Concept Map

Patient: R.C. 81 yo M
Allergies & Directives: Status: DNR
No known allergies
Primary Medical Condition: Subacute right basal ganglia bleed
Pathology: Intracerebral hemorrhage is bleeding within the brain
caused by a rupture of a vessel and accounts for about 10% of
all strokes . . . hypertension is the most common cause of
hemorrhage (Lewis 2014, p.1392).
Medications for Primary Medical Condition: Hydralazine 10mg (if
systolic pressure greater than 150 to prevent another hemorrhage of a
vessel) a direct-acting peripheral vasodilator that relaxes arteriolar
smooth muscle (Kluwer 2015, p.701)
Secondary Medical Condition / Procedure 1: Uncontrolled Hypertension
Relationship to Primary Medical Condition: hemorrhagic stroke was
likely caused by hypertension causing the blood vessel to burst
Medications for Secondary Medical Condition / Procedure 1:
Metoprolol 50mg- a selective beta blocker that selectively blocks beta
1receptors; decreases cardiac output, peripheral resistance, and
cardiac oxygenation consumption; and depresses renin secretion
(Kluwer 2015, p.938)
Amlodipine 5mg- Inhibits calcium ion influx across cardiac and
smooth-muscle cells, dilates coronary arteries and arterioles, and
decreases blood pressure and myocardial oxygen demand (Wolters &
Kluwer 2015, p.124)
Clonidine 0.1mg- thought to stimulate alpha2 receptors and inhibit
the central vasomotor centers, decreasing sympathetic outflow to the
heart, kidneys, and peripheral vasculature, and lowering peripheral
vasculature resistance, blood pressure, and heart rate (Kluwer 2015,
p.357)
Secondary Medical Condition 2: Paroxysmal atrial fibrillation
Relationship to Primary Medical Condition: Afib causes pooling of blood
in ventricles which promotes blood clots which can cause a stroke, this
patient took Xarelto to prevent a stroke; however, Xarelto is an
anticoagulant which can cause bleeding
Medications for Secondary Medication Condition 2: Xarelto (prior to
admission and discontinued)- Selectively blocks the active site of
factor Xa, which is necessary for coagulation (Kluwer 2015, p.1252)
Propafenone 225mg- reduces inward sodium current in cardiac cells,
prolongs refractory period in AV node, and decreases excitability,
conduction velocity, and automaticity in cardiac tissue (Kluwer 2015,
p.1190)
Aspirin 81mg- appears to interfere with clotting by keeping a plateletaggregating substance from forming (Kluwer 2015, p.156)

Pertinent Physical Findings:

Neuro: Alert. Patient oriented to person. Patient disoriented to place and time.
Tracks with eyes. Left sided facial droop. Clear, delayed speech.
Cardiac: BP: @0700 149/64 @1108 179/71 (right arm) @1109 171/66 (left arm)
@1208 144/55 (pharmacologic intervention: hydralazine 10mg @ 1130) Rhythm:
Regular NSR
Musculoskeletal: Upper and lower extremities purposeful response, generalized
weakness consistent with age, tremors bilaterally in upper extremities, gait
unsteady
Recent Laboratory / Diagnostic Test Results With Significance:
RBC- 3.44 low
HGB- 11.2 low
HCT- 33.1 low
[Result of hemorrhage]
BUN- 27 high
BUN/Creatinine ratio- 25 high
[Acute kidney injury]
Sodium- 134 low
Calcium- 7.8 low
Phosphorus- 2.2 low
Protein- 5.8 low
Albumin- 2.8 low
[Inadequate nutrition]
CT Scan- Slight decrease in small right basal ganglia hemorrhage
Contributing Factors Involved in the Hospitalization (lifestyle, PMH, FH):
Uncontrolled HTN, Xarelto use, Hx CAD, Hx Paroxysmal afib, COPD, previously
smoker, glaucoma
Psychosocial / Spiritual Issues and Discharge Needs:
Rehab, support for wife who will be taking on a caregiver role
Anticipated Patient Teaching Required:
seeking appropriate help when ambulating, safety awareness
Priority Nursing Diagnosis (3 parts): Impaired cerebral tissue perfusion related
to intracranial hemorrhage as evidenced by altered mental status.
Measureable outcome w/timeframe: Patient will maintain optimal
cerebral tissue perfusion as evidenced by absences of new neurological
deficits, and stable blood pressure by 1400 on 11/4/15.
Nursing interventions used with rationales:
Assess the patients neurologic status using Glasgow Coma Scale. This
information is used to determine the effects of stroke and identify lifethreatening complications such as increased intracranial pressure.
Monitor the patients vital signs as needed. The frequent assessment of BP is
essential. A normotensive state is desired to promote effective cerebral
perfusion pressure.
Administer Hydralazine if systolic blood pressure is greater than 150mmhg.
Maintain blood pressure at a stable state to prevent ineffective perfusion or
another burst in a blood vessel.

Evaluation: Goal not met. Patient did not have a resolution of confusion.
Patient documented as being oriented X3 on 11/5/15.
(Gulanick & Myers 2014, p.565)

References
Gulanick, M. & Myers, J. (2014). Nursing Care Plans: Diagnoses, Interventions, and
Outcomes (8th ed.). Philadelphia, PA: Elsevier Mosby.
Kluwer, W. (2015). Nursing 2015 drug handbook (35th ed.). Philadelphia, PA: Wolters
Kluwer.
Lewis, S. L., Dirksen, S.R., Heitkemper, M. M. & Bucher, L. (2014). Medical surgical
nursing: Assessment and management of clinical problems (9 th ed.). St. Louis,
MO: Elsevier Mosby.

Reflection: Caring and the Catholic Health care ministry

This week my patients wife was very supportive and involved in his care. She was very
attentive and anticipated his needs. She appeared to be knowledgeable about his healthcare,
but there were some areas that she did not seem to understand fully. For example, she knew
he was on metoprolol, but she did not know that the purpose of that medication was to
control his hypertension. She also appeared to be unaware of the full effects and possible
complications of his medical condition. The wife needed education and spiritual care almost
as much as her husband. I was glad that I was able to spend some time with her and listen to
her thoughts and concerns. I believe that she will be a great caregiver for her husband, but it
is important that she also is relieved from her caregiver role at times and is able to care for
herself as well.