Far Eastern UniversityInstitute of Nursing

Introduction

Intracranial hemorrhage is the escape of blood within the cranium due to the loss of

integrity of vascular channels and frequently leading to formation of a hematoma.

Intracranial bleeding occurs when a blood vessel within the skull is ruptured or leaks. It

can result from physical trauma (as occurs in head injury) or non-traumatic causes (as occurs in

hemorrhagic stroke) such as a ruptured aneurysm. Anticoagulant therapy, as well as disorders

with blood clotting can heighten the risk that an intracranial hemorrhage will occur.

Objectives

Define the Intracranial hemorrhage.

Know the case of ICH, its possible signs and symptoms, risk factors, and diagnostic and

laboratory exams.

Determine the treatment and to apply appropriate nursing interventions.

Lastly, to use the case as a tool in the improvement of one’s profession in applying

nursing interventions.

I. Biographic Data

Name: A.T.Address: Blk11 L3 SSDM, BulacanAge: 48 y/oGender: MaleReligion: Roman Catholic Admitting date/time: Sept. 04, 2009 8:08AMRoom and Bed No.: 200Chief Complaint: left sided body weakness 3hr. prior to admissionAdmitting Diagnosis: T/C CVA, infarctFinal diagnosis: ICH right basal ganglia score of 1, HCVD, CAD, T2DMAttending Physician: Dr. Boy Saw

II. Nursing History

A. Past Health History

The patient had measles and chickenpox during childhood. He cannot recall his immunization. There are no allergies in food and drugs. There are no foreign travels yet. He is asthmatic since childhood and had his last attack when he was in high school. He also has type 2 Diabetic Mellitus for 10 years and it is being maintained by Diamicron but after 7 years he stopped taking his medication because he assumed that his illness had been already cured.

B. History of Present Illness

The patient has Type 2 Diabetes Mellitus and Hypertension. 3 hours prior to admission, he experienced left sided body weakness. His friend noticed that he walked like tipsy wherein he is not sober that time and his friend decided to accompany him home. In their house, his son accompanied him to urinate when AT is about to fall. AT said to his son “Nanghihina ako” and his son noticed that he has slurring of speech.

C. Family History

Hypertension, diabetes mellitus and asthma runs through the family of AT. There are no other diseases noted.

III. Patterns of Functioning

A. Psychological Health

1. Coping PatternWhen asked about how the patient copes up with life’s problems, he verbalized,

“Naguusap-usap kami tungkol sa problema. Kapag gipit sa pera, tumatawag ako sa mga kapaid ko, humihingi ng pera.”

Interpretation:

The client and his children talk about their problems and if it is about financial problems, they ask money from his sisters.

Analysis:Coping may be described as dealing with problems or contending them successfully.

Short-term coping strategies can reduce stress to a tolerable limit temporarily but are in the long-run ineffective ways to deal with reality. Fundamentals of Nursing research by Kozier 7th

edition p. 1020).

2. Interaction PatternAT’s sister verbalized that “Ayos naman ang pakikitungo niya sa ibang tao,

marami siyang kaibigan sa village namin dahil nga security guard siya ng subdivision eh kilalang kilala siya doon at wala naman siyang kagalit.”

AT’s has slurring of speech during the interview. As verbalized by his son, “Hindi masyadong maintindihan yung sinasabi ni Papa kapag nagsasalita siya.” He also has slow and sluggish movements. He also showed appropritae hand movements.

Interpretation:The client has barriers to effective communication.

Analysis:Human communication is essential for learning, working, and social interaction.

Communication may affect every aspect of a person’s life based on a person’s cognitive level, educational attainment, and health status such as speech, language or hearing problems and disorders. (Fundamentals of Nursing by Taylor et al, 5th ed. Pp466-467)

3. Cognitive PatternWhen we asked about his education, AT said that he is a college graduate.

About his occupation he is an OIC of security guards in their village.

Interpretation:The client finished tertiary education and is a college graduate.

Analysis:COGNITVE DEVELOPMENT (PIAGET): Cognitive thinking culminates with the capacity

for abstract thinking. This stage, the period of formal operations, is Piaget’s fourth and last stage. It is typical of the period of concrete thought. They now think beyond the present. Without having to center attention on the immediate situation, they can imagine a sequence of events that might occur, such as college and occupational possibilities; how things might change in the future, such as relationships with parents; and the consequences of their actions. At this time their thoughts can be influenced by logical principles rather than just their own perceptions and experiences. (Wong’s Essentials of Pediatrics Nursing, by Donna Wong and Marilyn J. Hockenberr-Eaton, 6th Edition, p. 525)

4. Self-ConceptAT said that he is happy and contented even though he had been

separated from his wife for how many years. He lives with his daughter and son. He is also happy because of his job, as an OIC security guard.

Interpretation:

The client does not see any problem with his self-concept and the way how he lives his life with his two children.

Analysis:The self-concept becomes more differentiated as adults acquire a more complex picture

of themselves, one that takes situational factors into account. The self-concept gradually becomes more individualized and more distinct from the concepts of others. The advent of chronic disease or a permanent physical disability has very special significance and creates stress for the person. (Wong’s Essential of Pediatric Nursing by Wong and Eaton, 6 th edition, p. 525) Image of physical self or body image is how a person perceives the size, appearance and functioning of boy and its parts. Body sensation describes “how one feels and experiences oneself as physical being.” Fundamentals of Nursing by Kozier 6th edition p. 804)

5. Emotional PatternRegarding to the emotional pattern of the client, his sister verbalized that

“6 years na simula nung maghiwalay sila ng asawa niya, after 2 years nilang maghiwalay nakapag-move na din siya na wala silang komunikasyon at hindi na rin nasusustentuhan yung mga bata”. She also added that “Tinutuon na lang niya ang atensyon sa pagpapalaki sa mga anak niya at sa trabaho”.

Interpretation:The client’s emotional state is normal.

Analysis:Emotional pattern is the ability to manage stress and to express emotions appropriately.

It also involves the ability to recognize, accept, and express feelings and to accept one’s limitations. (Fundamentals of Nursing by Kozier 7th ed. P. 173)

6. SexualityAT acts appropriate to his gender. He is friendly in both male and female as

verbalized by his sister that he everyone in their village knows him.

Interpretation:The client is able to express his own sexuality.

Analysis:Sexual health is the integration of the somatic, emotional, intellectual, and social aspects

of sexual being, in ways that are positively enriching and that enhance personality, communication and love. (Fundamentals of Nursing by Kozier 7th ed. P. 973)

7. Family coping patternWhen asked about his family, his son verbalized “Ako at si papa po magkasama

sa bahay tapos yung kapatid kong babae nakatira sa tita ko” he added “Close naman po kami kay papa, minsan napapalo ako pag may nagawa akong kasalanan at yung ate ko nasisigawan niya minsan”

Interpretation:The client’s family is open whenever they have problems.

Analysis:

Family roles are especially important to clients, since family relationships are particularly close. All members of the family are empowered to maintain communication with each other. When it comes to decisions, the family members are considered as a whole that functions together and not individually. (Public Health Nursing-DOH book, pg, 118)

B. Socio-cultural PatternThe client’s siblings and his children are considered as significant others as mentioned

by his son.

