CRANIECT

OMY
BSN 4-2 SUB GROUP 3-2
RINOS, Jayson A.
ROMERO, Deinielle Ingrid M.
ROMERO, Pamela A.
RUFINO, Leslie Kriztel S.
 History of Past Illness:
NURSING HISTORY Client A 22-year-old male who smokes 3 cigarette per day, according to him he
only drink alcohol occasionally, he is generally fit and active. According to the
patient’s mother he had measles when he was 10 years old, and he completed
his childhood vaccines. He recently had a fall during his basketball game two
days ago.
SURGICAL HISTORY: No past surgical history.
ACCIDENT: He recently had a fall during his basketball game two days ago.
Which is related to the present condition.
MEDICATION: He recently take paracetamol due to his fever.
ALLERGIES: No known food and drug allergies.
History of Present Illness:
A healthy 22-year-old male presented to the emergency department with
progressive confusion, a fall, and a fever that began 1.5 days prior to
admission. The client complaint severe headache. CT showed a small
traumatic sub-arachnoid hemorrhage, likely related to the fall. He had a seizure
and declined neurologically. Given his fever, history, and mental status decline,
on the recommendation of the infectious disease department a repeat CT was
obtained followed by a lumbar puncture suggesting pneumococcal meningitis.
 AND
LABORATOR
Y
PROCEDURE
S
3
Diagnostic/Laboratory Date ordered/Date Indication/Purpose Normal values Result and Nursing responsibility
Procedure done interpretation
Complete Blood Count April 1, 2022 A complete blood count Normal values:   Before:
(CBC) is a blood test  WBC: 4,500-Result:  Explain test
used to evaluate your 11,000 white white blood cell procedure. Explain
overall health and blood cells per count was 20,000 that slight discomfort
may be felt when the
detect a wide range of microliter (mcL)  C-reactive protein skin is punctured.
disorders, including   was 24  Explain that fasting is
anemia, infection and  C-reactive protein  not necessary.
leukemia. Less than 10Analysis: Elevated However, fatty meals
mg/L WBC and C-reactive may alter some test
protein, indicate an results as a result of
infection. lipidemia.
 Encourage to avoid
stress if possible
because altered
physiologic status
influences and
changes normal
hematologic values.
After:
 Apply manual
pressure and
dressings over
puncture site on
removal of dinner.
 Monitor the puncture
site for oozing or
hematoma formation.
 

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Diagnostic/Laboratory Date ordered/Date
Procedure
Toxicology screen April 1, 2022
Indication/Purpose Normal values Result and Nursing responsibility
done interpretation
A toxicology screen is a Method:Result: Before:
test that determines the Spectrophotometry Negative  Explain test
approximate amount forethanol;   procedure. Explain
and type of legal or immunoassay for drugsAnalysis: A negative that slight discomfort
may be felt when the
illegal drugs that you’ve of abuse. value most often means skin is punctured.
taken. It may be used   that alcohol,  Explain that fasting is
to screen for drug Ethanol:None detected prescription medicines not necessary.
abuse, to monitor a   that have not been However, fatty meals
substance abuse Drug screen: Noneprescribed, and illegal may alter some test
problem, or to evaluate detected drugs have not been results as a result of
drug intoxication or detected. A blood lipidemia.
 Encourage to avoid
overdose. toxicology screen can stress if possible
determine the presence because altered
and level (amount) of a physiologic status
drug in your body. influences and
changes normal
hematologic values.
After:
 Apply manual
pressure and
dressings over
puncture site on
removal of dinner.
 Monitor the puncture
site for oozing or
hematoma formation.
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Diagnostic/Laboratory Date ordered/Date Indication/Purpose Normal values Result and Nursing responsibility
Procedure done interpretation
lumbar puncture April 1, 2022 lumbar puncture (LP) or Normal values:   Before:
spinal tap may be done  Pressure: 70 toResult:  Explain the
to diagnose or treat a 180 mm H2O. pneumococcal procedure to the
patient. Explain to
condition. For this  Appearance:meningitis. the patient the
procedure, your clear, colorless   purpose of lumbar
healthcare provider   Analysis: puncture, how and
inserts a hollow needle An inflammation of the where it’s done, and
into the space membrane covering the who will perform the
surrounding the spinal brain and spinal cord. procedure.
column (subarachnoid The inflammation is  Place the client in a
lateral decubitus
space) in the lower usually the result of a position.
back to withdraw some viral, bacterial, or fungal  Promote comfort.
cerebrospinal fluid infection. Instruct the patient to
(CSF) or inject empty the bladder
medicine. and bowel before the
procedure.
During:
 Instruct to remain
still. Explain that he
or she must lie very
still throughout the
procedure. Any
unnecessary
movement may
cause traumatic
injury.

