Case Presentation of Hemorrhagic Stroke (Subarachnoid Hemorrhage)

CASE PRESENTATIONOF

HEMORRHAGICSTROKE

(Subarachnoid hemorrhage)

Presented By:Presented By:

GROUP 3GROUP 3

Vernalin TerradoVernalin Terrado

Lerma AumanLerma Auman

Elenita MolinaElenita Molina

Richelle ManlangitRichelle Manlangit

Andres JoseAndres Jose

Bernard BartolomeBernard Bartolome

Marlen TignoMarlen Tigno

Subarachnoid hemorrhageSubarachnoid hemorrhage

INTRODUCTION:

A A Stroke,Stroke, cerebrovascular Accident, or what is now being termed as cerebrovascular Accident, or what is now being termed as ““brain attackbrain attack”” is a sudden loss of brain functions resulting from is a sudden loss of brain functions resulting from disruption of blood supply to a part of the brain resulting from disruption of blood supply to a part of the brain resulting from

pathologic blood vessels. It denotes an abnormality of the brain. Stroke pathologic blood vessels. It denotes an abnormality of the brain. Stroke can be classified into ischemic and hemorrhagic strokes. Ischemic can be classified into ischemic and hemorrhagic strokes. Ischemic

stroke can be divided into thrombotic and embolic stroke. Thrombotic stroke can be divided into thrombotic and embolic stroke. Thrombotic stroke results from the narrowing or occlusion of blood vessels due to stroke results from the narrowing or occlusion of blood vessels due to fat deposits while embolic strokes result from the occlusion of a blood fat deposits while embolic strokes result from the occlusion of a blood vessel from a blood clot originating from the other parts of the body, vessel from a blood clot originating from the other parts of the body,

most commonly from the heart.most commonly from the heart.

Hemorrhagic stroke is further classified into intracerebral Hemorrhagic stroke is further classified into intracerebral hemorrhage and subarachnoid hemorrhage. It results from the hemorrhage and subarachnoid hemorrhage. It results from the rupture of blood vessels in the brain. Rupture of arterioles rupture of blood vessels in the brain. Rupture of arterioles result in bleeding into the parenchyma of the brain, while result in bleeding into the parenchyma of the brain, while rupture of larger arteries or its tributaries result in bleeding in rupture of larger arteries or its tributaries result in bleeding in the subarachnoid space. Normal brain metabolism is impaired the subarachnoid space. Normal brain metabolism is impaired by interruption of blood supply, compression and increased by interruption of blood supply, compression and increased ICP.ICP.

Usually due to rupture of intracranial aneurysm, AV Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage.malformation, Subarachnoid hemorrhage.

Risk factors for hemorrhagic stroke includes age, gender, race, Risk factors for hemorrhagic stroke includes age, gender, race, hypertension, smoking and use of illicit drugs.hypertension, smoking and use of illicit drugs.

A stroke causes a wide variety of neurologic deficit, depending on A stroke causes a wide variety of neurologic deficit, depending on thelocation of the lesion,the size of the area of inadequate thelocation of the lesion,the size of the area of inadequate perfusion and the amount of severity of blood flow. It may perfusion and the amount of severity of blood flow. It may include vomiting, headache, seizures, hemiplegia and loss of include vomiting, headache, seizures, hemiplegia and loss of consciousness. Pressure on the brain tissue from increase consciousness. Pressure on the brain tissue from increase intracranial pressure may cause coma and death.intracranial pressure may cause coma and death.

General Objectives:General Objectives:

The primary concern of this study is to further The primary concern of this study is to further enhance the understanding of Cerebrovascular Accident enhance the understanding of Cerebrovascular Accident in congruence with the learned concepts of the Nursing in congruence with the learned concepts of the Nursing students.students.

Objectives of the Study:Objectives of the Study:This case presentation seeks to provide different This case presentation seeks to provide different

information about the disease to be presented about information about the disease to be presented about the client being considered with the ff. specific the client being considered with the ff. specific objectives:objectives:

1. 1. Give a brief introduction about Cerebrovascular Give a brief introduction about Cerebrovascular Accident together with it clinical manifestations.Accident together with it clinical manifestations.

2. Present a theoretical framework for the study in 2. Present a theoretical framework for the study in relation to a nursing approach applied to a patient relation to a nursing approach applied to a patient with hemorrhagic stroke.with hemorrhagic stroke.

3. Present the clients demographic and health history with 3. Present the clients demographic and health history with its Gordons eleven functional health pattern.its Gordons eleven functional health pattern.

4. Present the abnormal results of the physical assessment and 4. Present the abnormal results of the physical assessment and compare it to the normal values or findings.compare it to the normal values or findings.

5. Present the different laboratory test and results done to the client 5. Present the different laboratory test and results done to the client with its interpretation.with its interpretation.

6. Discuss the normal Anatomy and Physiology of Circulatory and 6. Discuss the normal Anatomy and Physiology of Circulatory and Central Nervous System.Central Nervous System.

7. Explain the Pathophysiology of Hemorrhagic stroke7. Explain the Pathophysiology of Hemorrhagic stroke

8. Identify Nursing Problems related to the situation and 8. Identify Nursing Problems related to the situation and case of the clientcase of the client

9. Discuss the drugs that has been used and prescribed to 9. Discuss the drugs that has been used and prescribed to the client by a drug analysis.the client by a drug analysis.

