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Case Study:  Spontaneous Intracranial Hemorrhage

In this case study, the patient is a 52 year old a male with a spontaneous intracranial hemorrhage.  I will evaluate the patient’s medical history, surgical history, and vital signs in order to thoroughly understand the etiology and clinical symptoms of this neurological disorder. The review of the patient’s most recent laboratory results, diagnostic tests, at-home diagnostics, and newly prescribed medications will also be included in the case study. I will cover what criteria needs to be met prior to discharge, a nursing diagnoses, and care plan review, information on evidence-based practices and recommendations for precision medicine. 

 

Admitting Data 

B.D is a 52-year-old retired male who presents to the acute-care clinic for evaluation of progressive symptoms. B.D had a worsening headache for two days with progressive symptoms of confusion, slurred speech, and mild left sided paralysis. On June 27, 2022, B.D.. finally decided to seek medical attention. B.D. was brought to the emergency department by his wife and was admitted due to assessment findings of worsening confusion, drowsiness, paralysis, and unequal pupil size. Upon admission a computed tomography scan was performed and the result indicated he suffered a spontaneous right sided intracranial hemorrhage. I assumed care of patient B.D. on June 29, 2022.  The patient has  a history of congestive heart failure, hyperlipidemia, and a left ventricular emboli. He was on coumadin and Aspirin prior to admission for the left ventricular embolism which was concluded to be the primary cause of his spontaneous intracranial hemorrhage. Patient B.D. is postoperative day 2 for a right decompressive hemicraniectomy and evacuation of subdural hematoma. 

Physical Assessment 

Patient B.D. is 5 feet and weighs 130 pounds. Skin color appropriate for race. Temp 97.3, skin cold to touch. Multiple bruises present bilaterally to the upper arms. Left hemicraniectomy scar with staples, Jackson-Pratt surgical drain to right cranium. Bilateral antecubital  20 G, right forearm and left radial arterial line. Bilateral periorbital edema present. Pulmonary assessment indicated regular, even, and unlabored respiration with a rate of 16 assisted. Symmetrical chest expansion, breath sounds clearly bilateral. Endotracheal tube size is 7 mm with bloody thin secretions. Ventilation assist control mode and no pressure support. Patient is oxygenating at 100% with a tidal volume of 450, FiO2 of 40%, expiratory positive airway pressure of 16, Positive end expiratory pressure of 5. Cardiovascular assessment reveals no jugular vein distention. S1 and S2 heart sounds present. Electrocardiogram is a normal sinus rhythm.  2 + pulses of carotid, radial, femoral, dorsalis pedis, and posterior tibial arteries. Capillary refill is less than 3 seconds. Skin color is usual for race and skin is cold to touch. No edema except for bilateral periorbital edema. Patient B.D. is receiving a nasogastric tube feed diet of 50 milliliters Vital AF 1.2 cal via left nare NG tube 18F. Abdomen is soft and round. Bowel sounds are active in all 4 quadrants. Last bowel movement is unknown. 

 

 

LABORATORY TESTS – Please indicate if results are H (high) or L (low)

Test: Normal range

Results

Date / Time

RELEVANT Rationale for ABNORMAL Test  Results:
CBC & DIFF:   6/69/22 0600  
WBC 3.8 9.2  
RBC 4.2-5.7 2.80  
HGB 13.6-16.9 8.1  
HCT 40-50 24  
Platelets 152-324 96  
Neutrophils   83.3  
Lymphocytes   7.9  
Monocytes   8.5  
Eosinophils   0.1  
Basophils   0.2  
BMP:      
Na   144  
K   3.5  
Cl   111  
CO2 / HCO3   26  
BUN   34  
Creatinine   0.94  
Glucose   126  
CMP (BMP plus the following):      
Calcium   8.0  
Albumin   2.9  
Total Protein   5.3  
AST   31  
ALT   28  
Alk Phos   79  
Bilirubin   1.0  

UA:

Color

  colorless  
Appear   clear   
PH   7.5  
Spec Gravity   1.040  
Protein   Negative  
Glucose   70   
Ketone   40  
Bilirubin   Negative  
Hgb   Negative  
Uro-bilinogen   2.0  
WBC   Negative  
Nitrate   Negative  
OTHERS:      

Coagulation Panel :

PT/INR, PTT, 

D-dimer

 

14.1/

1.11/

31.1

 

Cardiac:

CPK, Trop, Myoglobin

  0.01  

Sepsis:

Lactic Acid

  2.4  

 

Inflammation Panel:

ESR, CRP, ANA, RF

     

Lipid Panel:

Cholesterol, HDL, LDL, Triglycerides

     

Medication 

 

Medications:  

IV Hemodynamic / Continuous Drip Drugs ONLY

Drug name

Concentration: (mg or mcg/ml) 

Rate of infusion (ml/hr)

Patient Dose (mcg/kg/min, u/hr, etc)

Class / Action / Use

Normal Therapeutic Range (is pt. dose at/above/below this range? Rationale for dose < or > normal)

 

Adverse Effects Nursing Implications

 

Precedex 

400 mcg/100mL

 

     

 

Nicardipine

40mg/200 mL

 

     

 

3% Normal Saline

 

15 mL/hr 

 

     

 

MEDICATIONS – Routine, Intermittent and PRN (copy and paste section to add more medications if required)

 

Medication (Drug, Dose, Route, Schedule): Vitamin K 10 mg SQ daily

Classification / Action: ___________________________________________________

Rationale for use: _______________________________________________________

Rationale for your patient: ________________________________________________

Desired Effect: _________________________________________________________

Side Effects: ___________________________________________________________

Safe Dosage Range: _________________________________________  

Patient’s dose appropriate? (yes / no)

