Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City
________________________________________________________________

Grand Case
Submitted to
Sir. Elice Jude Rosete
Clinical Instructor

Submitted by:
Jia Laurice P. Barandino
Angel Marie Bergonio
Danica V. Gaspar
Rhoda S. Hatiya
Lavinia S. Miranda
Ma. Angelou V. Mortos
Pamela A. Romero
Diane C. Sanchez
John Radley S. Santos
Clinical Case Scenario #1: Intracerebral hemorrhage

This is a 21-year-old right-handed male, with a past

medical history significant for asthma and Attention
Deficit Disorder (ADD), treated with methylphenidate,
who was found in a gym bathroom with left sided
weakness and urinary incontinence shortly after lifting
weights. 

Upon arrival to the emergency department (ED), he was

following commands with left hemiparesis.  He
complained of severe headache. 

Initial laboratory studies revealed a normal platelet count,

coagulation profile, and negative toxicology screen.
Emergent non-contrast head CT revealed a right frontal
intracranial hemorrhage (Figure 1) and a CT
angiography (CTA) of the brain (Figure 2) revealed an
arterio-venous malformation (AVM). 

Soon after presentation, he became more lethargic with

episodes of bradycardia to the 30s and without
concomitant hypertension.  He was subsequently
intubated for airway protection with propofol and
rocuronium.  In addition, 50 grams of mannitol was
administered intravenously due to concerns of rising
intracranial pressure (ICP).  Now intubated, propofol
infusion was titrated to maintain deep sedation (no
response to painful stimuli).  He was then moved to the
neurointensive care unit (NICU).

Social history is notable for smoking cigarettes.  There is

no family history of vascular malformations or
subarachnoid hemorrhage.

Initial Physical Exam

The patient was examined in the ED prior to intubation.  His head of bed was at 30 degrees.  Vitals signs
were as follows: temperature of 95.5 °F, blood pressure (BP) of 130/79 mmHg, pulse of 63, respiratory
rate of 20, and oxygen saturation of 98% on 3 liters/minute nasal cannula.  He was diaphoretic.  His lungs
were clear to auscultation bilaterally.  He had a regular heart rate with normal S1 and S2.  No appreciable
murmurs, rubs or gallops.  His abdomen was soft, nontender, and nondistended with positive bowel
sounds.  He has no lower extremity edema.  He had 2+ dorsalis pedis pulses. Neurologically, his
Glasgow coma scale (GCS) was 15.  He opened eyes to voice (E4); he was oriented to person, place and
date (V5);  and he had a dense left hemiparesis but was able to move his right side against gravity to
commands (M6).  His speech was fluent.  He had right gaze preference.  His pupils were 4 mm, equal in
size and equally reactive to light bilaterally.  He had a left facial droop.  Babinski’s sign was absent.

Laboratory and Imaging Findings

Also Urine toxicology, including alcohol, amphetamines, barbiturates, benzodiazepines, cocaine, heroin,
Phencyclidine (PCP), and Tetrahydrocannabinol (THC), were all negative.

Imaging Findings:

1) Brain non-contrast CT (Figure 1) showed a large right frontal intraparenchymal hemorrhage with 7-mm
midline shift and partial effacement of the basilar cisterns.
2) Brain CTA showed the appearance of an apparent AVM supplied by the anterior cerebral arteries with
superficial drainage at the superior sagittal sinus.
3) Chest x-ray was clear.

Hospital Course / Case Resolution

Over a period of hours, while in the NICU, the patients GCS declined from 15 to 8. Given his deteriorating
neurological status, a parenchymal fiber optic bolt was placed to measure his ICP.  His initial ICP was 30
mmHg (normal < 20 mmHg), for which he received rapid intravenous boluses of 50 grams of mannitol and
500 mL of 3% saline.  Thereafter, 250 mL of intravenous 3% saline was administered every 6 hours to
maintain a serum sodium range of 145-150 mEq/L. 

A foleys catheter was inserted and a radial arterial catheter was placed to maintain a cerebral perfusion
pressure (CPP = Mean Arterial Pressure - Intracranial Pressure) between 60 and 80 mmHg with
norepinephrine intravenous drip titration.  Sedation with propofol and fetanyl was no longer held once ICP
monitoring was initiated.  Prophylactic antiepileptic treatment was initiated with 1.5 grams of phenytoin (20
mg/kg loading) to obtain a therapeutic level (10-20 total level or 1-2 free) and maintained with 100 mg IV
infusion every 8 hours. In order to monitor for nonconvulsive seizures, continuous electroencephalogram
(EEG) monitoring was used.

After the initial few hours of stabilization, the patient was moved to the
angiography suite for a 4-vessel angiogram, which confirmed an AVM
in the right frontal lobe (Figure 3),with no associated aneurysms.

Over the subsequent 24 hours, the patient’s ICP climbed up to 40

mmHg, despite multiple boluses of 3% saline (Na+ climbed to 147
mEq/dL from 136 mEq/dL on admission) and mannitol, heavy
sedation, paralysis and active
cutaneous cooling (Arctic Sun) to maintain normothermia.  Due to
refractory ICP elevation, the patient underwent an emergent right
fronto-temporo-parietal decompressive craniectomy
(Figure 4) without removal of the hematoma or AVM.  The ICP after
the decompressive hemicraniectomy was less than 20
mmHg.

On postoperative day 0 and post- bleed day 1, the patient followed

simple commands by showing 2 fingers on the right side.  On postoperative day 1, the patient developed
septic shock with fever of  103.6 °F, fluid refractory hypotension, oliguria, increasing serum lactate and
leukocytosis.   Day 3, escalating doses of norepinephrine infusion were necessary to maintain the CPP
goal.  A new left lower lobe infiltrate on chest xray was noted day 5 and cultures were sent from blood,
urine, and sputum.  Antibiotic was initiated with vancomycin 1gm every 12 hours administered in patient
central line when sputum culture grew Methicillin-Resistant Staphylococcus Aureus (MRSA), and overall
clinical improvement (defervescence and hemodynamic stability).  All other cultures and surgical incision
site did not suggest additional sources of infection.  Induced normothermia was initiated during this
period, with reductions in water temperature used as a surrogate for fever.  During this period, a mild
elevation in INR (1.5) was corrected with transfusion of fresh frozen plasma. The patient was started on
sequential compression devices for deep vein thrombosis prophylaxis on admission and subcutaneous
heparin on postoperative day 6.  On postoperative day 7, the patient was awake, alert, and oriented to
person, place and date.  He had fluent speech with a mild dysarthria and left facial droop.  His sensation
was intact and motor strength were intact except for persistent right sided weakness.  His motor exam
improved on the left side: upper extremity strength still flaccid 0/5 but the lower extremity improved from
flaccid to hip flexion 2/5, left knee extension 5-/5, and left foot dorsiflexion 4-/5 ( Table 2).  Right upper and
lower limb strength were normal,  as had been on admission.  His sensation was intact to light touch.  He
passed a swallow evaluation and was started on a mechanical soft diet.  He continued to participate with
physical and occupational therapy.  He was transferred to the floor on postoperative day 10 and was later
discharged to an acute rehabilitation center.

I. Introduction
 Intracerebral hemorrhage (ICH) is caused by bleeding within the brain tissue itself a life-
threatening type of stroke. A stroke occurs when the brain is deprived of oxygen and blood
supply. ICH is most commonly caused by hypertension, arteriovenous malformations, or head
trauma. Treatment focuses on stopping the bleeding, removing the blood clot (hematoma), and
relieving the pressure on the brain. (Mayfield Certified Health)

Tiny arteries bring blood to areas deep inside the brain. High blood pressure (hypertension) can
cause these thin-walled arteries to rupture, releasing blood into the brain tissue. The blood
collects and forms a clot, called a hematoma, which grows and causes pressure on surrounding
brain tissue. Increased intracranial pressure (ICP) makes a person confused and lethargic. As
blood spills into the brain, the area that artery supplied is now deprived of oxygen-rich blood
called a stroke. As blood cells within the clot die, toxins are released that further damage brain
cells in the area surrounding the hematoma.
Treatment depends on the amount of blood and the extent of brain injury that has occurred.
Because the most common cause of ICH is related to high blood pressure, getting your blood
pressure lowered and under control is the first key step. Sometimes surgery is required to relieve
pressure from the accumulation of blood and to repair damaged blood vessels.
Long-term treatment depends on the hemorrhage location and the amount of damage. Treatment
may include physical, speech, and occupational therapy. Many people have some level of
permanent disability.
Symptoms usually appear suddenly during ICH. They include headache, weakness, confusion,
and paralysis, particularly on one side of your body. The buildup of blood puts pressure on your
brain and interferes with its oxygen supply. This can quickly cause brain and nerve damage.
High blood pressure is the most common cause of ICH. In younger people, another common
cause is abnormally formed blood vessels in the brain.
Other causes include:

 Hypertension: an elevation of blood pressure that may cause tiny arteries to burst inside
the brain.
 Blood thinner therapy: drugs such as Coumadin, heparin, and warfarin used to treat
heart and stroke conditions.
 AVM: a tangle of abnormal arteries and veins with no capillaries in between.
 Aneurysm: a bulge or weakening of an arterial wall.
 Head trauma: fractures to the skull and penetrating wounds (gunshot) can damage an
artery and cause bleeding.
 Bleeding disorders: hemophilia, sickle cell anemia, DIC, thrombocytopenia.
 Tumors: highly vascular tumors such as angiomas and metastatic tumors can bleed into
the brain tissue.
 Amyloid angiopathy: a degenerative disease of the arteries.
 Drug usage: cocaine and other illicit drugs can cause ICH.
 Spontaneous: ICH by unknown causes.

