CASEPRESENTATION

OF
HEMORRHAGIC
STROKE
(Subarachnoidhemorrhage)

PresentedBy:
GROUP3
VernalinTerrado
LermaAuman
ElenitaMolina
RichelleManlangit
AndresJose
BernardBartolome
MarlenTigno

Subarachnoidhemorrhage

INTRODUCTION:
AStroke,cerebrovascularAccident,orwhatisnowbeingtermedas
brainattackisasuddenlossofbrainfunctionsresultingfrom
disruptionofbloodsupplytoapartofthebrainresultingfrom
pathologicbloodvessels.Itdenotesanabnormalityofthebrain.Stroke
canbeclassifiedintoischemicandhemorrhagicstrokes.Ischemic
strokecanbedividedintothromboticandembolicstroke.Thrombotic
strokeresultsfromthenarrowingorocclusionofbloodvesselsdueto
fatdepositswhileembolicstrokesresultfromtheocclusionofablood
vesselfromabloodclotoriginatingfromtheotherpartsofthebody,
mostcommonlyfromtheheart.

Hemorrhagicstrokeisfurtherclassifiedintointracerebral
hemorrhageandsubarachnoidhemorrhage.Itresultsfromthe
ruptureofbloodvesselsinthebrain.Ruptureofarterioles
resultinbleedingintotheparenchymaofthebrain,while
ruptureoflargerarteriesoritstributariesresultinbleedingin
thesubarachnoidspace.Normalbrainmetabolismisimpaired
byinterruptionofbloodsupply,compressionandincreased
ICP.
Usuallyduetoruptureofintracranialaneurysm,AV
malformation,Subarachnoidhemorrhage.

Riskfactorsforhemorrhagicstrokeincludesage,gender,race,
hypertension,smokinganduseofillicitdrugs.
Astrokecausesawidevarietyofneurologicdeficit,dependingon
thelocationofthelesion,thesizeoftheareaofinadequate
perfusionandtheamountofseverityofbloodflow.Itmay
includevomiting,headache,seizures,hemiplegiaandlossof
consciousness.Pressureonthebraintissuefromincrease
intracranialpressuremaycausecomaanddeath.

GeneralObjectives:

Theprimaryconcernofthisstudyistofurther
enhancetheunderstandingofCerebrovascularAccident
incongruencewiththelearnedconceptsoftheNursing
students.

ObjectivesoftheStudy:

Thiscasepresentationseekstoprovidedifferent
informationaboutthediseasetobepresentedabout
theclientbeingconsideredwiththeff.specific
objectives:
1.GiveabriefintroductionaboutCerebrovascular
Accidenttogetherwithitclinicalmanifestations.
2.Presentatheoreticalframeworkforthestudyin
relationtoanursingapproachappliedtoapatient
withhemorrhagicstroke.
3.Presenttheclientsdemographicandhealthhistorywith
itsGordonselevenfunctionalhealthpattern.

4.Presenttheabnormalresultsofthephysicalassessmentand
compareittothenormalvaluesorfindings.
5.Presentthedifferentlaboratorytestandresultsdonetotheclient
withitsinterpretation.
6.DiscussthenormalAnatomyandPhysiologyofCirculatoryand
CentralNervousSystem.
7.ExplainthePathophysiologyofHemorrhagicstroke

8.IdentifyNursingProblemsrelatedtothesituationand
caseoftheclient
9.Discussthedrugsthathasbeenusedandprescribedto
theclientbyadruganalysis.
10.PresentaNursingCarePlanfortheprioritized
problemsoftheclient.
11.ShowaDischargePlanningthattheclientmayuse
upondischargetothehospital.

