Page |1

RAHMAN INSTITUTE OF NURSING AND

PARAMEDICAL SCIENCES
RADHANAGAR, GUWAHATI-27

SUBJECT:
MEDICAL – SURGICAL NURSING – I

CASE PRESENTATION ON:

SUBARACHNOID HEAMORRHAGE.

SUBMITTED TO; SUBMITTED BY;

MS. ANITA SPONOWAL CH. ANJU CHANU

ASSOCIATE. PROFESSOR, M.Sc. 1st Year
Dept. Medical – Surgical Nursing RINPS
RINPS

Date: 13.4.2020.
 Page |2

INDEX
SR.NO TOPIC PAGE NO.
1. PATIENT BIODATA 1
2. PRESENTING COMPLAINT 1
3. HISTORY OF ILLNESS 1–2
4. SOCIO ECONOMIC STATUS 2
5. HABITS 2–3
6. PHYSICAL EXAMINATION OF PATIENT 3–5
A. Neurological System: 3
B. Sensory System 3–4
C. Respiratory System 4
D. Cardiovascular System 4
E. Gastro-Intestinal System 4
F. Renal/ Urinary System 5
G. Reproductive System 5
H. Integumentary System 5
I. Musculoskeletal System 5
16. DISEASE CONDITIONS 6 – 11
A. Anatomy And Physiology 6
B. Definition 7
C. Incidence And Prevalence 7
7
D. Risk factors 7–8
E. Etiological Factors 8
F. Pathophysiology 8
G. Clinical Manifestation 9
H. Management: 9 – 10
a. Medical Management:
9
b. Surgical Management:
10
c. Dietary Management:
10
I. Diagnostic Evaluations 11 – 12
27. INVESTIGATIONS 12 – 14
28. DRUG’S STUDY 15 – 17
29. NURSING CARE PLAN 18
30. NURSING PROCESS: 19 – 23
(Dorothea Orem: Self Care Deficit Theory)
31. DISCHARGE AND HOME CARE MANAGEMENT 24
32. EVALUATION OF CARE 24
 Page |3

33. BIBLIOGRAPHY 25
34. REFERENCES 25
 Page |4

1. PATIENT BIODATA:

Name : Mr. Ranjit Singha.

Age : 53 Years
Gender : Male
Religion : Hinduism
Marital status : Married
Occupation : Businessman
Source of health : Health City hospital khanapara.
care
IP. No. : 14314/20
Date of admission : 10/03/2020
Ward : ICU (3nd Floor)
Bed no. : 1627
Address : Balikuchi kamrup, Assam
Provisional : Subarachnoid Hemorrhage (SAH)
diagnosis
Date of surgery : Craniotomy on 11/03/2019
2. PRESENTING COMPLAINTS:
Mr. Ranjit Singha have the complaints of mild difficulty in breathing, involuntary micturation,
impaired mental status, confusion, drowsiness, mild restlessness, weakness of left lower limb .

HISTORY OF ILLNESS:

a. History of present illness:

Mr.Ranjit Singha was admitted in HEALTH CITY HOSPITAL , with the complaints of sudden
onset giddiness and tendency to fall of the patient 1 days back. It was associated with weakness of left
lower limb. Immediately, patient was taken to nearby clinic. Patient recovers spontaneously and gets
return to home. Patient again had the second episode in the evening and came to hospital . CT – scan
brain was than done in the hospital at 1.20 pm and it revealed SAH. Then, patient was immediately
shift ICU for further treatment.
History of past illness:
Mr. Ranjit Singha has history of RTA since 1 months nearby Kamrup railway station when he went
to drop his friend to the station. But immediately undergone treatment in clinic no any severe external
injury seen.Patient has no history of past illness like diabetes mellitus, tuberculosis, hypertension,
bronchial asthma, hepatitis, malaria, typhoid fever, dengue, etc.
b. History of present illness surgery:
Mr. Ranjit Singha has the present surgical history of Craniotomy on 11/03/2019 (under General
Anesthesia).
c.History of past illness surgery:
Mr. Ranjit Singha has no past surgical history like, appendectomy, tonsillectomy, septoplasty, etc.
 Page |5

d. Family history:
i. Family tree:
INDEX
Male
53 53 Yrs
years
Female

Patient
25 Yrs 20 Yrs
22
Yrs Death

ii. Family column:

Name of the Age/ Health status

Education Occupation Relationship
family
members Sex

57 Yrs Not
Mr. Ranjit 12th –Pass Businessman Patient
Singha Male Healthy
43 Yrs
Mrs. Ranjita 10th – Pass Housewife Wife Healthy
rawath Female
25 Yrs
Ms. Priya Graduate Self Daughter Healthy
Female employed
22 Yrs
Mr. Abhishek Graduate Self Son Healthy
Male employed
20 Yrs
Ms. Renu 12th- Pass Student Daughter Healthy
Female
iii. History of illness in the family members:
All family members are healthy except Mr. Ranjit Singha (Patient). There is no history of
any disease or illness and communicable disease like, tuberculosis, malaria, dengue,
hepatitis, etc. among the family members.
3. SOCIO-ECONOMIC STATUS OF THE FAMILY:
a. Head of the family: Mr. Mantosh Ghosh
b. Monthly family income: 30,000/- Rupees Per month.
c. Bread earners: Mr. Mantosh Ghosh
d. Expenditure on health: Approximately 1000 – 3000/- Rupees Per Month
4. HABITS:
a. Consumption of alcohol: Patient has the habits of alcohol occasionally.
b. Smoking: Patient no habits of smoking.
c. Tobacco chewing: Patient has habits of tobacco chewing since 3 years.
 Page |6

d. Sleeping Patterns: Patient have disturbed sleeping pattern but sleep around 8-10 hours
per day.
e. Exercise: Patient doesn’t take regular exercise.
f. Nutrition: Patient is non-vegetarian and had meat or beef once or twice a week before
illness.
g. Meal per day: Patient takes the meal twice per day.

5. PHYSICAL EXAMINATION OF PATIENT:

a. Height – 155 Cms = 1.55 Metres
b. Weight – 56 Kgs
Weight∈kgs 56
c. BMI =
(Height ∈metre)
=2 (1.55) =2 23.309
d. Vital signs:
Date Temperature Pulse Respiration Blood pressure
10/03/2020 98℉ 70 bts/min 22 br/ min 130/90 mm/Hg
11/03/2020 98.6℉ 76 bts/min 18 br/ min 110/80 mm/Hg
12/03/2020 97.6℉ 82 bts/min 18 br/ min 120/80 mm/Hg
13/03/2020 98℉ 78 bts/min 20 br/ min 140/80 mm/Hg
14/03/2020 97.8℉ 80 bts/min 18 br/ min 130/70 mm/Hg

e.General appearance:
The patient looks neat and tidy. He is well dressed, puts on dress according to Hospital policy.

i. Nourishment: He is well nourished.

ii. Body built : He is lean and thin.
iii. Body posture: He has normal body posture with no deformities such as lordosis or kyphosis.
iv. Gait: He has abnormal body gait (unable to walk).
v. Activity: He is unable to perform his activities of daily living without the help from the nurses.
vi. Body movements: He can move all his limbs normally. But there is weakness in left lower limb.
He used to change position by self from one position to another.

a.Level of : He is semi – conscious.

consciousness
b.Orientation : He is not oriented to place, person, and time.
c. GCS : 12/15;
a. Eye opening response – responds spontaneously
b. Verbal response – oriented but can’t speak because of
tracheostomy
c. Motor response – obey command but all limbs have
weakness
d.Eyes : Eyes respond to stimuli; Pupils reacted to light equally.
e. Neck : No restriction in head movement
f. Scar : Healing progressively, no infections no discharges.