10. Present a Nursing Care Plan for the prioritized 10. Present a Nursing Care Plan for the prioritized problems of the client.problems of the client.

11. Show a Discharge Planning that the client may use 11. Show a Discharge Planning that the client may use upon discharge to the hospital.upon discharge to the hospital.

Theoretical Framework: Virginia HendersonTheoretical Framework: Virginia Henderson

Difficulty of Difficulty of BreathingBreathing

Impaired skin Impaired skin IntegrityIntegrity HPNHPN UrinaryUrinary

dysfunctiondysfunctionHyperthermiaHyperthermia

Loss of Loss of consciousnessconsciousness immobilityimmobility Poor Poor

HygieneHygiene

Nursing interventionNursing intervention

Sleep and Sleep and restrest

Eliminate Eliminate body wastesbody wastes

Maintain Maintain body tempbody temp

Sleep and Sleep and rest and rest and

CommunicateCommunicate with with othersothers

Move and Move and maintain maintain DesirableDesirable posturespostures

Keep Keep body body clean clean

and welland well groomedgroomed

Breath Breath NormallyNormally

Eat and drink Eat and drink adequatelyadequately

Improved HealthImproved Health

Comprehensive History:Comprehensive History:Biographic History:Biographic History:NameName : D.A.C: D.A.CCity AddressCity Address :Blk 14, lot 52 PVR-1, Norzagaray, Bulacan:Blk 14, lot 52 PVR-1, Norzagaray, BulacanProvincial AddressProvincial Address :Romblon (Visayas):Romblon (Visayas)AgeAge : 53 years old: 53 years oldGenderGender : Male: MaleReligious AffiliationReligious Affiliation : Roman Catholic: Roman CatholicMarital StatusMarital Status : Married: MarriedOccupationOccupation : Unemployed (formerly a construction worker): Unemployed (formerly a construction worker)Source of InformationSource of Information: Daughter: DaughterRoom & Bed No.Room & Bed No. : Male Ward Bed #9: Male Ward Bed #9Date of BirthDate of Birth : November 18, 1955: November 18, 1955DiagnosisDiagnosis : Cerebrovascular Accident (subarachnoid : Cerebrovascular Accident (subarachnoid

hemorrhagic)hemorrhagic)PhysicianPhysician : Dr. Steve Conneroid: Dr. Steve ConneroidChief complaint:Chief complaint: : Loss of consciousness: Loss of consciousnessDate of admissionDate of admission : January 05, 2009: January 05, 2009

Present ConditionPresent Condition::

Two days prior to admission, the patient experienced highTwo days prior to admission, the patient experienced high

blood pressure accompanied by low grade fever. At thatblood pressure accompanied by low grade fever. At that

time, the client is having an argument with his daughtertime, the client is having an argument with his daughter

that day before the time he was admitted which serves asthat day before the time he was admitted which serves as

a triggering factor of his present illness. Upon admissiona triggering factor of his present illness. Upon admission

her daughter claim that her father experienced severeher daughter claim that her father experienced severe

headache followed by loss of consciousness. After series ofheadache followed by loss of consciousness. After series of

tests he was diagnosed to have experienced or suffered atests he was diagnosed to have experienced or suffered a

hemorrhagic stroke.hemorrhagic stroke.

Past Medical History:Past Medical History:

Three months prior to admission, the patientThree months prior to admission, the patient

Experienced intermittent flu and Arthritis in both knees. Experienced intermittent flu and Arthritis in both knees. While on this condition, the patient’s bloodWhile on this condition, the patient’s blood

pressure keeps elevating at a range of 150/90 mmHgpressure keeps elevating at a range of 150/90 mmHg

To 190/100 mmHg. To 190/100 mmHg.

The patient also experienced a vehicular accident on The patient also experienced a vehicular accident on his bicycle two months ago, but no abnormal his bicycle two months ago, but no abnormal manifestation has been observed aside from multiple manifestation has been observed aside from multiple superficial wounds.superficial wounds.

Family History:Family History:

The paternal side of the patient has a history of The paternal side of the patient has a history of pulmonary tuberculosis.pulmonary tuberculosis.

The maternal side of the patient has a history of The maternal side of the patient has a history of hypertension and heart disease.hypertension and heart disease.

Activities of daily livingActivities of daily living

A. Health perception and health management patternA. Health perception and health management pattern

According to her, her father doesn’t go to According to her, her father doesn’t go to the doctor for consultation on his health status. He the doctor for consultation on his health status. He seldom takes any medicine for his common seldom takes any medicine for his common illnesses though he sometimes takes paracetamol to illnesses though he sometimes takes paracetamol to relieve fever. She also states that her father is a relieve fever. She also states that her father is a heavy alcohol drinker and cigarette smoker.the heavy alcohol drinker and cigarette smoker.the patient self perception of health prior and upon patient self perception of health prior and upon hospitalization is undermined because the patient hospitalization is undermined because the patient is in the state of coma.is in the state of coma.

