Please use the concept map to plan care for Mr. Jackson. Mr. Jackson is a 38-year-old African American that presents with an altered level of consciousness (ALOC). He has been having headaches for the last three months but due to a hectic work schedule he has not been able to go to see his medical practitioner. During his last visit two years ago, his blood pressure was slightly elevated, but he never followed up. Upon arrival to the ED a CT scan is completed and it shows a large bleed near the frontal lobe. What should Mr. Jackson’s plan of care include?
Here’s a concept map outlining a plan of care for Mr. Jackson:
Mr. Jackson – Altered Level of Consciousness (ALOC)
- Assessment:
- Assess level of consciousness using Glasgow Coma Scale (GCS).
- Monitor vital signs, including blood pressure, heart rate, and oxygen saturation.
- Perform a comprehensive neurological assessment to evaluate motor and sensory function.
- Obtain a detailed history from Mr. Jackson or family members regarding symptoms, medical history, and recent changes in health status.
- Perform a thorough physical examination to identify any additional signs or symptoms.
- Stabilization and Monitoring:
- Ensure patent airway and provide supplemental oxygen if needed.
- Establish intravenous access for fluid administration and medication delivery.
- Initiate continuous cardiac monitoring.
- Monitor neurological status closely, including pupil size and reactivity, motor responses, and vital signs.
- Perform frequent neurological checks to detect any changes in level of consciousness.
- Neurological Interventions:
- Consult with a neurologist or neurosurgeon for further evaluation and management of the intracranial bleed.
- Consider urgent neurosurgical intervention, such as evacuation of the hematoma, if indicated.
- Administer medications as prescribed, such as osmotic diuretics (e.g., mannitol) to reduce cerebral edema, anticonvulsants to prevent seizures, and analgesics for pain relief.
- Maintain Mr. Jackson’s head in a neutral position to optimize cerebral perfusion.
- Blood Pressure Management:
- Monitor blood pressure closely to prevent further bleeding or complications.
- Administer antihypertensive medications as prescribed to control blood pressure within the recommended range.
- Consider a consultation with a hypertension specialist for long-term blood pressure management.
- Diagnostic Investigations:
- Perform additional diagnostic tests as needed, such as a complete blood count, coagulation profile, and renal function tests.
- Repeat neuroimaging studies, such as an MRI, to assess the extent of the bleed and identify potential underlying causes.
- Education and Support:
- Provide education to Mr. Jackson and his family regarding the importance of following up with healthcare providers and adhering to treatment plans.
- Offer emotional support to help Mr. Jackson and his family cope with the diagnosis and potential challenges ahead.
- Encourage lifestyle modifications, such as adopting a heart-healthy diet, regular exercise, stress management techniques, and smoking cessation, to reduce the risk of further complications.
- Discharge Planning and Follow-up:
- Arrange appropriate referrals and consultations for ongoing management, including neurology, neurosurgery, and hypertension specialist follow-up.
- Schedule regular follow-up appointments to monitor Mr. Jackson’s progress, adjust medications, and assess for any complications.
- Provide written instructions, including medication regimen, activity restrictions, and warning signs of worsening symptoms or complications.
Note: This concept map provides a general outline for Mr. Jackson’s care. The actual plan of care should be tailored to his specific condition, clinical judgment, and available resources.