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the subject name is Clinical Decision-Making in nursing, so i need to create case study in word file about patient have Intracerebral Hemorrhage take from this book page 276 https://www.pdfdrive.com/decision-making-in-emerge…, , after explain the case information and data and investigation i need how to apply decision making about the case in deep. i will attach case i made it before you can take a hint from it . if there is other websites or books regarding this you can use them also
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CASE STUDY
ON INTRACRANIAL HEMORRHAGE
Student’s Name: Talahi Sulaiman AlRsheedi
ID: 2231008236
Instructor’s Name: Dr. Najwa Ghonim
Advanced Critical Care Nursing
NCC 632
HISTORY
Personal History
Complaints
Present History
Past History
VITAL
SIGNS
Family History
Vital Signs
1.Name: Mrs M. A
2. Age: 23 years’ old
3. Sex: Female
4. Marital state: Married
5. Occupation: hair dresser
6. Residence: in urban areas
Patient came to ER via an ambulance after a
head trauma. Patient was brought in
unconscious, having a head swelling and
bleeding
Patient was relatively well in the morning, but
encountered a road traffic accident while
returning from work. This happened on a fast
lane, where her car ran into another bus. The
patient collided with her head to the front of
the car, resulting in swelling and hemorrhage.
This resulted from the head trauma, MRI and
head CT revealed an intracranial bleed
Left sided weakness 10 years ago, treated with
aspirin 325mg to full recovery; s/p
She is a known hypertensive not consistent
with her medication
She is diabetic, and currently on medication
(Metformin)
This could not be gotten as patient was
unconscious
Blood pressure: 190/89mmHg
Pulse rate: 132bpm
Temperature: 37.6°C
Respiratory rate: 32bpm
SPO2: 95%
Weight: 60kg
Patient was unconscious, had a swelling on the
head, no clubbing or pallor. Had severe
bleeding and was dehydrated
Upper limb: no finger clubbing, there is
Musculoskeletal scaring and pigmentation
Lower extremities: no oedema
System
Head: there is a wound on the scalp and
swelling
No abnormal heart sound, tachycardia
Inspection: no abnormal pulsation,
Cardiovascular
Percussion: Apex beat was noticed at 5th
system
intercostal space, no thrills
Auscultation: S1 and S2 were normal, no S3
and S4.
Chest Examination There is decreased air entry bilaterally,
presence of rhonchi heard on expiration
Inspection: no scarification or dilated vein seen
Gastrointestinal Percussion: L°S°K°, no fluid thrills
Auscultation: no bruit and bowel sounds were
heard and normal
Level of responsiveness: obtunded, arousal
only with repeated and painful stimuli
Verbal output cannot be comprehended
Some purposeful movement to stimuli
Pupillary Response: RRR
Corneal Reflex intact
B.1.1. Examination of mental functions:
1) State of consciousness: GCS 5/15 (
Neurological
E2V1M3) , patient is unconscious .
Examination
2) Orientation for time and place: No
orientation in time, place and person
a. Anterograde amnesia: presence of loss of
memory
b. Retrograde amnesia: presence of loss of
memory for remote events
B.1.2. Cranial nerve examination.
development of ocular motor CN disturbance.
All other than that has been noted normally .
EXAMINATION
General
examination
Investigations
MEDICATION
Investigations
Laboratory
Investigations
Medications
B.1.3. Examination of the motor system:
1) Inspection:
muscles Size : normal – Left side was affected ,
unilateral with Pseudo-hypertrophy .
2) Examination of muscle tone:
Decreased in muscle tone in the 4
Reflexes: Hyporreflexia in all 4 limbs
3)Examination of muscle strength:
For upper and lower right scoring 1, but for
upper left scoring 1 and lower left scoring 2.
4) Examination of muscle power:
Functional muscle testing: is scoring 1 for left
side, 1 for right side.
6) Meningeal irritation: no irritation
Chest x-ray: Pulmonary embolism noticed
ECG: normal sinus rhythm
CT scan: small infarction or artifact at the
right-sided pons and a skull fracture, with
intracranial bleeding
MRI: this showed severe bleeding into the
brain meninges
Laboratories:
• Blood Sugar: 8.5mol/dl
Full blood count is normal
Platelet count is normal
IV Fentanyl
Midazolam
Lisinopril
Nifedipine
Cefriaxone 5.2 gms IV OD
IV Line and Fluids
NURSING INTERVENTION AND NURSING CARE
Nursing Care Plan
Nursing Intervention
Patient should be given bed rest
Inability to move body parts
Ensure that patient is turned every 2 hrs
Assessment of patients power on all limbs
Patient in unconscious should be tilted sideways
Airway Maintenance
Sanctioning of patient when drooling
Use of oropharyngeal tube if there is obstruction
Lines are set on both arm
This helps for the giving of fluid and drugs in both
Ensure breathing and circulations
arms
SPO2 should be checked
Assessment for cyanosis
IV Fentanyl
Midazolam
Medication
Lisinopril
Nifedipine
Cefriaxone 5.2 gms IV OD
IV Line and Fluids
Quarterly monitoring of vital signs
General assessment
This include;
Blood pressure
Pulse rate
Temperature
Respiratory rate
SPO2
Weight
Fluid intake and output should be monitored
Patient should be placed on Electronic monitoring
device
This involves draining the blood in the brain. The
Surgical management
procedures are an open craniotomy
Insertion of external ventricular drain
Decompressive craniotomy
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