Concept Map and Plan of Care for Mr. Jackson: Hypertensive Intracerebral Hemorrhage Case Study

Understanding Mr. Jackson’s condition

Mr. Jackson’s history and CT findings are most consistent with a hemorrhagic stroke: a spontaneous intracerebral hemorrhage (ICH), most likely related to untreated hypertension. His headaches over three months may have reflected rising blood pressure. Chronic hypertension damages the walls of small cerebral arteries, which weakens them until one ruptures and bleeds into the brain tissue. The expanding hematoma, and the swelling around it, raise intracranial pressure (ICP), which explains his altered level of consciousness.

Because he is young (38) and the bleed is lobar (frontal), the team must also rule out other causes: arteriovenous malformation (AVM), aneurysm, tumor, coagulopathy, and sympathomimetic drug use such as cocaine or amphetamines.

Why the frontal lobe matters

The frontal lobe controls voluntary movement (motor cortex), expressive language (Broca’s area, usually in the left hemisphere), judgment, planning, personality and behavior. Mr. Jackson may develop weakness on the opposite side of the body, difficulty speaking, impulsivity or disinhibition, and impaired judgment. These affect his safety, communication and rehabilitation needs.

Risk factors and health equity

Black Americans have among the highest rates of hypertension in the world, develop it at younger ages, and experience higher rates of stroke and stroke death (Centers for Disease Control and Prevention [CDC], 2024). Mr. Jackson’s missed follow-up because of work demands illustrates how social determinants of health, such as job inflexibility, access to care and possibly insurance or cost, contribute to undiagnosed and untreated hypertension. His care plan must address these barriers, not only his acute bleed.

Concept map: plan of care for Mr. Jackson

Immediate priorities in the emergency department (ABCs and neuro)

1. Airway and breathing: assess airway protection, respiratory pattern and SpO₂. Intubation is needed if his Glasgow Coma Scale (GCS) score is 8 or below, if he cannot protect his airway, or if he has respiratory failure. Give oxygen to keep SpO₂ above 94%.
2. Circulation and blood pressure: for patients with mild to moderate ICH presenting with a systolic BP between 150 and 220 mmHg, current guidelines suggest careful acute lowering to a target systolic BP of about 140 mmHg (keeping it in the 130–150 mmHg range) to reduce hematoma expansion, while avoiding drops below 130 mmHg (Greenberg et al., 2022). Use titratable IV agents such as nicardipine or clevidipine infusions, or IV labetalol, with an arterial line for continuous monitoring.
3. Neurologic assessment: baseline and serial GCS, pupils, NIH Stroke Scale (NIHSS), and motor and speech function. Watch for signs of rising ICP: falling GCS, unequal or sluggish pupils, worsening headache, vomiting, and Cushing’s triad (widening pulse pressure, bradycardia and irregular respirations).
4. Coagulation: check PT/INR, aPTT and platelets. If he takes any anticoagulant or antiplatelet medication, reverse it urgently according to protocol.
5. Diagnostics: CT angiography (CTA) to look for a vascular lesion, and MRI when stable. Labs: CBC, BMP, glucose, troponin, ECG, toxicology screen, type and screen.
6. Consults: urgent neurosurgery (a large lobar hematoma may need surgical evacuation, or an external ventricular drain if hydrocephalus develops) and admission to a neuro-ICU or stroke unit.

Nursing diagnoses, goals, interventions and evaluation

The priority nursing diagnoses below use NANDA International terminology (Herdman et al., 2024) and are listed in order of priority.

1. Decreased intracranial adaptive capacity related to intracerebral hemorrhage and cerebral edema

Evidence: altered level of consciousness, a large frontal bleed on CT, and three months of headache.

Goal: Mr. Jackson will maintain stable or improving neurologic status (GCS, pupils, motor function), with no signs of increased ICP, throughout hospitalization.

Evaluation: GCS stable or improving; pupils equal and reactive; no Cushing’s triad; follow-up CT shows no hematoma expansion.

2. Risk for aspiration and ineffective airway clearance related to decreased level of consciousness and possible dysphagia

Goal: Mr. Jackson will maintain a patent airway and remain free of aspiration pneumonia.

• Keep NPO until a formal dysphagia screen is passed; refer to speech-language pathology.
• Elevate the head of bed; keep suction at the bedside; perform oral care regularly.
• Monitor respiratory rate, breath sounds and SpO₂; report any change.
• If intubated, follow the ventilator-associated pneumonia (VAP) prevention bundle.

