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OF
HEMORRHAGIC
STROKE
(Subarachnoid hemorrhage)
Presented By:
GROUP 3
Vernalin Terrado
Lerma Auman
Elenita Molina
Richelle Manlangit
Andres Jose
Bernard Bartolome
Marlen Tigno
Subarachnoid hemorrhage
INTRODUCTION:
5. Present the different laboratory test and results done to the client
with its interpretation.
Nursing intervention
Improved Health
Comprehensive History:
Biographic History:
Name : D.A.C
City Address :Blk 14, lot 52 PVR-1, Norzagaray, Bulacan
Provincial Address :Romblon (Visayas)
Age : 53 years old
Gender : Male
Religious Affiliation : Roman Catholic
Marital Status : Married
Occupation : Unemployed (formerly a construction worker)
Source of Information : Daughter
Room & Bed No. : Male Ward Bed #9
Date of Birth : November 18, 1955
Diagnosis : Cerebrovascular Accident (subarachnoid
hemorrhagic)
Physician : Dr. Steve Conneroid
Chief complaint: : Loss of consciousness
Date of admission : January 05, 2009
Present Condition:
4. EYES Inspection Parallel and evenly Dilated pupils which -Not Normal-
spaced symmetrical, is black in color and Indicates altered
non- protruding, non reacting to light. level of
pink palpebral He have some consciousness.
conjunctiva, and discharges around
pupils black in color, the lacrimal area.
equal in size, round
and constricts in
response to light.
5. NOSE Inspection Midline Midline Normal
symmetrical and symmetrical and
patent, no patent, no
discharge. discharge. With
presence of
nasogastric tube
insertion on the
right nares.
A. SKIN Inspection, Varies from light to With uniform deep Not normal-The
palpation deep brown, from brown skin color client has
ruddy pink to light with slightly elevatedimpaired skin
pink, from yellow temperature. Poor integrity with
overtones to olive, skin integrity and hyperthermia
generally uniform redness on bony and disruptions
skin temperature prominences. on skin integrity.
B. HAIR Inspection Thick, silky, Thick, oily with Normal
resilient, free from traces of white
infestation, evenly hairs evenly
distributed and distributed which
covers whole covers the whole
scalp. scalp and free from
infestation.
Right Atrium
Tricuspid Valve
Right Ventricle
Left Atrium
Bicuspid valve
Left ventricle
Aortic Valve
Aorta
Systemic Circulation
BRAIN: Cranial Nerves
1. Olfactory: Smell
2. Optic: Visual fields and ability to see
3. Oculomotor: Eye movements; eyelid opening
4. Trochlear: Eye movements
5. Trigeminal: Facial sensation
6. Abducens: Eye movements
7. Facial: Eyelid closing; facial expression;
taste sensation
8. Auditory/vestibular: Hearing; sense of balance
9. Glossopharyngeal: Taste sensation; swallowing
10. Vagus: Swallowing; taste sensation
11. Accessory: Control of neck and shoulder muscles
12. Hypoglossal: Tongue movement
• Cranial Nerves – There are 12 pairs of nerves that originate from
the brain itself. These nerves are responsible for very specific
activities and are named and numbered as follows:
• Olfactory: Smell
• Optic: Visual fields and ability to see
• Oculomotor: Eye movements; eyelid opening
• Trochlear: Eye movements
• Trigeminal: Facial sensation
• Abducens: Eye movements
• Facial: Eyelid closing; facial expression; taste sensation
• Auditory/vestibular: Hearing; sense of balance
• Glossopharyngeal: Taste sensation; swallowing
• Vagus: Swallowing; taste sensation
• Accessory: Control of neck and shoulder muscles
• Hypoglossal: Tongue movement
Cranial Meninges
BRAIN
BRAIN
Non-modifiable Risk PATHOPHYSIOLOGY Modifiable Risk Factors
Factors >HPN
>Advanced Age >Smoking
>Gender >excessive intake of foods
>Heredity high in fats and cholesterol
Triggering Factors
>Sudden extreme emotion
S/S:
Tissue Necrosis >Severe Headache Increase Intracranial
>Drowsiness Pressure
>Loss of consciousness
Neuronal Death
coma
Death
Drug study 1
Medication Classification/ Indication Contraindication Side effects Adverse effects Nursing consideration
Action
Generic name: Inhibits calcium Treatment of Hypersensitivity, Patients Dizziness, flushing, Use caution in
