What is the best nursing approach for a patient with a left parietal intraparenchymal hemorrhage?

Nursing Care for Left Parietal Intraparenchymal Hemorrhage

Patients with left parietal intraparenchymal hemorrhage require intensive neurological monitoring with a 1:2 nurse-patient ratio for the first 24 hours in a dedicated neuroscience intensive care unit or stroke unit, with nurses trained in recognizing signs of neurological deterioration and increased intracranial pressure. 1

Initial Assessment and Monitoring Protocol

Neurological Assessment Schedule

• Perform complete NIHSS assessment on admission to the ICU, with abbreviated versions every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours. 1
• Continue frequent neurological assessments (including Glasgow Coma Scale) for up to 72 hours after admission, as patients are at highest risk of neurological deterioration during this period. 1
• Immediately perform complete NIHSS if any neurological decline is detected. 1

Vital Sign Monitoring

• Blood pressure: Every 15 minutes for 2 hours, every 30 minutes for next 6 hours, then hourly for 24 hours. 1
• Heart rate and respirations: Continuous monitoring with telemetry. 1
• Pulse oximetry: Continuous monitoring; administer oxygen if saturation <92%. 1
• Temperature: Monitor frequently; maintain normothermia as fever worsens outcomes. 1, 2

Critical Signs of Deterioration to Monitor

Early Warning Signs of Neurological Decline

Watch for these signs indicating potential hematoma expansion or increased ICP: 1

• Change in level of consciousness (earliest and most important sign) 1
• Deterioration in motor examination, particularly worsening right-sided weakness 1
• Elevation of blood pressure 1
• New or worsening headache 1
• Nausea and vomiting 1
• Visual disturbances 1

Late Signs Requiring Emergency Intervention

These indicate imminent herniation and require immediate physician notification: 1

• Pupillary abnormalities (dilated or sluggish pupils) 1
• Persistent changes in vital signs 1
• Changes in respiratory pattern with arterial blood gas abnormalities 1

Positioning and Basic Care

Head of Bed Management

• Elevate head of bed 20-30 degrees with head in neutral position to facilitate venous drainage and prevent increased ICP. 1
• Maintain good head and body alignment to prevent increased intrathoracic pressure. 1
• If patient is at risk for aspiration, elevate to at least 30 degrees. 1

Airway and Respiratory Care

• Assess airway patency continuously; avoid slumped sitting position to prevent hypoxia. 1
• Position on paretic (right) side when significant hemiparesis is present to allow communication and prevent aspiration. 1
• Use soft sponges instead of toothbrushes for oral care in first 24 hours to prevent trauma. 1

Blood Pressure Management

Target Parameters

• Notify physician if systolic BP >185 mm Hg or <110 mm Hg; diastolic BP >105 mm Hg or <60 mm Hg. 1
• For patients with small hemorrhages without intracranial hypertension, target systolic BP around 140 mm Hg using beta blockers or calcium channel blockers. 3
• Avoid aggressive antihypertensive agents with venodilating effects (like nitroprusside) as they can increase ICP. 1

Blood Pressure Cuff Precautions

• Use automatic blood pressure cuffs with caution; check cuff site frequently, rotate and reposition every 2 hours. 1
• Discontinue automatic cuff if petechiae develop underneath. 1

Bleeding and Coagulopathy Monitoring

Skin and Bleeding Assessment

• Assess skin for hematomas, ecchymosis, or purpura at regular intervals. 1
• Monitor for minor bleeding: oozing from gums, venipuncture sites, hematuria, hemoptysis. 1
• Monitor for major bleeding: retroperitoneal, genitourinary, gastrointestinal hemorrhages. 1

Invasive Procedure Precautions

• Avoid arterial punctures, catheter insertions, or nasogastric tube placement in first 24 hours if patient received thrombolytics. 1
• If invasive procedures are necessary, apply prolonged pressure to puncture sites. 1

Glucose Management

Monitoring and Treatment

• Monitor serum glucose regularly to reduce risk of hyperglycemia and hypoglycemia. 1
• Treat hypoglycemia (<40-60 mg/dL or <2.2-3.3 mmol/L) immediately to reduce mortality. 1
• Treat moderate to severe hyperglycemia (>180-200 mg/dL or >10.0-11.1 mmol/L). 1
• Avoid intravenous solutions containing glucose (such as D5W) as glucose can worsen brain injury. 1

Fluid Management

Intravenous Therapy

• Maintain normal saline at 75-100 mL/hour to maintain normovolemia. 1
• Monitor intake and output closely. 1
• Avoid hypovolemia as it can worsen cerebral perfusion. 1

Seizure Monitoring and Prevention

Clinical Surveillance

• Monitor continuously for clinical seizures, which occur in up to 16% of patients, particularly with cortical involvement. 1
• Be prepared to administer antiepileptic medications as ordered if seizures occur. 1
• Recognize that seizures most commonly occur at or near onset of hemorrhage. 1

Prevention of Secondary Complications

Immobility-Related Complications

• Implement positioning protocols to prevent pressure ulcers. 4
• Maintain airway through proper positioning and suctioning as needed. 4
• Mobilize within physiological tolerance once stable. 1
• Monitor for deep vein thrombosis risk. 4

Infection Prevention

• Monitor for urinary tract infections, particularly if catheterized. 1, 4
• Assess for respiratory infections related to immobility. 4
• Use sterile technique for all invasive procedures. 4

Nurse-Patient Ratio and Staffing

Staffing Requirements

• Maintain 1:2 nurse-patient ratio for first 24 hours. 1
• If patient's condition is stable after 24 hours, ratio may be adjusted to 1:4 as appropriate. 1
• Ensure nurses are trained in detailed neurological assessment including NIHSS and Glasgow Coma Scale. 1

Emergency Response Protocols

When to Notify Physician Immediately

Contact physician emergently for: 1

• Any change in level of consciousness 1
• Worsening neurological deficits 1
• New pupillary changes 1
• Systolic BP >220 mm Hg or <110 mm Hg 1
• Temperature >99.6°F 1
• Respirations >24 per minute 1
• Pulse <50 or >110 per minute 1

Preparation for Emergency Interventions

• Be prepared to obtain rapid brain imaging (CT or MRI). 1
• Have emergency medications readily available. 1
• Be prepared to assist with emergency procedures including intubation or surgical intervention. 1

Psychosocial Support

Patient and Family Care

• Establish therapeutic relationships with patient and family. 4
• Provide emotional support and education about the condition. 4
• Address concerns and facilitate coping mechanisms. 4
• Educate regarding medication management and importance of follow-up. 4

Common Pitfalls to Avoid

Critical nursing errors that worsen outcomes: 1

• Failing to recognize early signs of deterioration (change in consciousness is earliest sign, not pupillary changes which are late) 1
• Using aggressive antihypertensives that cause venodilation 1
• Positioning head of bed flat when patient has increased ICP risk 1
• Allowing neck rotation or poor head alignment that impedes venous drainage 1
• Performing invasive procedures unnecessarily in first 24 hours 1
• Delaying physician notification when vital sign parameters are exceeded 1