As for his recreational activities, his son mentioned that he often drinks with his friends and neighbors in their village. He also loves to watch TV when at home.

The client lives in SSDM Bulacan wherein he is also the security guard of the said village. Since they live inside the village, their environment is not exposed to air pollution. Sometimes their house has cockroaches, mouse, and mosquitoes.

AT’s income is not enough for their basic needs and to the education of his children. That’s why sometimes he asks money from his sister.

Interpretation:The significant relationship pattern of the client is normal since the client is able

to regard people around her who are significant. The client’s recreational pattern is similar to others of his age which is interesting and can provide independence. Drinking often is not healthy. The client’s environment has no health hazards. The client’s source of income for their basic needs and the education of his children are not enough for the family.

Analysis:Significant other is an individual or group that takes on a special importance for

the development of self-esteem during a particular life stage. Significant others may include parents, siblings, peers, teachers and the like. (Fundamentals of Nursing by Kozier 6 th ed. p.806)

Recreational activities are often determined by what is popular and what can provide independence. It is a form of relaxation on the part of a person. It is also a time free of obligations and formal duties of paid work, thus an opportunity to pursue at one’s own pace, mental nourishment, enlivenment, pleasure and relief from fatigue of work. (Fundamentals of Nursing by Kozier 7th ed. P. 201)

The environment is all the conditions, circumstances, and influences surrounding and affecting the development of an organism or a person. It should provide physical and psychological comfort. (Fundamentals of Nursing by Kozier 6th ed. p.250)

All individual’s standard of living (reflecting occupation, income, and education) is related to health, morbidity, and mortality. Hygiene, food habits, and the propensity to seek health care advice and follow health care regimens vary among high-income and low-income groups. (Fundamentals of Nursing by Kozier, p. 178)

C. Spiritual PatternAT is a Roman Catholic. He believes in God and he goes to church once a month.

Interpretation:The client has a positive outlook in life and has faith in God.

Analysis:Spirituality refers to that part of human that seeks meaningfulness through intrapersonal,

interpersonal and transpersonal connection. It generally involves a belief with some higher power, creative force, divine being, or infinite source of energy. Spiritual and religious beliefs are important in many people’s lives. They can influence lifestyle, attitudes and feelings about illness and death. (Fundamentals of Nursing by Kozier 6th ed. p.313)

IV. Activities of Daily Living

Before Hospitalization

During Hospitalization

Interpretation and Analysis

Nutrition A.T. usually eats thrice a day. He eats all kind of foods.He is fond of eating pork liempo, barbeque, tokwa’t baboy and sisig. He always drink softdrinks while eating lunch. He has a good appetite. He drinks more than 8 glasses of water. He often drinks beer with his friends and he consumes 4-6 bottles of beer. He loves to eat pulutan such as Dinakdakan and Sisig.

The client maintains a soft low salt, low fat DM diet.

Interpretation:

The client is fond of eating foods with high cholesterol, softdrinks and alcoholic beverages that are bad to his health.During hospitalization the client is following his diet regimen

Analysis:Nutrition is a basic human need that changes throughout the life cycle and along the wellness-illness continuum. Carbohydrates, commonly known as sugars and starches, are organic compounds composed of carbon, hydrogen and oxygen. Tissue growth and repair, helps regulate fluid balance through oncotic pressure, helps regulate acid-base balance, component of body framework are the functions of protein in our body system.(Fundamentals of Nursing by Kozier 6th ed. p.714)

Elimination The client usually voids 6 times per day. His urine is light in color and aromatic in odor.He defecates once a day. His stool is brownish in color and smooth.

The client urinates 4-5 times and defecates once a day.

Interpretation:

patient has a normal elimination pattern

Analysis:A properly functioning urinary system is essential to the body’s physical well-being, to life itself, and to a person’s general sense of well-being. Elimination from the urinary

tract helps to rid the body of waste products and materials that exceed bodily needs. Elimination of the waste products of digestion is a natural process critical for human functioning. Although most people have experienced minor acute bouts of diarrhea or constipation, some patients experience severe or chronic alterations in bowel elimination that affect their fluid and electrolyte balance, hydration, nutritional status, skin integrity, comfort and self-concept.(Fundamentals of Nursing by Kozier 6th ed. p.918-920)

Exercise The client is always walking because of his job (subdivision’s security guard). Sometimes he plays basketball with his neighbors.

A.T. does bed exercises every morning by stretching.The client’s activities/ exercise are very limited due to his illness.

Interpretation: The client’s activities/ exercise are very limited due to his illness.

Analysis:Active exertion of muscles involving the contraction and relaxation of muscle groups is termed “exercise”. The human body was designed for motion, and regular exercise is necessary for its healthy functioning. Individuals who choose inactive lifestyles or who are forced into inactivity by illness or injury place themselves at high risk for serious health problems.(Fundamentals of Nursing by Kozier 6th ed. p.345)

Hygiene A.T. takes a bath 1-2 times a day and brushes his teeth twice a day. He always washes his hands before and after eating.

As for the client’s hygiene, he cannot do his daily routine or hygienic practices.

Interpretation:The patient has a limited movement that’s why he cannot do his daily hygienic practices.

Analysis:Personal hygiene promotes physical and psychological well-being. Various studies have confirmed that improved personal hygiene practices reduce illness rates.(Fundamentals of Nursing by Kozier 6th ed. p.117)

Sleep and Rest

The client usually sleeps 6 hours per day including his naps.

The client has shorter periods of sleep unlike before. There are times that he will be awakened to take his meds, for vital signs monitoring, changing of IV fluids.

Interpretation:The patient has a disturbed sleep and rest pattern related to illness.

Analysis:Rest connotes a condition in which the body is in decreased state of activity with the consequent feeling of being refreshed. Sleep is a state of rest accompanied by altered consciousness and relative inactivity.

Illness that causes physical distress can result in sleep problems, People who are ill require more sleep than normal and the normal rhythm of sleep and wakefulness is often disturbed.(Fundamentals of Nursing by Kozier 6th ed. p.998)

V. Physical Assessment

VITAL SIGNS:

Temperature: 36.7º C

Pulse Rate: 65Beats per minute

Respiration Rate: 20 Breaths per minute

Blood Pressure: 140/90 mmHg (Abnormal BP client is experiencing hypertension)

GCS: 15

APPEARANCE AND MENTAL STATUS:

ASSESSMENT NORMS AND

STANDARDS

ACTUAL FINDINGS ANALYSIS

Body Build: Proportionate, Varies

with Lifestyle

Medium body build,

appropriate for height.

Normal

Posture and Gait Relaxed, Erect

Posture, Coordinated

Movement

The client is relaxed and weak in appearance.He has generalized body weakness with minimal movement.

Asymmetry of movement, in

which only one side of the

body is affected, may occur

with disorders of the central

nervous system, principally

in those patients who had

cerebrovascular accidents.

(Medsurg 10th edi by

Brunners and Suddarths p.

68)

Hygiene and

Grooming

Neat and Clean Looks neat and clean;

clothes are appropriate

for the current condition

Normal

Body and Breath

Odors

No body or breath odor

related to activity.

No body and breath odor Normal

Signs of Distress No signs of distress. No sign of distress Normal

Attitude Cooperative

appropriate to the

situation

Cooperative sometimes Normal

Affect/Mood,

Appropriateness of the

clients responses

Client’s response is

appropriate to the

situation

The client has flat affect and irritable.