TheoreticalFramework:VirginiaHenderson
Difficultyof
Breathing

Impairedskin
Integrity

Urinary
dysfunction

HPN

Hyperthermia

Lossof
consciousness

immobility

Poor
Hygiene

Sleepand
restand
Communicate
with
others

Moveand
maintain
Desirable
postures

Keep
body
clean
andwell
groomed

Nursingintervention

Breath
Normally

Eatanddrink
adequately

Sleepand
rest

Eliminate
bodywastes

Maintain
bodytemp

ImprovedHealth

ComprehensiveHistory:
BiographicHistory:
Name
CityAddress
ProvincialAddress
Age
Gender
ReligiousAffiliation
MaritalStatus
Occupation
SourceofInformation
Room&BedNo.
DateofBirth
Diagnosis
Physician
Chiefcomplaint:
Dateofadmission

:D.A.C
:Blk14,lot52PVR1,Norzagaray,Bulacan
:Romblon(Visayas)
:53yearsold
:Male
:RomanCatholic
:Married
:Unemployed(formerlyaconstructionworker)
:Daughter
:MaleWardBed#9
:November18,1955
:CerebrovascularAccident(subarachnoid
hemorrhagic)
:Dr.SteveConneroid
:Lossofconsciousness
:January05,2009

PresentCondition:
Twodayspriortoadmission,thepatientexperiencedhigh
bloodpressureaccompaniedbylowgradefever.Atthat
time,theclientishavinganargumentwithhisdaughter
thatdaybeforethetimehewasadmittedwhichservesas
atriggeringfactorofhispresentillness.Uponadmission
herdaughterclaimthatherfatherexperiencedsevere
headachefollowedbylossofconsciousness.Afterseriesof
testshewasdiagnosedtohaveexperiencedorsuffereda
hemorrhagicstroke.

PastMedicalHistory:
Threemonthspriortoadmission,thepatient
ExperiencedintermittentfluandArthritisinbothknees.
Whileonthiscondition,thepatientsblood
pressurekeepselevatingatarangeof150/90mmHg
To190/100mmHg.
Thepatientalsoexperiencedavehicularaccidenton
hisbicycletwomonthsago,butnoabnormal
manifestationhasbeenobservedasidefrommultiple
superficialwounds.

FamilyHistory:
Thepaternalsideofthepatienthasahistoryof
pulmonarytuberculosis.
Thematernalsideofthepatienthasahistoryof
hypertensionandheartdisease.

Activitiesofdailyliving
A.Healthperceptionandhealthmanagementpattern
Accordingtoher,herfatherdoesntgotothe
doctorforconsultationonhishealthstatus.He
seldomtakesanymedicineforhiscommon
illnessesthoughhesometimestakesparacetamolto
relievefever.Shealsostatesthatherfatherisa
heavyalcoholdrinkerandcigarettesmoker.the
patientselfperceptionofhealthpriorandupon
hospitalizationisunderminedbecausethepatient
isinthestateofcoma.

B.NutritionalandMetabolicPattern
Beforethepatientwashospitalized,henormally
eatsfriedchicken,especiallytheskin,chicharonand
processedmeatssuchastocinoandlongganisa.He
seldomeatvegetablesandfruits.Heprefersmeatover
fish.

C.EliminationPattern
Priortoadmissionthepatienthasaregularbowel
patternbutafterhewashospitalizedhewasnotableto
defecatefor3days.Heurinates5to7timesadaywith
alightyellowcolorbeforeheisadmitted,nowhehas
anindwellingurinarycatheterdrainingdarkyellow
urine.

D.ActivityExercisePattern
Accordingtothepatientsdaughter,herfather
spendsmostofhistimegamblingorhavingadrinking
sessionwithneighborsandfriends.Hedoesnthavea
jobandhedidntmindlookingforone.Hedoesnthelp
inhouseholdchoresinsteadhepreferredspendinghis
timewatchingtelevision.

E.SleepRestPattern
Thepatienthasahabitoftakingshortnapinthe
afternoonfor2hours.Intheeveningheusuallyretires
ataround2:00amandusuallysleepsfor3hours.This
isprimarilyduetohisfathersfailingabilityto
promotesleep.

F.CognitivePerceptualPattern
Thepatientcanreadandwrite,hedoesnthave
hearingdifficultybeforehewashospitalized.He
doesntweareyeglasses.Hisdaughtersaidthather
fatherstillpossessasharpmemoryandstillrecallspast
experienceswithspontaneity.Herdaughteralso
reportedthatherfatherdoesnthaveanyspeech
problemandhasanormalsenseoftasteandsmell
beforehewashospitalized.

