Oral Presentation 4 Neuro

Oral Presentation 4
Clinical Experience 4

Neurology
Prepared by
MR MNAY
19927
PATIENT PROFILE
Name: XXX
Age: 42 years old
Sex: Male
Ward: A2 Neurology Ward
Pass medical history: Nil
Pass surgical history: Nil

Diagnosis
Spontaneous SAH (subarachnoid
hemorrhage) TRO Ruptured Aneurysm
Actual Nursing Diagnosis
1
Ineffective Cerebral Tissue Perfusion
related to hemorrhage as evidence by
change in motor and sensory response

Goal
Patient will be able to maintain usual and
improved level of consciousness
cognition, and motor function.

Nursing Intervention
Monitor vital signs:
Hypertension/hypotension, compare
BP readings in both arms;
Heart rate and rhythm; auscultate for
murmurs;
Respirations, noting patterns and rhythm,
e.g., periods of apnea after
hyperventilation, Cheyne-Stokes
respiration.
Maintain bed rest; provide quiet
environment; restrict visitors/activities
as indicated. Provide rest periods
between care activities, limit duration
of procedures.
Prevent straining at stool, holding
breath.
Administer supplemental oxygen as
indicated.




Evaluation

2
Impaired Physical Mobility related
muscle weakness as manifested by
decrease muscle strength

Goal
Maintain/increase strength and function
of affected or compensatory body part
Maintain skin integrity.

Change positions at least every 2 hr
(supine, sidelying) and possibly more
often if placed on affected side.
Begin active/passive ROM to all
extremities (including splinted) on
admission. Encourage exercises such as
quadriceps/gluteal exercise, squeezing
rubber ball, extension of fingers and
legs/feet.
Inspect skin regularly, particularly over
bony prominences. Gently massage any
reddened areas and provide aids such as
sheepskin pads as necessary.
Support dependent body partswith
pillows because To maintain position of
function and prevent pressure ulcers

Observe affected side for color, edema,
or other signs of compromised circulation.
Edematous tissue is more easily
traumatized and heals more slowly.
Assist to develop sitting balance (e.g.,
raise head of bed; assist to sit on edge of
bed, having patient use the strong arm to
support body weight and strong leg to
move affected leg; increase sitting time)
and standing balance.
Provide ripper mattress to the patient
Evaluation
Patients body is in normal strength and
part during hospitalization.
Patient not having any skin breakdown
during hospitalization.

Potential Nursing Diagnosis

1
Risk for injury (ruptured aneurysm)
related to raised of intracranial
pressure

Goal
Patient will be comfortable and safe
from any external force that can
trigger aneurysm to ruptured.
Carry out neurological observation with
the Glasgow Coma Scale. Report if the
scoring is less than 10 as its a clear sign
of further deterioration of patients
condition
Monitor patients vital sign such as blood
pressure for every one to two hours.

Cont.
Another simple method used to lower
ICP (particularly in trauma cases) is to
loosen neck collars and clothing.
Sandbags may be used to further limit
neck movement
Encourage RIB, provide quiet
environment, limit noxious stimuli; limit
stimulant, avoid ingestion stimulant-
coffee, alcohol, cigarette.
Teach client to avoid sneezing, serve
medication for coughing and vomiting
Maintain airway by elevate head of bed
15-30 or flat as prescribe; head and
neck should be neutral position to
promote venous drainage.

Encourage their significant others to
visit them so that patient will be more
comfortable and confident
Evaluation
Patient is comfortable and safe from
the external force that trigger the
aneurysm to ruptured
2
Risk of anxiety related to knowledge
deficit and stress
Goal
Patient will verbalize understanding of
procedure and expected outcome during
hospitalization.
Build rapport with the patient
Identify the communication or language
barrier and knowledge level
Explain sequence of treatment, and
teaching about aneurysm to the patient.
Provide instruction when doing
procedure and let the patient know the
procedure expected outcome
Let the patient rest in bed
Ask them to accompany him during
hospitalization
Asses the patient understanding about
the treatment and the procedure
Evaluation
Patient will demonstrate knowledge of
physiological and psychological response
to the procedure

Any Question ???
Thank You For Your
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