Hemorrhagic stroke is further classified into intracerebral hemorrhage and subarachnoid

hemorrhage. It result from the rupture of blood vessels in the brain. Rupture of arterioles results
in bleeding into the parenchyma of the brain, while rupture of larger arteries or its tributaries
result in bleeding in the subarachnoid space. Normal brain metabolism is impaired by
interruption of blood supply, compression and increased ICP.
Usually due to rupture of intracranial aneurysm, AV malformation, subarachnoid hemorrhage.
Risk factors for hemorrhage stroke include age, gender, race, hypertension, smoking and use of
illicit drugs. A stroke causes a variety of neurologic deficit, depending on the location of the
lesion, the size of the area of inadequate perfusion and the amount of severity of blood flow. It
may include vomiting, headache, seizures, hemiplegia and loss of consciousness. Pressure on the
brain tissue from increase intracranial pressure may cause coma and death.

Current trends and statistics about the disease condition

The worldwide incidence of intracerebral hemorrhage (ICH) ranges from 10 to 20 cases per
100,000 population and increases with age, 90% of them being older than 45 years. Intracerebral
hemorrhage is more common in males than females, with males having a 5-20% higher
incidence of ICH than females. Certain populations are also predisposed to ICH such as Japanese
and black since a higher incidence of hypertension is seen in these people younger than 45 years.

 Globally, about 17 million strokes occur every year and stroke is the second leading
cause of death after coronary heart disease, and the third most common cause of
disability
 Globally, the incidence of stroke due to ischemia is 68%, while the incidence of
hemorrhage stroke (intracerebral hemorrhage and subarachnoid hemorrhage combined) is
32%

Chronic Bronchitis Reports Local

In the Philippines, the most common etiology of ICH in young patients was hypertension, while
aneurysms and AVM's were the most common etiology in the subgroup aged 19 – 29 years.
Independent predictors of mortality were identified. Intracerebral hemorrhage accounts for 10 to
15 percent of all cases of stroke and is associated with the highest mortality rate, with only 38
percent of affected patients surviving the first year. Depending on the underlying cause of
bleeding, intracerebral hemorrhage is classified as either primary or secondary. In 2007, 5.2%
(173) of deaths in Region 3 were caused by stroke, making these the 4th causes of death,
respectively. 
Risk Factors (2009) In Region 3:

• 36.4% had high blood pressure

• 35.9% had high cholesterol
• 11.8% had diabetes
• 21.6% were smokers
• 73.4% were either overweight or obese
• 28.7% did not get enough physical exercise
• 83.2% did not eat more fruits and vegetables to lower risk of heart disease or stroke
Phil Heart Center J 2007; 13(2):155-160.

I. REASON FOR CHOOSING THE CASE FOR PRESENTATION

We have chosen this case as our topic during the case presentation because we would like that
we, student nurses, to be aware about intracerebral hemorrhage and also to broaden our
knowledge about the management and treatment of this disease.

Having awareness and gaining more knowledge about intracerebral would enhance our skills and
attitude in handling patients suffering from this disease

This case serves as a challenge for us student nurses to be committed and dedicated health
professionals for in the next days, we will take care of the health of the citizens

I. OBJECTIVES
General
At the end of the case presentation the presenters together with the audience will enhance
our understanding on the disease process of intracerebral hemorrhage, its nursing
management and paves a way to us student nurses appreciate our roles of being health
care providers in the country’s guest for health progress and development
Specific Objectives:
At the end of this case study, the student will able to:
Knowledge
 Observe necessary information regarding the patient and her condition
 Formulate and prioritize nursing care plan for patient
 Improve knowledge regarding intracerebral hemorrhage
 Identify the main cause of the disease
Skills
 Carry out independent and dependent intervention being done to the client appropriately
and with care
 Perform comprehensive nursing intervention based in the client priority needs
 Demonstrate critical thinking skills necessary for providing safe and effective nursing
care
 Utilize effective communication skills to the patient and during case presentation
Attitudes
 Avoid promising words that might worsen the client condition
 Strengthen cooperation and unity among member of the group by performing right and
proper nursing intervention and responsibilities
 Enhance our confidence in handling a patient with same condition
 Develop a warm environment between the student and the patient for better working
relationship towards improvement of health
Client Centered:
At the end of this case study, the patient will able to
Knowledge
 Identify the importance of the treatment done to the patient
 Observe for the client’s condition
 Understand the proper management of her condition

Skills
 Compliance to continue intervention and health teaching provided by the student
 Cooperate with the management of her condition
 Modify the needs for a healthy lifestyle to improve condition

Attitudes
 Express awareness on the needs and condition of her present status
  Develop the family’s support system and distinguish their respective roles in improving
her health status
 Show involvement in promoting on her general health
II. Nursing Process

A. Assessment

 Personal Data

Name: Patient X
Age: 21 years old
Height: 5’5
Weight: N/A
Address: Lilibangan, Concepcion Tarlac
Gender: Male
Date of Birth: May 16, 2000
Birth Place: Tarlac City
Civil Status: Single
Occupation: N/A
Nationality: Filipino
Chief Complaint: - Severe headache

Final Diagnosis: Intracerebral Hemorrhage

B. Environmental Status
Patient X is presently living in Lilibangan, Conception, Tarlac together with his family. Their
house is bungalow-type made up of concrete. Their house is near the highway, few trees
were planted around their house and water from a deep well is their main source of water.
Garbage and waste disposal are observed, garbage-collecting truck collects their waste
making sure that their surrounding are free from it. As their mode of transportation, they use
tricycle, jeepneys, and also buses to go to other places. Based on the data gathered, there is
no significant factors that may influence to his disease.
C. Lifestyle
Patient X does eat his meals at regular and usual intervals. He never tend to skip his
meals and he always attend his daily workout at the gym. Patient X states that he has no
specific type of diet and eats whatever is served to him. According to him, he smoke
cigarettes but doesn’t drink alcohol.
MEDICAL HISTORY:
According to Patient X, his last confinement was 7 years ago due to his asthma prior to
the previous confinement. He stated that he lasted for almost 4 days and got discharged
right away. His previous checkup was for his medication for his condition Attention
Deficit Disorder.
FAMILY HEALTH HISTORY:
Patient X has no family health history of vascular malformations or subarachnoid
hemorrhage. However, he stated that asthma is dominant to his mother’s side. We noted
other diseases as verbalized by the patient such as Hypertension.
HISTORY OF PRESENT ILLNESS
Few hours prior to admission at around 10:30 AM am on May 16 , 2021 patient was
found in a gym bathroom with left sided weakness and urinary incontinence shortly after
lifting weights.  Upon arrival to the emergency department (ED), he was following
commands with left hemiparesis and complained of severe headache.  Initial laboratory
studies revealed a normal platelet count, coagulation profile, and negative toxicology
screen. Emergent non-contrast head CT revealed a right frontal intracranial hemorrhage
and a CT angiography (CTA) of the brain revealed an arterio-venous malformation
(AVM). 

Soon after presentation, he became more lethargic with episodes of bradycardia to the 30s
and without concomitant hypertension.  He was subsequently intubated for airway
protection with propofol and rocuronium.  In addition, 50 grams of mannitol was
administered intravenously due to concerns of rising intracranial pressure (ICP).  Now
intubated, propofol infusion was titrated to maintain deep sedation (no response to
painful stimuli).  He was then moved to the neurointensive care unit (NICU).
 B. GENOGRAM
B. GENOGRAM

PATERNAL SIDE MATERNAL SIDE

78 70 88 75

57 55 50 45 42 40 39 35 33 32

*Died due to *Died due

a heart to a
motorcycle

MALE

FEMALE
BRONCHIAL ASTHMA
DEAD
24 21 19 15 PNEUMONIA
HYPERTENSION ECZEMA
ASTHMA DIABETES MELLITUS
ICH

PATIENT
13 Areas of Assessment

I. Social Status

Patient X is a 21 years old man, Lives in Brgy. Lilibangan, Concepcion

Tarlac. He lives with his Father and Mother and his brother. According to patient
X, he loves hang out with their relatives and friends. Patient X has a good
relationship with his family members.

Norms:
The ability to interact successfully with people and within environment of
which each person is a part to develop and maintain intimacy with significant
others and to develop respect and tolerance for those with different opinions and
beliefs which are necessary determinants for a person’s social state. (Kozier,
2015)

Analysis:
Patient X has a good social relationship with his family and friends.