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After:
• Apply brief pressure
to the puncture site.
Pressure will be
applied to avoid
bleeding, and the site
is covered by a small
occlusive dressing or
band-aid.
• Label and number the
specimen tube
correctly. Ensure all
samples are properly
labeled and sent to
the laboratory
immediately for
further evaluations.

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Diagnostic/Laboratory Date ordered/Date Indication/Purpose Normal values Result and Nursing responsibility
Procedure done interpretation
Computed tomography April 1, 2022 Computed tomography  Normal findings Pneumocephalus was BEFORE THE
(CT) (CT) scan is a useful on a CT scan seen on his CT PROCEDURE
diagnostic tool for shows bone  Informed Consent
detecting diseases and (which has the  Instruct the patient
to wear comfortable,
injuries. It uses a series densest tissue)
loose-fitting clothing
of X-rays and a appears as white during the exam.
computer to produce a areas. Tissues  Remove all metallic
3D image of soft densities will show objects. Items such
tissues and bones. CT as shades of gray, as jewelry, pins,
is a painless, and fat tissue buttons etc can
noninvasive way for appear as black or hinder the
your healthcare dark gray. visualization of the
provider to diagnose Cerebrospinal chest
conditions. You may fluid (has no DURING THE
have a CT scan at a tissue) will appear PROCEDURE
 Inform the patient
hospital or imaging as black. Air will that the procedure
center. also look black takes from five (5)
and darker than minutes to one (1)
hour depending on
the type of CT scan
and his ability to
relax and remain
still.
AFTER THE
PROCEDURE
Encourage the patient to
increase fluid intake (if a
contrast is given). This is
so to promote excretion

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 MEDICAL
MANAGEMENT
AND DRUG
STUDY

9
NAME OF DRUGS ROUTE OF MECHANISM OF INDICATION/PURPOSE CLIENT’S
  ADMINISTRATION; ACTION REACTION TO
DOSAGE AND TREATMENT
FREQUENCY OF
ADMINISTRATION
GENERIC NAME:   10mg per ml  The action of  Propofol is an  The patient is
PROPOFOL propofol involves intravenous anaesthetic able to tolerate
 
a positive agent used for induction the medication
BRAND NAME: 
DIPRIVAN modulation of the and maintenance of
  inhibitory function general anaesthesia. IV
DRUG CLASS: of the administration of propfol
SEDATIVE-HYPNOTIC neurotransmitter is used to induce
AGENT gama- unconsciousness after
  aminobutyric acid which anaesthesia may
(GABA) through be maintained using a
GABA-A combination of
receptors. medications. .

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NURSING RESPONSIBILTY

 Use cautiously with CVD, lipid disorder, increased ICP

 Monitor VS because diprivan can cause apnea, bradycardia, hypotension
 Assess insertion site can cause burning and pain at insertion site
 can turn urine green color
 assess respiratory status and hemodynamics
 maintain patent airway
 assess level of sedation

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 NAME OF DRUGS ROUTE OF
  ADMINISTRATION;DOSAG
E AND FREQUENCY OF
ADMINISTRATION
GENERIC NAME: • 1mg/vial
REMIFENTANIL • 2mg/vial
• 5mg/vial
BRAND NAME: • Anesthesia, Induction
ULTIVA • 0.5-1 mcg/kg/min IV until
after intubation; may
give initial dose of 1
DRUG CLASS: mcg/kg if intubation to
OPIOID ANALGESICS; occur less than 8 min
SYNTHETIC, OPIOIDS. after start of infusion
MECHANISM OF ACTION
Binds to opiate receptors in
the CNS, altering the
response to and perception
of pain. Produces CNS
depression.
INDICATION/PURPOSE CLIENT’S REACTION TO
TREATMENT
Analgesic supplement to The patient is able to
general anesthesia; usually tolerate the medication
with other agents (ultra–
short-acting barbiturates,
neuromuscular blockers,
and inhalation anesthetics)
to produce balanced
anesthesia.
Induction/maintenance of
anesthesia (with oxygen or
oxygen/nitrous oxide and a
neuromuscular blocker).
Analgesic component for
monitored anesthesia care
(MAC).
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NURSING RESPONSIBILTY

Examination and Evaluation

 
 Assess respiration, and notify physician immediately if patient exhibits any interruption in respiratory rate (apnea) or signs of
respiratory depression, including decreased respiratory rate, confusion, bluish color of the skin and mucous membranes (cyanosis),
and difficult, labored breathing (dyspnea). Monitor pulse oximetry and perform pulmonary function tests (See Appendix I) to quantify
suspected changes in ventilation and respiratory function. Apnea or excessive respiratory depression requires emergency care.
 