G.SelfperceptionandSelfConceptPattern
Accordingtothedaughterherfatherverbalizes
thathiscontentmentofawellbalancedhealth
condition.Nowhisselfperceptionisundermined,
sincetheclientisinthestateofcoma.

H.RoleRelationshipPattern
Significantpeopletotheclientarehisfamily.Heis
theheadofthefamily.Hisdaughterstatedthatthe
onlyproblemtheyhaveisthehospitalizationofher
fatherbecauseoffinancialproblemsthatarisesfromit.
Theyresolveandmanagetheirproblemsthrough
constantcommunicationthemselves.

I.SexuallyReproductivePattern

Hisdaughtersaidthatherfathershowshis
affectiontohisfamilybyconstantlykissingand
huggingthem.Theclienthasthreechildren:twogirls
andaboy.

J.CopingStressTolerancePattern
Beforebeinghospitalizedtheclientexperiences
manystressorsarebroughtaboutbyfinancialfactor
andhealthproblems.Theyareabletocopeupby
constantlycooperatingwithoneanother.

K.ValueBeliefPattern
Herfatherdoesnothearmassonaregularbasis
becausehebelievesthatGodisalwaysinourhearts
andthatwedontneedtogotochurchjusttopray.Yet
hebelievesthatbeingaCatholicisthebestwaytobe
closetoGod.

PhysicalAssessment:
BP:160/90
Temp:39C

PR:102Bpm
RR:38Bpm

BODYPARTS TECHNIQUE
USED

NORMAL
FINDINGS

ACTUAL
FINDING

ANALYSIS

1.SKULL

Inspection,
palpation

2.SCALP

Inspection

Proportionalto
thesizeofthe
body,round
with
prominencesin
thefrontaland
occipitalarea,
symmetricalin
allplace
White,clean,
freefrom
masses,lumps,
scars,and
lesionsnoareas
oftenderness

Theskullis
Normal
normocephalic
andsymmetrical
tothebodywith
prominencesin
thefrontaland
occipitalarea,
symmetricalinall
place
White,nomasses, Normal
lumps,scars,and
lesionsnoareaof
tendernessis
observed.

3.FACE

Inspection

4.EYES

Inspection

Oblongorround
orsquare,or
heartshaped,,
facialexpression
thatisdependent
onthemoodor
truefeelings,no
involuntary
muscle,
Symmetricfacial
movements.
Paralleland
evenlyspaced
symmetrical,non
protruding,pink
palpebral
conjunctiva,and
pupilsblackin
color,equalin
size,roundand
constrictsin
responsetolight.

Oblong.Nofacial
movementis
observed.There
werepresenceof
acnearoundhis
forehead.

Notnormal
Indicates
impairmentof
facialnerves
whichcause
paralysis.

Dilatedpupils
whichisblackin
colorandnon
reactingtolight.
Hehavesome
dischargesaround
thelacrimalarea.

NotNormal
Indicates
alteredlevel
of
consciousness.

5.NOSE

Inspection

6.EARS

Inspection

Midline
symmetrical
andpatent,no
discharge.

Midline
symmetrical
andpatent,no
discharge.With
presenceof
nasogastrictube
insertiononthe
rightnares.
Parallel
Parallel
symmetrical,
symmetrical,
proportionalto proportionalto
thesizeofthe
thesizeofthe
head,bean
head,bean
shaped,skinis shaped,skinis
samecoloras
samecoloras
thesurrounding thesurrounding
color,clean
color,withdust
firmcartilage. accumulation
onfirm

Normal

Notnormal
Indicates
poor
personal
hygiene
inadequate
selfcare
primarily
causedby
selfcare
deficit.