Behavior changes after a stroke.The client may exhibit flat affect.(medsurg by Black 7th edi. p.2116)

Quantity, Quality, and

Organization of

Speech

Understandable,

Moderate Pace,

Exhibits thought

association

He can’t verbalize well

for NGT is present.

Slurred speech .

Speech may be slurred

because of CNS disease or

because of damage to

cranial nerves.

(Med-Surg 10th edi. by

Brunners p. 68)

Relevance and

organization of

thoughts

Logical Sequence,

Makes sense, exhibits

thought association

Answers appropriately

but seldom if he can’t

answer the son or the

sister talk.

Normal

AREAS OR

THINGS TO BE

ASSESSED

TECHNIQU

E

NORMS AND

STANDARDS

ACTUAL

FINDINGS

ANALYSIS

INTEGUMENT

Skin Inspect Varies from light to

deep brown; ruddy

pink to light oink;

yellow overtones to

olive

Varies from

light to

deep

brown;

ruddy pink

to light

oink; yellow

overtones

to olive

Normal

Skin color generally

uniform except in

areas exposed to

sun; areas of lighter

pigmentation (palms,

lips, nail beds) in

dark-skinned people

Skin color generally

uniform

Normal

Observe Moisture in skin folds

and the axillae varies

with environmental

temperature, and

activity

Moist Normal

Palpate

Skin temperature of

the two feet and two

hands are uniform

and within the normal

range

Skin temperature of

the two feet and

two hands are

uniform and within

the normal range.

Normal

Note Skin Turgor:

When pinched, skin

springs back to

previous state

Skin Turgor:

When pinched, skin

springs back to

previous state

Normal

Hair Inspect The hair is evenly Thick and evenly Normal

distributed

Thick hair

Silky, Resilient Hair

No infection or

infestation

distributed hair. No

alopecia and other

infections.

Nails Inspect Convex curvature;

angle of nail plate

about 160o

Smooth texture

Highly vascular and

pink in light-skinned

people; dark-skinned

clients may have

brown or black

pigmentation in

longitudinal streaks.

Intact epidermis

Convex curvature;

angle of nail plate

about 160o

Smooth texture

Highly vascular and

pink in light-skinned

people; dark-

skinned clients may

have brown or

black pigmentation

in longitudinal

streaks.

Intact epidermis

Normal

Perform

Blanch test

of capillary

refill

Prompt return of pink

or usual color

(generally less than 4

seconds)

When performed

blanche test

capillary refill

returns back in

seconds in its usual

color.

normal

HEAD

Cranium and Face

Cranium Inspect Rounded

( normocephalic and

symmetrical, with

frontal, parietal and

occipital

prominences);

smooth skull contour

Rounded,

normocephalic and

symmetrical,

smooth skull

contour

Normal

Palpate Smooth, uniform

consistency;

absence of nodules

or masses

Smooth and no

presence of

masses and

nodules

Normal

Face Inspect Facial features are

symmetric or slightly

asymmetric facial

features; palpebral

fissures equal in size;

symmetric nasolabial

folds.

Slightly

Asymmetrical facial

features. Shallow

nasolabial folds to

the left

Almost all clients have some degree of mobility after a stroke. Hemiparesis, these deficit are usually caused by a stroke.(medsurg by Black 7th

edi. p. 2111)

Eyes and Visual Acuity

Eyebrows Inspect Eyebrows’ hair is

evenly distributed;

eyebrows’ skin are

intact;

eyebrows

symmetrically

aligned;

equal movement of

eyebrows

Evenly distributed;

asymmetrically

aligned with equal

movement.

Normal

Eyelashes Eyelashes are

equally distributed

and curled slightly

upward

Eyelashes are

equally distributed,

slightly curved

upward

Normal

Eyelids Eyelids’ skin are

intact; no discharge;

no discoloration;

Lids close

symmetrically;

15 to 20 involuntary

blinks per minute;

bilateral blinking;

When lids open, no

visible sclera above

cornea, & upper &

lower borders of

cornea are slightly

covered

Eyelids are intact .

negative presence

od discharge nor

discoloration.17

involunatary blinks

per minute. When

lids open no visible

sclera above

cornea and upper

and lower borders

of cornea are

slightly covered

Normal

Anterior Chamber Anterior chamber is

transparent no

shadows of light

when lighted

obliquely, and about

3 mm depth.

Transparent Normal

Pupil Pupils are black,

equal in size (3-7mm

in diameter), round,

smooth border, iris is

flat and round.

Equal in size;

round, smooth

Normal

Assess

Illuminated pupil

constricts (direct

response); Non

illuminated pupil

constricts when the

other pupil is

illuminated

(consensual

response)

Constricts when

illuminated. Non-

illuminated eye also

constricts.

Normal

Pupils constrict when

looking at near

objects; pupils dilate

when looking at far

objects; pupils

converge when near

object is moved

toward nose.

Pupils constrict

when looking at

near objects; pupils

dilate when looking

at far objects

Normal

Visual Fields Temporally, object

can be seen at right

angles (90o) to the

central point of

vision;

The upward field of

vision is normally 50o

because the orbital

ridge is in the way;

The downward field

of vision is normally

70o because the

cheekbone is in the

way.

Able to see objects

placed at periphery.

Normal

Extra Ocular

Muscle

Both eyes

coordinated, move in

unison, with parallel

alignment.

Coordinated

movement, eyes

are able to follow

the movement in

unison

Normal

Visual Acuity Able to read

newsprint

Able to read

newsprint

normal

20/20 Vision on

Snellen Chart

Not performed

Ears and Hearing

Auricles Inspect Color same as facial

skin;

Symmetrical;

Auricle aligned with

outer canthus of eye,

about 10o from

vertical

Same color with

facial skin;

symmetrically

aligned with eyes

outer canthus. Size

is appropriate for

the face.

Normal

Palpate Mobile, firm, and not

tender;

pinna recoils after it

is folded

Springs back after

being recoiled

Normal

Gross Hearing

Acuity

Assess Normal voice tones

audible

Able to hear normal

voice tone

Normal

Watch Tick

Test

Able to hear ticking in

both ears

Able to hear ticking

in both ears

Normal

Tuning Fork

Test

(Weber’s

test)

Sound is heard in

both ears or is

localized at the

center of the head

( Negative Weber

Test)

Not performed

Tuning Fork

Test

(Rinne Test)

Air-conducted

hearing is greater

than bone-conducted

hearing

(Rinne Test Positive)

Not performed

Nose and Sinuses

External Nose Inspect Symmetric and

Straight;

No discharge or

discoloration;

Uniform color

At the center of

face; straight and

symmetric. No

discharge. Color

same as facial skin

color.. presence of

NGT

Normal

Palpate Not tender; no

lesions

No tenderness,

masses or lesions

Normal

Patency of both

nasal cavities

Determine Air moves Freely as

the client breathes

through the nares

Patent nares Normal

nasal Cavity Inspect Air moves freely as

the client breathes

through the nares.

Air move freely

from both

nose.Presence of

NGT

Normal

Redness, swelling,

growths, and

discharge.

