Assessment Nursing Diagnosis Objectives Nursing Interventions Rationale Expected Outcome S>

(none)

O>
> GCS of ____
> Slowed movement
> limited ROM
> Extremity weakness
> limited ability to perform gross or fine motor movement
> Uncoordinated or jerky movements
> Movement induced shortness of breath
Impaired physical mobility r/t neuromuscular impairment secondary to CVA Short Term:
After 3 hours of NI, the SO will verbalize understanding of situation / risk factors & individual
treatment regimen & safety measures
Long Term:
After 3 days of NI, the pt will maintain or increase strength and function of affected body part or whole
body.
>Establish Rapport
>Assess patient condition
>Monitor vital signs
>Determine dx that contributes to immobility
>Determine degree of immobility
>Reposition client q2
>Support dependent body parts with pillows
>Provide safety measures including environmental management
>Feed thru NGT
>Encourage SO’s involvement in activities & decision making
>Peroform passive range of motion exercises daily
>Increase functional activities as strength improves
>To gain SO’s trust
>To obtain baseline data
>For comparison and baseline data
>To assess causative factors
>To assess functional ability
>Prevent development of pressure ulcers
>To maintain position of function and prevent pressure ulcers
>TO reduce risk for falls and further injury
>For optimum energy and nutrition
>Enhances commitment to plan and optimizing outcomes
>To preserve muscle strength and functional ability
>Limits fatigue and ability to perform ADLs.
The SO shall have verbalized understanding of situation / risk factors & individual treatment regimen
& safety measures
The pt shall have maintained or increased strength and function of affected body part or whole body.

