Question

A 70 year old male patient was just admitted to ICU after subarachnoid hemorrhage as a result of aneurysm rupture in the middle cerebral artery. His blood pressure is 180/ 100, his heart rate is 85 BPM, and his RR is 20. He complains of severe headache and lightheadedness.

Please develop a nursing care plan with rationale for your interventions for this patient in the ICU.

Answer 1

Assessment	Diagnosis		intervention	rationale	goal/outcome
patient hasBP180/100, headache,light headedness	ineffective cerebral tissue perfusion related to bleeeding or vasos		closely monitor for vital signs monitor neurolgical status( consciuous level, pupil reaction) elevate head of the bed 15-30 degree Avoid activity apply compression stockings/ sequential compression devices	fluctuations in vitalsigns occur due to cerebral pressure/ injury in vasomotor area of brain alteration in neurological status is an indicator for increased  intracranial pressure( ICP) and worsening disease condition head elevation , maintain optimal venous drainage and and helps to prevent increasing ICP activity will increase BP and ICP compression stockings /devices help to prevent deep vein thrombosis	vitalsigns in normal range, patient is able to verbalise
	Risk for injury / fall		apply universal fall prevention precaution/ seizure precaution	patient can develop seizure and fall or injury can happen	absence of complications