g.Cranial nerves examinations:

 Page |7

Sl. Cranial nerve Functions Right side Left side

No
1. Ryle’s tube present; unable to
Olfactory Sensory- Sense of
determine the sense of smell.
nerve smell
2. Pupil reacting; 2+ Pupil
Optic nerve Sensory- Vision Visual sense not reacting;
assess 2+
Visual sense
not assess
3. Occulomotor Motor and Sensory- Normal Normal
nerve Serves muscles of functioning functionin
eye g
4. Motor and Sensory-
Normal Normal
Trochlear Serves the superior
functioning functionin
nerve oblique eye muscle
g
5. Motor and Sensory-
Sensory from face
Trigeminal Normal functioning
and mouth; motor
nerve
muscle of
mastication
(chewing)
6. Motor and Sensory- Normal Normal
Abducent
Serves the lateral functioning but functionin
nerve
rectus eye muscle weak g but weak
7. Motor and Sensory-
Facial nerve Serves the muscles of
facial expression, Increased secretions of saliva and
lacrimal glands, and tears
salivary glands
8. Acoustic Mild loss of Mild loss of
Sensory- Equilibrium
nerve/ equilibrium and equilibriu
and hearing
hearing m and
Vestibulococ sensation hearing
hlear sensation
9. Motor and Sensory- Difficulty in swallowing because
Serves the throat for of Ryle’s tube.
Glossopharyn swallowing, posterior There is increase secretion of
geal nerve third of tongue, saliva but patient can’t
parotid salivary gland swallow/tolerate according to
need, so suctioning is required.
10. Motor and Sensory-
Sensations from
Vagus nerve visceral (internal) Normal functioning
 Page |8

organs, and
parasympathetic
motor regulation of
visceral organs
11. Motor and Sensory-
Serves muscles that Normal movement of head, neck
Accessory
move head, neck, and and shoulder
nerve
shoulder
12. Motor and Sensory-
Hypoglossal Normal functioning
Serves muscles of
nerve
tongue.

h.Sensory-Motor assessment:
Sensory assessment Motor assessment
 Light touch: Present sensation of light touch.
 Appearance:
 Pain and temperature: Present sensation on pain and Smooth and there is
temperature. present of no
 Two point discrimination: Unable to perform. deformities and no
 Sterogenesis: Unable to perform fasciculation of
muscles.
 Graphestesia: Unable to perform.
 Proprioception: Unable to perform  Tone: Tones of
muscles are good.

 Muscle strength:
Score as 2/5; Move
with gravity

i. Reflexes:
In Patient
Types of Reflexes
Right Side Left Side
Brachiorochiles 1+ 1+
Bicep 1+ 1+
Triceps 1+ 1+
Knee reflex 1+ 1+
Achilles reflex 2+ 2+
Babinski reflex 2+ 2+
Ankle reflex 1+ 1+
Cremisteric/ Geigel reflex 1+ 1+
Abdominal reflex 2+

j. Co-ordination:
 Page |9

 Finger to nose testing: Unable to perform.

 Rapid alternating finger movement: Unable to perform.
 Rapid alternating hand movement: Unable to perform.
 Heel to shin testing: Unable to perform.
Head to toe assessment (system-wise):
A. NEUROLOGICAL SYSTEM:
B. SENSORY SYSTEM:
a. Eyes:
His eyes are normal, react to light equally. Pupils are equal in size. He has no eyesight problem. He
has normal vision before illness. Eyeballs are normal. But there is an increased tears secretion. There
is no history cataract or glaucoma. Eyelashes and eyebrows are distributed evenly. There is no
infection, oedema of eyelids. Conjunctiva is pink in colour. There is no conjunctivitis.
b. Ears:
It is symmetric in shape and size. There is no infection, or discharge from ears. Pinna recoils after it
is folded. Tympanic membrane is not perforated. Hearing test is difficult to assess.

c. Nose:
Nose is symmetrical and alignment is straight. He does not have deviated nasal septum. There are no
lesions. There is no discharge. He can’t perceives smell.

d. Mouth and pharynx:

 Lips: There is dryness of lips. Lips are mildly cracked.
 Teeth: It is evenly distributed; no cavity/ dental caries are present.
 Gums: Gums are healthy and firm. There is no gum bleeding or infection.
 Mucous membrane: It is healthy; there is no infection or inflammation.
 Odour: Foul odour is present.

Dryness of mouth is not detected, there is no inflammation in the tonsil and uvula, tongue is in
central position. Foul odour is present. There is no infection in the oral cavity; oral hygiene is not
maintained properly.

C. RESPIRATORY SYSTEM

a. Chest : Symmetrical chest movement, normal expansion of chest, rhythmic respiration,

there is no retraction when breathing.
b. Trachea : Normal Position.
c. Breathing pattern : Normal breathing pattern but become abnormal when the patient in restlessness
or excitement.
d. Breathing sound : No abnormal sounds are detected; there is no dyspnea.

D. CARDIOVASCULAR SYSTEM
a. Cardiac pattern : Normal sinus rhythm with no tachycardia, regular heart rate.
b. Pericardial movement : No pericardial friction rub is noted, presence of fluid is not
detected.
c. Capillary refill : Capillary refill time is less than 2secs.
 P a g e | 10

E. GASTRO-INTESTINAL SYSTEM
a. Abdominal girth: 88 cm
b. Inspection: No scar marks are present, there is no visible pulsation, no engorged veins are seen;
umbilicus is centrally inverted.
c. Auscultation: Tympanic sound is noted. Bowel sounds are present.
d. Percussion: Tympanic sound is noted, ascites is absent.
e. Palpation: Soft and no tenderness present on right hypochondriac region; no organomegaly;
Murphy’s sign is positive. Abdomen is mildly distended.
f. Elimination pattern: Foley’s catheter is present.
g. Bowel pattern: Bowel pattern is normal; 1-2 times per day.

F. RENAL/ URINARY SYSTEM

a. Urine output/day - Urine output is around 1200- 1600ml per day.
b. Colour - Pale yellow
c. Voiding pattern - Continuous (Foley’s)
d. Characteristics - No sedimentation, no milky coloured urine or hematuria.

G. REPRODUCTIVE SYSTEM
There is no abnormal, no infection, no irritation. No abnormalities are present.

H. INTEGUMENTARY SYSTEM
 Skin colour - Brown
 Texture - Rough
 Temperature - Warm
 Dryness - Present
 Skin lesions - Surgical site is present on occipital part of the head.
 Infection - Absent
 Nails - Evenly distributed, thick, pink in colour.

I. MUSCULOSKELETAL SYSTEM
a. Activity level: He is unable perform his daily activities without the help of his family members.
b. Extremities: Extremities are normal and symmetric. There is no clubbing of foot, no digitally or
clinodactyly.
c. Any prosthesis or fracture: Nil
d. Muscle: Weakness of muscle and loss of muscle tones.
e. Joints: He can perform abduction, adduction, extension, flexion of all joints. But there is mild
restriction and mild pain.
f. Back: Posture is abnormal, no back pain.