Evaluation: clear breath sounds, SpO₂ ≥ 94%, no aspiration events, and a safe diet texture once cleared.

3. Risk for injury (seizures, falls) related to cortical hemorrhage, altered consciousness and impaired judgment

Goal: Mr. Jackson will remain free of injury.

• Lobar (cortical) hemorrhages carry a higher risk of seizures. Apply seizure precautions (padded rails, suction, oxygen ready), and give antiseizure medication for clinical seizures as ordered. Guidelines do not recommend prophylactic antiseizure medication for patients without seizures (Greenberg et al., 2022).
• Implement fall precautions: low bed, bed alarm, frequent rounding, and assistance with mobility. Impulsivity from frontal lobe injury increases fall risk.
• Reorient frequently, and involve family to provide calm, familiar support.

Evaluation: no seizures or falls during hospitalization.

4. Impaired physical mobility and risk for venous thromboembolism related to hemiparesis and bed rest

• Apply intermittent pneumatic compression devices from admission. Pharmacologic prophylaxis may be started later, once the bleed is stable and as ordered (Greenberg et al., 2022).
• Reposition every 2 hours, assess skin, and use pressure-redistribution surfaces.
• Refer early to physical and occupational therapy for range-of-motion exercises and early mobility when stable.

Evaluation: no DVT, pulmonary embolism or pressure injury; mobility improves with therapy.

5. Impaired verbal communication related to frontal lobe (Broca’s area) injury

• Assess speech and language; refer to speech-language pathology.
• Use simple yes/no questions, communication boards, gestures, and extra time to respond.
• Reduce frustration by acknowledging his effort and including family in communication strategies.

6. Ineffective health self-management related to untreated hypertension and work-related barriers to follow-up

Goal: before discharge, Mr. Jackson (or his family) will state his blood pressure target, demonstrate home BP monitoring, and identify a follow-up plan that fits his work schedule.

• Teach about hypertension and its link to his stroke, using plain language and teach-back.
• Long-term BP goal: below 130/80 mmHg to reduce the risk of a recurrent hemorrhage (Greenberg et al., 2022).
• Teach medication adherence and home BP monitoring, with a log or app.
• Lifestyle changes: the DASH, low-sodium diet; physical activity as tolerated; no tobacco or illicit drugs (especially stimulants); limit alcohol; healthy weight; sleep.
• Address barriers: involve a case manager or social worker to coordinate insurance, affordable medications, telehealth or after-hours follow-up, return-to-work planning, and FMLA or disability paperwork.
• Provide culturally respectful education, build trust, and include family or a support person.

7. Anxiety and risk for compromised family coping related to sudden critical illness

• Give family regular, honest updates; explain procedures and equipment.
• Prepare them for possible behavior and personality changes from frontal lobe injury.
• Offer chaplain, social work and support group resources.

Discharge planning and rehabilitation

• Interprofessional assessment for inpatient rehabilitation, skilled nursing or home with outpatient therapy.
• Follow-up with primary care within 1–2 weeks for BP management, plus neurology and neurosurgery as needed.
• Screen for post-stroke depression and cognitive changes.
• Give written and verbal stroke education: BE FAST warning signs (Balance, Eyes, Face, Arms, Speech, Time to call 911).
• Assess driving and return-to-work readiness.

Summary

Mr. Jackson’s altered level of consciousness and frontal lobe bleed most likely represent a hypertensive intracerebral hemorrhage after years of untreated high blood pressure. His plan of care should include:

1. Immediate stabilization of airway, breathing and circulation.
2. Careful blood pressure lowering.
3. Close neurologic monitoring and ICP-lowering measures.
4. Coagulation testing and reversal if needed.
5. Urgent neurosurgical evaluation.
6. Prevention of complications: aspiration, seizures, falls, VTE and pressure injury.
7. Early rehabilitation.
8. Comprehensive, culturally respectful education and case management to control his hypertension long term and remove the barriers that delayed his care.

References

Centers for Disease Control and Prevention. (2024). Stroke facts. https://www.cdc.gov/stroke/data-research/facts-stats/

Greenberg, S. M., Ziai, W. C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J. N., Hemphill, J. C., III, Johnson, R., Keigher, K. M., Mack, W. J., Mocco, J., Newton, E. J., Ruff, I. M., Sansing, L. H., Schulman, S., Selim, M. H., Sheth, K. N., Sprigg, N., & Sunnerhagen, K. S. (2022). 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke, 53(7), e282–e361. https://doi.org/10.1161/STR.0000000000000407

Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024–2026 (13th ed.). Thieme.