II. Mental Status

During our assessment, Patient X is not active and not participating in our
questions. Its because of his illness and condition, having a severe headache and
lethargic is hard to cooperate.

Norms:
The clients must be alert and awake with eyes open and looking at the
examiner and able to responds appropriately. (Weber)

Analysis:
Being not responsiveness and not able to answer questions is not normal.

III. Emotional Status

 While assessing patient X, he was quiet and lethargic due to the
bradycardia and severe headache. He claims anxiety and nervousness due to his
present condition that it might be.

Norms:
Normally, the patient should have the ability to manage stress and to
express emotion appropriately. It also involves the ability to recognize, accept
and express feelings and to accept one’s limitations. (Fundamentals of
Nursing: Concepts, Process, and Practice, 10th Edition, 2018)
Analysis:
Patient X was not able to answer our questions during assessment because of
his present condition.

IV. Sensory Perception

Upon the physical examination, it was noted that patient has left
hemiparesis. Patient X has a good eyesight, but due to his left side body
weakness, he had left visual field deficit. His hearing ability is normal using
whisper test with distance of two feet. His sense of smell is normal, and he can
distinguish foul and fresh odor. His lips are light in brown in color. His tongue is
slightly pink, and he can taste whatever foods he eats.

Norms:
Each of the five senses becomes less efficient in older adult hood. Changes
result in loss of visual acuity, less power of adaptation to darkness and dim
light, decreased in accommodation to near and far objects. The loss of hearing
is the ability related to aging effects people over age 65. Gradual loss of hearing is
more common among man than women, perhaps because men are more frequently in
noisy work environment. Older people have a poorer sense of taste and smell and
are less stimulated by food than young. Loss of skin receptors takes place gradually,
producing in increased threshold for sensations of pain, touch, and temperature.
(Fundamentals of Nursing 7th edition Barbara Kozier)
Analysis:
Patient has a good vision, but due to his left side body weakness, he had left
visual field deficit that’s why he has right gaze preference. The sense of smell, taste and
hearing can perceive stimuli accordingly. His sensation was intact to light touch.
V. Motor Status
Patient X need assistance when he’s standing up or when he’s doing a due
to his left hemiparesis. The one side of his entire body is weak, he need an
assistance on doing his ADLs to ensure his safety.

Norms:
Normal motor stability includes the ability to perform different activities
without causing pain and discomfort. It should be firm and have coordinated
movements. (Estes, 2011)
Analysis:
Patient X one side of his body is weak due to hemiparesis. His motor exam
improved on the left side: upper extremity strength still flaccid 0/5 but the lower
extremity improved from flaccid to hip flexion 2/5, left knee extension 5-/5, and left foot
dorsiflexion 4-/5.  Right upper and lower limb strength were normal, as had been on
admission

VI. Body Temperature

Norms:

Normal axillary temperature is within 34.4°C to 37.4°C. (Health assessment

and physical examination 3rd edition by Mary Ellen Zator Estes)
Analysis:
Patient X body temperature is normal.

Date Assessed Time Temperature

May 17, 2021 3:00 pm 35.5

VII. Respiratory Status

When he was auscultated in lungs, his breath sounds are normal, no cough
and difficulty in breathing noted. S1 and S2 are normal, No appreciable murmurs,
rubs or gallops.

Norms:

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of
pattern, normal respirations must be regular and even in rhythm. The normal
 depth of respirations is non exaggerated and effortless. (Health assessment
and physical examination 3rd edition by Mary Ellen Zator Estes).
Analysis:
Patient X has a normal breath sound, and his respiratory status is within normal
levels.

Date Assessed Time Respiratory rate

May 17, 2021 3:02 pm 20

VIII. Circulatory Status

During the assessment of her capillary refill, his nail beds returned to its
original color after 2 seconds.

Norms:
The normal cardiac rate or pulse rate of an adult is 60-100 bpm. The average
blood pressure of a healthy adult is 110 to 120 systole 70 to 80 diastole. The
normal capillary refill test is 2-3 seconds and upon capillary refill test was done
and it returns to normal state within 2-3 second. (Kozier, Fundamentals of Nursing 7th
Edition.)
Analysis:
The data given below shows that Patient X’s pulse rate and blood pressure is
within normal range. The results above shows that his capillary refill is within
normal.

Date Assessed Time Heart Rate Blood pressure

May 17, 2021 3:05 pm 20 130/79

IX. Nutritional Status

Patient X claims that he has a daily intake rice, fish and meat. Sometimes fruits
and vegetables. He eats 3 times a day and drinks 8 glasses of water. He also drink
coffee every morning.
 Norms:
According to the Health Asian Diet Pyramid, there should be a daily intake of
rice, grains, bread, fruit and vegetables; optional daily for fish, shellfish, and
dairy products; weekly for sweets, eggs and poultry, and monthly for meat.
There should be an increase intake of a wide variety of fruits and vegetables.
Include in the diet foods higher in vitamins C and E, and omega-3 fatty acid
rich foods. Fluid intake is on the average of 8-10 glasses per day (Mohan, 2002).
Analysis:
Patient X has a normal nutritional intake, he eats what the prescribed or the
normal meal of the person per day.

X. Elimination Status

Patient X claimed that he usually defecates once a day with semi solid
consistency, brownish in color and normal amount in elimination. He voids 4
times a day, light yellow in color with normal amount. .

Norms:
The typical adult bowel movement consists of a moderate amount of formed,
brown stool that is passed without difficulty. The normal frequency of bowel
elimination varies from several stools per day to only two or three per week.
Most adults experience bowel elimination every 1 to 2 days. Normal voiding
is 3 to 4 times a day with an output of 1200 to 1500 ml a day. Urine is clear to
yellowish in color. (Fundamentals of Nursing, kozier, 2007)
Analysis:
With regards to Patient X’s elimination status, it appears that his elimination
and voiding pattern is within normal.

XI. Reproductive Status

Patient X was circumcised at 10 years old. He didn’t undergo to any surgery for
sterility, and doesn’t have any disease pertaining to his genitalia. Upon admission,
there were no abnormalities noted and there are no presence of discharges,
lesions, and tenderness upon palpation and other deviations from the genitals and
its surrounding area. The pubic hair is well distributed 

Norms:
 Examination of the penis includes the skin, corporal erectile bodies, and
urethral meatus. It should be noted whether the patient is circumcised or
uncircumcised. The ease with which a redundant prepuce is retracted is assessed.
The entire penile skin, including that beneath the prepuce, should be examined for
ulcers, warts, rashes, or other lesions. The size and position of any skin lesion
should be described along with the degree of tenderness to palpation and fixation
to subcutaneous tissue. If penile skin lesions are found, correlation of palpable
deep or superficial inguinal adenopathy should be made at that time. Examination
for urethral discharge or urethral mucosal lesions near the meatus should also be
carried out by everting the lips of the meatus. (Maxwell White, Clinical Methods:
The history, Physical, and Laboratory Examination. 3rd edition.

Analysis:
 Based from the data, Patient X reproductive status is normal. There are
no assessed significant deviations from normal seen from the patient’s
reproductive status. 

XII. SLEEP-REST PATTERN

Patient X’s stated that he usually sleeps 7 to 8 hours a day. He usually
sleeps at 11 pm and wakes at 9:00 am. He usually watches television at home
during rest hours.

Norms:
Sleep refers to altered consciousness with general slowing of physiologic
process while rest refers to relaxation and calmness, both mental and physical. A
typical sleeper will pass through 7 to 9 hours of sleep and take a rest using home
relaxation activities such as reading, telling stories and others. (Nursing
Fundamentals by Rick Daniels)

Analysis:
Patient X has a normal and adequate sleep pattern.