6. DISEASE CONDITION:
A. ANATOMY AND PHYSIOLOGY OF BRAIN AND AFFECTED SYSTEM:
The brain and spinal cord form the central nervous system. These vital structures are surrounded
and protected by the bones of the skull and the vertebral column, as shown in the drawing. The
bones of the skull are often referred to as the cranium. In infants, the skull is actually composed of
separate bones, and an infant’s soft spot (anterior fontanel) is an area where four skull bones nearly
come together. The places where the bones meet and grow are called sutures.
 P a g e | 11

The brain is a large organ weighing around 1.4 kg that lies within the cranial cavity. Its parts are
 cerebrum
 thalamus
 hypothalamus
 midbrain
 pons
 medulla oblongata
 cerebellum
Blood supply and venous drainage
The circulus arteriosus and its contributing arteries play a vital role in maintaining a constant supply
of oxygen and glucose to the brain when the head is moved and also if a contributing artery is
narrowed. The brain receives about 15% of the cardiac output, approximately 750 mL of blood per
minute. Auto regulation keeps blood flow to the brain constant by adjustingthe diameter of the
arterioles across a wide range of arterial blood pressure (about 65–140 mmHg) with changes
occurring only outside these limits.
F
s P a g e | 12
 P a g e | 13

Venous blood from the brain drains into the dural venous sinuses and then downwards into the
internal jugular veins.
 Cerebrum
This is the largest part of the brain and it occupies the anterior and middle cranial fossae. It is
divided by a deep cleft, the longitudinal cerebral fissure, into right and left cerebral hemispheres,
each containing one of the lateral ventricles. Deep within the brain, the hemispheres are connected
by a mass of white matter (nerve fibres) called the corpus callosum. The falx cerebri is formed by
the dura mater. It separates the two cerebral hemispheres and penetrates to the depth of the corpus
callosum. The superficial part of the cerebrum is composed of nerve cell bodies (grey matter),
forming the cerebral cortex, and the deeper layers consist of nerve fibres (axons, white matter).
Functions of the cerebral cortex
There are three main types of activity associated with the cerebral cortex:
 higher order functions, i.e. the mental activities involved in memory, sense of responsibility,
thinking, reasoning, moral decision making and learning
 sensory perception, including the perception of pain, temperature, touch, sight, hearing, taste and
smell
 initiation and control of skeletal muscle contraction and therefore voluntary movement.
For descriptive purposes each hemisphere of the cerebrum is divided into lobes which take the
names of the bones of the cranium under which they lie:
 frontal
 parietal
 temporal
 occipital.
The boundaries of the lobes are marked by deep sulci. These are the central, lateral and parieto-
occipital sulci.
 Diencephalon
This connects the cerebrum and the midbrain. It consists of several structures situated around the
third ventricle, the main ones being the thalamus and hypothalamus, which are considered here. The
pineal gland and the optic chiasma are situated there.
Thalamus
This consists of two masses of grey and white matter situated within the cerebral hemispheres just
below the corpus callosum, one on each side of the third ventricle. Sensory receptors in the skin and
viscera send information about touch, pain and temperature, and input from the special sense organs
travels to the thalamus where there is recognition, although only in a basic form, as refined
perception also involves other parts of the brain. It is thought to be involved in the processing of
some emotions and complex reflexes. The thalamus relays and redistributes impulses from most
parts of the brain to the cerebral cortex.
Hypothalamus
The hypothalamus is a small but important structure which weighs around 7 g and consists of a
number of nuclei. It is situated below and in front of the thalamus, immediately above the pituitary
gland. The hypothalamus is linked to the posterior lobe of the pituitary gland by nerve fibres and to
the anterior lobe by a complex system of blood vessels. Through these connections, the
 P a g e | 14

hypothalamus controls the output of hormones from both lobes of the pituitary gland. Other
functions of the hypothalamus include control of:
 the autonomic nervous system
 appetite and satiety
 thirst and water balance
 body temperature
 emotional reactions, e.g. pleasure, fear, rage
 sexual behaviour and child rearing
 sleeping and waking cycles.
 Brain stem
Midbrain
The midbrain is the area of the brain situated around the cerebral aqueduct between the cerebrum
above and the pons below. It consists of nuclei and nerve fibres (tracts), which connect the cerebrum
with lower parts of the brain and with the spinal cord. The nuclei act as relay stations for the
ascending and descending nerve fibres and have important roles in auditory and visual reflexes.
Pons
The pons is situated in front of the cerebellum, below the midbrain and above the medulla oblongata.
It consists mainly of nerve fibres (white matter) that form a bridge between the two hemispheres of
the cerebellum, and of fibres passing between the higher levels of the brain and the spinal cord.
There are nuclei within the pons that act as relay stations and some of these are associated with the
cranial nerves. Others form the pneumotaxic and apnoustic centres that operate in conjunction with
the respiratory centre in the medulla oblongata to control respiration.
The anatomical structure of the pons differs from that of the cerebrum in that the cell bodies (grey
matter) lie deeply and the nerve fibres are on the surface.
Medulla oblongata
The medulla oblongata, or simply the medulla, is the most interior region of the brain stem.
Extending from the pons above, it is continuous with the spinal cord below. It is about 2.5 cm long
and lies just within the cranium above the foramen magnum. Its anterior and posterior surfaces are
marked by central fissures. The outer aspect is composed of white matter, which passes between the
brain and the spinal cord, and grey matter, which lies centrally. Some cells constitute relay stations
for sensory nerves passing from the spinal cord to the cerebrum. The vital centres, consisting of
groups of cell bodies (nuclei) associated with autonomic reflex activity, lie in its deeper structure.
These are the:
 cardiovascular centre
 respiratory centre
 reflex centres of vomiting, coughing, sneezing and swallowing.
 Cerebellum
The cerebellum is situated behind the pons and immediately below the posterior portion of the
cerebrum occupying the posterior cranial fossa. It is ovoid in shape and has two hemispheres,
separated by a narrow median strip called the vermis. Grey matter forms the surface of the
cerebellum, and the white matter lies deeply.
Functions
P a g e | 15
F
P a g e | 16
 P a g e | 17

The cerebellum is concerned with the coordination of voluntary muscular movement, posture and
balance. Cerebellar activity is not under voluntary control. The cerebellum controls and coordinates
the movements of various groups of muscles ensuring smooth, even, precise actions. It coordinates
activities associated with the maintenance of posture, balance and equilibrium. The sensory input for
these functions is derived from the muscles and joints, the eyes and the ears. Proprioceptor impulses
from the muscles and joints indicate their position in relation to the body as a whole; impulses from
the eyes and the semicircular canals in the ears provide information about the position of the head in
space. The cerebellum integrates this information to regulate skeletal muscle activity so that balance
and posture are maintained.
The meninges
The brain and spinal cord are completely surrounded by three layers of tissue, the meninges,
lying between the skull and the brain, and between the vertebral foramina and the spinal cord.
Named from outside inwards they are the:
 dura mater
 arachnoid mater
 pia mater.

The dura and arachnoid maters are separated by a potential space, the subdural space.
The arachnoid and pia maters are separated by the subarachnoid space, containing
cerebrospinal fluid.
 Dura mater
The cerebral dura mater consists of two layers of dense fibrous tissue. The outer layer takes the
place of the periosteum on the inner surface of the skull bones and the inner layer provides a
protective covering for the brain. There is only a potential space between the two layers except
where the inner layer sweeps inwards between the cerebral hemispheres to form the falx
cerebri; between the cerebellar hemispheres to form the falx cerebelli; and between the
cerebrum and cerebellum to form the tentorium cerebelli.
F
P a g e | 18
 P a g e | 19

 Arachnoid mater
This is a layer of fibrous tissue that lies between the dura and pia maters. It is separated from
the dura mater by the subdural space that contains a small amount of serous fluid, and from the
pia mater by the subarachnoid space, which contains cerebrospinal fluid. The arachnoid mater
passes over the convolutions of the brain and accompanies the inner layer of dura mater in the
formation of the falx cerebri, tentorium cerebelli and falx cerebelli. It continues downwards to
envelop the spinal cord and ends by merging with the dura mater at the level of the 2 nd sacral
vertebra.
 Pia mater
This is a delicate layer of connective tissue containing many minute blood vessels. It adheres to the
brain, completely covering the convolutions and dipping into each fissure. It continues downwards
surrounding the spinal cord. Beyond the end of the cord it continues as the filum terminale, pierces the
arachnoid tube and goes on, with the dura mater, to fuse with the periosteum of the coccyx.

