s head is normocephalic and symmetrical.

Parts of her hair were shaved in the area of the incision
for craniotomy and right sided facial droop noted.

2. Eyes The client has a spontaneous eye opening upon

neurological assessment. Isochoric pupils at 2-3mm,
EBRTL, the primary gaze is at midline. Even distribution
of hair on eyebrows and eyelashes. No nystagmus
noted.

3. Ears The client is able to hear words but is unable to

respond verbally due to insertion of ETT. The Auricles
are symmetrical and have the same color as her
facial skin. The auricles are aligned with the outer
canthus of the eye. The pinna recoils when folded
and with minimal amount of cerumen in the ear.

4. Nose and Sinuses The nose is in the midline of the face, septum is
straight, and nares are patent with a nasogastric tube
inserted on the left nare for feeding. Upon palpation
of frontal and maxillary sinuses, there is no tenderness
noted.

5. Mouth Lips are symmetrical, pale in color, dry, and chapped.

The client has ETT connected to a mechanical
ventilator and an incomplete set of adult teeth that
are yellowish in color. Oral mucosa is dry and pinkish.
Tonsils are bilaterally present and uvula is located
midline.

6. Neck There is no visible redness and swelling in the neck.

Upon palpation, there is no presence of lumps or
bumps and nodal enlargement.

7. Chest The chest is symmetrical with minimal use of accessory

muscle. Upon auscultation, occasional crackles was
noted on the right lower portion of the chest.

8. Cardiac Upon physical examination, the cardiac rate was

ranging between 70-97 beats per minute, with
irregular rhythm and blood pressure was ranging from
140-160 systolic and 90-100 diastolic. There are no
DOB and chest pain complaints.

9. Breast The breast color is similar to skin tone, the nipples are
dark in color and there is no abnormal pigmentation
noted.

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 10. Abdomen Normoactive bowel sounds heard in all the
quadrants. Abdomen is soft, flabby, and non-tender.
There are no masses and lesions noted.

11. Genitals The patient is connected to an indwelling Foley

catheter connected to a urine bag. No inflammation
and lesions in the inguinal and genital area.

12. Musculoskeletal The patient has a flaccid and plegic right extremities
with hyperreflexia and positive Babinski reflex. With
spontaneous movement on the left extremities, and
grimaces to pain on right extremities.

The patient has a limited range of motion and muscle

strength grade of 3/5- active movement against
gravity on the left extremities, and a muscle strength
grade of 0/5 on the right extremities.

13. Integumentary The patient’s forehead and extremities are cool to

touch. Nail beds are pale in appearance and
capillary refill time is < 2 seconds. No noted edema on
extremities. IVF and side drips are infusing well on the
right hand.

C. 13 Areas of Assessment

1. Psychosocial
The patient is sixty-nine years old Filipino citizen from Sabangan, Mt. Province.
She lives in her own house alone. She is a retired teacher and pensioner that can
achieve basic needs such as food, clothing, and shelter. However, she is non-
compliance with hypertensive and diabetes mellitus medications. No prior history of
stroke or heart attack. There are no religious restrictions in health management of the
client and no known vices. Based on Erik Erikson’s Theory of Psychosocial
Development, the patient falls under Integrity vs. Despair.

2. Mental and Emotional Status

Patient is unconscious and temporarily loses consciousness but wakes upon
stimulation. She is able to obeys commands, eye response is spontaneous and no
verbal response due to ETT. Upon received, the GCS is 11.

3. Environmental Status
There is a steady pattern of activity, light noise, ventilation, and color in her
environment. The bedside is kept and no waste is noted. She is accompanied by her
sister-in-law throughout the hospitalization and prior to the admission, the patient is
living alone.

4. Sensory Status
a. Visual Status
The client has a spontaneous eye-opening upon neurological
assessment. Isocoric pupils at 2-3 mm, EBRTL, primary gaze is at midline and her
right eye cannot open properly. There is an even distribution of hair on
eyebrows and eyelashes. No nystagmus noted.

b. Auditory
The patient is able to hear sounds. However, she is unable to respond
verbally due to insertion of ETT. The auricles are aligned with the outer canthus
of the eye. The pinna recoils when folded and with minimal amount of cerumen

7
 in the ear. No auditory device is being used by the patient.

c. Olfactory Status
The patient is not able to distinguish an odor because she has a
nasogastric tube inserted on her left nare. The nose was seen to be symmetrical
and the septum is located midline. Upon palpation of frontal and maxillary
sinuses, there is no tenderness noted.

d. Gustatory Status
Patient was intubated via ETT prior to craniotomy therefore some
assessment cannot be applied due to the patient’s condition.

e. Tactile Status
The patient can perceive pain as she is opening her eyes when
stimulated with the dull end of a pencil on her left plantar area.

5. Motor Status
The patient has a flaccid and plegic right extremities with hyperreflexia
and positive Babinski reflex. While on the right extremities there were no
deformities or tremors noted and able to move her right sided body.

6. Thermoregulatory Status

Throughout the clinical rotation, the patient didn’t develop seizures and
she was able to maintain normal temperature throughout the shift.

Date Time Temperature

August 8, 2022 7 36.3

8 36.5
9 36.2
10 36
11 36.5
12 36
1 36.2
2 36
3 36
4 36.3
5 36.5
6 36.6

August 9, 2022 7 36.3

8 36.5
9 36
10 36.2
11 36.5
12 36.2
1 36
2 36.5
3 36
4 36
5 36.3
6 36.2

August 10, 2022 7 36.5

8 36
9 36.2
10 36.4
11 36.3

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 12 36
1 36
2 36.2
3 36
4 36.5
5 36.4
6 36.3

7. Respiratory Status
The patient has an ETT connected to a mechanical ventilator to aid her
spontaneous breathing, with nebulization therapy. On the third day, the patient is
weaned off and shifted to non-rebtrerater face mask oxygen support on 6 lpm .
level. The patient respiratory rate ranges to 17 to 22 cpm and the O2 is 95%-97%.

Date Time Respiratory Rate SPO2

August 8, 2022 7 18 96%

8 20 97%
9 22 95%
10 20 95%
11 21 97%
12 19 96%
1 21 97%
2 19 97%
3 21 95%
4 20 95%
5 21 96%
6 21 96%

August 9, 2022 7 19 96%

8 19 96%
9 21 95%
10 20 95%
11 18 96%
12 21 96%
1 19 97%
2 20 96%
3 18 97%
4 20 97%
5 17 95%
6 20 95%

August 10, 2022 7 20 97%

8 21 98%
9 21 95%
10 18 96%
11 20 96%
12 17 97%
1 20 96%
2 21 97%
3 20
4 17

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 5 21 97%
6 19 95%
95%
96%

8. Circulatory Status
The patient has a sidedrip of Nicardipine and upon assessment, the
patient’s capillary refill is normal. The noted capillary refill time is consistently less
than 2 seconds in the whole rotational duty and the cardiac rate is normal.
However, the blood pressure of the client is elevated.

Date Time CR Capillary Refill BP

August 8, 2022 7 73 140/80

8 78 130/90
9 83 130/100
10 77 <2 150/90
11 76 140/90
12 92 160/100
1 86 150/90
2 89 150/80
3 83 140/80
4 86 130/100
5 78 130/100
6 83 130/90

August 9, 2022 7 75 140/80

8 80 120/80
9 86 130/90
10 89 120/90
11 85 130/80
12 87 <2 120/80
1 90 130/90
2 94 150/100
3 87 140/80
4 82 120/80
5 77 130/80
6 73 120/80

August 10, 2022 7 73 120/80

8 73 150/90
9 87 120/80
10 82 130/90
11 71 120/90
12 86 140/80
<2
1 97 160/100
2 94 150/100
3 87 140/80
4 82 130/80
5 85 130/90
6 87 120/80

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9. Nutritional Status

The patient’s diet prior to her admission is usually high in fats and
carbohydrates. During the hospitalization, she has a NGT on the left nare with a 250 ml
oral fluid diet per meal. She is on a OF diet. There are no cultural or religious
dietary restrictions reported by the patient’s significant other.