XIII. State of skin Appendages

Patient X’s skin is brown, his hair is thin, fine and black in color. His palpebral
conjunctiva is slightly pink and her sclera is white in color. Both nails in finger
and toes were assessed.
Norms:
Obvious changes occur in the integumentary system (skin, hair, nails) with
age. The skin becomes drier and more fragile, the hair loses color, the finger nails
and toe nails become thickened and brittle, and in man over 60, facial hair
increases. These integumentary system changes accompany progressive losses of
subcutaneous fat and muscle tissue, muscle atrophy, and loss of elastic fibers.
(Fundamental of Nursing 7th Edition by Barbara Kozier)
The palpebral conjunctiva should appear pink and moist. Normally, the
skin is a uniform whitish pink or brown color, depending on the patient’s race.
Normally, the nails have a pink cast in light-skinned individuals and are brown in
dark-skinned individuals. (Health Assessment and Physical Examination 3rd
Edition by Mary Ellen Zator Estes)

Analysis:
Based from the above information, the skin appendages of the patient is
normal.
III. Laboratory and Diagnostic Procedures

DIAGNOSTIC/LABORATORY DATE INDICATION/PURPOSE PREPARATION NORMAL RESULTS

PROCEDURE ORDERED/DATE VALUES
DONE
CT ANGIOGRAPHY OF THE May 17 CT (computed If your study was Results are Prominent
BRAIN tomography) angiography ordered without considered tangle of vessels
(CTA) is an examination contrast, you can normal if no located at the
that uses x-rays to eat, drink and problems are medial aspect of
visualize blood flow in take your seen. the right frontal
arterial vessels throughout prescribed hemorrhage
the body, from arteries medications and
serving the brain to those prior to your arteriovenous
bringing blood to the exam. If your malformation
lungs, kidneys, and the doctor orders
arms and legs. CT a CT scan with
combines the use of x-rays contrast, do not
with computerized eat anything
analysis of the images. three hours
before
your CT scan.
You are
encouraged to
drink clear
liquids.
DIAGNOSTIC/LABORATORY DATE INDICATION/PURPOS PREPARATIO NORMAL RESULTS INTERPRET
PROCEDURE ORDERED/DATE E N VALUES ATION
DONE
COMPLETE BLOOD COUNT May 17 The complete blood If your blood White blood WBC-11.8 X Normal CBC
(CBC) count (CBC) is a group sample is being cell count 103/ul results
of tests that evaluate tested only for (WBC)- 4.3
the cells that circulate a complete to 10.8 x HEMOGLOBIN
in blood, including blood count, 10/ul -12.1g/dl
red blood you can eat Platelet
cells (RBCs), white and drink count- HEMATOCRIT-
blood cells (WBCs), and normally 150,000 to 35.7%
platelets (PLTs). before the test. 400,000 per
The CBC can evaluate mm3. PLATELETES-
your overall health and Hemoglobin- 346X103/ul
detect a variety of 13.2-
diseases and conditions, 16.6g/dl
such as infections, Hematocrit-
anemia and leukemia 38.3-48.6%

DIAGNOSTIC/LABORATORY DATE INDICATION/PURPOS PREPARATION NORMA RESULT INTERPRETATION

PROCEDURE ORDERED/DAT E L S
E DONE VALUES
PROTHROMBIN TIME (PT) May 17 Prothrombin time (PT) You will not 11.0-12.5 27 When the PT is high,
is a blood test that need to fast seconds seconds it takes longer for the
measures how long it before a PT. blood to clot (17
takes blood to clot. You'll need to seconds, for
A prothrombin time have your example). This
test can be used to blood drawn usually happens
check for bleeding for a PT test. because the liver is
problems. PT is also This is an not making the right
used to check whether outpatient amount of blood
medicine to prevent procedure clotting proteins, so
blood clots is working usually the clotting process
performed at a takes longer. A high
diagnostic lab. PT usually means that
It takes only a there is serious liver
few minutes damage or cirrhosis.
and causes
little to no
pain.

DIAGNOSTIC/LABORAT DATE INDICATION/PURPO PREPARATION NORMA RESULT INTERPRETATI

ORY PROCEDURE ORDERED/DA SE L S ON
TE DONE VALUES
SODIUM (Na) May 17 Sodium is You don't need any 136-145 136 Normal Na
an electrolyte present in all special meq/L meq/l results
 body fluids and is vital to preparations for
normal body function, a sodium blood test 
including nerve and muscle
or an electrolyte
function. This test
measures the level of panel
sodium in the blood 

DIAGNOSTIC/LABORA DATE INDICATION/PURPOSE PREPARATION NORMA RESUL INTERPRETAT

TORY PROCEDURE ORDERED/D L TS ION
ATE DONE VALUES
POTASSIUM (K) May 17  A potassium blood test is You don't need any 3.5-5.0  Normal K
used to detect special preparations mEq/L 3.8 results
abnormal potassium level for mEq/L
s, including a potassium blood te
high potassium (hyperkal st or an electrolyte
emia) and panel
low potassium (hypokale
mia). It is often used as
part of an electrolyte
panel or basic metabolic
panel for a routine health
exam.

DIAGNOSTIC/LABORATOR DATE INDICATION/PURPOS PREPARATION NORMA RESULT INTERPRETATIO

Y PROCEDURE ORDERED/DAT E L S N
E DONE VALUES
BLOOD UREA May 17 A blood urea If 7 to 20 24mg/ A high BUN value
NITROGEN(BUN) nitrogen (BUN) test your blood sampl mg/dL dl can mean kidney
measures the amount e is being tested injury or disease
of nitrogen in only for blood is present. 
your blood that comes urea nitrogen,
from the waste you can eat and
product urea. Urea is drink normally
made when protein is before the test
broken down in your
body. 

DIAGNOSTIC/LABORATOR DATE INDICATION/PURPOS PREPARATIO NORMA RESULT INTERPRETATIO

Y PROCEDURE ORDERED/DAT E N L S N
E DONE VALUES
CARBON DIOXIDE BLOOD May 17  A CO2 blood You don't need 23 to 29 23 Normal CO2 blood
TEST test measures the any special mEq/L mEq/L test
amount of carbon preparations
dioxide in your blood. for a CO2
Too much or too blood test or
little carbon dioxide in an electrolyte
the blood can indicate a panel.
health problem.

DIAGNOSTIC/LABORATO DATE INDICATION/PURPOSE PREPARATIO NORMA RESULT INTERPRETATIO

RY PROCEDURE ORDERED/DAT N L S N
E DONE VALUES
RANDOM BLOOD SUGAR May 17  A You can eat 80 117mg/ Normal RBS
random blood sugar test  and drink mg/dl dL results
is the testing of before and 130
the blood sugar level at a random mg/dl
any time or random glucose test.
time of the day. It is
a test performed outside
the
regular testing schedule. 
.
Anatomy and Physiology
ICH is almost invariably associated with hypertension and is presumed by many to be
the result of the weakening of arterial walls by the trauma of excessive pulse
pressure. The most common sites of involvement are:

1. The region of the putamen-external capsule in the

distribution of the lenticulostriate branches of the
middle cerebral artery (50%). The putamen (a
common site for hypertensive bleed) is involved
in learning and motor contro l, including speech
articulation, and language functions, reward,
cognitive functioning, and addiction. Image is of
putamens position in skull.
2. The thalamus in the distribution of the small penetrating vessels from
the posterior cerebral and posterior communicating arteries (10%);
3. The cerebellum in the distribution of the deep penetrating branches of
the superior cerebellar artery (10%); and
4. The pons in the distribution of the paramedian branches of the basilar
artery (10%).
The remaining 20% occur into the white matter of various lobes of the cerebral
hemispheres.
 PATHOPHYSIOLOGY OF INTRACEREBRAL HEMORRHAGE

Modifiable Risk Factor: Non-Modifiable Risk Factor:

 Cigarette Smoking  Age
 right frontal AVM was confirmed  Gender
on 4-vessel cerebral angiography

Increase blood flow to the brain

Compromise of the integrity of the

cerebral arterioles

Weakening of the walls of the blood

vessel

Formation of aneurysm

Rupture of arterio-cerebral artery

INTRACEREBRAL HEMORRHAGE

Alteration of Cerebral Inflammation of

Component Frontal Lobe Presence of free blood
Hematoma Formation
in the instertitial

Increase intracranial
pressure Thrombus formation

ICP: 30 to 40 mmHG
Cellular Edema Vasospasm

Compression of the Decrease oxygen

brain supply Increased BP

BP: 130/79
Stimulation of
vasomotor centers
 RBC lysis Alteration in frontal
lobe fuction

Oxidative damage to proteins,

Mild Dysarthia Severe headache
nucleic acids, carbohydrates,
lipids

Other symptoms noted:

Necrosis
Fever: 39.8 C

GCS: From 15 to
Muscle

Left Hemiparesis Damaging Facial nerve

Left facial droop

SURGICAL MANAGEMENT:
Right fronto-temporo-parietal
decompressive craniectomy
without removal of the
hematoma or AVM.
 CHARTING
Subjective: “Sobrang sakit ng ulo ko.” as verbalized by the patient.

Objective:
-Lethargic

-Diaphoretic

Vital signs taken as follows:

- BP: 130/79mmHg

- PR: 63 bpm

- RR: 20 bpm

- Temp: 35.5

- O2Sat: 98% on 3 liters/minute nasal cannula

-Glasgow coma scale (GCS) is 15

- Non-contrast head CT revealed a right frontal intracranial hemorrhage and a CT angiography

(CTA) of the brain revealed an arterio-venous malformation (AVM). 

-ICP: 30mmHg

 Analysis: Altered tissue perfusion related to decrease cerebral blood flow as evidenced by
increased ICP.
 Planning:
Within 8 hours of providing appropriate nursing intervention the patient will be to

 Improve cerebral perfusion

 Intervention:
Independent:

1. Checked blood pressure, pulse rate, LOC, pupillary response, and motor function. Monitor
respiratory status and report changes immediately.
2. Maintained bed rest in a quiet, non stressful setting.