Ventricles of the brain

The brain contains four irregular-shaped cavities, or ventricles, containing cerebrospinal fluid (CSF).
They are:
 right and left lateral ventricles
 third ventricle
 fourth ventricle.

 The lateral ventricles

These cavities lie within the cerebral hemispheres, one on each side of the median plane just below the
corpus callosum. They are separated from each other by a thin membrane, the septum lucidum, and are
lined with ciliated epithelium. They communicate with the third ventricle by interventricular
foramina.
 The third ventricle
The third ventricle is a cavity situated below the lateral ventricles between the two parts of the
thalamus. It communicates with the fourth ventricle by a canal, the cerebral aqueduct.

 The fourth ventricle

The fourth ventricle is a diamond-shaped cavity situated below and behind the third ventricle, between
the cerebellum and pons. It is continuous below with the central canal of the spinal cord and
communicates with the subarachnoid space by foramina in its roof. Cerebrospinal fluid enters the
subarachnoid space through these openings and through the open distal end of the central canal of the
spinal cord.
Cerebrospinal fluid (CSF)
Cerebrospinal fluid is secreted into each ventricle of the brain by choroid plexuses. These are vascular
areas where there is a proliferation of blood vessels surrounded by ependymal cells in the lining of
ventricle walls. CSF passes back into the blood through tiny diverticula of arachnoid mater, called
arachnoid villi (arachnoid granulations), which project into the venous sinuses.
The movement of CSF from the subarachnoid space to venous sinuses depends upon the difference in
pressure on each side of the walls of the arachnoid villi, which act as one-way valves. When CSF
 P a g e | 20

pressure is higher than venous pressure, CSF is pushed into the blood and when the venous pressure is
higher the arachnoid villi collapse, preventing the passage of blood constituents into the CSF. There
may also be some reabsorption of CSF by cells in the walls of the ventricles.
From the roof of the fourth ventricle CSF flows through foramina into the subarachnoid space and
completely surrounds the brain and spinal cord. There is no intrinsic system of CSF circulation but its
movement is aided by pulsating blood vessels, respiration and changes of posture.
CSF is secreted continuously at a rate of about 0.5 mL per minute, i.e. 720 mL per day. The volume
remains fairly constant at about 150 mL, as absorption keeps pace with secretion. CSF pressure may
be measured using a vertical tube attached to a lumbar puncture needle inserted into the subarachnoid
space above or below the 4th lumbar vertebra (which is below the end of the spinal cord).
The pressure remains fairly constant at about 10 cm H 2O when lying on one side and about 30 cm
H2O when sitting up. If the brain is enlarged by, e.g. haemorrhage or tumour, some compensation is
made by a reduction in the amount of CSF. When the volume of brain tissue is reduced, such as in
degeneration or atrophy, the volume of CSF is increased. CSF is a clear, slightly alkaline fluid with a
specific gravity of 1.005, consisting of:
 water
 mineral salts
 glucose
F
P a g e | 21
 P a g e | 22

 plasma proteins: small amounts of albumin and globulin

 a few leukocytes
 creatinine
 urea
Functions of cerebrospinal fluid
CSF supports and protects the brain and spinal cord by maintaining a uniform pressure around
these vital structures and acting as a cushion or shock absorber between the brain and the skull.
It keeps the brain and spinal cord moist and there may be exchange of nutrients and waste
products between CSF and the interstitial fluid of the brain.
CSF is thought to be involved in regulation of breathing as it bathes the surface of the medulla
where the central respiratory chemoreceptors are located.
PARTS AND FUNCTIONS OF THE BRAIN

Region Location Functions

Forebrain, largest part Performs higher functioning processes
Cerebrum
of the brain divided such as vision, hearing, speech, emotion,
into two halves and movement
Responsible for language in most right-
handed people and about 50 percent of
Left hemisphere Left side of cerebrum left-handed people; controls analytical
reasoning and calculations; processes
motor and sensory signals for the right
side of the body
Interprets visual cues and spatial
Right Right side of cerebrum processing, including emotional, artistic,
hemisphere and visual reasoning; processes motor
and sensory signals for left side of the
body
Corpus Between the two Connects the left and right hemispheres
callosum hemispheres
Largest section of Helps form reasoning, emotions,
Frontal lobe
brain, front of the movement
head
Helps us understand our spatial relation
Parietal lobe Middle part of brain
to other people and objects; interprets
touch and pain
Occipital lobe Back of the brain Helps process visual information
Helps with memory, language, smell, the
Temporal lobes On each side of the
ability to recognize faces; interprets
brain
emotions
Controls fine motor movements,
Cerebellum Hindbrain
balance, and posture
In front of the Controls basic bodily functions that are
Brainstem
 P a g e | 23

cerebellum, connected necessary for survival

to the spinal cord
Controls eye movements, facial
Midbrain Top section of the
sensation, balance, and hearing
brainstem
Middle section of the
Pons Middle section of the brainstem
brainstem
Controls respiratory drive, swallowing,
Medulla Lowest section of coughing, gag reflex; helps to regulate
oblongata brainstem circulation, blood pressure, and heart
rate
Set of structures above
Limbic system Responsible for emotions
the brainstem
Responsible for integrating all of the
Thalamus Found under the sensory signals coming from the spinal
cerebrum cord and limbic system
Sends messages to pituitary gland and
Hypothalamus Sits right below the helps to regulate temperature, thirst,
thalamus water balance, sleep, hormone
production, and appetite
Amygdala Structure in limbic Processes aggressive behavior and fear
system
Hippocampus Structure in limbic Helps us remember new information
system
Pituitary gland Base of the brain Secretes hormones
Within the deep part of
Basal ganglia Coordinates steady movements
the cerebrum

TUMORS OF NERVOUS SYSTEM:

Some 50% of brain tumours are metastases from the other primary sites, often the bronchus, breast,
stomach or prostate.
Primary tumours of the nervous system usually arise from the neuroglia, meninges or blood vessels.
Neurones are rarely involved because they do not normally multiply. Nervous tissue tumours rarely
metastise. Because of this, the rate of growth of an intracranial tumour is more important than the
likelihood of spread outside the nervous system. In this context, ‘benign’ means slow growing and
‘malignant’ rapid growing. Early signs typically include headache, vomiting, visual disturbances and
papilloedema (swelling of the optic disc seen by ophthalmoscopy). Signs of raised ICP appear after the
limits of compensation have been reached.
Within the confined space of the skull, haemorrhage within a tumour exacerbates the increased ICP
caused by the tumour.
Slow-growing tumours
These allow time for compensation for increasing intracranial pressure, so the tumour may be quite
large before its effects are evident. Compensation involves gradual reduction in the volume of
cerebrospinal fluid and circulating blood.
 P a g e | 24

Rapidly growing tumours

These do not allow time for adjustment to compensate for the rapidly increasing ICP, so the effects
quickly become apparent. Complications include:
 neurological impairment, depending on tumour site and size
 effects of increased ICP
F
A P a g e | 25
 P a g e | 26

 necrosis of the tumour, causing haemorrhage and oedema.