10. Elimination Status

The patient wears an adult diaper and she has an intact IFC connected to a
urine bag. On the first and second day of duty the patient did not have any bowel
movement and on the third day she was given lactulose and had 1 bowel movement
at the end of the shift.

Urine Output
August 8 950cc
7AM-7PM
August 9 900cc
7AM-7PM
August 10 1100cc
7AM-7PM

11. Sleep, Rest and Comfort Status

The patient sleeps most of the time and wakes up when stimulated
awaken. She appears weak and irritable and eyes slightly sunken.

12. Fluids and Electrolytes Status

During the hospitalization, she has ongoing IVF of PNSS 1L X 16 hrs. Also,
she has side drip medication such as nicardipine with 90 mL of PNSS,
tranexamic acid 1g with 90ml of PNSS for 8 hours and Totilac 250 mL x 40cc/hr.
The patient’s capillary refill is less than 2 seconds, with dry and chapped lips.

13. Integumentary Status

The patient’s skin and nail bed are pale, the forehead was cool to the
touch and so are the extremities. No noted pressure ulcer and lesions. Her skin
turgor is less than 2 seconds, the fingernails are trimmed and well kept. No
noted edema on extremities. IVF and side drips are infusing well on the right
hand. Some parts of her hair were shaved in the area of incision for craniotomy.

11
XII. Diagnostics
Diagnostic procedure Description of procedure
and date done
CT Scan A Ct Scan may be ordered when a
person has any number of signs and
symptoms that may be related to
muscle and bone disorder such as
tumors and fractures. By doing this
procedure it can also reveal the
exact location of the blood clot,
tumor and even the infection. The
procedure can be a guide for
surgeries, biopsy and radiation
therapy.
Complete Blood A CBC may be ordered when a
Count person has any number of signs and
symptoms that may be related to
disorders that affect blood cells.
When an individual has an infection,
inflammation, bruising, or bleeding,
a doctor may order a CBC to help
diagnose the cause and/or
determine its severity.
It also measures many different parts
and features of your blood,
including red blood cell, WBC,
platelets, hemoglobin, hematocrit.
A complete blood count may also
include measurements of chemicals
Significance/ Purpose of the
procedure
To determine if the patient has
existing internal injuries and
bleeding as they have seen her
lying at the floor unconscious.
To determine general health
status, screen, diagnose, or
monitor any one of a variety of
diseases and conditions that
affect blood cells, such as
anemia, infection, inflammation,
bleeding disorder or cancer it is
recommended for patients who
have signs and symptoms of
systemic toxicity; such tests
include blood cultures, complete
blood cell (CBC) with differential,
and creatinine levels; blood and
skin samples may be taken to
confirm the diagnosis and type of
Significant findings Nursing Implications
- Positive Health care professional primary responsibility
capsuloganglionic bleed is to determine the right procedure and
left approximately 46cc treatment to give the patient. Prior to this
- Positive midline shift of diagnostic procedure the nurses needed
9mm informed consent to the family of an
unconscious patient, check the health history
and NPO status.
Red Blood Cells (RBC) RBC- has proteins that contains iron that helps
Normal Range: transports oxygen and carbon dioxide to and
4.7-6.1 from the lungs to various tissue around the
Result: body. Red blood cell production naturally
6.5-high rises to compensate for the decreased
oxygen supply. Thus, hemoglobin and
hematocrit levels will be higher than normal.
12
and other substances in your blood.
These results can give your health
care provider important information
about your overall health and risk for
certain diseases.
bacteria present. A bacterial
culture can occasionally identify
the organism that is causing the
problem

Hemoglobin (HgB) Clients Hemoglobin is high due to low

Normal Range: availability of the client’s oxygen state.
12-16. g/dl
Result:
16.2- slightly elevated

Hematocrit (HCT) When the blood oxygen levels are low, the
Normal Range: body produces more hematocrit cells to
37%-47% compensate for low oxygen levels.
Result: 48- slightly
elevated

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 White Blood Cell Low wbc indicates that the client is at risk for
Normal Range: 6200- infection
18800
Result: 16000

BASO Within normal range

Normal Range: 0-1
Result: 0

EOSINO Within normal range

Normal Range: 1-6
Result: 3

NEUTR Within normal range

Normal Range: 40-90
Result: 89

LYMPHOCYTES Low lymphocytes indicates that the client has

Normal Range: 20-60% less cell to fight infection
Result: 18%

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 MONO Within normal range
Normal Range: 2-8
Result: 3

Urinalysis A test for of your urine. It can help It is used to detect and manage a Glucose is positive When glucose is positive, the symptoms are
medical professionals detect wide range of disorders, such as excessive thirst, frequent urination, and may
problems that may be shown by urinary tract infections, kidney also indicate diabetes. In people with
your urine. disease and diabetes. diabetes, however, the body either doesn’t
make enough insulin or the insulin produced
doesn’t work properly. This causes glucose to
build up in the blood.

This test is important for the patient to assess

bladder, diabetes. dehydration and
preeclampsia.

PT A PT or Prothrombin time is a blood It is used to find the cause of NORMAL: A test result showing low value numbers
test used to measure how quickly abnormal bleeding or bruising. 11 to 13.5 seconds indicates that the clotting time of the patient
your blood forms a clot. Also it is use to check liver function RESULT: is slow. Whereas an increased value indicates
and look for signs of a blood 13.8 the presence of bleeding or possible
clotting or bleeding disorder. Slightly elevated problems with the blood.

15
PTT It is a test result to check the time This is used to see for problems with
when your blood will clot.
Chest X-ray A chest x-ray is a medical
examination that uses a small
amount of radiation (x-rays) to pass
through the chest to create images
of the lung structures and organs in
the chest. It should be the first
choice when considering and
testing for signs of abnormalities in
the lungs This technique is quick,
safe, inexpensive and painless.
bleeding or bruising. It can also be
used to detect if there is a blood
clot in a vein or artery.
This method is used to assess lung
status from airway images when a
patient exhibits the common signs
and symptoms of pneumonia or
pleural findings. This method
usually gives immediate results.
Resulting in sharper images which
answer whether the patient has
pneumonia or other abnormalities.
It is less expensive than other tests
and CT scans.
NORMAL: A test result showing low value indicates that
25 to 35 seconds the clotting time of the patient is slow.
RESULTS: Whereas an increased value indicates the
37 presence of bleeding or possible problems
Slightly elevated with the blood.
-Progression of coarse Pleural thickening develops when scar tissue
reticular densities in right thickens the delicate membrane lining the
lower lobe lungs (the pleura). Pleural thickening can
develop following asbestos exposure or other
-Minimal pleural effusion conditions, such as infection.
vs thickening in the right
costophrenic sulcus Pleural effusion is the accumulation of fluid in
space surrounding the lungs, “water on the
lungs,” is the build-up of excess fluid between
the layers of the pleura outside the lungs.
This means that the client has also pulmonary
problems.
16
XIII. Comprehensive Pathophysiology