B. Nutritional and Metabolic PatternB. Nutritional and Metabolic Pattern

Before the patient was hospitalized, he normally Before the patient was hospitalized, he normally eats fried chicken, especially the skin, chicharon and eats fried chicken, especially the skin, chicharon and processed meats such as tocino and longganisa. He processed meats such as tocino and longganisa. He seldom eat vegetables and fruits. He prefers meat over seldom eat vegetables and fruits. He prefers meat over fish. fish.

C. Elimination PatternC. Elimination Pattern

Prior to admission the patient has a regular Prior to admission the patient has a regular bowel pattern but after he was hospitalized he was not bowel pattern but after he was hospitalized he was not able to defecate for 3 days. He urinates 5 to 7 times a able to defecate for 3 days. He urinates 5 to 7 times a day with a light yellow color before he is admitted, now day with a light yellow color before he is admitted, now he has an indwelling urinary catheter draining dark he has an indwelling urinary catheter draining dark yellow urine.yellow urine.

D. Activity-Exercise PatternD. Activity-Exercise Pattern

According to the patientAccording to the patient’’s daughter, her father s daughter, her father spends most of his time gambling or having a drinking spends most of his time gambling or having a drinking session with neighbors and friends. He doesn’t have a session with neighbors and friends. He doesn’t have a job and he didn’t mind looking for one. He doesn’t help job and he didn’t mind looking for one. He doesn’t help in household chores instead he preferred spending his in household chores instead he preferred spending his time watching television.time watching television.

E. Sleep E. Sleep –– Rest Pattern Rest Pattern

The patient has a habit of taking short nap in The patient has a habit of taking short nap in the afternoon for 2 hours. In the evening he usually the afternoon for 2 hours. In the evening he usually retires at around 2:00am and usually sleeps for 3 retires at around 2:00am and usually sleeps for 3 hours. This is primarily due to his fathers’ failing hours. This is primarily due to his fathers’ failing ability to promote sleep.ability to promote sleep.

F. Cognitive F. Cognitive –– Perceptual Pattern Perceptual Pattern

The patient can read and write, he doesn’t have The patient can read and write, he doesn’t have hearing difficulty before he was hospitalized. He hearing difficulty before he was hospitalized. He doesn’t wear eyeglasses. His daughter said that her doesn’t wear eyeglasses. His daughter said that her father still possess a sharp memory and still recalls past father still possess a sharp memory and still recalls past experiences with spontaneity. Her daughter also experiences with spontaneity. Her daughter also reported that her father doesn’t have any speech reported that her father doesn’t have any speech problem and has a normal sense of taste and smell problem and has a normal sense of taste and smell before he was hospitalized.before he was hospitalized.

G. Self G. Self –– perception and Self perception and Self –– Concept Pattern Concept Pattern

According to the daughter her father verbalizes According to the daughter her father verbalizes that his contentment of a well balanced health that his contentment of a well balanced health condition. Now his self- perception is undermined, condition. Now his self- perception is undermined, since the client is in the state of coma.since the client is in the state of coma.

H. Role H. Role –– Relationship Pattern Relationship Pattern

Significant people to the client are his family. He Significant people to the client are his family. He is the head of the family. His daughter stated that the is the head of the family. His daughter stated that the only problem they have is the hospitalization of her only problem they have is the hospitalization of her father because of financial problems that arises from it. father because of financial problems that arises from it. They resolve and manage their problems through They resolve and manage their problems through constant communication themselves.constant communication themselves.

I. Sexually I. Sexually –– Reproductive Pattern Reproductive Pattern

His daughter said that her father shows his His daughter said that her father shows his affection to his family by constantly kissing and affection to his family by constantly kissing and hugging them. The client has three children: two girls hugging them. The client has three children: two girls and a boy.and a boy.

J. Coping J. Coping –– Stress Tolerance Pattern Stress Tolerance Pattern

Before being hospitalized the client experiences Before being hospitalized the client experiences many stressors are brought about by financial factor many stressors are brought about by financial factor and health problems. They are able to cope up by and health problems. They are able to cope up by constantly cooperating with one another. constantly cooperating with one another.

K. Value K. Value –– Belief Pattern Belief Pattern

Her father does not hear mass on a regular basis Her father does not hear mass on a regular basis because he believes that God is always in our hearts because he believes that God is always in our hearts and that we donand that we don’’t need to go to church just to pray. Yet t need to go to church just to pray. Yet he believes that being a Catholic is the best way to be he believes that being a Catholic is the best way to be close to God.close to God.

Physical Assessment:Physical Assessment:BP: 160/90BP: 160/90 PR: 102 BpmPR: 102 BpmTemp: 39˚CTemp: 39˚C RR: 38 BpmRR: 38 Bpm

BODY PARTS BODY PARTS TECHNIQUE TECHNIQUE USED USED

NORMAL NORMAL FINDINGS FINDINGS

ACTUAL ACTUAL FINDING FINDING

ANALYSIS ANALYSIS

1. SKULL 1. SKULL Inspection, Inspection, palpation palpation

Proportional to Proportional to the size of the the size of the body, round body, round with with prominences in prominences in the frontal and the frontal and occipital area, occipital area, symmetrical in symmetrical in all place all place

The skull is The skull is normocephalic normocephalic and symmetrical and symmetrical to the body with to the body with prominences in prominences in the frontal and the frontal and occipital area, occipital area, symmetrical in all symmetrical in all place place

Normal Normal

2. SCALP 2. SCALP Inspection Inspection White, clean, White, clean, free from free from masses, lumps, masses, lumps, scars, and scars, and lesions no areas lesions no areas of tenderness of tenderness

White, no masses, White, no masses, lumps, scars, and lumps, scars, and lesions no area of lesions no area of tenderness is tenderness is observed. observed.