 
 Monitor signs of laryngeal spasm and allergic bronchospasm, including tightness in the throat and chest, wheezing, cough, and severe
shortness of breath. Notify physician or nursing staff immediately if these reactions occur.
 
 
 Be alert for excessive sedation or changes in mood and behavior (confusion, excitation, delirium). Notify physician or nursing staff
immediately if patient is unconscious or extremely difficult to arouse.
 
 
 Use appropriate pain scales (visual analogue scales, others) to document whether this drug is successful in helping manage the
patient's pain.
 
 
 Assess blood pressure periodically and compare to normal values (See Appendix F). Report low blood pressure (hypotension) or signs
of circulatory depression, including dizziness, fainting, weakness, pallor, and light-headedness.
 
 
 Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report slow heart rate (bradycardia) or
symptoms of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.
 
 
 Be alert for residual muscle rigidity and decreased thoracic and limb movements after rapid IV administration. Report a sustained
increase in muscle tone.
 
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NAME OF DRUGS/FLUIDS ROUTE OF MECHANISM OF INDICATION/PURPOSE CLIENT’S REACTION
  ADMINISTRATION;DOSA ACTION TO TREATMENT
GE AND FREQUENCY OF
ADMINISTRATION
   1L  The mechanism of  Hypertonic Saline The patient is
HYPERTONIC SALINE action of hypertonic is a prescription able to tolerate
SOLUTION(0.9 sodium saline medicine used to the medication
chloride) is predominantly treat the
  through the marked symptoms of
  osmotic shift of fluid electrolyte and
from the intracellular fluid replenisher
to the interstitial and used as a source
intravascular space of water and
electrolytes.
Hypertonic Saline
may be used alone
or with other
medications.
Hypertonic Saline
belongs to a class
of drugs called
Mucolytics.

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NURSING RESPONSIBILTY

 Document baseline vital signs, edema, lung sounds, and heart sounds, and continue monitoring
during and after the infusion.
 Monitor for continued signs of hypovolemia, including urine output < 0.5 mL/kg/hour, poor skin
turgor, tachycardia, weak pulse, and hypotension.
 Monitor for signs of hypervolemia such as hypertension, bounding pulse, pulmonary crackles,
dyspnea, shortness of breath, peripheral edema, jugular vein distension(JVD) and extra heart
sounds such as S3.
 Caution in cardiac or renal disease

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NAME OF DRUGS ROUTE OF MECHANISM OF INDICATION/PURPOSE CLIENT’S REACTION TO
  ADMINISTRATION;DOSAGE ACTION TREATMENT
AND FREQUENCY OF
ADMINISTRATION
GENERIC NAME: Cerebral Edema    Mannitol injection The patient is
MANNITOL  Reduction of is used to reduce able to tolerate
  intracranial pressure swelling and
the medication
BRAND NAME: and treatment of pressure inside
OSMITROL cerebral edema 1.5-2 the eye or around
  g/kg intravenously the brain.
DRUG CLASS: (IV) infused over 30-
DIURETICS, OSMOTIC 60 minutes
AGENTS  
 
 

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NURSING RESPONSIBILTY

Assessment & Drug Effects

 Take care to avoid extravasation. Observe injection site for signs of inflammation or edema.
 Lab tests: Monitor closely serum and urine electrolytes and kidney function during therapy.
 Measure I&O accurately and record to achieve proper fluid balance.
 Monitor vital signs closely. Report significant changes in BP and signs of CHF.
 Monitor for possible indications of fluid and electrolyte imbalance (e.g., thirst, muscle cramps or weakness,
paresthesias, and signs of CHF).
 Be alert to the possibility that a rebound increase in ICP sometimes occurs about 12 h after drug administration.
Patient may complain of headache or confusion.
 Take accurate daily weight.
 