17
XIV. Treatment/ Management
A. Drugs

Drug Name Mode of Action Indication/ Adverse Effects Nursing Responsibilities

Contraindication

GENERIC: Selective serotonin (5-
Ondansetron HT3) receptor antagonist.
Serotonin receptors are
Hydrochloride
located centrally in the
chemoreceptor trigger
zone (CTZ) and
BRAND: peripherally on the vagal
Zofran nerve terminals.
Serotonin is released
THERAPEUTIC from the wall of the small
intestine and stimulates
CLASS:
the vagal efferents
Antiemitic
through the serotonin
receptors and initiates
PHARMACOLOGIC the vomiting reflex.
CLASS:
(Wilson Shannon & Stang
5-HT3 Antagonist
2007)
DOSAGE:
4mg
ROUTE:
PO
INDICATION: CNS: Headache dizziness, fatigue, Dx:
malaise, sedation, fever, pain
- Prevention of nausea -Monitored vital signs especially BP during
and vomiting CV: arrhythmia, chest pain IV administration
associated with initial
G1: Nausea, diarrhea, -Monitored fluid and electrolyte status.
and repeated courses constipation, decreased Diarrhea, which may cause fluid and
of cancer appetite, xerostomia, electrolyte imbalance, is a potential
chemotherapy, adverse effect of the drug.
GU: urine retention, gynecology
including high-dose
-Monitored for extrapyramidal reactions
cisplatin; RESPIRATORY:
-Verified doctor’s order
postoperative nausea
Hypoxia
and vomiting.
Tx:
SKIN:
-Gave direct IV doses slowly for 1-2 mins
CONTRAINDICATION: Puritus
-Monitor ECG
- hypersensitive to the Other: chills, injection site irritation
drug -Provided rest and comfort
- ECG changes Edx:
prolonged qt
-Encouraged patient to report untoward
signs and symptoms

18
 - patients with hepatic -Educated patient on possible side effects
impairment
-Encouraged patient to verbalize
concerns.

-Be aware that headache requiring an

analgesic for relief is a common adverse
effect.

Drug Name Mode of Action Indication/ Adverse Effects Nursing Responsibilities

Contraindication

GENERIC: Calcium entry blocker INDICATIONS: CNS: Dizziness or headache, BEFORE:

that inhibits the Either alone or with fatigue, anxiety, depression, Dx:
NICARDIPINE
transmembrane influx of beta blockers for parerethesias, insomnia, -Assess blood pressure before
HYDROCHLORIDE
somnolence, nervousness. administering. If BP is <90/80, hold and refer
calcium ions into cardiac chronic, stable (effort-
Side drip to the doctor
muscle and smooth associated) angina; CV: Pedal edema, hypotension, -Assess pain (note type, location, and
BRAND: muscle, thus affecting either alone or with flushing, palpitations, intensity) prior to administration
contractility. More other tachycardia, increased angina. Tx:
Cardene
selectively affects antihypertensives for -Administer accurate dose on right route as
THERAPEUTIC GI: Anorexia, nausea, vomiting,
vascular smooth muscle essential hypertension. dry mouth, constipation, prescribed
CLASS:
than cardiac muscle; dyspepsia. EDx:
Antihypertensive -Provide information on the possible
relaxes coronary vascular CONTRAINDICATIONS:
Agent Skin: Rash, pruritus. side/adverse effects that may occur
smooth muscle with little
during therapy
PHARMACOLOGIC Hypersensitivity to Body as a Whole: Arthralgia or
CLASS: DURING:
nicardipine; arthritis. Dx:

19
Calcium Channel or no negative inotropic advanced aortic -Be aware that patient may be at risk for
Blockers effect. stenosis; lactation. CV events monitor accordingly
Tx:
(Pearson Prentice Hall, - Administer with caution to patients with
ROUTE: 2007) hepatic or renal impairment
- Keep emergency equipment readily
IV
available at time of initial dose, in case of
DOSAGE: severe hypersensitivity reaction
EDx:
Adult: -Caution the patient and family/caregivers
IV 20 mg q8h PO = to guard against falls and trauma due to
0.5 mg/h; possible dizziness and drowsiness
AFTER:
30 mg q8h PO =
Dx:
1.2 mg/h;
- Observe for large peak and trough
differences in BP. Initially, measure BP at
40 mg q8h PO =
peak effect (1–2 h after dosing) and at
2.2 mg/h
trough effect (8 h after dosing).

-Assess fluid intake and output. Watch for

signs and symptoms of water intoxication.
Tx:
-Administer every 6 hrs or as indicated by
the physician to maintain serum levels and
control pain
EDx:
- Record and report any increase in
frequency, duration, and severity of
angina when initiating or increasing
dosage. Keep a record of nitroglycerin use

20
 and promptly report any changes in
previous anginal pattern. Increased
incidence and severity of angina has
occurred in some patients using
nicardipine.
- Do not change dosage regimen without
consulting physician.
- Be aware that abrupt withdrawal may
cause an increased frequency and
duration of chest pain. This drug must be
gradually tapered under medical
supervision.

Drug Name Mode of Action Indication/ Adverse Effects Nursing Responsibilities

Contraindication

GENERIC: A naturally occurring INDICATIONS: CV: Bradycardia, tachycardia, BEFORE:

endogenous nucleoside -CVA in acute and hypotension Dx:
CITICOLINE
involved in the recovery phase - Monitor blood pressure, heart rate, and
GI: Diarrhea, epigastric pulse rate
BRAND: biosynthesis of lecithin. It -Recent cranial discomfort, stomach pain - Assess allergic reactions such as GI
Cholinerv increases the synthesis of trauma/head injury
phosphatidylcholine and -Cognitive disorders CNS: Fatigue, dizziness, headache disturbances
THERAPEUTIC Tx:
CLASS: enhances acetylcholine -Disturbance in Skin: Rashes - Prepare prescribed dose and verify route
production. It is also consciousness of administration
psychostimulants/
claimed to increase following brain sugery Edx:
nootropic agent
- Instruct the client/SO on the possible
adverse effects of the drug during therapy
DURING:

21
PHARMACOLOGIC blood flow and oxygen CONTRAINDICATIONS: Dx:
CLASS: to the brain. -Hypersensitivity to -Continue monitoring vital signs
citicoline and its -Monitor for manifestations of
pyrimidine
ribonucleoside hypersensitivity. Report patient’s
components
diphosphates appearance promptly and discontinue
(MIMS Drug Reference, -Hypertonia of the drug
ROUTE: 2019) parasympathetic Tx:
nervous system - Administer prescribed dose via right route
IV
and check for induration or inflammation
DOSAGE: - Administer during prescribed time with or
1g IV q 6hrs without meals
Edx:
- Instruct patient and watcher to observe
for adverse/allergic reactions; notify
physician immediately if patient develop
hives, rash, itching, chest tightness, or
trouble breathing
AFTER
Dx:
- Assess for adverse effects and evaluate
for therapeutic response
Tx:
- Administer drug only for indicated use
- Maintain a safe environment against falls
and trauma
Edx:
- Teach client and SO to recognize and
immediately report adverse drug effects to
provide timely interventions

22
Drug Name Mode of Action Indication/ Adverse Effects Nursing Responsibilities
Contraindication

GENERIC: An antifibrinolytic agent Indications: CNS: Dizziness, fatigue BEFORE:

that inhibits the - Treatment of Dx:
TRANEXAMIC EENT: Visual defects - Monitor blood pressure, pulse, and
ACID breakdown of fibrin clots. excessive bleeding
respiratory status as indicated by severity of
CV: Hypotension,
BRAND: It blocks the lysine resulting from systemic bleeding
or local thromboembolism, thrombosis
binding sites of - Monitor neurologic status (pupils, level of
Hemobas hyperfibrinolysis
plasminogen and impairs GI: Diarrhea, nausea, vomiting, consciousness, motor activity) in patients
THERAPEUTIC - Prophylaxis in patients abdominal pain with subarachnoid hemorrhage
the endogenous
CLASS: with coagulopathy Tx:
fibrinolytic process, thus Musculoskeletal: Back pain, - Stabilize IV catheter to minimize
Hemostatic agent undergoing surgical
preserving and stabilizing procedures muscle cramps and spasm, thrombophlebitis. Monitor site closely
PHARMACOLOGIC the fibrin matrix structure. arthralgia Edx:
CLASS: - Provide information to client and SO on
Contraindications: Skin: Allergic dermatitis
possible adverse effects during therapy
Antifibrinolytic - Hypersensitivity to the - Instruct client and SO to inform healthcare
ROUTE: (MIMS Drug Reference, drug provider if there is presence of color
2022) - Active intravascular blindness, have a history of stroke, blood
IV
clotting clot, or bleeding in the brain
DOSE: - Subarachnoid DURING:
Dx:
Side Drip: hemorrhage
- Assess the patency of the IV site and IV
1g + 90mL PNSS x line prior to administration
8hrs Tx:
- Administer prescribed dose of drug at the
right route
- Administer at the right time without regard
to meals

