Question

Nursing care plan for the following case study using the rubric

1. Joan Smith, 55 years of age, is a female patient who presents to the intensive care unit with the diagnosis of intracranial hemorrhage. The patient stopped taking her antihypertensives suddenly because of the cost of the medications and she recently lost her job to outsourcing. The patient is slightly drowsy and complains of a headache and blurred vision. The patient’s blood pressure is 220/130 mm Hg upon presentation.

(Learning Objective 6)

NURSING CARE PLAN RUBRIC

Do not write the NCP using a grid format… use an essay format/ bullet point using the numbers of this rubric.

All NCP will be graded according to the following rubric.

1) Definition of the medical diagnosis __________10

etiology/pathophysiology

2) Common signs and symptoms ___________5

3) Potential complications ___________5

4) Head to toe physical assessment you are to write one….use the data in the case if there is none you create it as if this was your patient. ____________10

5) Diagnostic and lab studies ___________5

normal values

expected abnormalities

6) ALL NANADA Nursing diagnoses __________10

7) Develop 3 NANDA priority nursing diagnoses __________10

8) State a patient plan AND goal for each of the __________10

priority nursing diagnosis

9) Write interventions for each of __________10

priority nursing diagnosis

10) Write scientific rationales for you you ___________5

interventions

11) Write evaluation of your interventions __________10

your plan or make changes

12) List of typical medications __________10

category

usual dosage

side effects

patient teaching

Answer 1

1. ICH is defined as the bleeding in the skull or cranium

causes: injury, physical trauma, hypertension, blood thinning agents like heparin and warf, a tangle of abnormal blood vessels, aneurysm, bleeding disorder, intra cranial space occupying lesions ,amyloid angiopathy, drug usage like coccaine and alcohol

pathophysiology ; due to rupture of tiny arteries with in the brain tissues, as blood collects a hematoma causing increased pressure in brain. as blood spills into the brain the area that artery supplied is now deprived of O2. as blood cells within clot die, toxins are released that further damage brain

2. clinical features: sudden weakness, tingling sensation or paralysis of face, arm or legs

sudden onset of severe headache, trouble swallowing , vision, loss of balance and co ordination, dizziness, confusion and delerium

3. complications: vision loss, pneumonia, brain herniation or swelling, seizures, depression, para- hemi-quadri plegia, anaemia

4. physical examination : vitals to check, neurological assessment including cranial nerves, deep Musculo skeletal assessment, check signs of retinal detachment

5. hemoglobin to look or anemia, normal 12- 16 gms% in female and 14 - 18 in males, cbc to check for infection, MRI/CT, CT angiography

6. NANDA nursing diagnosis

ineffective cerebral tissue perfusion

impaired physical mobility

imparied verbal communication

disturbed sensory perception

ineffective coping

self care deficit

risk for unilateral neglect

deficient knowledge

7 to 11

a. ineffective cerebral tissue perfusion related to interruption of blood flow

intervention with rationale

assess factors related to individual situation to know the exact condition

do the neurological assessment to know the depth and severity of the condition

compare BP on both arms to check for flow rate and hypotension

assess the nucual rigidity

b. imparied physical mobility related to fatigue secondary to reduced blood flow to the brain

intervention with rationale

assess the level of physical activity to know the condition of the patient

help the patient to do his/her daily activities

encourage to do ROM

c. disturbed sensory perception related to involvement of sensory motor ares

assess the cranial nerves to know the condition

help to identify the weakness

encourage to use alternative communication methods

12

symptomatic treatment is used \

antibiotic coverage, anti epileptics