7.MOUTH

Inspection

Symmetrical,
gumspinkishin
color,lipsmargin
issymmetrical,
nolesionand
tenderness,
without
involuntary
movement

A.SKIN

Inspection,
palpation

Variesfromlight
todeepbrown,
fromruddypink
tolightpink,
fromyellow
overtonestoolive,
generallyuniform
skintemperature

Symmetrical,
gumsslightly
darkincolorwith
yellowishteeth,
lipsmarginis
symmetrical,no
lesionand
tenderness,
without
involuntary
movement
Withuniform
deepbrownskin
colorwithslightly
elevated
temperature.
Poorskin
integrityand
rednessonbony
prominences.

Normal

Notnormal
Theclienthas
impairedskin
integritywith
hyperthermia
and
disruptionson
skinintegrity.

B.HAIR

Inspection

Thick,silky,
resilient,free
from
infestation,
evenly
distributedand
coverswhole
scalp.

Thick,oilywith Normal
tracesofwhite
hairsevenly
distributed
whichcovers
thewholescalp
andfreefrom
infestation.

C.NAILS

Inspection,
palpation

Convex
curvature
smoothtexture,
highlyvascular
andpink,
promptreturn
ofpinkless
than4seconds

Longwith
Normal
convex
curvature
smoothtexture,
highlyvascular
withbluishto
pinkish
discoloration,
capillaryrefillis
prompt.

D.NECK
REGION

Inspection,
palpation

Symmetrical
andstraight,no
palpablelumps,
andsupple,
tracheaison
midlineofneck,
andspacesare
equalonboth
sides.

Symmetrical
Normal
andstraight,no
palpablelumps,
andsupple,
tracheaison
midlineofneck,
andspacesare
equalonboth
sides.

E.LUNGS

Auscultation

Symmetrical
chestexpansion,
clearbreath
sounds.

Difficultyof
breathingwith
breathsounds
(ronchi)audible
evenwithoutthe
useof
stethoscope
havingthe
respirationrate
of38Bpm.

Notnormal
Indicates
tachypnea
primarily
dueto
hypertension
.

F.HEART

Auscultation

Adynamic
pericardium,
normalrate,
regularrhythm,
nomurmur.

Palpitations
withelevated
heartrateof
115bpm.

NotNormal
indicates
increase
cardiac
overloaddue
toincrease
blood
pressure

G.PHERIPER
AL

Palpation

Symmetrical
pulsevolume,
fullpulsation

Symmetrical
pulsevolume,
fullpulsation

Normal

H.BREAST

Inspection,
palpation

I.ABDOMEN Inspection,
Auscultation,
Percussion,
Palpation.

Notenderness,
masses,nodules
anddischarge.

Notenderness, Normal
masses,nodules
anddischarge.

Uniformcolor,
rounded
symmetrical
contour,
audiblebowel
sounds,no
tenderness,
liverand
bladderarenot
palpable

Uniformcolor, Normal
rounded
symmetrical
contour,audible
bowelsounds,
notenderness,
liverand
bladderarenot
palpable

J.MALE
GENITALIA

Inspection

Normalpubic
hairdistribution
isnotedandfree
frominfestation.
Penilelesions,
masses,or
dischargesare
not
present.Testesis
symmetric
withoutmasses
orundue
tenderness.The
lefttestismaybe
slightlylarger
andhanglower
thantheright
testis.Inguinalor
femoralhernias
arenotpresent.

Thegenitalia
wasnot
assessed
becausethe
relatives
refusedtodo
so.Thepatient
alsohasan
indwelling
catheter.

NotNormal
Indicates
Urinary
dysfunction
(referto
laboratory
result).

K.UPPER
AND
LOWER
EXTREMITI
ES

Inspection

Equalsizeon
bothsidesof
thebody,no
contractures,
deformitiesand
tenderness,
normallyfirm,
jointsmove
smoothly.

Immobilization
ofallthe
extremities.

Notnormal
thepatientis
comatose.