Mucosa pink; Clear,

watery discharge;

No lesions, Nasal

septum intact & in

midline

Mucosa pink;

Clear, watery

discharge;

No lesions, Nasal

septum intact & in

midline

Normal

Maxillary and frontal

sinuses for

tenderness

Palpate Not tender No tenderness Normal

Mouth and Oropharynx

Outer Lips Inspect Uniform pink color

( darker, e.g. bluish

hue, in

Mediterranean

groups and dark-

skinned people);

Soft, moist, smooth

texture;

Symmetry of contour;

Ability to purse lips

Pinkish color; soft,

moist, smooth. Able

to purse lips.

Normal

Inner Lips and

buccal mucosa

Uniform pink color

(freckled brown

pigmentation in dark-

skinned clients)

Moist, smooth, soft,

glistening, and elastic

texture (drier oral

mucosa in elderly

due to decreased

salivation)

Uniform dark

pinkish color,

Moist, smooth, soft,

glistening, and

elastic texture.

.Normal

Palpate

Teeth Inspect 32 adult teeth;

smooth, white, shiny

tooth enamel

32 adult teeth;

smooth, white,

shiny tooth enamel

Normal

Gums Pink gums (bluish or

dark patches in dark-

skinned clients);

Moist, firm texture of

gums;

No retraction of gums

Pink to bluish gum

color;

Moist, firm texture

of gums;

No retraction of

gums

Normal

Surface of Tongue Central position;

Pink color (some

brown pigmentation

on tongue borders in

dark-skinned clients);

moist; slightly rough,

thin washing coating;

Smooth, lateral

margins; No lesions;

Raised papillae

Pink color; moist;

slightly rough, thin

washing coating;

Smooth, lateral

margins; No

lesions;

Raised papillae

Normal

Tongue Movement Assess Moves freely; no

tenderness

Moves freely Normal

Base of Tongue Inspect Smooth tongue base

with prominent veins

Smooth tongue

base

Normal

Tongue, mouth floor,

and frenulum

Palpate Smooth with no

palpable nodules

smooth Normal

Salivary Gland Inspect Same color of buccal

mucosa and floor of

mouth

Pinkish with

prominent vein.

Normal

Soft Palate Light pink, smooth,

soft palate

Pinkish in color and

smooth

Normal

Hard Palate Lighter pink hard

palate

Light pinkish color Normal

Uvula Positioned in midline

of soft palate

Seen at the

midline

Normal

Oropharynx Pink and smooth

posterior wall

Pinkish in color Normal

Tonsils Pink and smooth; no

discharge; Of normal

size (Grade 1: the

tonsils are behind the

tonsillar pillars)

Pinkish,smooth and

no discharge.

Normal

Glosso- Assess Present Present but weak Normal

Pharyngeal or vagus

nerve

(Elicit Gag

Reflex)

NECK

Neck Muscles Inspect Muscles equal in

size; head centered

Equal in size Normal

Head Movements Observe Coordinated, smooth

movements with no

discomfort;

Head flexes 45

degrees;

Head hyperextends

60 degrees;

Head laterally flexes

40 degrees;

Head laterally rotates

70 degrees;

Coordinated

movement

Normal

Neck Muscle

Strength

Assess Equal Strength Equal strength Normal

Neck Lymph Nodes Palpate Not palpable Not palpable

lymphnodes.

Normal

Trachea Central Placement in

midline of neck;

spaces are equal on

both sides

Seen at the

midline.

Normal

Thyroid Gland Inspect Not visible on

inspection;

Gland ascends

during swallowing but

is not visible

Not visible thyroid

gland

Normal

Palpate Lobes may not be

palpated; If palpated,

lobes are small,

smooth, centrally

located, painless,

and rise freely with

swallowing

Not palpable Normal

THORAX AND LUNGS

Thorax Inspect Anteroposterior to

transverse diameter

in ratio of 1:2;

Chest symmetric;

Symmetrical chest Normal

Spinal alignment The Spine vertically

aligned

Aligned at the

midline

Normal

Posterior Thorax Palpate Skin intact;

uniform temperature

Skin intact Normal

Posterior chest for

respiratory excursion

Full and symmetric

chest expansion

(when client takes a

deep breath, your

thumbs should move

apart an equal

distance and at the

same time; normally,

the thumb separate 3

to 5 cm)

Full and symmetric

lung expansion.

Normal

Posterior Chest for

tactile fremitus

Bilateral Symmetry of

vocal fremitus;

Fremitus is heard

most clearly at the

apex of the lungs;

Low pitched voices of

males are more

readily palpated than

higher pitched voice

of females

Not performed.

Patient doesn’t

want to.

Posterior Thorax Percuss Percussion notes

resonate, except over

scapula;

Lowest point of

resonance is at the

diaphragm;

Percussion on a rib

normally elicits

dullness

Patient doesn’t

want to

Breathing Patterns Inspect Quiet, rhythmic, and

effortless

qiuet Normal

Costal angle and the

angle at w/c the ribs

enter the spine

Costal angle is less

than 90 degrees, and

the ribs inserted to

the spine is

approximately 45

degrees angle

Not performed

Anterior Chest Palpate Skin intact; uniform

temperature

Skin is intact Normal

Anterior Chest for

respiratory excursion

Full and symmetric

chest expansion;

Normally, the thumb

separate 3 to 5 cm

full chest

expansion

Normal

Anterior Chest for

Tactile Fremitus

Fremitus is normally

decreased over heart

and breast tissue

Fremitus is heard. Normal

Anterior Chest Percuss Percussion notes

resonate down to the

sixth rib at the level

of the diaphragm but

are flat over areas of

heavy muscle and

bone, dull on areas

over the heart and

the liver, and

tympanic over the

underlying stomach

Resonance down

to the 6th rib,flat

over the muscle

and bones.and dull

over the heart and

the liver and

underlying

stomach.

Normal

Trachea Auscultate Bronchial and tubular

breath sounds

Sounds like air

moving through a

tube.

Normal

Anterior Chest Bronchovesicular and

vesicular breath

sounds

bronchovesicular

breath sound

Normal

HEART AND CENTRAL VESSELS

Aortic Area Inspect and

Palpate

No pulsations No pulsation Normal

Pulmonic Area

Tricuspid Area No pulsations; No lift

or heave

No pulsations Normal

Apical Area Pulsation is visible in

50% of adults and

palpable in most PMI

in fifth LICS at or

medial to MCL;

Diameter of 1 to 2

cm; No lift or heave

Pulsation heard. Normal

Epigastric Area Aortic pulsations Presence of

pulsation

Normal

Aortic Area Auscultate S1: usually heard at

all sites and usually

louder at apical area;

S2: usually heard at

all sites and usually

louder at the base of

the heart

Systole: silent

interval, slightly

shorter duration than

diastole at normal

heart rate;

Diastole: silent

interval, slightly

longer duration than

diastole at normal

heart rate;

S3 in children and

young adults;

S4 in many older

adults

S1 and S2 heard Normal

Pulmonic Area

Tricuspid Area

Apical Area

Carotid Artery No sounds heard on

auscultation

No sound Normal

Jugular Vein Inspect Veins not visible Not visible Normal

MUSCULOSKELETAL SYSTEM

Muscles Inspect Equal size on both

sides of the body;

No fasciculation or

tremors

Equal size Normal

Palpate Normally form;

smooth coordinated

movements

No contractures Normal

Strength

test

Equal strength on

each body side

Unequal muscle

strength on each

body graded as in left

side is (1/5) weak

than the right side

graded as (4/5) of the

body. Weakness in

face and arms is

greater than the legs

Hemiparesis of one

side of the body may

occur after stroke

(medsurg by black 7th

edi. p.2111)

Joints Inspect No swelling,

tenderness,

crepitation, or

nodules;

Joints move smoothly

No swelling,

tenderness,crepitai

on, or nodules; joint

move smoothly

except for the weak

left side.