 

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MEDICAL MANAGEMENT/TREATMENT
 
CRANIECTOMY
 RIGHT FRONTO-PARIETAL-TEMPORAL-
OCCIPITAL DECOMPRESSIVE
CRANIECTOMY WITH DURAPLASTY
 
 Craniectomy differs from craniotomy in
that the bone is not replaced to its
previous position; instead it is stored
for future insertion or may be discarded
(depending on pathology – e.g.
infection). This results in a cranial
defect. – If the bone flap needs to be
discarded, it is replaced with a custom
made implant.
 Is a neurosurgical procedure that
involves removing a portion of the
skull, where the patient's scalp is
closed without re-implantation of the
bone, leaving a resultant cranial defect.
INDICATION/PURPOSE CLIENT’S REACTION TO
TREATMENT
 Increases buffering capacity of The patient is able to tolerate
cranium. the medication
 Allows outward herniation of brain
tissue.
 preventing compression of brainstem
structures.
 reestablish brain perfusion.
 Intracranial pressure (ICP) reduction
15-85% depending on size of bone
removed.
 Decompressive Craniectomy is used
in urgent or emergent conditions
where there is substantial brain
swelling from bleeding, stroke or
infection.
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NURSING RESPONSIBILITIES

PRE-OP
• Seured consent after explaining the procedure by the surgeon and anesthesiologist
• Identification of the patient with two identifiers, such as name and date of birth
• Mental and physiological status of the patient
• Functional status (patient’s ability to perform ADLs, activities of daily living)
• Cardiovascular and respiratory status
• Skin condition
• Nutritional status (how long has the patient been NPO)
• Range of motion and mobility
• Pain
• Any prosthetics or corrective devices
• Sensory impairments, language barrier, cultural/spiritual needs
• Anxiety
• Previous surgeries and anesthesia experience
• Allergies
• Medications, herbs, nutritional supplements, and drug abuse

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NURSING RESPONSIBILITIES

POST-OP
• Keep the incision clean.
• Inspect the incision on the head and abdomen (if present) to ensure edges remain well approximated, and
staples/sutures are intact.
• Watch the incision for signs of infection or complications.
• Monitor for redness around the incision, discharge, and any other signs of infection.
• Control Pain
• Gradually return to activity
• Patients who have had a bone flap removed may still have their hair washed.
• Do not submerge the incision until all staple sutures have been removed or as per direction of your
physician.
• Be gentle when handling this area and do not rub too vigorously.
• Use a mild shampoo with no strong perfumes.
• Do not direct shower head directly to site
• Positioning may be supported with towels, pillows, and positioning devices to prevent pressure onto the
cerebrum and attempt to stay off the site
• Signage above the patient's bed allows all health care providers to recognize that patient has no bone flap.

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 NURSING
CARE PLAN

2
1
 ASSESSMENT DIAGNOSIS PLANNING

SUBJECTIVE: Acute Pain related to inflammatory process. SHORT-TERM:

The patient’s mother stated that he fell Within 1-2 hours of nursing intervention,
and hit his head. the patient will be able to:
   Maintain comfort and pain reduction
sensation.
OBJECTIVE:
 
 Bruise in the forehead
 Difficulty in lifting eyelid LONG-TERM
 Guarding of affected area
Within 12-24 hours of nursing intervention,
 Facial Grimace showing pain
the patient will be able to:
 CT scan result: small traumatic
subarachnoid hemorrhage  Maintain normal laboratory results.
 Lumbar puncture result:
pneumococcal meningitis
 WBC; 20,000 (elevated)
 C-Reactive: 24 (Elevated)
 VS taken:
-BP:150/100
-Temp: 38.6C
 
 

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 INTERVENTION RATIONALE

INDEPENDENT: INDEPENDENT:
1. Keep the atmosphere calm and the patient’s room darker. 1. This intervention is beneficial since dimming the room will
2. Minimize distractions and limit visitation. alleviate photophobia.
3. Control the surroundings to promote relaxation. 2. Distractions can elevate intracranial pressure,
4. Turn the patient’s position frequently and carefully. exacerbating the symptoms.
5. Raise the side rails and lower the bed at all times. 3. Increased noise and dazzling light in the surroundings
produce sensory overload, which causes cerebral
DEPENDENT:
inflammation and leads to seizures.
6. Administer antibiotic and corticosteroids prescribed. 4. This approach improves the patient’s relaxation while
7. Administer analgesics such as acetaminophen or NSAIDs reducing irritability and tension.
if the pain becomes intolerable. 5. Helps ensure the patient’s safety
DEPENDENT:
6. Antibiotics and corticosteroid therapy are prescribed to
decrease inflammation and pain.
7. This intervention must be considered since NSAIDs are
used to manage pain.