3. Elevated the head of the bed in 15-30 degrees or as ordered.

4. Avoided any activity that suddenly increases blood pressure or obstructs venous return.

5. Instructed patient to exhale during voiding or defecation to decrease strain.

6. Applied antiembolism stockings or sequential compression devices.

7. Observed legs for signs and symptoms of DVT, redness, swelling, warmth and edema.

Dependent:

1. Administered osmotic diuretics such as mannitol to decreased ICP as ordered.

2. Administered anticoagulant as ordered.

Evaluation: After 8 hours of providing appropriate nursing intervention the patient was able to
 Improved cerebral perfusion as evidenced by the patient feeling comfortable in sleep amd
maintained VS within normal range.
 CHARTING

Subjective: “Hindi ko magalaw yung yung kaliwang parte ng katawan ko. Parang nanghihina.” As
verbalized by the patient

Objective:

 Left hemiparesis
 Limited ROM
 Difficulty on turning
 Slowed movements
 Muscle strength grades as follows:
Right Arm: 5/5
Right Leg: 5/5
Left Arm: 0/5
Left Leg:
- Hip Flexion: 2/5
- Knee Extension: 5/5
- Foot Dorsiflexion: 4/5
Vital signs taken as follows:

- BP: 130/79mmHg

- PR: 63 bpm

- RR: 20 bpm

- Temp: 35.5

- O2Sat: 98% on 3 liters/minute nasal cannula

 Analysis: Impaired physical mobility related to neuromuscular involvement secondary to

intracerebral hemorrhage as manifested by left hemiparesis.
 Planning:
Short Term:
Within 3 hours appropriate nursing interventions, patient will demonstrate willingness to
participate in activities necessary for their routine ADL.
Long Term:
Within 3 days appropriate nursing interventions, patient will be able to improve and increase
strength hand and leg function of affected body part.
 Intervention:
1. Established rapport
2. Monitored vital signs.
3. Noted emotional/ behavioral responses to problems of immobility
4. Determined readiness to engage in activities/ exercises.
5. Assisted patient reposition self on a regular schedule
6. Provided for safety measures including fall prevention
7. Identified energy conserving techniques for ADLs
8. Involved patient and SO in care, assisting them to learn ways of managing problems of
immobility.
9. Assisted patient to do passive range of motion
10. Provided restful environment for patient after periods of exercise.
 Evaluation:
Short Term:
After 3 hours appropriate nursing interventions, patient demonstrated willingness to participate in
activities necessary for their routine ADL.
Long Term:
Within 3 days appropriate nursing interventions, patient was able to improve and increase
strength hand and leg function of affected body part.
 CHARTING
Subjective: “Nilalagnat siya.” As verbalized by the significant other.
Objective:
 Lethargic
 Diaphoretic
 Skin warm to touch
 Vital sign taken post op as follows:
o BP: 130/79 mmHg
o T: 103.6F (39.8)
o PR: 63 bpm
o RR: 20 bpm
o O2Sat: 98% on 3 liters/minute nasal cannula

 Analysis: Hyperthermia related to infectious process or post-operative surgery secondary to

intracerebral hemorrhage
 Planning: Within 8 hours of comprehensive nursing intervention, the patient temperature
will lower down to normal levels: T: 36.5°C–37.5°C
 Intervention:
 Provided tepid sponge bath.
 Assessed fluid loss & facilitate oral intake.
 Promoted bed rest
 Provided cool circulating air using a fan.
 Assisted patient in changing into dry clothing.
 Provided oral hygiene.
 Monitored vital signs.
 Maintained IV fluids as ordered by physician.
 Administered anti- pyretic as ordered.
 Administered antibiotic as ordered.
 Monitored hematologic test & other pertinent lab records

 Evaluation: After 8 hours of comprehensive nursing intervention, the patient temperature

will lower down to normal levels: T: 36.5°C–37.5°
 NURSING CARE PLAN #1
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Altered tissue Within 8 hours of Independent: After 8 hours of

“Sobrang sakit ng ulo perfusion related providing appropriate  Check blood pressure,  For baseline data and to providing
ko.” as verbalized by to decrease nursing intervention the pulse rate, LOC, pupillary compare before, during, appropriate nursing
the patient. cerebral blood patient will be to response, and motor and after nursing intervention the
Objective: flow as evidenced  Improve cerebral function. Monitor interventions or patient was able to
-Lethargic by increased ICP. perfussion respiratory status and medications given.  Improved
-Diaphoretic report changes cerebral
Vital signs taken as immediately. perfussion as
follows:  Maintain bed rest in a  To minimize the risk for evidenced by
- BP: 130/79mmHg quiet, non stressful setting. increase intracranial the patient
- PR: 63 bpm pressure. feeling
- RR: 20 bpm  Elevate the head of the  For proper circulation of comfortable in
- Temp: 35.5 bed in 15-30 degrees or as blood in the body. sleep amd
- O2Sat: 98% on 3 ordered. maintained VS
liters/minute nasal  Avoid any activity that  To prevent increase ICP within normal
cannula suddenly increases blood and other complications of range.
-Glasgow coma scale pressure or obstructs the disease.
(GCS) is 15 venous return.
- Non-contrast head  Instruct patient to exhale  To relax the muscles
CT revealed a right during voiding or involve during voiding and
frontal intracranial
defecation to decrease defecation to decrease
hemorrhage and a CT
angiography (CTA) strain. strain.
of the brain revealed
 Apply antiembolism  To prevent DVT
an arterio-venous
malformation stockings or sequential formation.
(AVM). 
compression devices.
-ICP: 30mmHg  Observe legs for signs and  Elevate the foot of the bed
symptoms of DVT, and apply antiembolic
redness, swelling, warmth stockings to minimize
and edema. edema and DVT
Dependent:
 Administer osmotic  It reduces cerebral edema
diuretics such as mannitol by increasing urine output.
to decreased ICP as
ordered.
 Administer anticoagulant  To prevent
as ordered. thromboembolism.
 NURSING CARE PLAN #2
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Impaired physical Short Term: Priority Nursing To have baseline date Short Term:
“Hindi ko magalaw yung mobility related to Within 3 hours of intervention: and to improve After 3 hours of
yung kaliwang parte ng neuromuscular appropriate Monitor vital signs mobility and secure appropriate nursing
safety.
katawan ko. Parang involvement nursing and assist patient on interventions, the
nanghihina.” As secondary to interventions, the doing ADL as well as patient was able to
verbalized by the patient intracerebral patient will able to encouraging to do demonstrated
Objective: hemorrhage as demonstrate passive ROM willingness to
 Left hemiparesis manifested by left willingness to INDEPENDENT: INDEPENDENT: participate in
 Left facial droop hemiparesis. participate in 1. Establish rapport activities necessary
1. To promote
 Limited ROM activities 2. Monitor vital signs. for their routine
 Difficulty on turning cooperation
necessary for their 3. Note emotional/ ADL.
 Slowed movements behavioral responses 2. To have a baseline
 Muscle strength routine ADL. data
to problems of
grades as follows: immobility 3. To assess Long Term:
Right Arm: 5/5 Long Term: 4. Determine functional ability Within 3 days
Right Leg: 5/5 Within 3 days of readiness to engage in 4. To assess expected appropriate nursing
Left Arm: 0/5 appropriate activities/ exercises. interventions, patient
level of participation
Left Leg: nursing 5. Assist patient was able to
reposition self on a 5. To promote
- Hip Flexion: interventions, the optimal level of improved and
regular schedule
2/5 patient will be able function and prevent increased strength
6. Provide for safety
- Knee to improve and hand and leg
measures including complications
Extension: increase strength fall prevention function of affected
5/5 6. To prevent
hand and leg 7. Identify energy occurrence of injury body part.
- Foot conserving techniques
function of 7. Limits fatigue,
Dorsiflexion: for ADLs
4/5 affected body part. maximizing
8. Involve patient and
Vital signs taken as SO in care, assisting participation
them to learn ways of 8. To promote
follows:
managing problems of wellness.
- BP: 130/79mmHg immobility.
9. To promote
9. Assist patient to do
- PR: 63 bpm circulation and
passive range of
- RR: 20 bpm motion prevent contracture.
10. Provide restful 10. To facilitate
- Temp: 35.5
environment for recuperation.
- O2Sat: 98% on 3 patient after periods of
exercise.
liters/minute nasal
cannula