Hemiparesis of one

side of the body may

occur after stroke

(medsurg by black 7th

edi. p.2111)

NEUROLOGIC SYSTEM

Cranial nerve Inspect

2 2-3 mm pupils

equally reactive to

light and

accommodation

Normal

3,4,6

11 Symmetrical lifting of

shoulders

Intact extraocular

muscles

Can lift shoulders

Right greater than

Left

Normal

Muscle weakness,

paralysis, abnormal

or lost sensation on

one side of the body

occur after a stroke.

(medsurg by black 7th

edi. p.2112)

VI. LABORATORY EXAMINATIONS

COMPLETE BLOOD COUNTSeptember 4, 2009

Result Normal Findings Interpretation and AnalysisRBC Count 5.50 x

10^12 /LM: 5.5-6.5x1012/L Normal

Hemoglobin 17.00 g/dL 14-16 g/dL HighMay indicate Polycythemia, Dehydration and COPDFundamentals of Nursing by Kozier p.759

Hematocrit 0.50 L/L M:0.42-0.52L/LF:0.37-0.47L/L

Normal

WBC 7.84 x 10^9 /L 5-10 x10 ^ 9/L Normal

MCV (Mean Corpuscular Volume)

91.7 f 82-92 fl Normal

MCH (Mean Corpuscular Hemoglobin)

30.9 pg 27-33 pg Normal

MCHC (Mean Corpuscular Hemoglobin Concentration)

34.0 pg 32-38% Normal

Eosinophils 0.01 0.03-0.05 LowWith stress and certain medications such as epinephrine, thyroxine and ACTHFundamentals of Nursing by Kozier p.759

Segmenters 0.67 0.55-0.65 HighThere might be an acute infection, tissue necrosis, leukemias and drug influences such as aspirin, heparin, digitalis, epinephrine, lithium, histamine, antibioticsFundamentals of Nursing by Kozier p.759

Lymphocytes 0.26 0.25-0.35 Normal

Monocytes 0.06 0.02-0.06 Normal

ROENTGENOGRAPHIC REPORTSeptember 4, 2009

Impression:Atheromatous aorta

Chest:No active lung infiltrate seen. Pulmonary vascular markings are within normal limits. Heart is not enlarged. Aorta is calcified. Diaphragm and bony thorax are unremarkable.

URINALYSISSeptember 4, 2009

Actual Findings Normal Findings AnalysisColor Light Yellow Light straw to dark

amberNormal

Sp. Gravity 1.010 1.005-1.030 NormalCharacter Hazy Clear Bacteria,

Pus, tissueRBCsWBCsPhosphatesProstatic fluid

Urates, uric acidBilirubin Negative Negative NormalProtein Negative Negative NormalGlucose Negative Negative NormalBlood Negative Negative NormalKetone +2 Negative Abnormal

Ketone bodies, a product of the breakdown of fatty acids, normally are not present in the urine. They may, however, be found in the urine of clients with poorly controlled diabetes.Fundamentals of Nursing by Kozier p.771

Nitrite Negative Negative NormalLeukocytes Negative Negative NormalPus Cells Negative 0-2 hpf Normal

RBC Negative 0-3 hpf Normal pH 6.0 4.6-8 Low

Urine is slightly acidic with an average pH of 6.Fundamentals of Nursing by Kozier p.770

Casts None None NormalCrystals None None NormalBacteria Moderate None Abnormal

Bacteria present in stool indicate infection. Bacterial gastroenteritis, sometimes called acute gastroenteritis, is an inflammation of the stomach and intestines caused by the introduction of certain types of bacteria into the

digestive tract.

DIFFUSION WEIGHTED MRI OF THE BRAINSeptember 4, 2009

Indication:The patient presents left-sided body weakness and slurring of speech.

Pertinent MR findings:There is 2.8 x 2.5 x 3.9 cm (APxTxH) abnormal signal, which is ointense on T1W1 slightly hyperintense on T2W1 and shows blooming artifact on GRE, in the R basal ganglia and surrounding capsules extending superiorly into the R corona radiate. These findings are indicative of intracerebral hemorrhage in hyperacute stage. There is an associated perilesional edema with apparent mild compression effect to the right lateral ventricle producing some mild bowing of the midline structures leftwardly. There is also 1.0 x 0.4 (APxT) focal hemorrhage in subacute stage in the left lentiform nucleus and left external capsule. Minimal perilesional edema is likewise present. In addition, there is a probable petechial hemorrhage in the right occipital region.

Other worth mentioning findings include chronic small vessel ischemic changes in the centrum semiovale/coron radiate, left frontal subcorticalwhite matter and both forceps major. There are old lacunar infarcts in the left external capsule and probably also in the anterior portion of both corona radiata.

Remarks:There are finding of bilateral intracerebral hemorrhage of differing ages as described.

SEROLOGYSeptember 5, 2009

Actual Findings Normal Findings AnalysisHgbA1c 10.7% 4-7% % Abnormal

Indicates Diabetes.http://diabetes_basics/what/high_blood_sugar.html

BLOOD CHEMISTRY

September 4, 2009

September 7, 2009

September

8,2009

Normal Findings

Interpretation and Analysis

RBS 358 --- --- 70-100 High

mg/dL mg/dLGreater than normal levels (hyperglycemia) may indicate:

Acromegaly (very rare) Cushing syndrome (rare) Diabetes mellitus Impaired fasting glucose

(also called "prediabetes") Hyperthyroidism Pancreatic cancer Pancreatitis Pheochromocytoma (very

rare) Too little insulin Too much food

http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm

Crea 92 mmol/L

--- --- M: 62-115 mmol/LF: 53-97 mmol/L

Normal

SGPT 166 U/L --- --- 0-55 U/L HighElevations of SGPT, an enzyme found within the liver cells, indicate that the liver cells are either leaky (internal contents are entering the blood) or damaged. A wide array of conditions can cause this problem. For example, viral hepatitis or alcohol can cause elevated SGPT. We know that patients can have elevated liver tests as a result of fatty liver, a condition that does not necessarily mean generalized obesity. Usually fatty liver is not a cause for significant liver problems.http://www.valdezlink.com/pages/SGPT.htm

Na 131.70 mmol/L

--- 147.60 mmol/L

135-148 mmol/L

Normal

K 4.29 mmol/L

3.20 mmol/L

2.83 mmol/L

3.50-5.30 mmol/L

Normal

Glucose 12.71 mmol/L

--- --- 3.90-6.00 mmol/L

HighIndicates diabetes mellitus.