Normal Normal

3. FACE 3. FACE Inspection Inspection Oblong or round Oblong or round or square, or or square, or heart shaped,, heart shaped,, facial expression facial expression that is dependent that is dependent on the mood or on the mood or true feelings, no true feelings, no involuntary involuntary muscle, muscle, Symmetric facial Symmetric facial movements.movements.

Oblong. No facial Oblong. No facial movement is movement is observed. There observed. There were presence of were presence of acne around his acne around his forehead. forehead.

Not normal-Not normal-Indicates Indicates impairment of impairment of facial nerves facial nerves which cause which cause paralysis. paralysis.

4. EYES 4. EYES Inspection Inspection Parallel and Parallel and evenly spaced evenly spaced symmetrical, non- symmetrical, non- protruding, pink protruding, pink palpebral palpebral conjunctiva, and conjunctiva, and pupils black in pupils black in color, equal in color, equal in size, round and size, round and constricts in constricts in response to light. response to light.

Dilated pupils Dilated pupils which is black in which is black in color and non color and non reacting to light. reacting to light. He have some He have some discharges around discharges around the lacrimal area. the lacrimal area.

-Not Normal--Not Normal-Indicates Indicates altered level altered level of of consciousness. consciousness.

5. NOSE 5. NOSE Inspection Inspection Midline Midline symmetrical symmetrical and patent, no and patent, no discharge. discharge.

Midline Midline symmetrical symmetrical and patent, no and patent, no discharge. With discharge. With presence of presence of nasogastric tube nasogastric tube insertion on the insertion on the right nares. right nares.

NormalNormal

6. EARS 6. EARS InspectionInspection Parallel Parallel symmetrical, symmetrical, proportional to proportional to the size of the the size of the head, bean-head, bean-shaped, skin is shaped, skin is same color as same color as the surrounding the surrounding color, clean color, clean firm cartilage. firm cartilage.

Parallel Parallel symmetrical, symmetrical, proportional to proportional to the size of the the size of the head, bean-head, bean-shaped, skin is shaped, skin is same color as same color as the surrounding the surrounding color, with dust color, with dust accumulation accumulation on firm on firm cartilage. cartilage.

Not normal-Not normal-Indicates Indicates poor poor personal personal hygiene-hygiene-inadequate inadequate selfcare selfcare primarily primarily caused by caused by self care self care deficit.deficit.

7. MOUTH 7. MOUTH Inspection Inspection Symmetrical, Symmetrical, gums pinkish in gums pinkish in color, lips margin color, lips margin is symmetrical, is symmetrical, no lesion and no lesion and tenderness, tenderness, without without involuntary involuntary movement movement

Symmetrical, Symmetrical, gums slightly gums slightly dark in color with dark in color with yellowish teeth, yellowish teeth, lips margin is lips margin is symmetrical, no symmetrical, no lesion and lesion and tenderness, tenderness, without without involuntary involuntary movement movement

NormalNormal

A. SKIN A. SKIN Inspection, Inspection, palpation palpation

Varies from light Varies from light to deep brown, to deep brown, from ruddy pink from ruddy pink to light pink, to light pink, from yellow from yellow overtones to olive, overtones to olive, generally uniform generally uniform skin temperature skin temperature

With uniform With uniform deep brown skin deep brown skin color with slightly color with slightly elevated elevated temperature. temperature. Poor skin Poor skin integrity and integrity and redness on bony redness on bony prominences.prominences.

Not normal-Not normal-The client has The client has impaired skin impaired skin integrity with integrity with hyperthermia hyperthermia and and disruptions on disruptions on skin integrity. skin integrity.

B. HAIR B. HAIR Inspection Inspection Thick, silky, Thick, silky, resilient, free resilient, free from from infestation, infestation, evenly evenly distributed and distributed and covers whole covers whole scalp. scalp.

Thick, oily with Thick, oily with traces of white traces of white hairs evenly hairs evenly distributed distributed which covers which covers the whole scalp the whole scalp and free from and free from infestation. infestation.

Normal Normal

C.NAILS C.NAILS Inspection, Inspection, palpation palpation

Convex Convex curvature curvature smooth texture, smooth texture, highly vascular highly vascular and pink, and pink, prompt return prompt return of pink less of pink less than 4 seconds than 4 seconds

Long with Long with convex convex curvature curvature smooth texture, smooth texture, highly vascular highly vascular with bluish to with bluish to pinkish pinkish discoloration, discoloration, capillary refill is capillary refill is prompt. prompt.