Specific tumours
Brain tumours typically arise from different cells in adults and children, and may range from
benign to highly malignant. The most common tumours in adults are glioblastomas and
meningiomas, which are usually benign and originate from arachnoid granulations.
Astrocytomas and medulloblastomas account for most brain tumours in children.
Metastases in the brain
The prognosis of this condition is poor and the effects depend on the site(s) and rate of growth
of metastases. There are two forms: discrete multiple tumours, mainly in the cerebrum, and
diffuse tumours in the arachnoid mater.

B. DEFINITION:
• Subarachnoid hemorrhage (SAH) refers to bleeding within the subarachnoid space, which
is the area between the brain and the tissues that cover the brain.
• Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area
between the arachnoid membrane and the pia mater surrounding the brain.
C. INCIDENCE AND PREVALENCE:
The risk is higher in blacks than in whites; however, people of all ethnic groups develop
intracranial aneurysms. The disparity in frequency of rupture has been attributed to population
variance with respect to prevalence of risk factors and age distribution.
The incidence of SAH in women is higher than in men (ratio of 3 to 2). The risk of SAH is
significantly higher in the third trimester of pregnancy, and SAH from aneurysmal rupture is a
leading cause of maternal mortality, accounting for 6-25% of maternal deaths during
pregnancy. A higher incidence of AVM rupture also has been reported during pregnancy.
Incidence increases with age and peaks at age 50 years. Approximately 80% of cases of SAH
occur in people aged 40-65 years, with 15% occurring in people aged 20-40 years. Only 5% of
cases of SAH occur in people younger than 20 years. SAH is rare in children younger than 10
years, accounting for only 0.5% of all cases.

D. RISK FACTORS:
 • High blood pressure
 • Assualt.
 • Smoking cigarettes
 • Excessive alcohol use
 • Cocaine and/or methamphetamine use
 • Family history of brain aneurysmCertain types of connective tissue disorders
 Prior brain aneurysm
 RTA.

E. ETIOLOGICAL FACTORS:
 Bleeding from a tangle of blood vessels called an arteriovenous malformation (AVM)
 Bleeding disorder.
 Bleeding from a cerebral aneurysm (weak area in the wall of a blood vessel that causes the
blood vessel to bulge or balloon out)
 Head injury.
 Berry aneurysmAtherosclerosis
x
A
D
g
B
R
w
T
v
,lb




d
f
ito
c
p
a
h
m
s
y
r
u
e
n
.
Congenital defect of the vessel wall
Hypertensive vascular disease
Unknown cause (idiopathic)

F. PATHOPHYSIOLOGY:

G. CLINICAL MANIFESTATIONS:

H. MANAGEMENT:
IN BOOK
Neck pain
Numbness throughout the body
Shoulder pain
Seizures
Confusion
Irritability
Sensitivity to light
Decreased vision
Double vision
Nausea
Vomiting
Rapid loss of alertness
IN PATIENT
Absent
Present
Absent
Absent
Present
Present
Present
Absent
Absent
Absent
Absent
Present
P a g e | 27
 P a g e | 28

a. Medical management:
IN BOOK IN PATIENT
Antibiotcs (Inj. Tazar 4.5gm, Inj. Linox 600 mg &
Given
Inj. Tobramycin 80 mg)
Osmotic Diuretics (Inj. Mannitol 100 mlg) Given
Antiepileptic (Inj. Fosolin150 mg) Given
Inj. Cerebrolycin 20 ml (slowly 10 min) Given
Multivitamins & Multiminerals (Cap. Rejux Plus
Given
& Syp. Supradyn)
Proton – Pump Inhibitors (Inj. Pan 40 mg) Given
Laxatives (Syp. Lactulose) Given
Bronchodilators and Expectorants (Duolin
Given
Respules and Budecort Respules)
Antiemetics (Inj. Ondansteron) Given
Calcium Channel Blockers (Tab. Nimodip 30 mg Given
– 2 Tab)
Analgesics & Anti – pyretic (Inj. PCM 100 ml) Given

b. Surgical management:

Name of the surgical procedure (In In Patient

Book)
Craniotomy Done on 11/03/2020
Minimally invasive endonasal endoscopic Not done
surgery
Minimally invasive neuroendoscopy Not done
Deep Brain stimulation Not done

c. Dietary management:

In book In Patient
RT feeding every three hourly with
Fats and salt restricted diet vegetables soup, dal soup, soup and
Ensure Plus Powder.

I. DIAGNOSTIC EVALUATION:10/3/20

In Book In Patient
Computerized tomography (CT) scan Done
Magnetic resonance imaging (MRI) Done
Lumber Puncture Not done
Cerebral angiogram Not done
Functional MRI Not done
 P a g e | 29

Transcranial Ultrasound Not done

ECG on admission Done

7. INVESTIGATIONS:

Date Investigation Patient Normal value Inference

done value
ABO blood
10/03/2020 grouping & ‘B’- Positive -- --
Rh Typing
ANTI-HIV ½ 0.60 (0 – 0.89) Non-
Reactive Non-Reactive
10/03/2020 HBsAg 0.39
ANTI HCV 0.04 (0.90 – 1.0)
Borderline
(>1.0) Reactive
10/03/2020 HAEMATOLOGY
Complete blood count (CBC)
Slightly
TLC 11,500 cells/ 4,000 -11,000 increased
Cmm cells/Cmm
DLC;
Polymorphs 64% (50 -70) % Increased
Lymphocytes 24% (20 -40) % level of
Monocytes 2% (02 -10) % Eosinophils
Eosinophils 8% (01-06) %

(0 -10) mm 1st Normal value

ESR 20 mm Hr- Male
(0-20) mm 1st
Hr- Female
normal)
(12-16) gm% -
Hemoglobin 14.2 gm%
Male
(Hb %)
(11-14) gm% -
Female

Slightly
RBC Count 4.1 (4.5-5.5) decreased
million/cm million/cmm
m

Platelet count 3.05 (1.5-4) Normal value

Lacs/cmm Lacs/cmm

PCV 40.7 % (35-47) % Normal value

 P a g e | 30

normal)
MCV 96.Cumic (76-96) cumic
Slightly
MCH 33.6 picgm (27-32) picgm increased

MCHC 34.9 % (30-35) % Normal value

11/03/2020 BIOCHEMISTRY
Glucose (R) 124.6 mg/dl (70-140) mg/dl Normal
Urea 18.2 mg/dl (15-43) mg/dl Normal
Creatinine 0.53* (0.6-1.3) Decreased
Sodium 137.2 mmol/ (137-145) Normal
L mmol/L
Potassium 4.57 mmol/L (3.5-5.1) mmol/ Normal
L
11/03/2020 TSH 1.06 µIU/ml (0.45-4.68) Normal
µIU/ml
12/03/2020 HAEMATOLOGY
(12-16) gm% -
Hemoglobin 13.6 gm% Male Normal value
(Hb%)
(11-14) gm% -
Female
PCV 38.4 % (35-47) % Normal
Prothombin
time; 13.8 sec -- --
Test 13.8 sec -- --
Control 1.02 -- --
INR