LaboratoryTest:
BLOODCHEMISTRY
Test

Results

Normal Values

Glucose HGT

105

75-115mg/dl

Creatinine

1.7

0.6-1.1mg/dl

Sodium

142

135-140mmol/L

Potassium

3.5

3.5-5.3mmol/L

Uric acid

4.5

3.4-7.0mg/dl

Total Cholesterol

250

<200mg/dl

Triglycerides

133

<200mg/dl

HDL

40.8

40-58.7mg/dl

BLOODHEMATOLOGY
Results

Normal Values

RBC

8.0

4.5-5.8 x 12/L

WBC

15,900

5000-10000/cumm

Hgb

21

14-18 x 12/L

Hct

0.62

0.42-0.52 x 12/L

300000

150000-450000/cumm

Segmenters

0.66

0.50-0.66

Lymphocytes

0.30

0.20-0.40

Monocytes

0.04

0.02-0.08

Platelet count

AnatomyandPhysiology
BloodCirculation:

UnoxygenatedBlood
Superior&InferiorVenacava
RightAtrium
TricuspidValve

RightVentricle
Pulmonarytrunk&pulmonary
Arteries

LUNGS(processfoxygenation)

PulmonaryVein

LeftAtrium
Bicuspidvalve

Leftventricle
AorticValve
Aorta

Systemic Circulation

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

BRAIN:CranialNerves
Smell
Visualfieldsandabilitytosee
Eyemovements;eyelidopening
Eyemovements
Facialsensation
Eyemovements
Eyelidclosing;facialexpression;

Olfactory:

Optic:
Oculomotor:
Trochlear:
Trigeminal:
Abducens:
Facial:
tastesensation
Auditory/vestibular:
Glossopharyngeal:
Vagus:
Accessory:
Hypoglossal:

Hearing;senseofbalance
Tastesensation;swallowing
Swallowing;tastesensation
Controlofneckandshouldermuscles
Tonguemovement

 CranialNervesThereare12pairsofnervesthatoriginatefrom
thebrainitself.Thesenervesareresponsibleforveryspecific
activitiesandarenamedandnumberedasfollows:
Olfactory:Smell
Optic:Visualfieldsandabilitytosee
Oculomotor:Eyemovements;eyelidopening
Trochlear:Eyemovements
Trigeminal:Facialsensation
Abducens:Eyemovements
Facial:Eyelidclosing;facialexpression;tastesensation
Auditory/vestibular:Hearing;senseofbalance
Glossopharyngeal:Tastesensation;swallowing
Vagus:Swallowing;tastesensation
Accessory:Controlofneckandshouldermuscles
Hypoglossal:Tonguemovement

CranialMeninges

BRAIN

BRAIN

NonmodifiableRisk
Factors
>AdvancedAge
>Gender
>Heredity

PATHOPHYSIOLOGY

ModifiableRiskFactors
>HPN
>Smoking
>excessiveintakeoffoods
highinfatsandcholesterol

TriggeringFactors
>Suddenextremeemotion

Cerebralaneurysm
rupture

Arteriovenous
malformation
Bleedingintothebraintissue
andsubarachnoidspace

BloodClotsinthe
SubarachnoidSpace

BrainCompression

Bloodsupplyinterruption

TissueNecrosis
NeuronalDeath

S/S:
>SevereHeadache
>Drowsiness
>Lossofconsciousness

RegionalParalysis

IncreaseIntracranial
Pressure

EpilepticSeizure:
increaseintraocular
pressure=blindness

TotalParalysis
coma

Death

Drugstudy1
Medication

Classification/ Indication
Action

Contraindication Sideeffects

Adverseeffects

Nursing
consideration

Genericname:
nifedipine

Inhibits
calciumion
influxacross
allmembrane
during
cardiac
depolarization
,produces
relaxationof
coronary
vascular
smooth
muscleand
peripheral
vascular
smooth
muscle,dilates
coronary
arteries,
increase
myocardial
oxygen
deliveryin

Hypersensitivity,
cardiovascular
shock,
combinationwith
rifampicine
contraindicated
inunstable
anginaandafter
resentMIsevere
hypotension,
withsystolic
pressureless
than90mmHg
decompensate
heartfailure
pregnancyand
lactation

Dizziness,
flushing,
headache,
hypotension
peripheral
edema,
tachycardiaand
palpitation

Usecautionin
severeaortic
stenosisorsevere
hepatic
impairment

Brandname:
Calcibloc
Route:oral
Dosage:180mg
Frequency:once
aday

Treatmentof
vasospatic,
angina,
chronicstable
angina,
hypertension
(sustained
released
tabletsonly.