NormalNormal

D.NECK D.NECK REGION REGION

Inspection, Inspection, palpation palpation

Symmetrical Symmetrical and straight, no and straight, no palpable lumps, palpable lumps, and supple, and supple, trachea is on trachea is on midline of neck, midline of neck, and spaces are and spaces are equal on both equal on both sides. sides.

Symmetrical Symmetrical and straight, no and straight, no palpable lumps, palpable lumps, and supple, and supple, trachea is on trachea is on midline of neck, midline of neck, and spaces are and spaces are equal on both equal on both sides. sides.

Normal Normal

E. LUNGS E. LUNGS Auscultation Auscultation Symmetrical Symmetrical chest expansion, chest expansion, clear breath clear breath sounds. sounds.

Difficulty of Difficulty of breathing with breathing with breath sounds breath sounds (ronchi) audible (ronchi) audible even without the even without the use of use of stethoscope stethoscope having the having the respiration rate respiration rate of 38 Bpm. of 38 Bpm.

Not normal-Not normal-Indicates Indicates tachypnea tachypnea primarily primarily due to due to hypertensionhypertension..

F. HEART F. HEART Auscultation Auscultation A dynamic A dynamic pericardium, pericardium, normal rate, normal rate, regular rhythm, regular rhythm, no murmur. no murmur.

Palpitations Palpitations with elevated with elevated heart rate of heart rate of 115 bpm. 115 bpm.

Not Normal-Not Normal-indicates indicates increase increase cardiac cardiac overload due overload due to increase to increase blood blood pressure pressure

G.PHERIPERG.PHERIPERAL AL

Palpation Palpation Symmetrical Symmetrical pulse volume, pulse volume, full pulsation full pulsation

Symmetrical Symmetrical pulse volume, pulse volume, full pulsation full pulsation

Normal Normal

H. BREAST H. BREAST Inspection, Inspection, palpation palpation

No tenderness, No tenderness, masses, nodules masses, nodules and discharge. and discharge.

No tenderness, No tenderness, masses, nodules masses, nodules and discharge. and discharge.

Normal Normal

I. ABDOMEN I. ABDOMEN Inspection, Inspection, Auscultation,Auscultation,

Percussion, Percussion, Palpation. Palpation.

Uniform color, Uniform color, rounded rounded symmetrical symmetrical contour, contour, audible bowel audible bowel sounds, no sounds, no tenderness, tenderness, liver and liver and bladder are not bladder are not palpable palpable

Uniform color, Uniform color, rounded rounded symmetrical symmetrical contour, audible contour, audible bowel sounds, bowel sounds, no tenderness, no tenderness, liver and liver and bladder are not bladder are not palpable palpable

Normal Normal

J.MALE J.MALE GENITALIA GENITALIA

Inspection Inspection Normal pubic Normal pubic hair distribution hair distribution is noted and free is noted and free from infestation. from infestation. Penile lesions, Penile lesions, masses, or masses, or discharges are discharges are not not present.Testes is present.Testes is symmetric symmetric without masses without masses or undue or undue tenderness. The tenderness. The left testis may be left testis may be slightly larger slightly larger and hang lower and hang lower than the right than the right testis.Inguinal or testis.Inguinal or femoral hernias femoral hernias are not present.are not present.

The genitalia The genitalia was not was not assessed assessed because the because the relatives relatives refused to do refused to do so. so. The patient The patient also has an also has an indwelling indwelling catheter. catheter.

Not Normal-Not Normal-Indicates Indicates Urinary Urinary dysfunction dysfunction (refer to (refer to laboratory laboratory result).result).

K. UPPER K. UPPER AND AND LOWER LOWER EXTREMITIEXTREMITIES ES

Inspection Inspection Equal size on Equal size on both sides of both sides of the body, no the body, no contractures, contractures, deformities and deformities and tenderness, tenderness, normally firm, normally firm, joints move joints move smoothly. smoothly.

Immobilization Immobilization of all the of all the extremities. extremities.

Not normal Not normal the patient is the patient is comatose.comatose.

Laboratory Test:

BLOOD CHEMISTRY

Test Test Results Normal Values

Glucose HGT 105 75-115mg/dl

Creatinine 1.71.7 0.6-1.1mg/dl

Sodium 142142 135-140mmol/L

Potassium 3.5 3.5-5.3mmol/L

Uric acid 4.5 3.4-7.0mg/dl

Total Cholesterol 250250 <200mg/dl

Triglycerides 133 <200mg/dl

HDL 40.8 40-58.7mg/dl

BLOOD HEMATOLOGY

Results Normal Values

RBC 8.08.0 4.5-5.8 x 12/L

WBC 15,90015,900 5000-10000/cumm

Hgb 2121 14-18 x 12/L

Hct 0.620.62 0.42-0.52 x 12/L

Platelet count 300000 150000-450000/cumm

Segmenters 0.66 0.50-0.66

Lymphocytes 0.30 0.20-0.40

Monocytes 0.04 0.02-0.08

LUNGS (process f oxygenation)

Pulmonary trunk & pulmonary Arteries

Right Ventricle

Tricuspid Valve

Right Atrium

Superior & Inferior Vena cava

Unoxygenated Blood

Blood Circulation:Blood Circulation:

Anatomy and Physiology

Aorta

Aortic Valve

Left ventricle

Bicuspid valve

Left Atrium

Pulmonary Vein

Systemic CirculationSystemic Circulation

BRAIN: Cranial Nerves1.1. Olfactory:Olfactory: Smell Smell 2.2. Optic: Optic: Visual fields and ability to see Visual fields and ability to see 3.3. Oculomotor: Oculomotor: Eye movements; eyelid opening Eye movements; eyelid opening 4.4. Trochlear: Trochlear: Eye movements Eye movements 5.5. Trigeminal: Trigeminal: Facial sensation Facial sensation 6.6. Abducens:Abducens: Eye movements Eye movements 7.7. Facial: Facial: Eyelid closing; facial expression; taste Eyelid closing; facial expression; taste

sensation sensation 8.8. Auditory/vestibular:Auditory/vestibular: Hearing; sense of balance Hearing; sense of balance 9.9. Glossopharyngeal: Glossopharyngeal: Taste sensation; swallowing Taste sensation; swallowing 10.10. Vagus: Vagus: Swallowing; taste sensation Swallowing; taste sensation 11.11. Accessory: Accessory: Control of neck and shoulder muscles Control of neck and shoulder muscles 12.12. Hypoglossal: Hypoglossal: Tongue movement Tongue movement

• Cranial Nerves – There are 12 pairs of nerves that originate from Cranial Nerves – There are 12 pairs of nerves that originate from the brain itself. These nerves are responsible for very specific the brain itself. These nerves are responsible for very specific activities and are named and numbered as follows: activities and are named and numbered as follows:

• Olfactory: Smell Olfactory: Smell • Optic: Visual fields and ability to see Optic: Visual fields and ability to see • Oculomotor: Eye movements; eyelid opening Oculomotor: Eye movements; eyelid opening • Trochlear: Eye movements Trochlear: Eye movements • Trigeminal: Facial sensation Trigeminal: Facial sensation • Abducens: Eye movements Abducens: Eye movements • Facial: Eyelid closing; facial expression; taste sensation Facial: Eyelid closing; facial expression; taste sensation • Auditory/vestibular: Hearing; sense of balance Auditory/vestibular: Hearing; sense of balance • Glossopharyngeal: Taste sensation; swallowing Glossopharyngeal: Taste sensation; swallowing • Vagus: Swallowing; taste sensation Vagus: Swallowing; taste sensation • Accessory: Control of neck and shoulder muscles Accessory: Control of neck and shoulder muscles • Hypoglossal: Tongue movement Hypoglossal: Tongue movement

Cranial MeningesCranial Meninges

BRAINBRAIN

BRAINBRAIN

PATHOPHYSIOLOGY Non-modifiable Risk Factors

>Advanced Age>Gender

>Heredity

Modifiable Risk Factors>HPN

>Smoking>excessive intake of foods high in fats and cholesterol

Triggering Factors>Sudden extreme emotion

Bleeding into the brain tissue and subarachnoid space

Cerebral aneurysmrupture

Blood Clots in the Subarachnoid Space

Arteriovenous malformation

Brain CompressionBlood supply interruption

S/S:>Severe Headache>Drowsiness>Loss of consciousness

Tissue Necrosis

Neuronal Death

Increase Intracranial Pressure

Epileptic Seizure:increase intraocular pressure= blindness

Regional Paralysis

Total Paralysis

Death

coma

Medication Medication Classification/ Classification/ ActionAction

Indication Indication Contraindication Contraindication Side effects Side effects Adverse effects Adverse effects Nursing Nursing consideration consideration

Generic name: Generic name: nifedipinenifedipine

Brand name:Brand name:

Calcibloc Calcibloc

Route: oralRoute: oral

Dosage: 180mg Dosage: 180mg

Frequency: once Frequency: once a day a day

Inhibits Inhibits calcium ion calcium ion influx across influx across all membrane all membrane during during cardiac cardiac depolarizationdepolarization, produces , produces relaxation of relaxation of coronary coronary vascular vascular smooth smooth muscle and muscle and peripheral peripheral vascular vascular smooth smooth muscle, dilates muscle, dilates coronary coronary arteries, arteries, increase increase myocardial myocardial oxygen oxygen delivery in delivery in patients with patients with vasospastic vasospastic

Treatment of Treatment of vasospatic, vasospatic, angina, angina, chronic stable chronic stable angina, angina, hypertension hypertension (sustained- (sustained- released released tablets only. tablets only.