NURSING CARE PLAN #3

 ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Hyperthermia Within 8 hours of Priority Nursing After 8 hours of
“Nilalagnat siya.” related to comprehensive intervention: comprehensive
As verbalized by the infectious process nursing Monitor body nursing intervention,
significant other. or post-operative intervention, the temperature and the patient
Objective: surgery secondary patient temperature administer medication temperature will
 Lethargic to intracerebral will lower down to as ordered. lower down to
 Diaphoretic hemorrhage normal levels: T: INDEPENDENT: INDEPENDENT: normal levels: T:
 Skin warm to 36.5°C–37.5°C  Provide tepid Enhances heat loss by 36.5°C–37.5°C
touch sponge bath. evaporation &
 Vital sign taken  Assess fluid loss conduction.
post op as & facilitate oral Increases metabolic
follows: intake.
o BP: 130/79 rate & diaphoresis.
 Promote bed rest Reduces body heat
mmHg  Provide cool
o Temp: 103.6F production.
circulating air
(39.8) using a fan. Dissipates heat by
o PR: 63 bpm  Assist patient in convection.
o RR: 20 bpm changing into Increases comfort.
o O2Sat: 98% on dry clothing. Prevents herpetic
3 liters/minute  Provide oral lesions of the mouth.
nasal cannula hygiene. Notes progress &
 Monitor vital changes of condition.
signs.
DEPENDENT:
DEPENDENT:
 Maintain IV Prevents dehydration.
fluids as ordered Reduces fever.
by physician.  Treats underlying
  Administer anti- cause.
pyretic as
ordered.
 Administer
antibiotic as
COLLABORATIVE:
ordered.
Indicates presence of
COLLABORATIVE: infection & dehydration.
 Monitor Ensures continuous
hematologic test & intervention.
other pertinent lab
records.
Charting
Subjective:
“Nahihirapan siyang magsalita”, as verbalized by the significant other.
Objective:
 Mild dysarthria
 Slurring
 Difficulty with tongue and lip movements
 Inappropriate words
 Problem speaking in a regular rhythm, with frequent hesitations.
Assessment: Impaired verbal communication related to alteration of motor speech area of the
brain
Planning: Within 3 days of nursing interventions, the client will be able to establish method
of communication in which needs can be expressed.
Interventions:
 Monitor vital signs with emphasis to BP.
 Provide an atmosphere of acceptance and privacy through speaking slowly and in a
normal tone, not forcing the client to communicate.
 Maintain eye contact with patient when speaking. Stand close, within patient’s line of
vision (generally midline).
 Give the patient ample time to respond.
 Maintain a calm, unhurried manner. Provide sufficient time for patient to respond.
 Use short sentences, and ask only one question at a time.
 Allow significant others the opportunity to ask questions about the patient’s
communication problem.

Evaluation:
After 3 days of nursing interventions, the client was able to establish method of
communication in which needs can be expressed.
Objective:
- Post op (surgical incision) for decompressive craniectomy
- Presence of bolt to monitor ICP
- Left Hemiparesis
Assessment: Risk for Infection related to Surgical Incision
Planning: Within 3 days of nursing interventions, the patient will be able to show no signs of
infections as evidenced by non-tender surgical incision, dischargeless wound site, and bolt
insertion site along with absence of inflammation.
Interventions:
 Note risk factors for occurrence of infection in the incision.
 Observed for localized signs of infection at insertion sites of invasive lines, surgical
incisions or wounds.
 Maintain aseptic technique when changing dressing/caring wound.
 Keep area around wound clean and dry.

Evaluation:
After 3 days of nursing interventions, the patient will be able to show no signs of infections
as evidenced by non-tender surgical incision, dischargeless wound site, and bolt insertion site
along with absence of inflammation.
 NURSING CARE PLAN #4
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Impaired verbal Within 3 days of - Monitor vital - Establishes Goal partially met,
“Nahihirapan siyang communication nursing signs with baseline data for after 3 days of
magsalita”, as related to alteration interventions, the emphasis to BP. review of nursing interventions,
verbalized by the of motor speech area client will be able to existing the client was able to
significant other. of the brain establish method of - Provide an conditions. established method
  communication in atmosphere of - Impaired ability of communication in
Objectives: which needs can be acceptance and to communicate which needs can be
- Mild dysarthria expressed. privacy through spontaneously is expressed.
- Slurring speaking slowly frustrating and
- Difficulty with and in a normal embarrassing.
tongue and lip tone, not forcing Nursing actions
movements the client to should focus on
- Inappropriate communicate. decreasing the
words tension and
- Problem conveying an
speaking in a understanding of
regular rhythm, how difficult the
with frequent situation must be
hesitations. - Teach for the client.
techniques to - Deliberate
improve speech actions can be
by initially asking taken to improve
questions that speech. As the
client can answer client’s speech
with a “yes” or improves, his
“no”. confidence will
increase and he
will make more
attempts at
- Used strategies speaking.
to improve the - Improving the
client’s client’s
comprehension comprehension
by using touch can help to
and behavior to decrease
communicate frustration and
calmness and increase trust.
adding other
non-verbal
methods of
communication
such as pointing
or using
flashcards for
basic needs;
using
pantomime; or
using paper and - Enhances
pen. participation and
- Involve the commitment to
significant others plan.
in the plan of
care.
 NURSING CARE PLAN #5
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
  Risk for Infection Within 3 days of - Observe for - To detect Goal partially met,
Objectives: related to Surgical nursing interventions, localized signs of infection at its after 3 days of
- Post op (surgical Incision the patient will be infection on all primary stage nursing interventions,
incision) for able to show no signs the sites of thus allowing the patient was able
decompressive of infections as incision or prompt to show no signs of
craniectomy evidenced by non- trauma. intervention. infections as
- Presence of bolt tender surgical evidenced by non-
to monitor ICP incision, dischargeless - Emphasize the - It serves as a tender surgical
- Left Hemiparesis wound site, and bolt importance of first line of incision, dischargeless
insertion site along handwashing defense against wound site, and bolt
with absence of technique. infection. insertion site along
inflammation. with absence of
- Maintain aseptic inflammation.
technique when - Regular wound
changing dressing
dressing/caring promotes fast
wound. healing and
drying of
- Keep area wounds.
around wound
clean and dry. - Wet area can
lodge area of
bacteria.

- Used strategies
to improve the
 client’s
comprehension
by using touch
and behavior to - Enhances
communicate participation
calmness and and
adding other commitment to
non-verbal plan.
methods of
communication
such as pointing
or using
flashcards for
basic needs;
using
pantomime; or
using paper and
pen.
- Involve the
significant others
in the plan of
care.

VII. DRUG STUDY

Name of Route and Mechanism of Indication Contraindicat Side Effect Nursing Responsibility
Drug Dosage Action ion
Generic 1.5 grams of Limits seizure  Control of Pregnancy. IV  Hypersensitivity, lack  Use only clear parenteral solutio
Name: phenytoin propagation by grand mal admin in sinus of appetite, headache, a faint yellow color may devel
Phenytoin (20 mg/kg altering ion (tonic-clonic) bradycardia, dizziness, tremor, but this has no effect on potency
Brand name: loading) to transport. May and heart block, or transient nervousness, the solution is refrigerated or froz
Dilantin obtain a also decrease psychomotor Stokes-Adams insomnia, GI a precipitate might form, but t
Drug therapeutic synaptic seizures syndrome. disturbances (e.g. will dissolve if the solution
Classification level (10-20 transmission.  Prevention and nausea, vomiting, allowed to stand at roo
: total level or Antiarrhythmic treatment of constipation), temperature. Do not use solutio
antiarrhythmi 1-2 free) and properties as a seizures tenderness and that have haziness or a precipitate.
cs (group IB), maintained result of occurring hyperplasia of the  WARNING: Administer IV slow
anticonvulsan with 100 mg shortening the during or gums, acne, hirsutism, to prevent severe hypotension;
ts IV infusion action potential following coarsening of the margin of safety between f
every 8 and ↓ neurosurgery facial features, rashes, therapeutic and toxic doses is sm
hours. automaticity.  Parenteral osteomalacia. Continually monitor patien
Therapeutic administration: Phenytoin toxicity as cardiac rhythm and check
Effects: Diminishe Control of manifested as a frequently and regularly during
d seizure activity. status syndrome of infusion. Suggest use
Termination of epilepticus of cerebellar, vestibular, fosphenytoin sodium if IV route
ventricular the grand mal ocular effects, notably needed.
arrhythmias. type nystagmus, diplopia,  Monitor injection sites careful
 Unlabeled slurred speech, and drug solutions are very alkaline a
uses: ataxia; also with irritating.
Antiarrhythmic mental confusion,  WARNING: Monitor for therapeu
, particularly in dyskinesias, serum levels of 10–20 mcg/mL.
digitalis- exacerbations of  Give oral drug with or without fo
induced seizure frequency, in a consistent manner. Give w
arrhythmias hyperglycaemia. food if patient complains of
(IV Solutions for inj may upset.
preparations); cause local irritation or  Recommend that the oral phenyto
treatment of phlebitis. Prolonged prescription be filled with the sa
trigeminal use may produce brand each time; differences
neuralgia (tic subtle effects on bioavailability have be
douloureux) mental function and documented.
cognition, especially in  Suggest that adult patients who
children. controlled with 300-mg extend
 Potentially phenytoin capsules try once-a-d
Fatal: Toxic dosage to increase compliance a
epidermal necrolysis, convenience.
Stevens-Johnson  WARNING: Reduce dosa
syndrome. discontinue phenytoin, or substit
other antiepileptic medicati
gradually; abrupt discontinuati
may precipitate status epilepticus.
 Phenytoin is ineffective
controlling absence (petit m
seizures. Patients with combin
seizures will need other medicati
for their absence seizures.
  WARNING: Discontinue drug
rash, depression of blood cou
enlarged lymph nod
hypersensitivity reaction, signs
liver damage, or Peyronie’s disea
(induration of the corpora caverno
of the penis) occurs. Instit
another antiepileptic drug promptl
 Monitor hepatic funct
periodically during long-te
therapy; monitor blood counts a
urinalysis monthly.
 Monitor blood or urine sugar
patients with diabetes melli
regularly. Adjustment of dosage
hypoglycemic drug may be need
 because antiepileptic may inhi
insulin release and indu
hyperglycemia.
 WARNING: Have lymph no
enlargement occurring dur
therapy evaluated careful
Lymphadenopathy that simula
Hodgkin’s lymphoma has occurr
Lymph node hyperplasia m
progress to lymphoma.
  Monitor blood proteins to det
early malfunction of the immu
system (eg, multiple myeloma).
 Arrange instruction in proper o
hygiene technique for long-te
patients to prevent development
gum hyperplasia.