Patients
withdrawn
from
blockers
whiletaking
nifedifine
may
experience
increase
angina

Assesspotential
forinteractions
withother
pharmacological
agentsorherbal
productspatients
istakingthatmay
increaseriskof
hypotensionand
toxicity
Monitorblood
pressureand
pulsebefore
therapy,during
dose

filtrationand
periodicallyduring
therapymonitor
ECGperiodically
duringprolonged
therapy
Assesstherapeutic
effectivenessand
adversereaction
Assesslocation,
durationintensity,
precipitatingfactor
ofpatientsangina
pain

Drugstudy2
Medication
Genericname:
Mannitol

Classification/ Indication
Action

Increasesthe
osmotic
pressureof
Brandname:
the
Osmitrol
glomerular
Route:IV
filtrate,
Dosage:
thereby
Adult0.252g/kg inhibiting
as15to25%
reabsorption
solutionover30
ofwaterand
to60min.
electrolytes.
Children12g/kg
(3060g/m2)as
a15to20
solution0ver30
60%
Frequency:
4xdaily

Adjunctinthe
treatmentof
acuteoliguric
renalfailure,
adjunctinthe
treatmentof
edema,
redunctionof
intraocular
pressure,to
promotethe
excreationof
certaintoxic
substances.

Contraindication Sideeffects

Adverseeffects

Nursing
consideration

Hypersensitivity,
anuria,
dehydration,
intracranial
bleeding.

CNS:headache,
confusion.

Monitorvital
signs,urine
output,CVP,and
pulmonaryartery
pressurepriorto
andhourly
throughout
administration.

EENT:blurred
vision,rhinitis
CV:transient
volume
expansion,
tachycardia,
chestpain,
congestiveheart
failure,
pulmonary
edema.
GI:thirst,
nausea,
vomiting
GU:renal
failure,urinary

Assesspatientfor
signsand
symptomsof
dehydrationor
signsoffluidover
load.
Assesspatientfor
anorexia,muscle
weakness,
numbness,
tingling,confusion
andexcessive
thirst.

Monitorneurologic
statusand
intracranial
pressurereadings
inpatientreceiving
thismedicationto
decreasecerebral
edema.

Drugstudy3
Medication

Classification/ Indication
Action

Contraindication Sideeffects

Adverseeffects

Nursing
consideration

Genericname:

Inhibitsinflux
ofcalciumion
acrosscell
membranesto
produce
relaxationof
coronary
vascular
smooth
muscle
(dilatationof
coronary
arteries)
decrease
peripheral
vascular
resistanceof
smooth
muscle
(decrease
blood
pressure)

Sicksinus
syndrome;
secondorthird
degree
artrioventicular
blockexeptwith
afunctioning
pacemaker

Palpitations,
peripheral
edema,syncope,
tachycardia,
bradycardia,
arrythmias,
ventricular
asystoles,
headache,
dizziness,
lightheadedness,
fatigue,
lethargy,
somnolence,
dermatitis,rash
pruritus,
uticaria,nausea,
abdominal
discomfort,
cramps,
dyspepsia,
shortnessof
breath,

Assesscardio
respiratorystatus.
Anginapain,B/P
pulse,respiration,
ECG

Amlodipine
Brandname:
Amvasc,norvasc
Route:
Dosage:
5mg
Frequency:
Oncedaily

Hypertension,
chronicstable
angina,
vasospatic
angina

CHF,
hepatic
impairment,
caustious
useis
required

Assesshydration
andfluidvolume
status,inputand
outputratio,
presenceof
edema,distended
neckveins,luck
crackles,adequate
pulsesandskin
turgor.

andincreases
myocardial
oxygen
deliveryin
patientswith
vasospatioc
angina.

dyspnea,
wheezing,
flushing,
sexual
difficulties,
muscle
cramps,pain
or
inflammation

Monitorliver
functionALT,
AST,bilirubin
Monitorifplatelet
countislessthan
150,000/mm,drug
isusually
discontinuedand
anotherdrug
started.