12/03/2020 HAEMATOLOGY
Hemoglobin (12-16) gm% - Normal value
(Hb%) 11.5 gm% Male
(11-14) gm% -
Female
normal
PCV 35.8 % (35-47) %
BIOCHEMISTRY
Sodium 134.6* (137-145) Decreased
mmol/L mmol/L
Potassium 3.57 mmol/ (3.5-5.1) mmol/ Normal
L L
13/03/2020 BIOCHEMISTRY
Sodium 140.9* (137-145) Normal
mmol/L mmol/L
 P a g e | 31

Potassium 3.56 mmol/ (3.5-5.1) mmol/ Normal

L L
14/03/2020 BIOCHEMISTRY
Sodium 141.5 (137-145) Normal
mmol/L mmol/L
Potassium 3.71 mmol/L (3.5-5.1) mmol/ Normal
L
11/03/2020 HAEMATOLOGY
Bleeding time 1 min 10 sec < 4 min Normal
Clothing time 4 min 20 sec < 10 min Normal
APTT 28.7 sec (22-34) sec Normal
14/03/2020 HAEMATOLOGY
Slightly
TLC 12,400 cells/ 4,000 -11,000
increased
Cmm cells/Cmm
DLC;
Polymorphs 64% (50 -70) % Decreased
Lymphocytes 24% (20 -40) % Eosinophils
Monocytes 2% (2 -10) % level
Eosinophils 9% (01-06) %
14/03/2020 BIOCHEMISTRY
Sodium 135.2* (137-145) Decreased
mmol/L mmol/L
Potassium 4.45 mmol/ (3.5-5.1) mmol/ Normal
L L
 P a g e | 32

10. DRUG STUDY:

Name Of the Dosage & Nursing
Route Action Indication Contraindication Side Effects
Drugs Frequency Responsibilities
Inj. Tazar IV 4.5g Tazar 4.5g Injection is a  Urinary tract  Clostridium  Assess
combination of two infections difficile infection  Rash hypersensitivity to
BD
Pharmacologi medicines: Piperacillin and  Pneumonia  Low amount of  Vomiting the product
cal name: Tazobactum. Piperacillin is potassium  Allergic  Assess the vital
an antibiotic. It works by  Gynecological  Increased risk of reaction signs
Piperacillin preventing the formation of infections bleeding due to  Nausea  Monitor the intake
and the bacterial protective clotting disorder  Diarrhea and output ratio
Tazobactum  Intra – abdominal
covering which is essential  Kidney disease  Encourage patient
Infection
for the survival of bacteria.  Severely Decreased to increase intake.
Tazobactum is a beta-  Skin and Skin Neutrophils  Ask the patient to
lactamase inhibitor which Structure Infection  Allergies: report any
reduces resistance and  Penicillins complications.
 Bacterial  Betalactams
enhances the activity of
infections
Piperacillin against bacteria.
 Neutropenia with
fever

Inj. IV 20 ml Cerebrolysin promotes;  Stroke  Hypersensitivity to  Assess

Cerebrolysin BD Brain-derived neurotrophic cerebrolysin or any  Loss of hypersensitivity to
 Traumatic Brain component of the appetite the product
factor, Glial cell line
Injury formulation  Headache  Assess for the
derived neurotrophic factor,
Nerve growth factor, Ciliary  Vascular Dementia  Epilepsy/tonic-  Fever changes in
Pharmacologi clonic seizures  Lower back behaviors
neurotrophic factor, and
cal name:  Alzheimer's  Severe renal pain  Assess the vital
Insulin-like growth factor-1 disease
(IGF-1). It does cross the impairment  Shortness of signs
 Severe coagulation breath  Monitor the intake
 P a g e | 33

Cerebrolysin blood brain barrier. disorder  Chills and output ratio

 Intramuscular  Irregular  Ask the patient to
injection in patients heartbeat report any
taking oral  Diarrhea complications.
anticoagulants  Injection site
reactions
 Vomiting
 Indigestion

Inj. Fosolin IV 150 mg It works by slowing down  Monitor & notify

 Alcoholism
TDS impulses in the brain that  Status Epilepticus  Sleep
the physician about
disturbances
cause seizures. Its  Epilepsy  Complete heart difficulty with gait
Pharmacologi  Nausea or
main mechanism is to block block
cal name: Vomiting or coordination.
frequency-dependent, use-  Second degree  Abdominal  Lab tests: Periodic
Phosphenytoin
dependent and voltage- atrioventricular pain CBC with
dependent neuronal sodium heart block  Black or differential, Hct &
channels, and therefore limit tarry stools
 Adams-stokes Hgb, LFTs.
repetitive firing  Blurred
syndrome vision  Monitor for
of action potentials. changes in
 Dizziness
 Sinus bradycardia phenytoin blood
and fainting
 Abnormal ekg with  Confusion levels with
qt changes from  Redness of coadministered
birth the skin drugs.
especially
 Low blood on the face
pressure and neck
 Headache
 Liver problems  Excessive
 Kidney disease sweating
with reduction in  Unusual
 P a g e | 34

tiredness or
kidney function weakness
 Systemic lupus  Anxiety
erythematosus
 An autoimmune
disease
 Swollen lymph
nodes
 Pregnancy
Inj. Pantop IV 40 mg/ Proton pump inhibitor  Assess bowel
 Vitamin B12
BD (suppresses gastric secretion  Treating  Diarrhea sounds
gastroesophageal deficiency  Nausea
by inhibiting hydrogen  Ask the patient to
Pharmacologi reflux disease  Low amount of  Vomiting
enzyme system in gastric report severe
cal name: (GERD) magnesium in the  Constipation
parietal cell; it blocks the diarrhoea, black
blood
Pantoprazole final step of acid  Treating ulcers of  Rash tarry stools
the stomach  Interstitial nephritis  Headaches
production)  Advice to avoid
(peptic) and  Subacute  Stomach pain alcohol, salicylates,
duodenum cutaneous lupus  Gas NSAIDs
 Healing erosive erythematosus  (flatulence)  Asks the patient
esophagitis  Systemic lupus  Joint pain to continue taking
 Treating Zollinger- erythematosus  Dizziness it even if feeling
Ellison syndrome  Osteoporosis  Sensitivity to better.
 Broken Bone sunlight
 CYP2C19 poor (phototoxic)
metabolizer
 Allergies to Proton
Pump Inhibitors
Inj. PCM IV 100 ml Produces analgesia by It is suitable for the  Caloric under  Nausea or  Check that the
 P a g e | 35

TDS unknown mechanism, but it treatment of pains of nutrition Vomiting patient is not
Pharmacologi is centrally acting in the all kinds (headaches,  Acute liver failure  Allergic skin taking any other
cal name: CNS by increasing the pain dental pain,  Liver problems reaction medication
threshold by inhibiting postoperative pain,  Severe renal  Bloody and containing
Paracetamol cyclooxygenase. Reduces pain in connection impairment cloudy urine paracetamol.
fever by direct action on with colds, post-  Shock  Anemia  Evaluate
hypothalamus heat- traumatic muscle  Acetaminophen  Fatigue therapeutic
regulating center with pain). Migraine overdose  Headache response.
consequent peripheral headaches,  Acute  Insomnia  Immediate
vasodilation, sweating, and dysmenorrhea and inflammation of medical advice
dissipation of heat. It joint pain can also be the liver due to should be sought
provides temporary influenced hepatitis C virus in the event of an
analgesia for mild to advantageously. In  Allergies to overdose, even if
moderate pain. In addition, cancer patients, acetaminophen patients feel well,
acetaminophen lowers body paracetamol is used because of the
temperature in individuals for mild pain or it risk of delayed,
with a fever. can be administered serious liver
in combination with damage.
opioids (e.g.
codeine).
P a g e | 36
 P a g e | 37