 Teaching points
 Take this drug exactly as prescrib
with food to reduce GI upset,
without food—but maint
consistency in the manner in wh
you take it. Be especially careful n
to miss a dose if you are on once
day therapy.
 Do not discontinue this dr
abruptly or change dosage, exc
on the advice of your health c
provider.
 Maintain good oral hygiene (regu
brushing and flossing) to prev
 gum disease; arrange frequent den
checkups to prevent serious gu
disease.
 Arrange for frequent checkups
monitor your response to this drug
 Monitor your blood or urine su
regularly, and report a
abnormality to your health c
provider if you have diabetes.
 This drug is not recommended
use during pregnancy. It is advisa
to use some form of contracepti
other than hormonal contraceptive
 Wear a medical alert tag so that a
emergency medical personnel w
know that you have epilepsy and
taking antiepileptic medication.
 You may experience these s
effects: Drowsiness, dizzine
confusion, blurred vision (avo
driving or performing other tas
requiring alertness or visual acui
alcohol may intensify these effect
GI upset (take drug with food,
frequent small meals).
 Report rash, severe nausea
vomiting, drowsiness, slur
speech, impaired coordinati
(ataxia), swollen glands, bleedi
swollen or tender gums, yellow
discoloration of the skin or ey
joint pain, unexplained fever, s
 throat, unusual bleeding or bruisi
persistent headache, malaise, a
indication of an infection
bleeding tendency, abnorm
erection, pregnancy.

NAME OF DRUG DOSAGE, MECHANISM OF INDICATION CONTRAINDICATI SIDE EFFECTS NURSING

ROUTE AND ACTION ON RESPONSIBI
 FREQUENCY Y

Generic Name: Dosage: 7.5 mg 1 Increases osmotic pressure of Test  Hypersensitivity CNS: dizziness, Priority Nursi
Mannitol tab plasma in glomerular filtrate, dose for  Anuria headache, seizures Responsibility
Route: PO inhibiting tubular marked  DHN CV: chest pain, Check ICP bef
Frequency: BID reabsorption of water and oliguria  Active intracranial hypotension,
Brand name: administration
electrolytes (including or bleeding hypertension,
Osmitrol sodium and potassium). tachycardia,
Classification: suspect Before
These actions enhance water thrombophlebitis,
flow from various tissue ed heart failure, - Observe 15 ri
Osmotic Diuretic
sand ultimately decrease inadequ vascularoverload in drug
intracranial and intraocular ate EENT: blurred administration
pressures. renal vision, rhinitisGI: - Assess for
functio nausea, vomiting,
contraindicatio
n, diarrhea, dry
mouth the drug.
prevent
acute GU: polyuria, - Monitor
renal urinary retention, neurologic stat
failure osmotic nephrosis and ICP readin
during Metabolic: patients receiv
dehydration, water this medication
cardiov
intoxication,
ascular cerebral edema
hypernatremia,
and hyponatremia,
other hypovolemia, -Observe infus
surgerie hypokalemia,hype site frequently
s, acute rkalemia,
renal metabolic acidosis -Confer physic
failure, regarding the u
to FBC
reduce
intracra
nial -IV: if solution
pressur contains crysta
e and warm bottle in
brain water and shak
mass, vigorously
reduce
intraocu -Explain the
lar purpose of the
pressur
therapy to the
e, to
patient
promot
e
dieresis
in drug
toxicity
,
irrigatio
n
during
transure
thral
resectio
n of
prostate
.
DRUG STUDY
Drug Order Mechanism of Action Indications Contraindications Adverse Effect Nursing
Responsibility
Generic Name:  Stimulates alpha-  Produces  Contraindicated  CNS: anxiety, Nursing Priority: ECG
Norepinephrine adrenergic vasoconstriction in: Vascular, dizziness, should be monitored
Brand Name: receptors located and myocardial mesenteric, or headache, continuously. CVP,
Levophed mainly in blood stimulation, peripheral insomnia, intraarterial
Classification: vessels, causing which may be thrombosis; OB: restlessness, pressure, pulmonary
Vasopressor constriction of required after low uterine tremor, artery diastolic
Route: IV both capacitance adequate fluid blood flow; weakness. pressure, pulmonary
Dosage: 60 to 80 and resistance replacement in Hypoxia;  Resp: dyspnea. capillary wedge
mmhg vessels. Also has the treatment of Hypercarbia;  CV: arrhythmias, pressure (PCWP), and
minor beta- severe Hypotension bradycardia, cardiac output may
adrenergic hypotension and secondary to chest pain, also be monitored
activity shock. hypovolemia hypertension. Before:
(myocardial (without  GU: low urine  Monitor vital
stimulation). appropriate output, renal signs
volume failure. Endo:  Assess for allergy
replacement); hyperglycemia. in medicine.
Hypersensitivity  F and E: During:
to bisulfites metabolic  Monitor the
acidosis. patient before,
 Local: phlebitis at during and after
IV site. the
  Misc: fever administration of
medicine.
After:
 Monitor the
patient for any
adverse effect.
 Notify the
attending
physician for any
error occurred.

Drug Order Mechanism of Action Indication Contraindication Adverse Effect Nursing

Responsibility
i. Generic  Increases the  Adjunct in the  Contraindicated  CNS: confusion, Nursing Priority:
Name: osmotic pressure treatment of: in: headache. Monitor neurologic
Mannitol of the glomerular Acute oliguric Hypersensitivity;  EENT: blurred status and
ii. Brand Name: filtrate, thereby renal failure, Anuria; vision, rhinitis. intracranial pressure
Osmitrol inhibiting Edema, Dehydration;  CV: transient readings in patients
iii. Classification: reabsorption of Increased Active volume receiving this
Diuretics water and intracranial or intracranial expansion, chest medication to
iv. Route (if electrolytes. intraocular bleeding; Severe pain, HF, decrease cerebral
given): IV Causes excretion pressure, Toxic pulmonary pulmonary edema
v. Dosage: 50 of: Water, overdose. edema or edema,  Check the
grams Sodium, congestion. tachycardia. expiration date
Potassium,  GI: nausea, thirst, of the medicine.
Chloride, vomiting.  Give the
Calcium,  GU: renal failure, medicine at the
Phosphorus, urinary right time.
Magnesium, retention.  Notify the patient
Urea, Uric acid  F and E: what the
dehydration, medicine is for.
hyperkalemia,  Assess lung
 hypernatremia, sounds, pulse
hypokalemia, rate and blood
hyponatremia. pressure before
 Local: phlebitis at giving the drug
IV site. and during the
peak of
medication.
 Monitor the
patient especially
when side effects
are visible.
 Notify the
physician if any
error occurred.

SURGICAL MANAGEMENT

Name of Date performed Brief description Indication/purpose Client’s Nursing

procedure response to responsibilities
operation prior to, during,
and surgical
procedure(actual)
Craniotomy May 17, 2021 Craniotomy is the A craniotomy may be Patient's Pre-op
surgical removal done for a variety of condition is good
of part of the reasons, including, which means his Secure consent
bone from the but not limited to, the recovery is doing
skull to expose following: well
the brain. Diagnosing, Explain procedure to
Specialized tools removing, or treating the patient
are used to brain tumors.
remove the Clipping or repairing Monitor vital signs to
section of bone of an aneurysm. patient safety prior to
called the bone Removing blood or operation
flap. The bone blood clots from a
flap is leaking blood vessel
temporarily Monitor neurological
removed, then status every hour
replaced after the using GCS
brain surgery has
been done. Instruct patient for
NPO Remove if
patient having a nail
polish for easy access
for monitoring
cyanosis

Intra op

Ensure sterility

Perform surgery
safety checklist

Post-op

1.Respiratory status
is assessed by
monitoring rate,
depth, and pattern of
respiration. A patient
airway is maintained

2. Vital signs and

neurological status is
monitored using GCS

3. Arterial and
central venous
pressure CVP are
monitored

4. Pharmacological
agents may be
prescribed to control
increased ICP.
Mannitol is given

5. Incisional and
headache pain may
be controlled with
mild analgesic:
codeine and
acetaminophen
 6. Position the patient
in semi fowler
position with head is
in the midline
position

7. Turn side to side

every 2 hrs

8. Advise patient to
restrict fluid intake

MEDICAL MANAGEMENT
MEDICAL DATE PERFORMED/ CLIENT’S
INDICATION/PURPOS
MANAGEMENT/ CHANGED/ GENERAL DESCRIPTION RESPONSE TO
E
TREATMENT DISCONTINUED TREATMENT
3% Saline 500 mL + May 2021 3% Saline is a sterile, non- Mannitol is a crystalloid The patient
50g Mannitol pyrogenic, hypertonic solution for intravenous fluid consumed the
fluid and electrolyte replenishment in composed of a six-carbon intravenous fluid
single dose containers simple sugar dissolved in without adverse
for intravenous administration. The water. It is FDA-approved effects. Gradually,
pH may have been adjusted with for use in decreasing it lowered the ICP
hydrochloric acid. It contains no intracranial pressure and of patient.
antimicrobial agents. brain mass, and decreasing
intraocular pressure when
other interventions have
 failed to do so.

