Nursing Care Plan For Patient With Intracerebral Hemorrhage
Narrative of Diagnosis
The patient is a 20-year-old with the diagnosis of intracerebral hemorrhage caused by a ruptured arteriovenous malformation. The patient was admitted to the hospital on September 4th, 2018 after mom found patient in room unresponsive around 7pm. Mom reports patient went to a bar-b-que with family then went to a club following the party. To the mother’s knowledge the patient did not drink at either place. The next day around noon the patient had nausea and vomiting three times. Patient was also complaining of headache all morning. Patient decided to take a nap around 1pm and when the mother went to check on him around 7:45pm patient was unresponsive. Patient tested positive for marijuana and alcohol, but no other drugs were found in system. Mom reports she is unaware of patient hitting his head on anything. Once in the emergency room a CT scan was done to confirm an intracranial hemorrhage. Patient was sent to surgery for a craniotomy and a right bone flap was removed to release the pressure from the bleeding. After surgery the patient was sent to the ICU for hemodynamic monitoring and close observation. While in the ICU patient was declining rapidly and was taken to CT scan again where they noted there was more bleeding and again patient was taken for a craniotomy. They removed another portion of bone flap on the right side and patient was returned to the ICU. Later, it was determined the bleed was caused from an arteriovenous malformation in the patient’s brain.
Arteriovenous malformation, AVM, results when veins are fed by arteries through a tangle of abnormal vessels. The malformed vessels do not have a true capillary bed. One or several arteries can feed the AVM. The arteries that feed the AVM are commonly called, feeder arteries. These feeder arteries, along with the draining veins, have high pressure blood flow. After strenuous pressure is placed on the feeder vessels they will become dilated. Once blood is shunted into the AVM from the feeder vessels the surrounding brain tissue is denied adequate perfusion. Also, due to the draining veins shunting the high-pressure blood flow from the arteries to the AVM they commonly will burst and cause a spontaneous brain bleed. The day of the incident the patient had complained of a headache throughout the day and felt very nauseated. This is a common indicator of an AVM and intracerebral brain bleed. Headaches are a sign of intracerebral hemorrhage because the bleeding causes pressure on intracranial structures. This also results in increased intracranial pressure that ultimately is the cause of the headache. The vomiting that the patient was experiencing is caused again by intracranial pressure. Pressure changes in the brain is the result of the unexpected vomiting the patient is experiencing.
Intracerebral hemorrhage, ICH, is a form of hemorrhagic stroke that is caused by blood that leaves the vascular system and enters brain tissue. The patient had both intracerebral hemorrhage and intraparenchymal hemorrhage. The two terms both are used to describe a nontraumatic brain bleed that goes directly into the brain matter. Parenchymal hemorrhage is used to describe a brain bleed that happens from a rupture of a small artery, like an AVM. ICH is a broad term used to describe, simply, that there is bleeding in the brain tissue.
Once ICH happens there is an increase in intracranial pressure, destruction of cerebral tissue, and cerebral edema. Like with this patient, ICH normally presents as an unconscious critically ill patient who will need ventilator support. For patients with ICH evidence of increased intracranial pressure can be seen upon admit to the emergency department. Symptoms for increased intracranial pressure include a change in the level of consciousness, unequal pupil size, headache, vomiting, and decreased pupillary response. Once the symptoms are present to the healthcare provider the use of a CT scan is used to verify the increase in intracranial pressure. Once verified it is important to provide airway support and intubate the patient. It is also important to lower the blood pressure to reduce the amount of bleeding but being careful not to lower the pressure too rapidly or too low to avoid inadequate perfusion to cerebral tissue. When the intracranial pressure becomes too great a craniotomy may be needed to remove a portion of bone flap. Once the bone flap is removed it allows a chance for the scalp to expand and relieve pressure from the brain. After craniotomy is completed and the patient is sent to the ICU nursing priorities are directed to neurovascular checks, hemodynamic monitoring, monitoring for complications, and educating the family on expectations.
Long Term Goals (Discharge Criteria)
To be considered for discharge the rehabilitation nurse will assess the patient for the patient’s ability to participate in rehabilitation, the physical status of body systems, any complications, cognitive status, support system, and any expectations the family may have for the rehabilitation process. ICH leads to serious and complex disabilities and requires the assistance of multidisciplinary rehabilitation. Factors that the team should focus on are physical, behavioral, cognitive, social factors, and emotional. The rehabilitation should begin as soon as the patient is stabilized and continued on for as long as deemed necessary.
Goals for the rehabilitation facility to place for this client are to improve function and prevent any deformities. To accomplish these goals three units of therapy are required including physical, occupational, and speech therapy. Mobility, transfer techniques, equipment needed, and progressive ambulation are all focal points for the physical therapist. Eating, cooking, hygiene, and dressing are all components of activities of daily living that the occupational therapist will work to improve upon for the patient. Eating abilities, communication, cognition, and speech are all key points the speech therapist will focus on for the patient. For this patient, he was seen by speech and physical therapy to help kickstart his therapy while still in ICU. After, the patient was to be removed from ventilation and stabilized he was set to be moved to the rehab floor in the hospital. On the rehab floor he will be able to have constant access to therapists to assist in his recovery. Other options for this patient after time in the hospital recovery will include home therapy to continue working to improve the patient’s ability to eat, walk, and participate in everyday activities again.
Discharge Planning
To plan for discharge for this patient the nurse should establish goals necessary to make a smooth transition. The goals for the patient following an ICH is the patient will have an improved level of consciousness, will work with physical therapy to improve physical mobility, work with occupational therapy to relearn activities of daily living and self-care activities, will work with speech therapy to improve the ability to swallow, will be extubated and able to protect own airway, slowly regain control of bodily functioning, and tolerate tube feedings and maintain adequate nutrition. It is also important to assist the family in finding the appropriate coping assistance and support groups. The diagnosis of the patient is one that will have a long recovery time and it important to have support for not only the patient but the family too. Assess the anxiety level of the family and answer any questions in a short and simple manner. This allows the family to interpret the information easier and allow them to feel informed and knowledgeable of what is happening to their family member. Also, assess the willingness of the family in wanting to help care for the patient. Allow them the chance to help and utilize the teach back method to assess if they can care for the patient appropriately for tasks they can complete without a healthcare provider. It is also important to teach the family of important risk factors of a reoccurrence and when to alert the healthcare provider.