23
 Edx:
- Caution client and SO to avoid products
containing aspirin or NSAIDs
AFTER:
Dx:
- Assess client for adverse effects and
evaluate therapeutic response
- Monitor client for unusual bleeding
patterns
Tx:
- Be alert for bleeding gums, nosebleeds, or
other unusual bleeding or bruising that
might indicate inadequate drug effects
Edx:
- Advise client and SO to immediately
report severe allergic reactions such as
rash, hives, itching, dyspnea, tightness in
the chest, and swelling of the mouth, face,
lips, or tongue

Drug Name Mode of Action Indication/ Adverse Effects Nursing Responsibilities

Contraindications

GENERIC: Fentanyl binds to opioid Indications: CNS: Agitation, ataxia, confusion, BEFORE:
receptors, especially the - As adjunct to delusions, dizziness, drowsiness, Dx:
Fentanyl mu opioid receptor, regional euphoria, fever, headache, lack - Assess the patient’s overlying condition
which are coupled to G- anesthesia
BRAND: of coordination, ligh-headedness, before starting drug therapy.
proteins. Activation of - IV injection
opioid receptors causes nervousness, paranoia, seizures - Monitor vital signs and bladder function.
Sublimaze
GTP to be exchanged for Tx:
GDP on the G-proteins Contraindications:

24
THERAPEUTIC which in turn regulates Hypersensitivity CV: Bradycardia, chest pain, - Verify the physician's order before
CLASS: adenylate cyclase, to fentanyl or its hypotension, tachycardia, administering the drug.
reducing concentrations components, orthostatic, edema Edx:
Narcotic (opioid) of cAMP. Reduced intermittent
Analgesic - Educate the patient or the watcher on
cAMP decreases cAMP pain, opioid EENT: Blurred vision, dry mouth,
dependent influx of non tolerance, information regarding the drug.
PHARMACOLOGIC rhinitis, tooth loss, dental caries - Educate the patient or the watcher on
calcium ions into the cell. significant
AL CLASS: sneezing the adverse effects before starting drug
The exchange of GTP for respiratory
Opioid agonist GDP results in depression, therapy.
RESP: Hypoventilation, dyspnea,
hyperpolarization of the treatment of
cell and inhibition of mild to respiratory depression
ROUTE: DURING:
nerve activity. moderate pain
IV Other: Anaphylaxis, weight loss Dx:
responsive to
(Wandel C, Kim R, Wood nonopioid drugs, - Monitor vital signs and respiratory status.
DOSAGE: M, Wood A, 2022) upper airway Tx:
obstruction - Administer the prescribed dose and right
2 mg iv q 2 hours
route.
Edx:
-Instruct patient or watcher to change
positions slowly to minimize orthostatic
hypotension.

AFTER:
Dx:
- Assess the patient for withdrawal
symptoms after dosage reduction or
conversion to another opioid analgesic.
- Assess for adverse effects and reactions.
Tx:
- Administer every 2 hours according to the
physician’s order.
Edx:

25
 - Encourage the patient or the watcher to
report any untoward accidents or adverse
effects of the drug

Drug Name Mode of Action Indication/ Adverse Effects Nursing Responsibilities

Contraindications

GENERIC: Dilate or enlarge the INDICATIONS: CNS: Tremor, anxiety, nervousness, BEFORE:
airways by relaxing the restlessness, convulsions, Dx:
ALBUTEROL muscles surrounding the - Bronchospasm weakness, headache, - Check inhalation technique
airways. Synthetic associated with acute
BRAND: hallucinations - Review directions for correct use of
sympathomimetic amine or chronic asthma,
and moderately medication and inhaler
Salbutamol bronchitis, or other CV: Palpitation, hypertension,
selective beta2- Tx:
reversible obstructive hypotension, bradycardia, reflex - Confirm the right dose before
THERAPEUTIC adrenergic agonist with
comparatively long airway diseases tachycardia administering
CLASS:
action. Acts more - Put no smoking sign on the door and
Bronchodilators prominently on beta2 - Exercise-induced EENT: Blurred vision, dilated pupils
ensure to avoid irritants
receptors (particularly bronchospasm.
PHARMACOLOGIC smooth GI: Nausea, vomiting EDx:
muscles of
CLASS: bronchi, uterus, and CONTRAINDICATION: - Provide adequate information about the
Other: Muscle cramps, possible side and adverse effects
vascular supply to
Beta-2 Adrenergic - Hypersensitivity to the hoarseness, hypersensitivity
skeletal muscles) than on
Antagonist drug and its reaction
beta1 (heart) receptors. DURING:
ROUTE: Inhibits histamine release components Dx:
by mast cells. Produces - Observe for bronchospasm (wheezing)
Inhalation bronchodilation, - Pregnancy (category
regardless of C) - Counsel SO on proper use of nebulizer
DOSAGE: administration route, by
relaxing smooth muscles Tx:
2mg
of bronchial tree.
- Confirm clients name and administer
medication
- Evaluate therapeutic response.

26
 (MIMS Drug Reference, - Avoid getting in eyes
2019) EDx:
- Instruct SO to observe any adverse
reaction and report immediately

AFTER:
Dx:
- Assess client response to medication and
document
Tx:
- Rinse client’s mouth and apply lubricant
to clients’ lips after administration to
minimize dry mouth
EDx:
- Instruct SO to report any untoward events

B. IV Fluids
Name Classification Component/s Use & Effects Nursing Responsibilities

PNSS Crystalloid Fluid - Sodium Chloride (sodium ● Used for fluid and BEFORE:
(0.9% Sodium chloride (sodium chloride electrolyte replenishment Dx:
Chloride) injection) injection) Injection, for intravenous - Monitor vital signs for baseline data
USP is a sterile, nonpyrogenic administration. Normal - Obtain patient’s history of fluid and
Generic Name: solution for fluid and electrolyte levels prior to therapy
Saline may be used alone
Sodium chloride electrolyte replenishment in Tx:
or with other medications.
injection single dose containers -Verify doctor’s order for IV fluid
for intravenous administration. administration and double check correct
● Brand Name: type and bottle of IV fluid to be infused