nifedipine ion influx across vasospatic, cardiovascular withdrawn headache, severe aortic stenosis
Brand name: all membrane angina, chronic shock, combination from blockers hypotension or severe hepatic
Calcibloc during cardiac stable angina, with rifampicine while taking peripheral edema, impairment
depolarization, hypertension contraindicated in nifedifine may tachycardia and Assess potential for
Route: oral produces (sustained- unstable angina and experience palpitation interactions with
Dosage: 180mg relaxation of released tablets after resent MI increase angina other
Frequency: once a coronary vascular only. severe hypotension, pharmacological
day smooth muscle with systolic agents or herbal
and peripheral pressure less than 90 products patients is
vascular smooth mmHg taking that may
muscle, dilates decompensate heart increase risk of
coronary arteries, failure pregnancy hypotension and
increase and lactation toxicity
myocardial Monitor blood
oxygen delivery pressure and pulse
in patients with before therapy, during
vasospastic dose
filtration and
periodically during
therapy monitor ECG
periodically during
prolonged therapy
Assess therapeutic
effectiveness and
adverse reaction
Assess location,
duration intensity,
precipitating factor of
patients angina pain
Drug study 2
Medication Classification/ Indication Contraindication Side effects Adverse effects Nursing consideration
Action
Generic name: Increases the Adjunct in the Hypersensitivity , CNS: headache, Monitor vital signs,
Mannitol osmotic pressure treatment of acuteanuria, dehydration, confusion. urine output, CVP,
Brand name: of the glomerular oliguric renal intracranial bleeding. and pulmonary artery
Osmitrol filtrate, thereby failure, adjunct in EENT: blurred pressure prior to and
inhibiting the treatment of hourly throughout
Route: IV vision, rhinitis
reabsorption of edema, administration.
Dosage: water and redunction of Assess patient for
Adult 0.25-2 g/kg as electrolytes. intraocular CV: transient signs and symptoms
15 to 25% solution pressure, to volume expansion, of dehydration or
over 30 to 60 min. promote the tachycardia, chest signs of fluid over
Children 1-2 g/kg excreation of pain, congestive load.
(30 – 60 g/m2)as a certain toxic heart failure,
Assess patient for
15 to 20 solution substances. pulmonary edema.
anorexia, muscle
0ver 30 – 60% weakness, numbness,
Frequency: GI: thirst, nausea, tingling, confusion
4x daily vomiting and excessive thirst.
Generic name: Inhibits the •Mild to Previous GI: hepatic •Advise patient to
Acetomenophen synthesis of moderate pain hypertensive necrosis take medication
prostaglandin that •Fever Product containing DERM: rash, exactly as directed
Brand name:
may serve as alcohol, aspartame, urticaria. and not to take more
Aminofen mediators of pain than the
saccharin, sugar or
Route: and fever. tartrazine. recommended
IV amount.
Dosage: Therapeutic effects. Severe and
325-1000mg every 4 •Analgesic (due to permanent liver
to 6 hrs needed damage may result
peripheral
prostaglandin from prolonged use
or high doses of
inhibitors)
acetomenophe.
•Antipyresis (lowers
fever); due to Adult should not take
acetomenophen
inhibitors of
longer than 10 days
prostaglandin in the
CNS and children longer
than 5 days unless
No significant anti directed by
inflammatory physician.
properties
•Advise the patient to consult
the physician if discomfort or
fever is not relieved by
routine dosages of this drug
or if fever is greater than 39.5
(103 F) or lasts longer than 3
days
Nursing Care Plan One
ASSESSMENT DIAGNOSIS OBJECTIVE PLANNING INTERVENTION RATIONALE EVALUATION
Objective cues: Ineffective After four Plan ways on Position head midline To open or After four hours of
airway hours of how to reduce with flexion maintain airway nursing
clearance nursing congestion on appropriate for to the client. intervention the
•Clavicular
related to intervention airway. condition. client air way
•Breaking retained mucus the client To clear airway clearance is
•Rhonchi secretion due to airway Oropharyngial when secretions cleared.