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 EVALUATION
SHORT-TERM:
After 2 hours of nursing intervention, the patient was able to maintain
comfort and pain reduction sensation.
 
GOAL MET.
 
LONG-TERM
Within 24 hours of nursing intervention, the patient was able to maintain
normal laboratory results.
 
GOAL MET.

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 ASSESSMENT DIAGNOSIS PLANNING

SUBJECTIVE: Ineffective cerebral tissue perfusion related SHORT-TERM

to internal bleeding.
The patient’s mother stated that his son Within 1-2 hours of nursing intervention:
fell, and they find difficulty talking to
 Patient and relative will be able to:
him.
verbalize understanding of condition,
  therapy regimens, and when to
contact health care provider.
OBJECTIVE:
 
 Can’t answer questions properly
LONG-TERM
 Difficulty lifting eyelid
Within 24-72 hours of nursing intervention,
 Confused facial expression
patient will be able to:
 Bruise in the forehead
 Increase cerebral tissue perfusion as
 Facial grimace showing pain evidence by increased level of
consciousness and vital signs will be
 GCS score= 11 at normal range.
 CT scan result: small traumatic
subarachnoid hemorrhage
 Vital signs taken:
-BP: 150/90mmHg
-Temp: 38.6C
25
 INTERVENTION RATIONALE

INDEPENDENT: INDEPENDENT:

1. Maintain bed rest; provide quiet environment; Keep the patient’s room darker, 1. Continual stimulation/ activity can increase ICP. Absolute rest and quiet may
restrict visitors/ activities as indicated. Provide rest periods between care be needed to prevent rebleeding in the case hemorrhage. This intervention is
activities, limit duration of procedures. beneficial since dimming the room will alleviate photophobia.
2. Position the patient. Elevate the head of the bed at 30 degrees 2. To promote venous drainage from the patient’s head to the rest of the body to
reduce cerebral edema.
3. Provide information regarding the client’s condition.
3. To increase the client’s relatives, knowledge about the condition.
4. Discuss to relatives for meeting the client’s self-care needs.
4. Varying levels of assistance may be required/ need to be planned for bases
5. Prevent straining at stool, holding breath, physical exertion. on individual situation.
6. Raise the side rails 5. Valsalva maneuver increases and potentiates the risk of rebleeding.
DEPENDENT: 6. Helps ensure the patient’s safety who has decreased LOC
7. Administer supplemental oxygen as indicated. DEPENDENT:
8. Administer medication as ordered: 7. Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and
increase pressure or edema formation.
 Tissue plasminogen activator (tPA)
8. Indications:
 Antihypertensives
 Tissue plasminogen activator (tPA)- tPA converts plasminogen to plasmin,
 Stool softeners
dissolving the blood clot that is blocking blood flow to the brain.
3. Monitor laboratory studies as indicated
 Antihypertensives- blood pressure control is essential to decrease the risk of
4. Prepare for surgery, as ordered. rebleeding.

 Stool softeners- Prevents straining during bowel movement and the

corresponding increase of ICP.

3. Provides information about drug effectiveness and therapeutic level.

 
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 EVALUATION

SHORT-TERM
After 1-2 hours of nursing intervention, the relative was able to verbalize
understanding of condition, therapy regiments, and when to contact health care
provider.
 
GOAL PARTIALLY MET.
 
LONG-TERM
After 72 hours of nursing intervention the patient was able to show Increased cerebral
tissue perfusion as evidenced by increased LOC and vital signs was at normal range.
 
GOAL MET.