CLINICAL CHEMISTRY RESULT

Capillary Blood Glucose

Actual Findings Normal Findings

Interpretation and Analysis

September 4, 2009

@ 1pm 277 mg/dL@ 2pm 271 mg/dL@6pm 369 mg/dL@ 7pm 237 mg/dL

@ 10pm 346 mg/dL

70-110 mg/dL High*Indicates Diabetes.

Having too much sugar in the blood for long periods of time can cause serious health problems if it's not treated. Hyperglycemia can cause damage to the vessels that supply blood to vital organs, which can increase the risk of heart disease and stroke, kidney disease, vision problems, and nerve problems in people with diabetes. These problems don't usually show up in kids or teens with diabetes who have had the disease for only a few years. However, these health problems can occur in adulthood in some people with diabetes, particularly if they haven't managed or controlled their diabetes properly.http://diabetes_basics/what/high_blood_sugar.html

September 5, 2009

@ 2mn 242 mg/dL@ 6am 190 mg/dL@11pm 150 mg/dL@ 12nn 397 mg/dL@ 1pm 377 mg/dL@ 3pm 382 mg/dL@ 4pm 283 mg/dL@ 5pm 256 mg/dL

70-110 mg/dL High*

September 6, 2009

@ 5am 207 mg/dL@ 11am 167mg/dL@ 5pm 125 mg/dL

70-110 mg/dL High*

September 7, 2009

@ 5am 106 mg/dL@ 5pm 163 mg/dL

70-110 mg/dL High*

September 8, 2009

@ 5am 110 mg/dL@ 5pm 92 mg/dL

70-110 mg/dL Normal

September 9, 2009

@ 5am 204 mg/dL@ 5pm 141 mg/dL

70-110 mg/dL High*

September 10, 2009

@ 5am 105 mg/dL 70-110 mg/dL Normal

VII. Drug Study

Generic/Trade Name

Dosage/ Frequency

Classification Indication Contraindication Side Effects Nursing Responsibilities

Citicholine 1g BID Nootropics & Neurotonics

Parkinson's disease; Cerebrovascular disorders and head injury

Contraindicated to patients with allergy with the drug

elevated body temperature, restlessness, and difficulty sleeping if the supplement is taken in the evening.insomnia, headache, diarrhea, low or high blood pressure, nausea, blurred vision, chest pains,

Assess patient for any allergy of the drug.

Advise patient to seek emergency medical attention if he feels adverse effects of the drug.

Omeprazole 2mg 1 CAP OD

Antacids, Antireflux Agents & Antiulcerants

Eradication of H. pylori infection,Prophylaxis of acid aspiration,to treat symptoms of gastroesophageal reflux disease (GERD) and other conditions caused by excess stomach acid. Omeprazole is also used to promote healing of erosive esophagitis (damage to your esophagus caused by stomach acid).

Contraindicated in patients with known hypersensitivity to any component of the formulation.

Diarrhoea, nausea, fatigue, constipation, vomiting, flatulence, acid regurgitation, taste perversion, arthralgia, myalgia, urticaria, dry mouth, dizziness, headache, paraesthesia, abdominal pain, skin rashes, weakness, back pain, upper respiratory

Assess patient for any allergy of the drug.

Advise patient to seek emergency medical attention if he has chest pain or heavy feeling, dizziness, pain spreading to the arm or shoulder, sweating, nausea or vomiting, and a general ill feeling.

Give each dose of omeprazole with a full glass (8 ounces) of water.

infection, cough.Potentially Fatal: Anaphylaxis.

Do not crush, break, or open a delayed-release capsule. It is specially made to release medicine slowly in the body. Breaking or opening the pill would cause too much of the drug to be released at one time.

Store omeprazole at room temperature away from moisture and heat.

Lactulose 30cc @ HS Laxatives, Purgatives

to treat chronic constipation.

Galactosaemia, intestinal obstruction. Patients on low galactose diet.

Diarrhoea (dose-related), nausea, vomiting, hypokalaemia, bloating and abdominal cramps.Potentially Fatal: Dehydration and hypernatraemia on aggressive treatment.

Assess patient for any allergy of the drug.

Advise patient to seek emergency medical attention if he feels adverse effects of the drug.

Not to be given to patients on a special diet low in galactose (milk sugar).

May be given w/ meals to reduce GI discomfort

Monitor electrolyte

imbalance. Special

prescaution for Lactose intolerance; diabetics.

Measure liquid medicine with a special dose-measuring spoon or cup, not a regular table spoon.

Lactulose powder should be mixed with at least 4 ounces of water.

Store lactulose at room temperature away from moisture and heat.

Mannitol 150cc OD in pm

Diuretics Oliguric phase of renal failure,Raised intracranial pressure; Raised intraocular pressure; Cerebral oedema,to reduce swelling and pressure inside the eye or around the brain.

Pulmonary congestion or oedema; intracranial bleeding; CHF; metabolic oedema with abnormal capillary fragility; anuria due to severe renal disease; severe dehydration.

Fluid and electrolyte imbalance; acidosis (with high doses). Nausea, vomiting, thirst; headache, dizziness, convulsions, chills, fever; tachycardia, chest pain; blurred vision; urticaria and hypotension

Assess patient for any allergy of the drug.

Assess for history of severe or long-term kidney disease, lung swelling or congestion, severe dehydration, bleeding in brain not caused by surgery, or if kidneys have

or hypertension; acute renal failure; skin necrosis; thrombophloebitis.

already shut down and unable to urinate.

Check for signs of fluid and electrolyte imbalance.

Should not be administered with whole blood.

Advise patient to get emergency medical help if he has any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Losartan 50mg/tab OD in pm

Angiotensin II Antagonists

HTN; Diabetic nephropathy in Type 2 DM;to treat high blood pressure (hypertension).

contraindicated in patients with known hypersensitivity to any component of the formulation.

Headache, dizziness, back pain, myalgia, respiratory tract disorders, asthenia/fatigue, first dose hypotension, rash, angioedema, neutropenia, GI disturbances, transient elevation of liver enzymes, impaired renal function, taste disturbances and

Assess patient for any allergy of the drug.

Assess for history or presence of kidney disease; liver disease; congestive heart failure; or dehydration.

Advise patients to avoid drinking alcohol. It can lower blood pressure and may increase some of

hyperkalaemia. the side effects of losartan.

Do not give potassium supplements or salt substitutes while patient is taking losartan, unless prescribed by doctor.

Check blood pressure on a regular basis.

Monitor serum-potassium concentration.

Kalium durule 1tab x 6 doses TID

Electrolytes Adults & elderly Prophylaxis, hypokalemia

Renal insufficiency, hyperkalemia, untreated Addison's disease, constriction of the esophagus &/or obstructive changes in the alimentary tract.

Nausea and vomiting, ECG changes in hyperkalemia

Assess patient for any allergy of the drug.

Should be taken with food (Swallow whole w/ 1/2 glass of liqd, do not break/chew/crush. Do not administer to a patient in a supine position.).

Report weakness, fatigue, polyuria, polydypsia, as these could be signs of K+ deficit.

Notify physician for persistent vomiting as K= loss may occur.

Humulin 70/30 25 units @ am

15 u @pm

Insulin Preparations

Treatment of IDDM.

Hypoglycemia, IV administration & hyperglycemic coma.

Lipodystrophy, insulin resistance. Local & generalised allergic reactions.

