The nurse is caring for a 72-year-old patient brought to the ED with severe headache and decreasing level of consciousness. The nurse reviews the patient's assessment data to prepare the plan of care.

Exhibits

Complete the bowtie by dragging and dropping the condition the patient is most likely experiencing, two interventions the nurse would perform/anticipate related to the condition, and two parameters the nurse would monitor.

Condition the Patient is Most Likely Experiencing:

Intracerebral Haemorrhage (ICH) : The patient presents with a severe headache, lethargy, decreased level of consciousness, and slurred, incomprehensible speech, which are common signs of a stroke or intracerebral haemorrhage. A history of hypertension and atrial fibrillation increases the risk for both ischemic and hemorrhagic strokes. The use of apixaban, an anticoagulant, suggests the patient is at risk for bleeding complications, including intracerebral haemorrhage.

Interventions to Perform/Anticipate:

1. Perform a CT Scan of the Head:
   • Rationale: A CT scan will help determine if there is bleeding or an ischemic event in the brain. It is crucial for differentiating between ischemic and hemorrhagic stroke, guiding subsequent treatment.
2. Administer Intravenous Antihypertensives:
   • Rationale: Controlling blood pressure is critical to reduce the risk of further bleeding in the brain. Immediate BP management is essential in the acute setting of suspected stroke.

Parameters to Monitor:

1. Neurological Status:
   • Rationale: Monitoring changes in the patient’s level of consciousness, pupil reactions, and motor response will help assess the progression of the neurological deficit and effectiveness of interventions.
2. Blood Pressure:
   • Rationale: Maintaining blood pressure within a safe range is essential to prevent exacerbation of the hemorrhage. Hypertension management is key to avoid further complications.