Drugstudy4
Medication

Classification/
Action

Indication

Contraindication Side
effects

Adverseeffects Nursing
consideration

Genericname:

Inhibitsthe
synthesisof
prostaglandin
thatmayserve
asmediatorsof
painandfever.

Mildto
Mildto
moderate
pain

Previous
hypertensive

GI:hepatic
necrosis

Product
containing
alcohol,
aspartame,
saccharin,sugar
ortartrazine.

DERM:rash,
urticaria.

Acetomenophen
Brandname:
Aminofen
Route:
IV
Dosage:
3251000mg
every4to6hrs
needed

Therapeutic
effects.
Analgesic(due
Analgesic(due
toperipheral
prostaglandin
inhibitors)
Antipyresis
Antipyresis
(lowersfever);
duetoinhibitors
ofprostaglandin
intheCNS
Nosignificant
anti
inflammatory

Fever
Fever

Advisepatientto
Advisepatientto
takemedication
exactlyas
directedandnot
totakemorethan
therecommended
amount.
Severeand
permanentliver
damagemay
resultfrom
prolongeduseor
highdosesof
acetomenophe.
Adultshouldnot
take
acetomenophen
longerthan10
daysandchildren
longerthan5
daysunless
directedby

Advisethepatientto
Advisethepatientto
consultthephysicianif
discomfortorfeverisnot
relievedbyroutine
dosagesofthisdrugorif
feverisgreaterthan39.5
(103F)orlastslonger
than3days

ASSESSMEN DIAGNOSIS
T
Objective
cues:
Clavicular
Breaking
Rhonchi
breathing
sound
Increase
respiratory
rateof36to
38bpm

Ineffective
airway
clearance
relatedto
retained
mucus
secretiondue
toabsenceof
coughreflex.
Scientific
Explanation:
Inabilityto
clear
secretionsor
obstruction
fromthe
respiratory
tractto
maintaina
clearair

OBJECTI
VE
Afterfour
hoursof
nursing
interventio
ntheclient
airway
clearance
willbe
cleared.

NursingCarePlanOne
PLANNING INTERVENTION
Planwayson
howto
reduce
congestionon
airway.

Positionhead
midlinewithflexion
appropriatefor
condition.
Oropharyngial
suctioning(as
needed)

RATIONAL
E
Toopenor
maintain
airwaytothe
client.

EVALUATION

Afterfour
hoursof
nursing
interventionthe
clientairway
clearanceis
Toclear
airwaywhen cleared.
secretionsare
blockingon
airway.

Elevateheadofthe
bedandchange
positionevery2
hrs.

Todecrease
thepressure
onthe
diaphragm.

Increasedfluid
intakeatleast3000
ml/day

Tohelp
liquefy
secretion

Auscultatebreath Tomaitain
soudsandassess statusandnote
airmovement
progress

NursingCarePlanTwo
ASSESSMEN
T

NURSING
DIAGNOSIS

SubjectiveCues:

ObjectiveCues:

Hyperthermia
relatedto
inflammationof
cerebraltissueas
evidenceby
elevatedbody
temp.

>elevatedbody
tempof39C

ScientificEXP:

>tatlongaraw
nasiyang
nilalagnatas
verbalizedby
therelatives.

>flushingskin
>warmtotouch
>increaseRR
witharateof38
Bpm
>diaphoresis

Bodytemperature
elevatedabove
normalrange,
becauseofbodys
responseto
inflammation
fromhemorrhage
thatresultfrom
rupturedcerebral
artery.

OBJECTIV PLANNING
E

NURSING
INTERVENTION

>after2
hoursof
nursing
interventions
theclients
temperature
willdecrease
toanormal
range.