27
● Normal Saline
-It contains no antimicrobial
agents. The nominal pH is 5.5
Dose/Volume: (4.5 to 7.0). Composition,
1000mL to run for osmolarity, and ionic
16 hrs. concentration are shown
below:
-Check for the correct patient to be
administered to before giving the bottle
-Check integrity of IV solution including
clarity, intact seals, and leaks to ensure
sterility
EDx:
- Teach patient and watchers to recognize
signs and symptoms of fluid overload such
as swelling and difficulty of breathing
DURING:
Dx:
- Continue monitoring patient’s vital signs,
edema status, and lung & heart sounds
- Monitor patient frequently for signs of
infiltration and fluid overload
-Monitor and record input and output
accurately
Tx:
-Regulate IV drop rate as indicated and
properly label IV bottle
- Promote comfort and proper positioning
-Change IV fluid as necessary and observe
aseptic technique when changing
EDx:
-Instruct patient on the proper positioning
of extremity where the insertion site is
located to ensure better infusion
AFTER:
Dx:
28
 - Monitor manifestations of continued
hypovolemia such as decreased urine
output, poor skin turgor, tachycardia, and
hypotension
-Continue checking for signs of infiltration
and fluid overload
Tx:
- Ensure IV-line patency, make sure that line
is open and not blocked, check for
presence of air or bubbles
- Check IV insertion site if dry, intact, and
secured
EDx:
-Instruct patient and watcher to report
adverse reactions immediately and to
notify the nurse if the patient is having
trouble breathing or notices any swelling

Name Classification Component/s Use & Effects Nursing Responsibilities

Totilac Hypertonic Lactate - Totilac is a sterile non- ● It resuscitates BEFORE:

pyrogenic solution (hypertonic) and Dx:
Generic Name: containing hypertonic energizes, involving a - Monitor vital signs for baseline data.
Hypertonic concentration of high content of - Assess patients' pain before starting
Lactate Solution sodium lactate with lactate, which is the therapy and regularly thereafter to monitor
physiological preferred fuel of the drug’s effectiveness.
Brand name: concentration of brain. In patients with Tx:
Totilac potassium chloride cardiac problems, it is -Do not administer unless the solution is
and calcium chloride used to increase clear and the container is undamaged.
Dose/volume: in water for injection. cardiac index. Discard unused portions.
This solution has an

29
250 ml with an osmolarity of 1020 -Verify doctor’s order for IV fluid
infusion rate of 40 mOsm/L and a pH of ± administration and the dose. Double
cc per hour. 7.0. check correct type and bottle of IV fluid to
be infused
- It contains strong ions Edx:
which are fully - Educate the watcher on adverse effects
dissociated into anions of the solution.
(lactate and chloride) DURING:
and cations (sodium, Dx:
potassium, calcium) -If an adverse reaction does occur,
when dissolved in discontinue the administration, evaluate
water. the patient, institute appropriate
therapeutic countermeasures and save
the remainder of the fluid for examination
if deemed necessary.
Tx:
- Regulate drop rate as indicated.
- Replace fluid as necessary.
EDx:
-Instruct watcher on the proper positioning
of the patient when receiving the solution.
AFTER:
Dx:
- Continue checking for signs of fluid
overload and infiltration
Tx:
- Check IV-line patency and for bubbles
and air, make sure that the IV insertion site
is dry and secured.
Edx:

30

C. Surgery
Procedure Description & Indication
Craniotomy A procedure done where neurosurgeons temporarily
August 7, 2022 remove a small portion of the skull bone to obtain
access to the brain in order to treat several brain
abnormalities. The client has undergone left fronto-
temporal craniotomy with the major indication to
remove intracerebral hematoma or blood clots to
prevent brain tissue compression which may cause
life-threatening complications. The evacuation will
be done by gently removing the hematoma through
suction and irrigation, and after the surgery, the
surgeon will replace the removed bone flap using
plates and screws.
- Instruct the watcher to report any adverse
reactions.
Nursing Care/Responsibilities
Preoperative:
● Perform appropriate and necessary pre-
operative preparations to the patient including
accomplishment of surgical informed consent
● Perform baseline neurologic assessment for
evaluation and post-operative comparison
● Monitor vital signs, respiratory status, and GCS
closely as indicated until recovery and ward
transfer
Post-operative:
● Position head of the bed at 15-30 degrees to
promote venous drainage
● Maintain ICP within normal range
● Assess craniotomy site for bleeding, CSF
leakage, and signs of infection
● Perform wound care as necessary to keep the
incision clean
● Use sterile technique for dressing changes,
catheter care, and ventricular drain
management
● Have suction equipment ready at bedside
31
● Assist patient in pain management as
prescribed
● Instruct patient and SO to avoid activities that
can elevate ICP such as excessive flexion and
extension of the head and other ROM exercises
and Valsalva maneuver

32
XV. Nursing Care Plans
A. Prioritization of Problems

A1. List of Problems

1. Ineffective Airway Clearance related to post-operative intracerebral brain hemorrhage as evidenced by inability to cough up secretions.

2. Ineffective cerebral tissue perfusion r/t interruption of blood flow as evidenced by unstable BP, right sided weakness and inability to perform gross motor skill.

3. Impaired Verbal Communication related to neurologic deficit as evidenced by slurred, stuttered speech and difficulty speaking.

4. Risk for bleeding

5. Risk for injury

A2. Basis for Prioritization

Nursing Diagnosis Justification

1. Ineffective Airway Clearance related to post-operative intracerebral brain
hemorrhage as evidenced by inability to cough up secretions.
2. Ineffective cerebral tissue perfusion r/t interruption of blood flow as
evidenced by unstable BP, right sided weakness and inability to perform
gross motor skill
According to the ABC rule, which stands for Airway, Breathing, and Circulation,
the airway must receive the first priority. Additionally, respiratory problems might
make a client anxious and cause other problems, which is why they require
prompt care. Giving the customer a clear airway will result from addressing the
issue with the appropriate healthcare practitioner. Every cell needs oxygen to
work properly, therefore any issues with the cell may quickly have an impact on
how well a person is doing.
Ineffective tissue perfusion describes the lack of oxygenated blood flow to areas
of the body. Proper perfusion is detrimental to the function of organs and body
systems as organs and tissues that are not perfusing will die. Poor perfusion to the
brain may result in confusion, speech changes, poor motor control, vision loss,
changes in sensation, and loss of consciousness. This makes Ineffective cerebral
tissue perfusion our second priority. The early management and prevention of its
other manifestation will help the patient in her fast recovery.

33
 3. Impaired Verbal Communication related to neurologic deficit as
evidenced by slurred, stuttered speech and difficulty speaking.
4. Risk for bleeding
Communication assists in the performance of accurate and consistent nursing
care, ensuring both the satisfaction of the client and the protection of the health
professional. Without communication, concerns and needs of the client won’t be
addressed which makes this our third priority.
The patient undergoing a craniotomy has a higher risk of bleeding since the
incision will allow the extra fluid in the brain to drain. Due to the rarity of significant
blood loss, this was given the fourth priority. However, according to PubMed
Central, substantial blood loss can lead to hemodynamic instability, which can
raise mortality and morbidity.

5. Risk for injury An intracerebral brain hemorrhage may permanently affect a patient's gait,
locomotion, and cognitive functioning, which raises the risk of injury. Furthermore,
they might require extensive or complete assistance with ADL.

B. Nursing Care Plans

Actual Problem: Ineffective Airway Clearance related to post-operative intracerebral brain hemorrhage as evidence by inability to cough up secretions.

Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation

problem
Subjective Data: Ineffective airway Short Term: Diagnostic STO:
- N/A clearance is the Within 8 hours of Established rapport with Essential to therapeutic nurse- After 8 hours of effective nursing
inability to clear effective nursing the significant other. patient relationship. Provides interventions, patient was
Objective Data: secretions or interventions, patient will unable to excrete airway
actual information concerning
- GCS11, obstructions from be able to excrete the diagnosis, treatment, and secretions but SPO2 remained
E4V1M6 the respiratory tract. airway secretions prognosis. in normal range. Goal partially
- Unable to Ineffective cough met.
Assessed Glasgow To assist in the diagnosis and
cough up compromises airway Coma Scale and Vital prognosis. To assist the current
secretions clearance and Signs. health status and to identify
prevents mucus Long Term: needed care of the patient. LTO:

34
- SpO2; 98, from being Within 3 days of Assessed and noted use To assist in the diagnosis and
RR; 18 expelled. effective nursing of accessory muscle prognosis. To assist the current After 3 days of effective nursing
- Clear Respiratory muscle interventions, patient will while breathing, health status and to identify interventions, patient
breath fatigue, severe demonstrate increased breathing pattern, needed care of the patient. demonstrated normal air
sounds bronchospasm, or air exchange. patency of airway and exchange as evidenced by
- Use of thick and tenacious auscultated lung sounds. normal breath sounds and
accessory secretions are Therapeutic normal respiration. Goal met.
muscles possible. Positioned to high Promote maximum lung
while fowlers position. expansion for efficient gas
breathing. Reference: exchange.
Doenges, M. E.,
Facilitated oral care and Oral care to promote health
Moorhouse, M. F., & Murr,
A. C. (2019). Nurse’s suction orally and maintenance of the oral
Pocket Guide Diagnoses, endotracheal tube as mucosa. Suction to remove
Prioritized Interventions,
needed. secretions and promote
and Rationales (15th ed.).
F. A. Davis Company.
patency of airway.
Facilitated nebulization Nebulization to promote
and oxygen therapy as looseness of secretion and for
ordered. easier expectoration or
suction. Oxygen therapy for as
support since patient cannot
breathe independently.
Ensured seizure Promote safety and protect
precaution; siderails client from harm and danger.
elevated.
Educative
Instructed significant To promote involvement in the
other to report any care process and for early
untoward circumstances delivery of care or intervention.
to report.

35
 Encouraged significant To alleviate anxiety and
other to verbalize health provide actual condition of the
concerns about the patient.
patient.
Reiterated significant Protect the patient for further
other to importance of acquisition of nosocomial
infection control and infection.
waste management.

Actual Problem: Ineffective cerebral tissue perfusion r/t interruption of blood flow as evidenced by unstable BP, right sided weakness and inability to perform gross motor skills.

Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation

problem
Subjective Data: The client is a stroke Short Term: Diagnostic STO:
N/A patient caused by Within 8 hours of Monitored BP for Stable BP is needed to keep After 8 hours of effective nursing
Objective Data: intracerebral effective nursing orthostatic changes sufficient tissue perfusion. interventions, patient’s BP
● Minimal hemorrhage interventions, patient will Medication effects such as remained unstable but
response to located on the left demonstrate stable vital altered autonomic control, absence of increased ICP was
command thalamocapsular signs and absence of decompensated heart failure, observed. Goal was partially
area. The increased ICP. reduced fluid volume, and met.
● Right sided interruption of blood vasodilation are among many
body flow causes Long Term: LTO:
factors potentially jeopardizing
weakness iInsufficient arterial Within 3 days of After 3 days of effective nursing
optimal BP.
● Inability to blood flow, effective nursing Monitored and Assessing trends in LOC and interventions, demonstrated
perform decreasing nutrition interventions, patient will document neurologic potential increased ICP is improvement of sensory and
gross motor and oxygenation at show improvement in status and compare with useful in determining location, movement as appropriate.
skills the cellular level. LOC, cognition, motor the baseline. extent and progression or Goal partially met.
Decreased tissue and sensory function. resolution of CNS damage.

36
 ● altered LOC perfusion can be Observed for rapid Electrolyte/acid-base
temporary, with few changes or shifts of variations, hypoxia, and
● GCS11, or minimal mental status systemic emboli influence
E4V1M6 consequences to cerebral perfusion. In addition,
● Significant the health of the it is directly related to cardiac
change in patient, or it can be output.
BP: more acute or Therapeutic
> 7am: 140/90 protracted, with Administered oxygen To reduce hypoxemia and
> 9 am: 130/100 potentially and medication as manage hypertension to
> 12 pm: 160/100 destructive effects indicated. prevent further tissue damage.
on the patient. Positioned the head of Reduces arterial pressure by
When diminished the patient slightly promoting venous drainage
tissue perfusion elevated and in neutral and may improve cerebral
becomes chronic, it position circulation
can result in tissue or Provided adequate rest, Continual stimulation can
organ damage or quiet environment and increase ICP. Absolute rest and
death. restrict visitors as quietness may be needed to
indicated. prevent recurrence of
bleeding in cases of
hemorrhagic stroke.
Provided ROM exercises Active ROM exercises maintain
as tolerated and improve muscle strength,
minimizes muscle atrophy,
promote circulation and helps
prevent contractures
Educative
Evaluated eye opening Establishes arousal ability or
level of consciousness.
Evaluated motor Purposeful movement can
reaction to simple consist of grimacing or
commands, noting withdrawing from painful

37
 purposeful and no stimuli. Other movements
purposeful movement. (posturing and abnormal
Document limb flexion of extremities) usually
movement and note specify disperse cortical
right and left sides damage. Absence of
individually. spontaneous movement on
one side of the body signifies
damage to the motor tracts in
the opposite cerebral
hemisphere.
Educated patient’s Early assessment facilitates
watcher signs and immediate treatment
symptoms of increased
ICP

Actual Problem: Impaired verbal communication r/t neurologic deficit as evidenced by slurred, stuttered speech and difficulty speaking

Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation

problem
Subjective Data: The client suffered Short Term: Diagnostic STO:
N/A from stroke which Within 8 hours of Assessed for neurological Neurological conditions such After 8 hours of effective nursing
Objective Data: was caused by effective nursing conditions impacting as stroke, brain trauma, and interventions, the patient was
- Slurred intracerebral interventions, the speech neuromuscular weakness can still unable to express needs
speech hemorrhage patient will be able to affect ability to verbally but responds through
- Stuttering located on the left establish method of communicate eye opening. Goal partially
- Difficulty thalamocapsular communication in Assessed GCS and To establish baseline data met.
speaking area. This sudden which needs can be monitored vital signs and assist in providing timely
vascular expressed interventions

38
- Minimal compromise Noted for presence of Artificial airways such as LTO:
response to causing disruption Long Term: physical barriers, tracheostomy and ET tube After 3 days of effective nursing
commands of the blood vessels Within 3 days of specifically endotracheal can impede ability to speak interventions, the patient was
- Connected in the brain and effective nursing intubation able to follow simple
to cutting off blood interventions, the Therapeutic commands but still has difficulty
mechanical and oxygen supply patient will be able to Provided alternative Provides a method of responding verbally as
ventilator via resulted to an injury demonstrate congruent methods of communicating needs based evidenced by slurred speech,
ET tube to the brain centers, verbal and nonverbal communication such as on the individual situation stuttering, and difficulty opening
- GCS: 11, specifically the left communication and hand gestures and non- and underlying deficit the mouth. Goal partially met.
E4V1M6 hemisphere where utilize communication verbal cues
the Broca’s area or resources appropriately Keep communication To reduce confusion and
the motor speech simple through short lessen anxiety to process
area is located. This phrases and simple information at one time
damage, thus, questions that require
caused the simple responses
patient’s impaired Speak slowly and clearly, To increase likelihood of
verbal and provided sufficient being understood
communication. time for the patient to
respond
Reduced extraneous noise To reduce anxiety and
that can interfere with confusion associated with
comprehension sensory overload
Educative
Encouraged significant To reduce the patient’s
other to continue isolation, promote effective
communicating with the communication, and
patient maintain a sense of
connectedness
Discussed ways to provide To maintain contact with
environmental stimuli as reality. Unwanted sound may
appropriate increase fatigue and make

39

Encouraged patient and
significant other to use
therapeutic
speech communication more
difficult
To improve general
communication skills