breathing sound absence of clearance will suctioning (as needed) are blocking on
•Increase cough reflex. be cleared. airway.
respiratory rate
of 36 to 38 bpm Scientific
To decrease the
Explanation: Elevate head of the pressure on the
Inability to bed and change diaphragm.
clear secretions position every 2 hrs.
or obstruction
from the To help liquefy
respiratory tract Increased fluid intake secretion
to maintain a at least 3000 ml/day
clear air way.
Auscultate breath To maitain status
souds and assess air and note progress
movement
Nursing Care Plan Two
ASSESSMENT NURSING OBJECTIVE PLANNING NURSING RATIONALE EVALUATIO
DIAGNOSIS INTERVENTION N
Subjective Cues: Hyperthermia related >after 2 hours of >Plan techniques >Identify under lying >To assess causative >after 2 hours of
>”tatlong araw na to inflammation of nursing in which the cause factors to the clients nursing
siyang nilalagnat” cerebral tissue as interventions the temperature of fever thus formulation intervention the
as verbalized by the evidence by elevated client’s the client will of appropriate nursing client’s
relatives. body temp. temperature will decrease to a intervention. temperature is
Objective Cues: decrease to a normal rage. >Heat loss by decreased to a
normal range. evaporation and normal range
>elevated body Scientific EXP:
conduction
temp of 39˚C Body temperature
elevated above >Promote surface
>flushing skin
normal range, cooling by means of >Heat loss by
>warm to touch tepid sponge bath
because of body’s convection.
>increase RR with a response to >Establish cool
rate of 38 Bpm inflammation from environment by
>diaphoresis hemorrhage that opening air vents and
result from ruptured window panes >to avoid further
cerebral artery. >Advise relatives not increase of clients
to cover the client with temperature.
a blanket, and use less
restrictive clothing’s
> Administer > For immediate
antipyretics through IV alteration of body
as prescribed. temperature
Nursing Care Plan Three
ASSESSMENT DIAGNOSIS OBJECTIVE PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues: >Risk for >After 3 hour s >Plan strategies>Note for general > To assess After two hours
>reddened skin impaired skin of nursing on how to debilitation, reduced aggravating of nursing
>poor skin turgor Integrity related to intervention the eliminate the mobility, changes in factor to skin intervention the
physical client relatives risk for skin and muscle breakdown and possibilities for
>immobility immobilization. will identify risk impaired skin mass, poor make appropriate impaired skin
>friction factors for integrity. nutritional status intervention to it. integrity of the
impaired skin and problems of self client is
Scientific
integrity , care eliminated.
Explanation:
verbalize > Maintain strict
At risk for skin understanding
skin hygiene, using
being potentially of therapy
mild non-detergent > To prevent skin
vulnerable to regimens and
breakdown soap, drying gently irritation
demonstrate and thoroughly. and
because of behaviors and lubricating with
immobilization techniques to
lotion
prevent skin
breakdown.
>Instruct the >To reduce tissue
relative to turn the pressure and
patient every two prevent pressure
hours sore.
T > Educate & instruct the family to monitor the blood pressure and pulse rate
before administering medication.
>Inform the relative the importance of proper hygiene of the patient from
head to toe.
H >regular inspection of the diaper of the patient and change if there a presence
of fecal material, urine or even redness that would lead to skin rashes.
>Educate and instruct the relatives on how to feed the client through
nasogastric tube.
>Instruct them to turn the client every 2 hrs to avoid pressure sores.
>Inform the family of the patient to have a regular check-up for the continuity
O of treatment.
>Instruct the family of the patient to monitor if there is any sudden change to
the patient and report immediately.
>Instruct the relative to feed the client on time with nutrition food that is low
D in sodium, low in cholesterol, low in fat and give citrus fruits, moderate in
fluid intake and increase fiber diet to improve health.
>Follow the diet prescribed by the doctor.