Hypersensitivity, Hypersensitivity, cardiovascular cardiovascular shock, shock, combination with combination with rifampicine rifampicine contraindicated contraindicated in unstable in unstable angina and after angina and after resent MI severe resent MI severe hypotension, hypotension, with systolic with systolic pressure less pressure less than 90 mmHg than 90 mmHg decompensate decompensate heart failure heart failure pregnancy and pregnancy and lactation lactation

Patients Patients withdrawn withdrawn from from blockers blockers while taking while taking nifedifine nifedifine may may experience experience increase increase angina angina

Dizziness, Dizziness, flushing, flushing, headache, headache, hypotension hypotension peripheral peripheral edema, edema, tachycardia and tachycardia and palpitation palpitation

Use caution in Use caution in severe aortic severe aortic stenosis or severe stenosis or severe hepatic hepatic impairmentimpairment

Assess potential Assess potential for interactions for interactions with other with other pharmacological pharmacological agents or herbal agents or herbal products patients products patients is taking that may is taking that may increase risk of increase risk of hypotension and hypotension and toxicitytoxicity

Monitor blood Monitor blood pressure and pressure and pulse before pulse before therapy, during therapy, during dosedose

Drug study 1Drug study 1

filtration and filtration and periodically during periodically during therapy monitor therapy monitor ECG periodically ECG periodically during prolonged during prolonged therapytherapy

Assess therapeutic Assess therapeutic effectiveness and effectiveness and adverse reactionadverse reaction

Assess location, Assess location, duration intensity, duration intensity, precipitating factor precipitating factor of patients angina of patients angina pain pain



Generic name: Generic name: MannitolMannitol

Brand name: Brand name: Osmitrol Osmitrol

Route: IVRoute: IV

Dosage:Dosage:

Adult 0.25-2 g/kg Adult 0.25-2 g/kg as 15 to 25% as 15 to 25% solution over 30 solution over 30 to 60 min.to 60 min.

Children 1-2 g/kg Children 1-2 g/kg (30 – 60 g/m2)as (30 – 60 g/m2)as a 15 to 20 a 15 to 20 solution 0ver 30 solution 0ver 30 – 60%– 60%

Frequency:Frequency:

4x daily 4x daily

Increases the Increases the osmotic osmotic pressure of pressure of the the glomerular glomerular filtrate, filtrate, thereby thereby inhibiting inhibiting reabsorption reabsorption of water and of water and electrolytes.electrolytes.

Adjunct in the Adjunct in the treatment of treatment of acute oliguric acute oliguric renal failure, renal failure, adjunct in the adjunct in the treatment of treatment of edema, edema, redunction of redunction of intraocular intraocular pressure, to pressure, to promote the promote the excreation of excreation of certain toxic certain toxic substances.substances.

Hypersensitivity , Hypersensitivity , anuria, anuria, dehydration, dehydration, intracranial intracranial bleeding.bleeding.

CNS: headache, CNS: headache, confusion.confusion.

EENT: blurred EENT: blurred vision, rhinitisvision, rhinitis

CV: transient CV: transient volume volume expansion, expansion, tachycardia, tachycardia, chest pain, chest pain, congestive heart congestive heart failure, failure, pulmonary pulmonary edema.edema.

GI: thirst, GI: thirst, nausea, nausea, vomitingvomiting

GU: renal GU: renal failure, urinary failure, urinary retention.retention.

Monitor vital Monitor vital signs, urine signs, urine output, CVP, and output, CVP, and pulmonary artery pulmonary artery pressure prior to pressure prior to and hourly and hourly throughout throughout administration.administration.

Assess patient for Assess patient for signs and signs and symptoms of symptoms of dehydration or dehydration or signs of fluid over signs of fluid over load.load.

Assess patient for Assess patient for anorexia, muscle anorexia, muscle weakness, weakness, numbness, numbness, tingling, confusion tingling, confusion and excessive and excessive thirst.thirst.


Monitor neurologic Monitor neurologic status and status and intracranial intracranial pressure readings pressure readings in patient receiving in patient receiving this medication to this medication to decrease cerebral decrease cerebral edema.edema.



Generic name:Generic name:

AmlodipineAmlodipine


Amvasc, norvascAmvasc, norvasc

Route: Route:

Dosage:Dosage:

5 mg5 mg

Frequency:Frequency:

Once daily Once daily

Inhibits influx Inhibits influx of calcium ion of calcium ion across cell across cell membranes to membranes to produce produce relaxation of relaxation of coronary coronary vascular vascular smooth smooth muscle muscle (dilatation of (dilatation of coronary coronary arteries) arteries) decrease decrease peripheral peripheral vascular vascular resistance of resistance of smooth smooth muscle muscle (decrease (decrease blood blood pressure)pressure)

Hypertension, Hypertension, chronic stable chronic stable angina, angina, vasospatic vasospatic angina angina

Sick sinus Sick sinus syndrome; syndrome; second-or-third- second-or-third- degree degree artrioventicular artrioventicular block exept with block exept with a functioning a functioning pacemaker pacemaker

CHF, CHF, hepatic hepatic impairment, impairment, caustious caustious use is use is required required

Palpitations, Palpitations, peripheral peripheral edema, syncope, edema, syncope, tachycardia, tachycardia, bradycardia, bradycardia, arrythmias, arrythmias, ventricular ventricular asystoles, asystoles, headache, headache, dizziness, dizziness, lightheadedness, lightheadedness, fatigue, fatigue, lethargy, lethargy, somnolence, somnolence, dermatitis,rash dermatitis,rash pruritus, pruritus, uticaria,nausea, uticaria,nausea, abdominal abdominal discomfort, discomfort, cramps, cramps, dyspepsia, dyspepsia, shortness of shortness of breath, breath,

Assess cardio Assess cardio respiratory status. respiratory status. Angina pain, B/P Angina pain, B/P pulse, respiration, pulse, respiration, ECGECG