Potential Problem: Risk for bleeding

Assessment Explanation of the Objectives Nursing Intervention Rationale Expected Outcome

problem
Subjective Data: It is common to Short Term: Diagnostic STO:
N/A have bleedings Within 8 hours of Monitored for signs of Bleeding may start Goal met if:
Objective Data: after surgery from effective nursing bleeding such as pallor immediately or after several After 8 hours of effective nursing
- CT scan: the incision. Injuries interventions, patient and hematoma. days after surgery. It may interventions, patient will not
Positive from the cerebral will show no signs of occur inside or outside the show signs of bleeding and
capsulogan arteries may cause bleeding and infection. body. infection and wound is in good
glionic bleeding. Other Long Term: Assessed current status Baseline data healing process.
bleed left cause may come Within 3 days of Observed for skin necrosis, Patient on anticoagulant
approximate from effective nursing changes in blue or purple therapy remains at risk for LTO:
ly 46cc and anticoagulants interventions, patient mottling feet that developing emboli Goal met if:
positive such as heparin. will have stable blanches with pressure or After 3 days of effective nursing
midline shift hematocrit and fades when legs are interventions, patient’s
of 9mm hemoglobin levels and eleven hematocrit and hemoglobin are
- RBC: 6.5- desired ranges for Therapeutic stable.
High coagulation profiles. Performed wound care Check for early signs of
and assessment infection, bleeding and
healing process

40
 - HgB: 16.2- Administered antibiotics as Maybe given
slightly ordered prophylactically for
elevated suspected infection or
contamination
- Lymphocyte
Raised bedrails, paddings Provides patient safety snd
s- Low and lock bed wheels as prevents injury to the head
- Urinalysis: necessary and extremities if patient
positive becomes combative while
disoriented
- PT: 13. 8- Educative
slightly Instructed to minimize Increased movement may
elevated effort in moving. disturb the tissue healing
- PTT: 37- process
slightly Emphasized importance of Protect the patient for further
elevated infection control. acquisition of nosocomial
infection.
Instructed to report any To promote involvement in
untoward signs and the care process and for
symptoms. early delivery of care or
intervention.

Potential Problem: Risk for Injury

Assessment Explanation of the Objectives Nursing Intervention Rationale Expected Outcome

problem
Subjective Data: The patient suffered Short Term: Diagnostic STO:
- N/A from stroke Within 8 hours of Determined the client’s These factors play a role in Goal met if:
Objective Data: depriving the brain effective nursing age, developmental the client’s ability to keep After 8 hours of effective nursing
- GCS 11: E4V1M6 of oxygen and interventions, the SO will stage, health status, themselves safe from injury interventions the SO will be able
- Limited ROM blood supply. A CT verbalize understanding lifestyle, impaired to verbalize understanding of

41
- Right sided body scan was done and of factors that can communication, and the factors that can contribute
weakness reveals a contribute to injuries mobility to injury by identifying excessive
- Inability to perform thalamocapsular and will modify Assessed GCS and To establish baseline data and prolonged pressure on a
gross motor skills bleeding at around patient’s environment monitored vital signs and assist in providing timely body part can cause pressure
- Needs full 46cc that puts to enhance safety interventions ulcers, and will be observed
Assistance to pressure on the Assessed the client’s ability Alterations in mobility repositioning the patient and
activities of daily brain that causes Long Term: to ambulate and identify secondary to muscle raising side rails.
living disturbance in Within 3 days of the risk for falls. weakness, paralysis, poor
sensory, behavioral effective nursing balance, and lack of
and cognitive interventions, the coordination increase the risk LTO:
Nursing Diagnosis: functions. The patient will remain free Goal met if:
of falls.
Risk for injury patient undergone of injuries. After 3 days of effective nursing
Therapeutic
craniotomy to Performed Oral care, skin The skin acts as a barrier interventions, the patient will be
evacuate the care and assisted with internal systems. Good free from any kind of injury.
blood pool in the toileting needs Hygiene slows multiplication
brain. Upon of microorganisms
assessment, the Raised bedrails, paddings Provides patient safety and
patient is noted to and lock bed wheels as prevents injury to the head
have limited range necessary and extremities.
of motion, Muscle Repositioned patient every To promote circulation and
weakness, Muscle hour reduce risk for injury. Affected
strength of 3/5, thus side has decreased
making the patient circulation and decreased
at risk for injury. Risk sensation
for injury is the state Educative
in which an
individual is at risk Instructed SO to avoid Patients with decreased
for harm because extremes in temperature cognition or sensory deficits
of a perceptual or (e.g., heating pads, hot cannot discriminate between
physiologic deficit, water for baths/showers) extremes in temperature
a lack of awareness when rendering care.

42
of hazards, or Educated SO on the To involve SO in assistive care
maturational age. importance of and learn importance
repositioning the patient
Reference: regularly.
Doenges, M. E.,
Instructed SO to report any To promote involvement in
Moorhouse, M. F., & Murr,
A. C. (2019). Nurse’s untoward signs and the care process and for
Pocket Guide Diagnoses, symptoms. early delivery of care or
Prioritized Interventions,
intervention.
and Rationales (15th ed.).
F. A. Davis Company.

43
C. Discharge Plan

Health Teaching
Diet/Nutrition 1. Advice the client to eat foods with amino acids, iron,
zinc, and omega-3 fats because the body needs more
of it than usual after an operation. It needs it to repair
cells, fight infection, and heal incisions. Antioxidants
vegetables and are also good choices because it can
protect cells from damage. Leafy greens are high in
vitamin C, manganese, magnesium, folate, and
provitamin A, all of which are essential for immune
function and overall health
2. Encourage eight to 10 glasses of water and non-
caffeinated beverages per day, plenty of fruits and
vegetables as well as lower fat foods.
3. Evaluate personal health and health eating
practices. Let the patient recite the importance of
proper nutrition to maintain healthy body and lifestyle.
4. Teach the dietary guidelines to the patient. Let the
patient have a pencil and paper test regarding the
dietary guidelines.
Activity & Environment 1. Instruct the client to ask for help with chores and
errands while recovering.
2. Instruct client not to lift anything heavy and vacuum
or do active or strenuous housework until the
healthcare provider says it is okay.
3. Encourage patient to do the range-of-motion
exercises that she has learned in the hospital.
4. Have a tidy living space to avoid hitting the surgical
wound on anything
5. Keep the living space clean in order to prevent
infection
6.) Maintain an emotionally supportive environment
with family and friends to promote mental well-being.
7.) It is recommended for the patient to have an safe
environment and free from stressors; an atmosphere
suitable for healing and relaxation.
8.) Refer client to physical therapist for gradually
improvement of neurologic deficit of muscular
function.
Incision and Dressing Care
1. Instruct patient not to remove the dressing, steri-strips
or stitches. If the dressing or steri-strips fall off, do not
attempt to replace them.
2. Encourage client wash the wound area with mild
soap and water and use a towel to dry incision
thoroughly after washing by being careful not to touch
or remove the sutures.

Medication 1. Educate the patient and family prior to discharge,

including proper storage of medications, right dose,
side effects and reiterate the importance of complying
to maintenance medications.
2. Provide the patient and family members with an
accurate list of medications.
3. Educate patient not to take medication not
prescribed by the physician or doctor.
4. Educate patient to attend follow-up appointments.

44
XVI. Learning Insights

A. Awan, Cherry Pearl A.

In this case study, I learned more about CVD as well as stroke which we
commonly see in the hospital especially to older adults. It is one of the cause of
disability and death to many. An immediate treatment is needed to avoid further
complications. Though, the case is quiet challenging because it's different from other
past cases but through this I was able to know its pathology, etiology and treatment.
This study is very important on the part of student nurses for they are trained and
learned to know information needed in helping for the recovery of the patient.
B. Campilis, Glayssa S.