Correct Syringe: Doses of insulin are measured in units. Use only U-100 insulin syringe.

Failure to use the proper syringe can lead to a mistake in dosage, causing serious problems eg, a blood glucose level that is too low or too high.

Syringe Use: To help avoid contamination and possible infection, follow these instructions exactly:

Disposable syringes and needles should be used only once and then discarded. Needles and syringes must not be shared.

Preparing the Dose: Wash hands. Carefully shake or rotate the insulin bottle several times to completely mix the

insulin.

Inspect the insulin. Humulin 70/30 should look uniformly cloudy or milky. Do not use it if anything unusual in the appearance is noticed.

If using a new bottle, flip off the plastic protective cap, but do not remove the stopper. When using a new bottle, wipe the top of the bottle with an alcohol swab.

Draw air into the syringe equal to the insulin dose. Put the needle through the rubber top of the insulin bottle and inject the air into the bottle.

Turn the bottle and syringe upside down. Hold the bottle and syringe firmly in 1 hand and shake

gently.

Making sure the tip of the needle is in the insulin, withdraw the correct dose of insulin into the syringe.

Before removing the needle from the bottle, check the syringe for air bubbles which reduces the amount of insulin in it. If bubbles are present, hold the syringe straight up and tap its side until the bubbles float to the top. Push them out with the plunger and withdraw the correct dose.

Remove the needle from the bottle and lay the syringe down so that the needle does not touch anything.

Administration: Injection: Cleanse the skin with alcohol

where the injection is to be made. Stabilize the skin by spreading it or pinching up a large area. Insert the needle as instructed by the doctor. Push the plunger in as far as it will go. Pull the needle out and apply gentle pressure over the injection site for several seconds.

Do not rub the area. To avoid tissue damage, give the next injection at a site at least ½ inch from the previous site.

Always examine the appearance of the insulin before administering a dose. The vial must be carefully shaken or rotated injection, and the cartridge rolled between the palms 10 times and inverted 180° 10 times before each injection so that the contents are uniformly mixed.

Humulin should look uniformly cloudy or milky after mixing. Do not use if the insulin substance (the white material) remains visibly separated from the liquid after mixing.

Do not use if there are clumps in the insulin after mixing.

Do not use if solid white particles stick to the bottom or wall of the vial/cartridge, giving it a frosted appearance. Always check the appearance of the vial/cartridge of insulin before using, and note anything unusual in the appearance of the insulin or a marked change in the insulin requirements.

VIII. PathophysiologyAneurysm Severe Hypertension AV Malformation

Rupture of cerebral vessel

Intracerebral bleeding occursBleeding in the Right basal ganglia

Contralateral hemiplegia, with initial flaccidity progressing to spasticity

Sudden severe headache

Nausea and vomiting

Coma

DEATH

Increased ICP

Risk factors DM HPN Smoking Obesity High cholesterol

levels Heart Disease Age Gender Race Family history

Decreased insulin production

Diminished insulin action

Hyperglycemia

S/Sx: Generalized weakness and malaise, excessive urine production, excessive thirst, blurred vision, unexplained weight loss

Imbalance bet. The blood supply and the demand of the heart for oxygenated

Limitations to coronary blood flow with vasospasm and thrombosis

Increased metabolic demands of the heart and everyday activities Perfusion pressure may be insufficient to

provide adequate blood flow

X. Ecologic Model

A. Hypothesis

The condition of the client might have been resulted from the interrelationship of the risk factors that the client gained overtime. Factors like diet, familial history, and the client’s lifestyle aggravates the condition of the client.

B. Predisposing Factors

The host, male 48 years of age, with a nationality of Filipino and is residing at Barangay San Manuel SSMD, Bulacan.Working as a security guard in the subdivision. With familial history of hypertension and Diabetes Mellitus.He engages in drinking alcohol often with friends consumes 4-6 bottles of beer. He is fond of eating pork foods which is high in cholesterol. Client is known to be hypertensive and with DMT2

Last September 4, 2009 the client experienced left side body weakness 3 hours PTA.

.

C. Ecologic Model,

D. Analysis

There are several factors of CVA. The modifiable factors are hypertension, sedentary lifestyle, obesity, increase salt, cholesterol, and fatty foods intake, smoking, stress, diabetes mellitus. The non-modifiable factors are sex (women are more likely to die from a stroke), age (two-thirds of strokes occur in people over age 65), race (affect blacks more often than whites, and are more likely to be fatal among blacks) and heredity.

CVA

MALE

FAMILY HISTORYHPN, DM

HYPERTENSION

CAD

DMT2

HIGH-CHOLESTEROL DIET

ENVIRONMENTDRINKING ALCOHOL

OCCUPATION SECURITY GUARD

In this case, factors contributing to the client’s attack are FAMILIAL HISTORY,GENDER,HPN,DMT2,LIFESTYLE, DIET,AGE,OCCUPATION.GENDER As in all diseases, a genetic predisposition increases one’s risk of having the disease. His advancing age also cause a lot of physiologic changes in his body. As a person ages, his blood vessels become less elastic and covered by atheroma or fat plaques which narrows or obstructs the passage of blood causing an infarct to the area. Present illness HPN,DM2 aggreviates the disease. Food habits and alcohol consumption, also intensified his risk because such acts increase the deposition of fat in the vessels and its hardening. Lastly, the incidence of stroke is higher in men than that of women.

E. Conclusion and Recommendations

The factors contributing to the disease are Familial history, Lifestyle, DM2, HPN, Occupation. Such factors that are not modifiable; thus, care must be focused on ensuring client comfort and wellness and decreasing further complications and worsening of the disease. The body becomes weaker and vulnerable to a lot of diseases as it matures. Remind the family to be in constant monitor of the client in case of an attack. Also, always be in assistance with the client because with this disease, the client becomes too weak with sensory and motor impairments

Lifestyle should also be modified. His food habits must be corrected. His alcohol consumption . Though this may not reverse the problem, such actions may prevent worsening of the disease.

XI. Prioritization

NURSING PROBLEM CUES JUSTIFICATION Impaired Tissue Perfusion (cerebral) related to bleeding

Subjective: “Nanghihina ako.”

Changes in BP (BP): 140/90 mmHg

slurring of speech left sided body weakness flat affect and irritable

Cerebral perfusion of the cerebrum is critical for survival and long term outcome; therefore it should be the first priority in the care of the client. Decrease in cerebral blood flow may be secondary to thrombus, embolus, hemorrhage, edema or spasm

(p.1858 Medical Surgical Nursing by Joyce Black)

Impaired physical mobility related to neuromuscular

left sided body weakness slow and sluggish

movements

Almost all clients have some degree of immobility after a stroke.

impairmentPressure ulcers are common problem for anyone with a lower than normal level of activity. It can be deadly for a patient who can’t turn or move by him/herself. Infected pressure ulcers are one of the primary causes of death in a patient with neurological diagnosis, even when not infected, pressure ulcer still cause prolonged distress and adversely affect the patient’s ability to function and his/her quality of life.