Intracerebral hemorrhage (ICH) is a type of stroke caused by bleeding within the brain tissue itself – a
very life-threatening situation. A stroke occurs when the brain is deprived of oxygen due to an
interruption of its blood supply. ICH is most commonly caused by hypertension, arteriovenous
malformations, or head trauma. Treatment focuses on stopping the bleeding, removing the blood clot
(hematoma), and relieving the pressure on the brain.
What is an intracerebral hemorrhage (ICH)?
Tiny arteries bring blood to areas deep inside the brain (see Anatomy of the Brain). High blood
pressure (hypertension) can cause these thin-walled arteries to rupture, releasing blood into the brain
tissue. The blood collects and forms a clot, called a hematoma, which grows and causes pressure on
surrounding brain tissue (Fig. 1). Increased intracranial pressure (ICP) makes a person confused and
lethargic. As blood spills into the brain, the area that artery supplied is now deprived of oxygen-rich
blood – called a stroke. As blood cells within the clot die, toxins are released that further damage brain
cells in the area surrounding the hematoma.
An ICH can occur close to the surface or in deep areas of the brain. Sometimes deep hemorrhages can
expand into the ventricles – the fluid filled spaces in the center of the brain.
What are the symptoms?
If you experience the symptoms of an ICH, call 911 immediately! Symptoms usually come on suddenly
and can vary depending on the location of the bleed. Common symptoms include:
• headache, nausea, and vomiting
• lethargy or confusion
• sudden weakness or numbness of the face, arm or leg, usually on one side
• loss of consciousness
• temporary loss of vision
• seizures
What are the causes?
• Hypertension: an elevation of blood pressure that may cause tiny arteries to burst inside the
brain.
• Blood thinner therapy: drugs such as coumadin, heparin, and warfarin used to treat heart and
stroke conditions.
• AVM: a tangle of abnormal arteries and veins with no capillaries in between.
 • Aneurysm: a bulge or weakening of an arterial wall.
• Head trauma: fractures to the skull and penetrating wounds (gunshot) can damage an artery
and cause bleeding.
• Bleeding disorders: hemophilia, sickle cell anemia, DIC, thrombocytopenia.
• Tumors: highly vascular tumors such as angiomas and metastatic tumors can bleed into the
brain tissue.
• Amyloid angiopathy: a degenerative disease of the arteries.
• Drug usage: cocaine and other illicit drugs can cause ICH.
• Spontaneous: ICH by unknown causes.
Who is affected?
Ten percent of strokes are caused by ICH (approximately 70,000 new cases each year). ICH is twice as
common as subarachnoid hemorrhage (SAH) and has a 40% risk of death. ICH occurs slightly more
frequently among men than women and is more common among young and middle-aged African
Americans and Japanese. Advancing age and hypertension are the most important risk factors for ICH.
Approximately 70% of patients experience long-term deficits after an ICH.
How is a diagnosis made?
When you or a loved one is brought to the emergency room with an ICH, the doctor will learn as much
about your symptoms, current and previous medical problems, current medications, family history, and
perform a physical exam. Diagnostic tests help doctors determine the source and location of the
bleeding.
Computed Tomography Angiography (CTA) scan is a noninvasive X-ray to review the
anatomical structures within the brain to see if there is any blood in the brain (Fig. 2). A
newer technology called CT angiography involves the injection of contrast into the blood
stream to view arteries of the brain.
Angiogram is an invasive procedure, where a catheter is inserted into an artery and passed
through the blood vessels to the brain. Once the catheter is in place, a contrast dye is
injected into the bloodstream and X-ray images are taken.
Magnetic resonance imaging (MRI) scan is a noninvasive test, which uses a magnetic
field and radio-frequency waves to give a detailed view of the soft tissues of your brain. An
MRA (Magnetic Resonance Angiogram) is the same non-invasive study, except it is also an
angiogram, which means it examines the blood vessels as well as the structures of the brain.
What treatments are available?
Once the cause and location of the bleeding is identified, medical or surgical treatment is performed to
stop the bleeding, remove the clot, and relieve the pressure on the brain. If left alone the brain will
eventually absorb the clot within a couple of weeks – however the damage to the brain caused by ICP
and blood toxins may be irreversible.
Generally, patients with small hemorrhages (<10 cm3) and minimal deficits are treated medically.
Patients with cerebellar hemorrhages (>3 cm3) who are deteriorating or who have brainstem
compression and hydrocephalus are treated surgically to remove the hematoma as soon as possible.
Patients with large lobar hemorrhages (50 cm3) who are deteriorating usually undergo surgical removal
of the hematoma.
Medical treatment
Blood pressure is managed to decrease the risk of more bleeding yet provide enough blood flow
(perfusion) to the brain.
Controlling intracranial pressure is the biggest factor in the outcome of ICH. A device called an ICP
monitor is placed directly into the ventricles or within the brain to measure pressure. Normal ICP is
20mm HG.
Removing cerebrospinal fluid (CSF) from the ventricles is a common method to control ICP. A
ventricular catheter (VP shunt) may be placed in the ventricles to drain CSF fluid to allow room for the
hematoma to expand without damaging the brain. Hyperventilation also helps control ICP. In some
cases, coma may be induced with drugs to bring down ICP.
Surgical treatment
The goal of surgery is to remove as much of the blood clot as possible and stop the source of bleeding
if it is from an identifiable cause such as an AVM or tumor. Depending on the location of the clot either
a craniotomy or a stereotactic aspiration may be performed.
• Craniotomy involves cutting a hole in the skull with a drill to expose the brain and remove the
clot. Because of the increased risk to the brain, this technique is usually used only when the
hematoma is close to the surface of the brain or if it is associated with an AVM or tumor that
must also be removed.
• Stereotactic aspiration is a less invasive technique preferred for large hematomas located deep
inside the brain. The procedure requires attaching a stereotactic frame to your head with four
pins (screws). The pin site areas are injected with local anesthesia to minimize discomfort. A
metal cage, which looks like a birdcage, is placed on the frame. Next, you undergo a CT scan to
help the surgeon pinpoint the exact coordinates of the hematoma. In the OR, the surgeon drills a
small hole about the size of quarter in the skull. With the aid of the stereotactic frame, a hollow
needle is passed through the hole, through the brain tissue, directly into the clot. The hollow
needle is attached to a large syringe, which the surgeon uses to suction out the contents of the
blood clot.
Recovery & prevention
Immediately after an ICH, the patient will stay in the intensive care unit (ICU) for several weeks where
doctors and nurses watch them closely for signs of rebleeding, hydrocephalus, and other complications.
Once their condition is stable, the patient is transferred to a regular room.
ICH patients may suffer short-term and/or long-term deficits as a result of the bleed or the treatment.
Some of these deficits may disappear over time with healing and therapy. The recovery process may
take weeks, months, or years to understand the level of deficits incurred and regain function.
Clinical trials
linical trials are research studies in which new treatments—drugs, diagnostics, procedures, and other
therapies—are tested in people to see if they are safe and effective. Research is always being conducted
to improve the standard of medical care. Information about current clinical trials, including eligibility,
protocol, and locations, are found on the Web. Studies can be sponsored by the National Institutes of
Health (see clinicaltrials.gov) as well as private industry and pharmaceutical companies (see
Pathophysiology
Blood from an intracerebral hemorrhage accumulates as a mass that can dissect through and compress
adjacent brain tissues, causing neuronal dysfunction. Large hematomas increase intracranial pressure.
Pressure from supratentorial hematomas and the accompanying edema may cause transtentorial brain
herniation, compressing the brain stem and often causing secondary hemorrhages in the midbrain and
pons (see Fig. 1: Coma and Impaired Consciousness: Brain herniation.. If the hemorrhage ruptures into
the ventricular system (intraventricular hemorrhage), blood may cause acute hydrocephalus. Cerebellar
hematomas can expand to block the 4th ventricle, also causing acute hydrocephalus, or they can dissect
into the brain stem. Cerebellar hematomas that are > 3 cm in diameter may cause midline shift or
herniation. Herniation, midbrain or pontine hemorrhage, intraventricular hemorrhage, acute
hydrocephalus, or dissection into the brain stem can impair consciousness and cause coma and death.