11. NURSING CARE PLAN: APPLICATION OF NURSING THEORY

a. Nursing Assessment:
 Evaluate gag reflex and ability to swallow.
 Teach patient to direct food and fluids toward the unaffected side. Assist patient to an
upright position to eat, offer a semisoft diet, and have suction readily available if gag
response is diminished.
 Reassess function postoperatively.
 Perform neurologic checks. Monitor vital signs. Maintain a neurologic low record.
Space nursing interventions to prevent rapid increase in ICP.
 Reorient patient when necessary to person, time, and place. Use orienting devices
(personal possessions, photographs, lists, clock). Supervise and assist with self-care.
Monitor and internvene to prevent injury.
 Monitor patients with seizures.
 Check motor function at intervals; assess sensory disturbances.
 Evaluate speech.
 Assess eye movement, pupil size and reaction.

b. Nursing Diagnosis:
 Ineffective cerebral tissue perfusion related to cerebral vasospasm and cerebral edema
as evidenced by decreased oxygen saturation and changes in vital signs
 Disturbed Sensory Perception related to neurological trauma or deficit as evidenced by
disorientation, confusion and restlessness
 Impaired physical mobility related to perceptual and cognitive impairment changes as
evidenced by impaired coordination and decreased muscle strength or control
 Ineffective coping related to situational crises, vulnerability, cognitive perceptual
changes as evidenced by inability to cope/difficulty asking for help, change in usual
communication patterns and inability to meet basic needs/role expectations
 Risk for infection related to traumatized tissues and invasive procedure
 Ineffective cerebral tissue perfusion related to cerebral edema as evidenced by
memory loss and changes in motor/sensory responses.
 Risk for infection related to traumatized tissues and invasive procedure.

c. Theory Application:
Mr. Ranjit Singha have the complaints of mild difficulty in breathing, impaired mental status,
confusion, drowsiness, mild restlessness, weakness of left lower limb and inability to perform her
daily activities. So, I applied (Dorothea E. Orem’s Theories of Self – Care):to provide essential
care of the patient and to improve her health status
 P a g e | 38

NURSING PROCESS; (Dorothea E. Orem’s Theories of Self – Care):

Assessment Nursing Diagnosis Outcomes Nursing system Implementation Evaluation

Universal self – care requisites: Ineffective cerebral Maintain Wholly  Monitor vital signs Mr. Ranjit
tissue perfusion effective compensatory  Assess factors related Singha
Air related to cerebral tissue system
Mild difficulty in breathing to individual situation maintained
vaso¬spasm and perfusion as
for decreased cerebral effective tissue
Water cerebral edema as evidenced by
evidenced by increased perfusion and potential perfusion as
Excessive fluid volume; cerebral edema
decreased oxygen oxygen for increased ICP. evidenced by
Food saturation and saturation and increased
Ryle’s Tube Feeding; 200 ml 3 hourly.  Closely assess and
changes in vital signs improvement oxygen
monitor neurological
Elimination in saturation and
Foley’s catheter present; adequate urine output motor/sensor status frequently and
compare with baseline. maintained
y responses.
Activity and Rest normal vital
Frequently change position by self and mild  Assess higher
signs.
restlessness. functions, including
speech
Solitude and social interaction
Visitors are his wife, son, daughter and  Position with head
daughter in law. slightly elevated and in
Hazard Prevention neutral position.
Bed rails are kept up; applied restraints in hand  Maintain bed rest,
Function within social groups provide quiet and
At home he interact with friends and relaxing environment,
neighbours; good social relationship; he, wife, and restrict visitors and
sons, daughter in law, grand – son and grand – activities.
daughter are the member of group living
together.  Assess for nuchal
rigidity, twitching,
Development of self – care requisites
increased restlessness,
Health deviation self – care requisites irritability, onset
 P a g e | 39

Can’t walk due to disoriented and confusion of Administer oxygen

state therapy as needed.

Assessment Nursing Diagnosis Outcomes Nursing system Implementation Evaluation

Universal self – care requisites: Disturbed Sensory Regain/ Wholly  Observe behavioral Mr. Ranjit
Perception related to maintain usual compensatory responses: crying, Singha
Air neurological trauma or level of system regained
Mild difficulty in breathing inappropriate affect,
deficit as evidenced consciousness usual level of
agitation, hostility,
Water by disorientation, and perceptual consciousness
agitation, hallucination. and
Excessive fluid volume; cerbral edema confusion and functioning
restlessness.  Establish and maintain perceptual
Food
communication with functioning
Ryle’s Tube Feeding; 200 ml 3 hourly.
the patient. Set up a as evidenced
Elimination simple method of by decreased
Foley’s catheter present; adequate urine output in
communicating basic
restlessness
Activity and Rest needs. and
Frequently change position by self and mild
 Eliminate extraneous confusion.
restlessness.
noise and stimuli as
Solitude and social interaction
necessary.
Visitors are his wife, son, daughter and
daughter in law.  Speak in calm,
comforting, quiet
Hazard Prevention
Bed rails are kept up; applied restraints in hand voice, using short
sentences. Maintain
Function within social groups
Ascertain patient’s
At home he interact with friends and
neighbours; good social relationship; he, wife, perceptions. Reorient
sons, daughter in law, grand – son and grand – patient frequently to
daughter are the member of group living environment, staff, and
together. procedures.
Development of self – care requisites  Assess sensory
 P a g e | 40

awareness: dull from

sharp, hot from cold,
Health deviation self – care requisites
position of body parts,
Can’t walk due to disoriented and confusion state
joint sense.

Assessment Nursing Diagnosis Outcomes Nursing system Implementation Evaluation

Universal self – care requisites: Impaired physical Maintain/ Wholly  Assess extent of Mr. Ranjit
mobility related to increase compensatory impairment initially and Singha
Air perceptual and strength and system increased
Mild difficulty in breathing on a regular basis.
cognitive impairment function of strength and
Classify according to 0–
Water changes as evidenced affected or function of
by impaired compensatory 4 scale. affected or
Excessive fluid volume; cerebral edema
coordination and body part.  Change positions at least compensatory
Food decreased muscle body part,
every 2 hr
Ryle’s Tube Feeding; 200 ml 3 hourly. strength or control maintained
Maintain  Use arm sling when
Elimination optimal
optimal patient is in upright
Foley’s catheter present; adequate urine output position of
position of position, as indicated. the function
Activity and Rest function as
 Observe affected side for and
Frequently change position by self and mild evidenced by
color, edema, or other maintained
restlessness. absence of
skin integrity
contractures, signs of compromised
Solitude and social interaction as evidenced
foot drop. circulation.
Visitors are his wife, son, daughter and by maintain
daughter in law.  Inspect skin regularly, coordination,
Maintain skin particularly over bony absence of
Hazard Prevention
integrity. prominences. contractures
Bed rails are kept up; applied restraints in hand
and food
Function within social groups  Begin active or passive drop.
At home he interact with friends and ROM to all extremities
neighbours; good social relationship; he, wife, (including splinted) on
sons, daughter in law, grand – son and grand – admission.
daughter are the member of group living
 P a g e | 41

together.  Provide egg-crate

Development of self – care requisites mattress, water bed,
flotation device, or
Health deviation self – care requisites specialized beds, as
Can’t walk due to disoriented and confusion state indicated.