Actions taken to correct the issue? (yes / no).  If yes, what? ____________________________________

Nursing Implications_____________________________________________________

Medication (Drug, Dose, Route, Schedule): Keppra, 500 mg IVPB, q12

Classification / Action: ____________________________________________________

Rationale for use: ________________________________________________________

Rationale for your patient: ________________________________________________

Desired Effect: __________________________________________________________

Side Effects: ____________________________________________________________

Safe Dosage Range: ______________________________________________________

Patient’s dose appropriate? (yes / no)

Any actions required? (yes / no).  If yes, why? __________________________________________________

Nursing Implications_______________________________________________________

Medication (Drug, Dose, Route, Schedule): Magnesium oxide, 400 mg ng, BID

Classification / Action: ____________________________________________________

Rationale for use: ________________________________________________________

Rationale for your patient: ________________________________________________

Desired Effect: __________________________________________________________

Side Effects: ____________________________________________________________

Safe Dosage Range: _______________________________________________________

Patient’s dose appropriate? (yes / no)

Any actions required? (yes / no).  If yes, why? __________________________________________________

Nursing Implications_______________________________________________________

Medication (Drug, Dose, Route, Schedule): Topamax 200mg/ng q12

Classification / Action: ________________________________________________

Rationale for use: ____________________________________________________

Rationale for your patient: ________________________________________________

Desired Effect: ______________________________________________________

Side Effects: ________________________________________________________

Safe Dosage Range: __________________________________________________

Patient’s dose appropriate? (yes / no)

Any actions required? (yes / no).  If yes, why? __________________________________________________

Nursing Implications_________________________________________________

 

Medication (Drug, Dose, Route, Schedule): Colace

Classification / Action: ________________________________________________

Rationale for use: ____________________________________________________

Rationale for your patient: __________________________________________________

Desired Effect: ______________________________________________________

Side Effects: ________________________________________________________

Safe Dosage Range: __________________________________________________

Patient’s dose appropriate? (yes / no)

Any actions required? (yes / no).  If yes, why? __________________________________________________

Nursing Implications_________________________________________________

 

Nursing Clinical Problem List:

(how are these being addressed?)

Feeding:
Analgesia:
Sedation:
Thrombo-prophylaxis:
Elimination: 
Readiness for extubation / Respiratory Status:
Head of Bed:
Ulcer Prevention (gastric):
Glucose Control:
Skin Precautions:

 

Psycho-Social and Spiritual Assessment 

Psycho-Social Systems

 

Individual/Family Developmental Stage and Family Dynamics:

 

Cultural Influences/Health Beliefs and Values:

 

Individual / Family Strengths Individual / Family Challenges
   
   
   

 

Individual/Family Coping with the Current Stressors:

 

Spiritual System

 

Spiritual Assessment (Ref. any spiritual nursing resource):

 

Spiritual Strengths Spiritual Needs Spiritual Resources
     
     
     

 

Discharge Needs

DISCHARGE PLAN
Educational Needs Evaluation of Teaching* Medications / Treatments / Equipment Referrals / Follow-up / Disposition

       

              *V Verbalizes understanding

  D  Demonstrates procedure

                 N  Not receptive to learning

  R  Reinforcement needed

  U/E Unable to evaluate

 

Conclusion

_________________________________________________________________________________

Develop a nursing care plan: Take 3 nursing diagnoses (two biological and one psycho-social/spiritual deficit) and process them each with the following criteria: complete 3 part nursing diagnosis, SMART goals/outcome criteria, interventions, and evaluation. Each diagnosis must have at least one short term, and 1 long term goal with relevant interventions and scientific rationale for each intervention, and evaluation.  

Nursing Care Plan
Nursing Diagnosis

SMART Patient Outcome / Goals 

(1 short and 1 long term)

Nursing / Collaborative Health Care Interventions

Rationale for Interventions

(citations required)

Evaluation of each goal  Modification to the plan of care (potential or actual)

Ineffective tissue perfusion related to increased intracranial pressure as evidenced by slow reflexes, decreased respiratory or pulse rates, and hemiparesis of the left side. 

 

1) The patient’s brain function will improve as demonstrated by normal vital signs, increased alertness, and no further decrease in consciousness. 

2) 

Monitor vital signs every hour, observing any changes in respiration, heart rate, or rhythm, particularly measuring pulse pressure. 

Evaluate mental status,  motor, reflexes, and cranial nerves. 

 

Maintain the client’s head in a neutral position by progressively elevating the bed around 15-45 degrees. 

 

To detect early indicators of ICP such as erratic blood pressure, tachycardia, and tachypnea. 

 

These evaluations will assess whether or not a patient’s neurological conditions have changed as a result of ICP.

The position will lower arterial pressure and improve cerebral perfusion by facilitating venous drainage.  

   

 

Nursing Care Plan
Nursing Diagnosis

Patient Outcome / Goals 

(short and long term)

Nursing / Collaborative Health Care Interventions Rationale for Interventions Evaluation of each goal  Modification to the plan of care (potential or actual)

Disturbed sensory perception 

 

         

 

Nursing Care Plan
Nursing Diagnosis

Patient Outcome / Goals 

(short and long term)

Nursing / Collaborative Health Care Interventions Rationale for Interventions Evaluation of each goal  Modification to the plan of care (potential or actual)

Anxiety 

 

         

 

 

 

 

 

 

 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
UNRS 411P

 

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