(p.1859 Medical Surgical Nursing by Joyce Black; p. 122 Medical Surgical Nursing by Lippincott Williams & Wilkins)

Impaired verbal communication related to decrease in circulation to brain

“Hindi masyadong maintindihan yung sinasabi ni Papa kapag nagsasalita siya.”

slurred speech showing of hand

movements

The inability to speak is frustrating for clients. Early recognition of this problem decreases some of the frustration in meeting everyday needs and the ability to effectively communicate and express feelings and sensations to other people.

(p.1860 Medical Surgical Nursing by Joyce Black)

XII. Nursing Care Plan

NURSING PROBLEM

ANALYSIS GOAL AND OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Impaired Tissue Perfusion (cerebral) related to intracranial hemorrhage as evidenced by left sided body weakness

Cues:Subjective:“Nanghihina ako, ” as verbalized by the client.

Objectives: slurring of

speech left sided

body weakness

flat affect and irritable

Measurement:VITAL SIGNS:Temp: 36.7º CPR: 65 BPMRR: 20 BPMBP: 140/90 mmHg

Immediate Cause:Ineffective tissue perfusion

Intermmediate Cause:Intracranial hemorrhage

Root Cause:Cerebrovascular Accident(stroke)

The cerebral hemisphere of our bicameral (two-chambered) brain is known as the seat of thought, memory, awareness, motor function, sensory function, and speech -- i.e., the higher brain. When a hemorrhage (bleeding from traumatic injury or arterial damage) occurs inside the brain in one or both of the hemispheres,

Goal:After 5 hours of nursing interventions, the client will have no further deterioration as mainifested by improved cerebral tissue perfusion and stabilized neurological deficits.

Objectives:

IndependentAfter 1 hour of nursing intervention the client will be able to:

a. maintain adequate oxygenation

b. maximize tissue perfusion

Administer oxygen therapy

Assess heart rate and rhythm; auscultate for murmurs;

O2 therapy may be required to maintain adequate airway and to improve cerebral tissue perfusion.

Changes in rate, especially bradycardia, can occurbecause of the brain damage. Dysrhythmias and murmursmay reflect cardiac disease, which may have precipitated

Goal met as the client had adequate and improved cerebral perfusion as evidenced by stable vital signs, improved cognition, motor and sensory function, and appropriate affect and mood.

Symptoms depend on distribution of the cerebral vessel(s) involved.

Hypertension (High Blood Pressure) is one of the prime causes. It is also suspected that the underlying blood vessels of the brain may be abnormal with microaneurysms (i.e., tiny outpouchings of the arterial walls which are weak and subject to bursting).

Bleeding commonly occurs in the basal ganglia, and less commonly in the pons, thalamus, cerebellum, and cerebral white matter. The hemorrhage (bleeding) may extend into the ventricular system or subarachnoid space of the brain. The bleeding, in some cases, may compress the brain

b. maintain blood pressure within normal range

c. maintain head/ neck in neutral position.

Assess respirations, noting patterns and rhythm

Evaluate pupils, noting size, shape, equality, lightreactivity.

Assess higher functions, including speech, if patient isalert.

Frequently monitor blood pressure

Position with head slightly elevated and in neutralposition.

CVA.

Irregularities can suggest location of cerebralinsult/increasing ICP and need for further intervention, including possible respiratory support.

Response to light reflects combined functionof the optic (II) and oculomotor (III) cranial nerves and is useful in determining whether thebrainstem is intact.

Changes in cognition and speech content are an indicator of location/ degree of cerebral involvement and may indicate deterioration/ increased ICP.

To maintain perfusion without promoting cerebral edema.

Reduces arterial pressure by promoting venous drainageand may improve cerebral circulation/perfusion.

stem (lower part of the brain). If brain stem compression occurs, the death rate is very high.

d. maintain normo-thermia.

CollaborativeAfter 1 hour of intervention the client will be able to:

a. Engage in pharmacologic therapy.

Monitor client’s temperature.

Administer medications (eg. anticoagulants, antihypertensives, stool softeners) as prescribed by the physician.

Normo- thermia reduces cerebral glucose and oxygen consumption.

Will aid in the recovery of the patient and help prevent further complications

XIII. Discharge Plan

Medications Exercise Treatment/Therapy Health Teaching Outpatient Diet Support System

Medicines may be needed in addition to lifestyle changes.

Statins to help lower choleste-rol.

Beta-

Get regular exercise on most, if not all, days of the week. Your doctor can suggest a safe level of exercise

Procedures may be done to improve blood flow to the heart.

Angioplasty is used to open blocked arteries. It isn't major surgery. During angioplasty, the

Treatment focuses on taking steps to manage your symptoms and reduce your risk for heart attack and stroke.

Lifestyle changes are the first step for anyone with coronary artery

See the doctor for regular follow-up appointments. This lets the doctor keep track of the risk factors and adjust his

Lowering of LDL cholesterol by reducing saturated fat intake.

Lowering of Triglyceride levels by reducing consumption of sugary and

Get the support you need to succeed in making lifestyle changes. Ask family or friends to share a healthy meal or join a stop-

blockers or ACE inhibitors to lower blood pressure.

Aspirin or other medicines to reduce the risk of blood clots.

Nitrates to relieve chest pain.

for you. Walking is great exercise that most people can do. A good goal is 30 minutes or more a day.

doctor guides a thin tube (called a catheter) into the narrowed artery and inflates a small balloon. This widens the artery to help restore blood flow. Often a small wire-mesh tube called a stent is placed to keep the artery open. The doctor may use a stent that is coated with medicine, called a drug-eluting stent. When the stent is in place, it slowly releases a medicine that prevents the growth of new tissue. This helps keep the artery open.

Bypass surgery, which is major surgery, may

disease. These changes may stop or even reverse coronary artery disease. To improve your heart health:

Don't smoke. This may be the most important thing you can do. Quitting smoking can quickly reduce the risk of heart attack or death.

Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. See a dietitian if you need help making better food choices.

Lower your stress level. Stress can huzrt your heart.

Changing old habits may not be easy, but it is

treatment as needed.

Take medicines exactly as prescribed. Do not stop or change medicines without talking to the doctor.

Instruct to keep nitroglycerin with him at all times, if the doctor prescribed it for chest pain.

processed foods.

Reduction of Homocysteine levels by supplementation with Vitamins B6 and B12, and folic acid.

Increased antioxidant activity by higher consumption of fruits and vegetables.

Lowering of fibrinogen and growth factors by cutting back on foods such as red meat, dairy products, poultry and eggs.

smoking program with you. Or ask your doctor about a cardiac rehab program. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits

be used if more than one coronary artery is blocked. It uses healthy blood vessels to create detours around narrowed or blocked arteries.

very important to help you live a healthier and longer life. Having a plan can help. Start with small steps. For example, commit to eating five servings of fruits and vegetables a day. Instead of having dessert, take a short walk. When feeling stressed, stop and take some deep breaths

Far Eastern UniversityInstitute of Nursing

Case Study

Intracranial Hemorrhage

Submitted to:Pepito B. Ruzol JR., PT, RN, RM, MSN

Submitted by:

BSN117Group 67

GALINATO, Maria JunelsiaGAMBOA, Jessedith AnnGAMBOA, Michael BrianGANCENIA, Bettina Rose

GARCIA, JaniceGARCIA, Kimberly Ann

BSN117Group 68

MATULAC, Famela JeanTEOVISIO, Jessely

TUY, Barry VASQUEZ, Neil