Being able to learn about the types of strokes and about CVD was awesome
since I was able to acquire new knowledge. Furthermore, I was able to further
understand what are the types of strokes, its causative factor, and how it happens.
Reading about this case presentation, I can say that having a stroke sucks. It may
impair a person's body function or cognitive aspect of the human.

C. Cando, Charlene S.

This case study gave me an opportunity to acquire new knowledge about

cerebrovascular accident specifically on hemorrhagic stroke which is common here
in the Philippines and one of the leading cause of disabilities and death. In this case
study I was able to read on the causative factors, complications, medical treatment
and surgery of ICH. As a nursing student it gave me a framework on planning to care
and it helped me practice skills in caring for patients who suffered from stroke, which
can help me be a competent nurse in the future.

D. Dao-ey, Bryan C.

The case was a challenge to my knowledge, attitude, and practice. Handling

CVA, post-operative craniotomy requires hourly assessment and evaluation making
sure that the client receives appropriate intervention in order to prevent such
unexpected events. It was my first to encounter a ICH case and through the
experience, readings regarding its pathophysiology help me better understood the
case.

E. Estaris, Marl Nathaniel L.

Upon doing our case presentation, it is really important to detect

cardiovascular disease as early as possible so that management with counselling and
medicines can begin as we should address its risk factors. Due to the life-altering
impact a stroke can have on a family, it is important for everyone to understand
strokes, recognize them, and employ measures to lower risks for themselves and their
families. I always heard that stroke is one of the common cases in ICU, and through
this, it gave me idea how to properly carry out nursing managements.

F. Mendoza, Yvette Marie L.

This case study is different from the academic case presentations we handled in
the past, but we are all aware that CVA accidents are something we constantly hear
and see in a variety of settings. However, comprehending and carefully analyzing this
situation allows us to learn from it and increase our awareness of how to give care to
people who have suffered from CVA or ICH. Since immediate treatment is required to
prevent further neurological dysfunction and impairment of consciousness,
understanding this as a prospective nurse in the clinical setting would help CVA
sufferers benefit from learning about this case. In general, investigating this instance
helps us pinpoint the contributing elements and risk factors that might play a
significant role.

G. Serran, Abcde Zynmil Z.

For me, this is my most complicated case study because CVD and ICH are not
familiar to my vocabulary, we are glad that we handled this in our rotational duty at
the intensive care unit understanding the brain is hard for me but by researching and
45
 asking questions and by teamwork I was able to understand our case study. This case
helps us to develop our knowledge about the specific problem and to have a broader
analyzation of our case, which is a very important capability of a nurse to acquire

H. Tiglao, Kayla Marie D.

Through this case study, I was able to learn the disease process of CVD and
stroke which is one of the most common cases that are seen in the ICU. Through this
experience of being rotated in the MICU/CCU, we were able to carry out complex
and critical nursing responsibilities since our patients are at risk for life-threatening
complications thus, intensive monitoring is very important. I have learned the
significance of performing each intervention in reducing actual and potential
problems and to improve the patient’s quality of life. In terms of completing our case
study, it may be challenging but teamwork and cooperation helped us have a better
output where we can all learn and apply in our future duties if we encounter a similar
case.

I. Tubaña, Faith Greyle Q.

Being deployed in the MCU/CCU, I was able to appreciate the different

diseases since we were able to handle the patients for 3 days. This case study helped
me in understanding more of the condition of the patient. I have learned that close
monitoring to neuro-patients are really important because they could deteriorate or
recover. Small details should be closely monitored and should be reported
immediately because these can help in the course of treatment of the patients.
Through the rotation I have also learned to use the Glasgow Coma Scale to an actual
patient. This case study helped me in understanding more of the case of the patient
which would help me in my future duties.

J. Wong, Heather Shane A.

Upon reading our case, I had a hard time understanding the disease because
I am not familiar with it. Through this, I was able to learn more about CVD, despite me
not having first-hand experience in the MCU/CCU. I also learned that proper
assessment and monitoring of our patients will lead to a more holistic and quality
nursing care. This case study serves as a guide if ever I will encounter such patients
with the same problem.

46
XVII. List of References

ASA. (2022). Hemorrhagic Stroke (Bleeds). Retrieved from https://www.stroke.org/en/about-

stroke/types-of-stroke/hemorrhagic-strokes-bleeds. Retrieved on November 12, 2022

ASA. (2022). Stroke Symptoms. Retrieved from https://www.stroke.org/en/about-stroke/stroke-

symptoms. Retrieved on November 12, 2022

CDC. (2022). About Stroke. Retrieved from

https://www.cdc.gov/stroke/about.htm#:~:text=There%20are%20two%20types%20of,
Hemorrhagic%20stroke. Retrieved on November 12, 2022

CDC. (2022). Stroke Signs and Symptoms. Retrieved from

https://www.cdc.gov/stroke/signs_symptoms.htm#:~:text=Sudden%20numbness%20
or%20weakness%20in,balance%2C%20or%20lack%20of%20coordination. Retrieved on
November 12, 2022

Collantes MEV, Zuñiga YH, Granada CN, Uezono DR, De Castillo LC, Enriquez CG, Ignacio KD,
Ignacio SD and Jamora RD (2021) Current State of Stroke Care in the Philippines. Front.
Neurol. 12:665086. doi: 10.3389/fneur.2021.665086

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide Diagnoses,
Prioritized Interventions, and Rationales (15th ed.). F. A. Davis Company.

Fekadu, G., Chelkeba, L., and Kebede. A. (2019). Risk factors, clinical presentations and
predictors of stroke among adult patients admitted to stroke unit of Jimma university
medical center, south west Ethiopia: prospective observational study. Retrieved from
https://d-
nb.info/1202198511/34#:~:text=Risk%20factors%20for%20stroke%20can,modifiable%20
risk%20factors%20%5B11%5D. Retrieved on November 12, 2022

McIntosh, J. (2020). Everything you need to know about stroke. Retrieved from
https://www.medicalnewstoday.com/articles/7624. Retrieved on November 12, 2022

Patel, N., and Simon, S. (2022). Intracerebral Hemorrhage. Retrieved from

https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-
Treatments/Intracerebral-
Hemorrhage#:~:text=Intracerebral%20hemorrhage%20(bleeding%20into%20the,or%2
0abnormal%20development%20or%20trauma. Retrieved on November 12, 2022

WHO. (2022). World Stroke Day 2022. Retrieved from

https://www.who.int/srilanka/news/detail/29-10-2022-world-stroke-day-2022.
Retrieved on November 12, 2022

47
XVIII. Appendices

Appendix A
Approval/Request Letter

TO:
Sheila Maria G. Batoon, PhDNS, RN
Clinical Coordinator
University of the Cordilleras
College of Nursing

Dear Ma’am

Greetings!

We, the Level IV Section E Group A, would like to reserve the case with a diagnosis of CVD-
Intracerebral Hemorrhage Left thalamocapsular area S/P front temporal craniotomy
evacuation of hematoma, for our case presentation this first semester of school year 2022-
2023. We have handled this case during our duty in MICU/CCU of Baguio General Hospital
and Medical Center on August 8-10, 2022, under Dr. Godfrey G. Mendoza.

Thank you and, we look forward to your favorable response to this request.

Respectfully,

Cherry Pearl A. Awan Yvette Marie L. Mendoza

Glayssa S. Campilis Abcde Zynmil Z. Serran

Charlene S. Cando Kayla Marie D. Tiglao

Bryan C. Dao-ey Faith Greyle Q. Tubaña

Marl Nathaniel L. Estaris Heather Shane A. Wong

Noted by:

Godfrey G. Mendoza, PhD, RN

Clinical Instructor

Approved by:

Sheila Maria G. Batoon, PhDNS, RN

Clinical Coordinator

48