27
 ASSESSMENT DIAGNOSIS PLANNING

SUBJECTIVE: Hyperthermia related to infective process of Within 7-8 hours of nursing intervention, the
bacterial meningitis. patient will be able to:
The patient’s mother verbalized that his son
had seizure, and his temperature is high.  Gradually maintain normal range of
temperature from 38.6C to 37.4C
 
 Decrease sweating as evidenced by less
OBJECTIVE: soaked garments and clothing.
 Hot, flushed skin.  Increase motor movements
 Profuse Sweating
 Weakness evidenced by minimal motor
movement
 Documented seizure
 GCS- 11
 Lumbar puncture result: pneumococcal
meningitis
 WBC; 20,000 (elevated)
 C-Reactive: 24 (Elevated)
 VS taken:
-BP: 150/100
-Temp: 38.6C

28
 INTERVENTION RATIONALE

INDEPENDENT: INDEPENDENT:
1. Remove excessive clothing, blankets, and linens. Adjust the 1. Exposing skin to room air decreases heat and increases
room temperature. evaporative cooling.
2. Provide a tepid bath or sponge bath. 2. A tepid sponge bath is a non-pharmacological measure to allow
evaporative cooling.
3. Modify cooling measures based on the patient’s physical
response. Monitor the patient for shivering. 3. Excessive cooling or cooling too rapidly may cause shivering,
which increases metabolic rate and temperature. Shivering
4. Raise the side rails and lower the bed at all times. should be avoided as it will hinder cooling efforts.
5. Provide mouth care. 4. Helps ensure the patient’s safety even without the presence of
6. Increase Fluid intake. seizure activity

DEPENDENT: 5. Application of water-soluble lip balm can help with dryness and
cracks caused by dehydration.
7. Administer the prescribed antibiotic and anti-pyretic
medications. 6. If the client is alert enough to swallow, provide cool liquids to
help lower the body temperature. Additionally, if the patient is
dehydrated or diaphoretic, fluid loss contributes to fever.
DEPENDENT:
7. Use the antibiotic to treat bacterial infection, which is the
underlying cause of the patient’s hyperthermia. Use the fever-
reducing medication to stimulate the hypothalamus and
normalize the body temperature.

29
 EVALUATION
After 8 hours of nursing interventions, the patient was able to decrease
temperature from 38.6C to 37.4C, has decreased sweating as evidenced by
less soaked garments and clothing, and has increased motor movements.

30
 ASSESSMENT DIAGNOSIS PLANNING

SUBJECTIVE: Disturbed Sensory Perception related to Within 24-72 hours of nursing intervention,
cerebral inflammation. patient will be able to:
The patient’s mother verbalized that his
son seems to be having difficulty in  Maintain his typical level of
answering questions. consciousness.
 Be knowledgeable about the
 
symptoms of his condition.
OBJECTIVE:
 Can’t answer questions properly
 Difficulty lifting eyelid
 Confused facial expression
 Bruise in the forehead
 Facial grimace showing pain
 GCS score= 11
 CT scan result: small traumatic
subarachnoid hemorrhage
 Vital signs taken:
 -BP: 150/90mmHg
 -Temp: 38.6C
 

31
 INTERVENTION RATIONALE

INDEPENDENT: INDEPENDENT:
1. Upraise the bed head to 30° to 45° while keeping the patient’s 1. This technique promotes venous circulation from the brain and
head in a normal position. aids in the reduction of intracranial pressure.
2. As necessary, reorient the patient to the surroundings. 2. It is critical to practice coping techniques regularly to improve
3. Retain the atmosphere calm and the lighting dark. cognitive performance.
4. Monitor and inform the doctor if the patient’s level of 3. This technique inhibits stimuli that could trigger or exacerbate a
consciousness continues to deteriorate. convulsion attack.
5. Raise the side rails and lower the bed at all times. 4. If consciousness levels begin to decline, an additional or
different treatment may be required.
5. Helps ensure the patient’s safety
DEPENDENT:
DEPENDENT:
6. Administer supplemental oxygen as indicated.
7. Administer medication as ordered: 6. Reduces hypoxemia. Hypoxemia can cause cerebral
 Tissue plasminogen activator (tPA) vasodilation and increase pressure or edema formation.
 Antihypertensives 7. Indications:
 Stool softeners  Tissue plasminogen activator (tPA)- tPA converts plasminogen
1. Monitor laboratory studies as indicated to plasmin, dissolving the blood clot that is blocking blood flow to
  the brain.
 Antihypertensives- blood pressure control is essential to
decrease the risk of rebleeding.
 Stool softeners- Prevents straining during bowel movement and
the corresponding increase of ICP.
1. Provides information about drug effectiveness and therapeutic
level.
 

32
 EVALUATION
After 72 hours of nursing intervention, patient was able to maintain his typical
level of consciousness and be knowledgeable about the symptoms of his
condition.
 
GOAL MET.

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THANK
YOU