Lung abscess is defined as necrosis of the pulmonary parenchyma caused by microbial infection.
Some authorities use the term "necrotizing pneumonia" or "lung gangrene" to distinguish pulmonary
necrosis with multiple small abscesses from a larger cavitary lesion, but this actually represents a
continuum of the same process.
The classification, clinical features, diagnosis, and treatment of lung abscess will be reviewed here.
Aspiration pneumonia, which may precede the development of a lung abscess, is discussed separately.
(See "Aspiration pneumonia in adults".)
CLASSIFICATION
The term "lung abscess" is often applied to reflect the clinical features that are useful in management
decisions, such as duration of prior symptoms, presence of associated conditions, or microbial etiology.
• Lung abscesses can be classified as acute or chronic based upon the duration of symptoms prior
to presentation for medical care; symptoms present for one month or more are considered
chronic.
• Lung abscess may be primary or secondary based upon the presence or absence of common
associated conditions. Abscesses in patients prone to aspiration or patients who have been
healthy previously are usually considered primary; the term "secondary lung abscess" typically
indicates an associated bronchogenic neoplasm or systemic disease that compromises immune
defenses, such as the acquired immunodeficiency syndrome (AIDS) or organ transplantation.
• Lung abscess can also be defined by the responsible microbial pathogen (eg, Pseudomonas lung
abscess, anaerobic bacterial lung abscess, or Aspergillus lung abscess).
When no pathogen was recovered from expectorated sputum five decades ago, the lesion was referred
to as a "nonspecific lung abscess." It is now thought that these infections were caused by anaerobic
bacteria. Putrid lung abscess refers to the offensive odor that is often found in patients with lung
abscesses and is thought to be diagnostic of anaerobic bacterial infection. A review of more than 1000
reported cases of lung abscess during the antibiotic era indicates that approximately 80 percent were
considered primary; 60 percent were putrid; 40 percent were "nonspecific";

Pathophysiology
Lung abscess commonly occurs in patients with a predisposition to gastric content aspiration due to
altered consciousness. [4] Aspiration of gastric contents can also result from dysphagia associated with
neurological or oesophageal disease. Common causes of gastric content aspiration include alcoholic
stupor, seizures, stroke, neurological bulbar dysfunction, drug overdose, and general anaesthesia. Other
causes include dental or oropharyngeal surgery (especially tonsillectomy in the sitting position) and
oesophageal diseases (stricture, malignancy, and reflux). Nasogastric and endotracheal tubes that
interfere with normal anatomical barriers predispose to aspiration of oropharyngeal fluid. Aspiration of
contaminated oropharyngeal secretions results in necrotising infection that follows a segmental
distribution limited by the pleura. The resultant cavity is usually solitary, with a thick, fibrous wall at its
periphery. Expansion to the pleural space is uncommon. As gastric content aspiration usually occurs in
the supine position, in aspiration-related lung abscess lesions are found in the right lung and in the
dependent portions of the lungs (i.e., posterior segment of the right upper lobe and superior segments of
both lower lobes).
Other processes that may result in lung abscess include infection distal to an obstructing tumour or
foreign body, secondary infection of an infarct related to a pulmonary embolus, and septic embolisation
from right-sided (e.g., tricuspid valve) bacterial endocarditis or peripheral septic thrombophlebitis. [26]
Abscesses due to septic embolisation typically involve multiple, non-contiguous areas of the lung. [27]
Nearly 50% of lung abscesses occurring in adults >50 years of age are associated with lung tumours,
and preceding pneumonia is reported in 17% to 40% of cases. [8] [23] Lemierre's syndrome is an acute
oropharyngeal infection usually affecting young, healthy people. It is caused by Fusobacterium species
and is complicated by jugular vein thrombophlebitis and metastatic septic embolisation. [28] Variants
of this syndrome include multiple lung abscesses after inferior vena cava thrombosis due to a soft tissue
leg abscess. [29] Finally, direct expansion through the diaphragm of a liver amoebic abscess may result
in an amoebic lung abscess, which typically occurs in the right lower lobe.