Assessment Nursing Diagnosis Outcomes Nursing Implementation Evaluation

system
Universal self – care requisites: Ineffective coping Meet Wholly  Assess extent of altered Mr. Ranjit
related to situational psychological compensator perception and related Singha met
Air crises, vulnerability, needs as y system the usual
Mild difficulty in breathing degree of disability.
cognitive perceptual evidenced by psychologica
Determine Functional
Water changes as evidenced appropriate l need as
Independence Measure score evidenced by
Excessive fluid volume; cerebral edema by inability to expression of
cope/difficulty asking feelings,  Identify meaning of the appropriate
Food expression of
for help, change in identification dysfunction and change to
Ryle’s Tube Feeding; 200 ml 3 hourly. feelings,
usual communication of options, and patient. Note ability to
Elimination patterns and inability use of understand events, provide identification
Foley’s catheter present; adequate urine output to meet basic resources of options,
realistic appraisal of the
needs/role and used of
Activity and Rest situation.
expectations resources
Frequently change position by self and mild
restlessness.  Determine outside stressors:
family, work, future
Solitude and social interaction
healthcare needs.
Visitors are his wife, son, daughter and
daughter in law.  Support behaviors and
efforts such as increased
Hazard Prevention
Bed rails are kept up; applied restraints in hand interest/participation in
rehabilitation activities.
Function within social groups
 Monitor for sleep
 P a g e | 42

At home he interact with friends and disturbance, increased

neighbours; good social relationship; he, wife, difficulty concentrating, and
sons, daughter in law, grand – son and grand –
statements of inability to
daughter are the member of group living
together. cope, lethargy, and
withdrawal.
Development of self – care requisites
 Refer for
neuropsychological
Health deviation self – care requisites evaluation and/or
Can’t walk due to disoriented and confusion state counselling as indicated.

Assessment Nursing Diagnosis Outcomes Nursing system Implementation Evaluation

Universal self – care requisites: Risk for infection Remains free Wholly  Monitor vital signs Mr. Ranjit
related to traumatized of infection, as compensatory  Adhere to facility Singha is now
Air tissues and invasive evidenced by system free from
Mild difficulty in breathing infection control,
procedure. normal vital infection, as
signs and sterilization, and evidenced by
Water
Excessive fluid volume; cerebral edema absence of aseptic policies and normal vital
signs and procedures. signs and
Food symptoms of absence of
Ryle’s Tube Feeding; 200 ml 3 hourly.  Verify that preoperative
infection signs and
skin, vaginal, and bowel
Elimination symptoms of
Foley’s catheter present; adequate urine output cleansing procedures infection
have been done as
Activity and Rest
needed
Frequently change position by self and mild
restlessness.  Examine skin for breaks
or irritation, signs of
Solitude and social interaction
Visitors are his wife, son, daughter and infection.
daughter in law.  Apply sterile dressing.
Hazard Prevention  Administer antibiotics as
Bed rails are kept up; applied restraints in hand indicated.
 P a g e | 43

Function within social groups  Maintain fluid and

At home he interact with friends and electrolyte balance.
neighbours; good social relationship; he, wife,
sons, daughter in law, grand – son and grand –  Monitor white blood cell
daughter are the member of group living (WBC) count
together.  Maintain or teach asepsis
Development of self – care requisites for dressing changes and
wound care, peripheral
IV and central venous
Health deviation self – care requisites management, and
Can’t walk due to disoriented and confusion state
catheter care and
handling.
 P a g e | 33

12. DISCHARGE PLANNING:

 Hospital discharge information

Upon discharge, the hospital should provide the patient and family members with a wide range of
information on topics such as:
 Prescriptions and medications
 Cognitive changes and how to respond appropriately
 Symptoms of any complications that could need urgent treatment
 Activities to avoid and for how long (e.g. work, driving, drinking alcohol)
The first few days after discharge
 Ensure someone stays with the person for the first two days
 Make sure that patient can easily contact emergency services if needed
 Avoid drinking of any alcohol.
 Rest as much as possible and don't rush into activities.
 Important symptoms to watch out for
Learn as much as patient can about brain disorders such as traumatic brain injury. There are various
symptoms that are very normal after a brain injury such as headaches, inability to concentrate,
fatigue, depression, memory problems and poor sleep. These generally do not require medical
treatment but if patient have any concerns, and then can consult the doctor.
However there are symptoms that could indicate urgent treatment is needed. Examples of these
include:
 Any unconscious episodes
 Vomiting
 Increased disorientation or loss of balance
 Loss of hearing in one or both ears
 Changes in vision
 Sudden difficulty understanding or speaking
 Paralysis or weakness in the limbs
 Bleeding from the ears, or clear fluid from ears or nose
 Severe headaches not relieved by Paracetamol.
 Ongoing rehabilitation
The family plays a key role in ongoing rehabilitation after hospital discharge and any formal period
of rehabilitation are over. If the rehabilitation team has not provided any information on how the
family can help in the long term, contact them for this information.
In some cases, a person returns home after a brain injury and has unrealistic expectations about how
soon they can return to activities such as work and driving, if at all. The family may need to help the
person slowly come to terms with their abilities and how long recovery may take, especially if self-
awareness has been affected.
Fatigue is an extremely common problem after a brain injury, and it's common to experience several
days of extreme fatigue simply by overdoing activities. Family members often need to monitor how
much a person is doing in order to avoid fatigue, and ensure regular rest breaks are taken. Providing a
structured daily routine will greatly reduce stress for the person with the brain injury and help them
manage their low energy reserves.
 P a g e | 34

Challenging behaviours such can emerge after the return home due to various cognitive changes.
These can be very difficult for the family but having consistent appropriate responses to these
behaviours can make a significant difference. Most rehabilitation specialists recommend avoiding
alcohol for at least two years, if not permanently, after a significant brain injury.
 Support for family members
Family members may have to take on new roles and responsibilities. For example, a person may now
have to take on the role of bread winner or full time parenting for the first time. Children may find
they need to help out around the house more. It is important to obtain as much support for the family
as possible to ensure the own health in the long-term and provide consistent support.

13. EVALUATION OF CARE:

I met the patient when I was posted in ICU. He was confused and disoriented but his family member
provides me the information regarding his health condition. Nursing interventions were carried out
according to his priority needs. Health teachings were given and taught about regular follow-up.

14. SUMMARY
Mr. Ranjit Singha was admitted in city hospital khanapara Assam, with the complaints sudden
onset giddiness and tendency to fall of the patient 1 days back. It was associated with weakness of left
lower limb. Patient was brought to the Dispur Hospital, Guwahati, Assam and they refer the patient
city hospital for further management. In city hospital, craniotomy was done on 11/03/2020 and he
was kept in mechanical ventilation after the craniotomy. Next day i.e. on 14/03/2020 ventilator
support was removed and kept in T – Piece oxygen support. On 15/03/2020, he was extubated.
 P a g e | 35

BIBLIOGRAPHY

 Waugh A & Grant A. Ross And Willson; Anatomy And Physiology In Health And Illness.
12th Edition. India. Elsevier Ltd. 2014.

 Lewis, Dirksen, Heikemper, Bucher. Lewis’s Medical-Surgical Nursing; Assessment and

Management of Clinical Problems. Second South Asia Edition. India. Elsevier India Private
Limited. 2017.

 Johnson JY. Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 11 th
Edition. New Delhi. Wolters Kluwer (India) Pvt. Ltd. 2009.

 Roth S. Mosby’s 2017 Nursing Drugs Reference. First South Asia Edition. India. RELX India
Private Limited. 2017.

 Ajesh KTK, Chandran S. Application of Nursing Theories. First Edition. New Delhi. Jaypee
Brothers Medical Publishers (P) Ltd. 2017.