>Identifyunder
lyingcause

>Plan
techniquesin
whichthe
temperature
oftheclient
willdecrease
toanormal
rage.

>Promotesurface
coolingbymeans
oftepidsponge
bath
>Establishcool
environmentby
openingairvents
andwindowpanes
>Adviserelatives
nottocoverthe
clientwitha
blanket,anduse
lessrestrictive
clothings

RATIONALE

EVALUATI
ON

>Toassesscausative
factorstotheclients
feverthus
formulationof
appropriatenursing
intervention.

>after2
hoursof
nursing
intervention
theclients
temperature
isdecreased
toanormal
range

>Heatlossby
evaporationand
conduction
>Heatlossby
convection.

>toavoidfurther
increaseofclients
temperature.

>Administer
antipyreticsthrough
IVasprescribed.

>Forimmediate
alterationofbody
temperature

NursingCarePlanThree
ASSESSMEN
T
Objective
Cues:
>reddened
skin
>poorskin
turgor
>immobility
>friction

DIAGNOSIS
>Riskfor
impairedskin
Integrity
relatedto
physical
immobilization
.

OBJECTIVE PLANNING

>After3
hoursof
nursing
intervention
theclient
relativeswill
identifyrisk
factorsfor
impaired
Scientific
skinintegrity
Explanation:
,verbalize
Atriskforskin
understandin
being
goftherapy
potentially
regimensand
vulnerableto
demonstrate
breakdown
behaviors
becauseof
and
immobilization
techniquesto
preventskin
breakdown.

>Plan
strategieson
howto
eliminate
theriskfor
impaired
skin
integrity.

INTERVENTIO
N

RATIONALE

EVALUATIO
N

>Notefor
general
debilitation,
reduced
mobility,
changesinskin
andmuscle
mass,poor
nutritionalstatus
andproblemsof
selfcare

>Toassess
aggravating
factortoskin
breakdown
andmake
appropriate
intervention
toit.

Aftertwo
hoursof
nursing
intervention
the
possibilities
forimpaired
skinintegrity
oftheclientis

>Maintainstrict
skinhygiene,
>Toprevent
usingmildnon
skinirritation
detergentsoap,
dryinggently
andthoroughly.
andlubricating
withlotion

eliminated.

>Instructthe
relativetoturn
thepatientevery
twohours

>Toreduce
tissuepressure
andprevent
pressuresore.

>Avoidfriction
whenchanging
position

>Topreventa
shearingforce
ontheskin.

>Provide
protectionby
useof
pads,pillows,
foammattress.

>Toincrease
circulationand
eliminate
excessivetissue
pressure.

>Observefor
reddenedor
blanchedareas
andgiveproper
managementif
thereisany.

>Reduces
likelihoodof
progressionto
skinbreakdown.

DischargePlan

>Nifedipinemustbegiven10mgonceadaybysublingualas
prescribed.
>Instructtherelativetofollowmedicationregimen.

>Encouragetherelativetodosomeexerciseslikeapassiverangeof
motioninaffectedandunaffectedpartsofthebodyoftheclient.

>Educate&instructthefamilytomonitorthebloodpressureand
pulseratebeforeadministeringmedication.

>Informtherelativetheimportanceofproperhygieneofthepatient
fromheadtotoe.
H

>regularinspectionofthediaperofthepatientandchangeiftherea
presenceoffecalmaterial,urineorevenrednessthatwouldleadtoskin
rashes.
>Educateandinstructtherelativesonhowtofeedtheclientthrough
nasogastrictube.
>Instructthemtoturntheclientevery2hrstoavoidpressuresores.

>Informthefamilyofthepatienttohavearegularcheckupforthe
continuityoftreatment.
>Instructthefamilyofthepatienttomonitorifthereisanysudden
changetothepatientandreportimmediately.
>Instructtherelativetofeedtheclientontimewithnutritionfoodthat
islowinsodium,lowincholesterol,lowinfatandgivecitrusfruits,
moderateinfluidintakeandincreasefiberdiettoimprovehealth.
>Followthedietprescribedbythedoctor.