3% Saline Injection, is
indicated as a source of
water and electrolytes.
Oxygen therapy is the administration In an effort to increase the The patient has
of oxygen as a medical intervention, fraction of inspired oxygen finished the course
which can be for a variety of purposes concentration (FiO2) of treatment
in both chronic and acute patient care. available to a patient, a without adverse
It is essential for cell metabolism, and variety of oxygen delivery effects.
in turn, tissue oxygenation is essential devices are employed to
Oxygen Therapy @
May 2021 for all normal physiological functions administer medical
3lpm
oxygen. The oxygen may
be administered with or
without humidity.
DIET

TYPE OF DIET DATE INDICATIONS NURSING RESPONSIBILITY

Low-Fat Diet   A low-fat diet is one that restricts Instruct the patient to:
fat, and often saturated fat and
-avoid convenience foods such as canned soups,
cholesterol as well. Low-fat diets
entrees, vegetables, pasta and rice mixes, frozen
are intended to reduce the
dinners, instant cereal and puddings, and gravy
occurrence of conditions such as
sauce mixes
heart disease and obesity.
-Avoid late-night snacking.
Encourage the patient or the relative to:
- to blend/smash the food using blender
- use fresh, frozen, no-added-salt canned
vegetables, low-sodium soups, and low-sodium
lunch meats.
-eat small, frequent meals and do not skip meals.
-foods that contain Omega-3 fatty acids have been
found to be very powerful in lowering
triglycerides.
 

TYPE OF DIET DATE INDICATIONS NURSING RESPONSIBILITY

Low Sugar   The low sugar diet involves Instruct the patient to follow low sugar diet
reducing your intake of added include:
sugars and sweeteners, as well as
-Try sugar-free gelatin, popsicles, yogurts, and
foods that contain natural sugars.
puddings instead of the regular versions.
It may also help with weight loss.
The primary goal of a low sugar -Cut back on or avoid eating sweets and dessert
diet is to maintain a healthy level foods, including cookies, cakes, pastries, pies, ice
of glucose in the body. cream, frozen yogurt, sherbet, gelato, and
flavored ices. All of these foods contain high
levels of sugar.
-Substitute beverages like colas, fruit drinks, iced
tea, lemonade, Hi-C and Kool-Aid with artificially
sweetened beverages labeled “sugar-free” or
“diet.”
-Avoid adding table sugar and brown sugar to
cereal, drinks or foods.
 

TYPE OF DIET DATE INDICATIONS NURSING RESPONSIBILITY

Low Sodium   Too much salt can raise your Instruct the patient to follow low sugar diet
blood pressure. Read labels and include:
choose lower salt options. Don’t
Much like vegetables, fruits are naturally low in
add salt when cooking or at the
sodium. Apples, apricots, papayas, and pears are
table. Use herbs and spices to
your best bets, along with bananas, which are
increase flavour instead. If you
also packed with heart-friendly potassium
reduce your intake gradually, your
taste buds will adjust in a few Instruct the patient to avoid frozen, salted meat
weeks or fish, canned meat, breaded meats.
 
TYPE OF DIET DATE INDICATIONS NURSING RESPONSIBILITY

High-Fiber Diet   A diet high in the non-digestible Instruct and encourage the patient to eat foods
part of plants, which is fiber. Fiber high fiber include:
is found in fruits, vegetables,
-Fruits and vegetables Eggs, egg whites. Exotic
whole grains, and legumes. A fiber
fruits are also good sources of fiber: A mango has
can lower cholesterol
5 grams, a persimmon has 6, and 1 cup of guava
has about 9. Dark-colored vegetables. In general,
the darker the color of the vegetable, the higher
the fiber content. Carrots, beets, and broccoli are
fiber-rich.
-Advice the patient that the good sources of fiber
include barley, oatmeal, beans, nuts, and fruits
such as apples, berries, citrus fruits, and pears.
-Advice the patient and relative of the patient to
use blender to blend/smash the food

EXERCISE
TYPE OF EXERCISE/ACTIVITY DATE INDICATION NURSING RESPONSIBILITY

 Breathing exercises can  May 2021 When the patient is physically active, 1. Identify the prescribed
strengthen breathing muscles, the heart and lungs work harder to activity level.
get more oxygen, and breathe supply the additional oxygen your
2. Continue to assess strength
with less effort. muscles demand. Just like regular
and joint mobility.
exercise makes the muscles stronger, it
 Aerobic activities like simple
also makes the lungs and heart stronger. 3. Perform physical mobility
walking for 30 minutes to
Exercise has lots of benefits for activities in conjunction with
improve their endurance.
everyone. Physical activity can reduce daily care.
 Lifting: Try not to lift, the risk of serious illness, including heart 4. Provide good body alignment
push, or pull more than disease, stroke, diabetes and some and frequent position changes.
10 pounds for four weeks forms of cancer, including lung cancer.
after surgery. 5. Avoid unnecessary restraint
that limits physical mobility.
 Activity: It is important to
get out of bed and move 6. Consult with the physical

as soon as possible after therapist to determine a

surgery to avoid suitable activity/exercise plan

developing problems that maintains muscle strength

such as blood clots or and joint mobility.

pneumonia. Walk with 7. Verify that the patient is

assistance if patient will suitably dressed for activity and
feel unsteady. Get plenty that he or she has the proper
of rest. Avoid rigorous footwear.
activity for 4 weeks after
8. Provide pain medication in a
surgery. Can walk for
timely manner so that maximal
exercise. At 4 weeks after
benefits from the medication
surgery, you may begin
occur when greatest physical
EVALUATION
DISCHARGE PLANNING
For the patient to completely recover after treatment, the nurses will ensure the continuity of
health and care for him as he leave the hospital premises through teaching the patient about her
condition, medications, self-care strategies and importance of follow-up care and check-ups.

MEDICATIONS
Instruct the patient’s significant other to give medication to the patient at the same time of the
day as prescribed and for the length of time prescribed.
Instruct the patient’s significant other about all medications, including dosage, potential side
effects, and drug interactions.

FOLLOW UP
The patient’s significant other was instructed to make a follow-up appointment as directed.

HEALTH TEACHINGS
 Encourage patient to eat a healthy well-balanced diet.
 It should be rich in fruits and vegetables, and low in meat and dairy.
 Avoid salty and fatty foods and stay away from fast food restaurants.
 Instruct patient to stop smoking.
 Instruct patient to check blood pressure frequently and follow his doctor's
recommendations for keeping it in a safe range
 Emphasized rest to prevent overexertion.
 Educated the patient to limit their activities until their symptoms improve.
 Gradually start their normal activities when they can do them without pain.
 Avoid straining, bending at the waist, high impact exercise such as running and
heavy lifting (over 10 pounds) for at least 2 weeks after surgery.
 Shower as needed. But keep the incision dry. They can wash their hair with mild soap
after the stitches or staples have been removed.
 Provided teaching and support regarding his condition.
RECOMMENDATION
Student Nurse
The case study allows student nurses to discover and explore about intracranial
hemorrhage. It is recommended for student nurses because it serves as a guidelines and reference
on their studies.
Health Care Provider
Health Care Provider engaged themselves in promoting health and prevention of disease.
This study focuses on prevention and promotion to decrease complications, mortality among
people with intracerebral hemorrhage.

CONCLUSION
Intracranial hemorrhage refers to any bleeding within the intracranial vault, including the brain
parenchyma and surrounding meningeal spaces. A recent study showed that risk factors for
intracranial hemorrhage include male sex, older age, and Asian ethnicity. The most important
risk factors for ICH include hypertension and cerebral amyloid angiopathy. Treatment may
include lifesaving measures, symptom relief, and complication prevention. Once the cause and
location of the bleeding is identified, medical or surgical treatment is performed to stop the
bleeding, remove the clot, and relieve the pressure on the brain.