Assess hydration Assess hydration and fluid volume and fluid volume status, input and status, input and output ratio, output ratio, presence of presence of edema, distended edema, distended neck veins, luck neck veins, luck crackles, adequate crackles, adequate pulses and skin pulses and skin turgor. turgor.


and increases and increases myocardial myocardial oxygen oxygen delivery in delivery in patients with patients with vasospatioc vasospatioc

angina.angina.

dyspnea, dyspnea, wheezing, wheezing, flushing, flushing, sexual sexual difficulties, difficulties, muscle muscle cramps, pain cramps, pain or or inflammationinflammation

Monitor liver Monitor liver function ALT, function ALT, AST, bilirubinAST, bilirubin

Monitor if platelet Monitor if platelet count is less than count is less than 150,000/mm, drug 150,000/mm, drug is usually is usually discontinued and discontinued and another drug another drug

started.started.


Indication Indication Contraindication Contraindication Side Side effects effects

Adverse effects Adverse effects Nursing Nursing consideration consideration

Generic name:Generic name:

AcetomenophenAcetomenophen


AminofenAminofen

Route: Route:

IVIV

Dosage:Dosage:

325-1000mg 325-1000mg every 4 to 6 hrs every 4 to 6 hrs neededneeded

Inhibits the Inhibits the synthesis of synthesis of prostaglandin prostaglandin that may serve that may serve as mediators of as mediators of pain and fever.pain and fever.

Therapeutic Therapeutic effects.effects.•Analgesic (due Analgesic (due to peripheral to peripheral prostaglandin prostaglandin inhibitors)inhibitors)•Antipyresis Antipyresis (lowers fever); (lowers fever); due to inhibitors due to inhibitors of prostaglandin of prostaglandin in the CNSin the CNS

No significant No significant anti anti inflammatory inflammatory propertiesproperties

•Mild to Mild to moderate moderate painpain•FeverFever

Previous Previous hypertensivehypertensive

Product Product containing containing alcohol, alcohol, aspartame, aspartame, saccharin, sugar saccharin, sugar or tartrazine.or tartrazine.

GI: hepatic GI: hepatic necrosisnecrosis

DERM: rash, DERM: rash, urticaria.urticaria.

•Advise patient to Advise patient to take medication take medication exactly as exactly as directed and not directed and not to take more than to take more than the recommended the recommended amount.amount.

Severe and Severe and permanent liver permanent liver damage may damage may result from result from prolonged use or prolonged use or high doses of high doses of acetomenophe.acetomenophe.

Adult should not Adult should not take take acetomenophen acetomenophen longer than 10 longer than 10 days and children days and children longer than 5 longer than 5 days unless days unless directed by directed by physician.physician.


•Advise the patient to Advise the patient to consult the physician if consult the physician if discomfort or fever is not discomfort or fever is not relieved by routine relieved by routine dosages of this drug or if dosages of this drug or if fever is greater than 39.5 fever is greater than 39.5 (103 F) or lasts longer (103 F) or lasts longer than 3 daysthan 3 days

Nursing Care Plan OneNursing Care Plan OneASSESSMENASSESSMEN

TTDIAGNOSISDIAGNOSIS OBJECTIOBJECTI

VEVEPLANNINGPLANNING INTERVENTIONINTERVENTION RATIONALRATIONAL

EEEVALUATIONEVALUATION

Objective Objective cues:cues:

•ClavicularClavicular

•BreakingBreaking

•Rhonchi Rhonchi breathing breathing soundsound

•Increase Increase respiratory respiratory rate of 36 to rate of 36 to 38 bpm38 bpm

Ineffective Ineffective airway airway clearance clearance related to related to retained retained mucus mucus secretion due secretion due to absence of to absence of cough reflex.cough reflex.

Scientific Scientific Explanation: Explanation: Inability to Inability to clear clear secretions or secretions or obstruction obstruction from the from the respiratory respiratory tract to tract to maintain a maintain a clear air clear air way.way.

After four After four hours of hours of nursing nursing interventiointervention the client n the client airway airway clearance clearance will be will be cleared.cleared.

Plan ways on Plan ways on how to how to reduce reduce congestion on congestion on airway.airway.

Position head Position head midline with flexion midline with flexion appropriate for appropriate for condition.condition.

Oropharyngial Oropharyngial suctioning (as suctioning (as needed)needed)

Elevate head of the Elevate head of the bed and change bed and change position every 2 position every 2 hrs.hrs.

Increased fluid Increased fluid intake at least 3000 intake at least 3000 ml/dayml/day

To open or To open or maintain maintain airway to the airway to the client.client.

To clear To clear airway when airway when secretions are secretions are blocking on blocking on airway.airway.

To decrease To decrease the pressure the pressure on the on the diaphragm.diaphragm.

To help To help liquefy liquefy secretionsecretion

After four After four hours of hours of nursing nursing intervention the intervention the client air way client air way clearance is clearance is cleared.cleared.

Auscultate breath Auscultate breath souds and assess souds and assess air movement air movement

To maitain To maitain status and note status and note progressprogress

Nursing Care Plan TwoNursing Care Plan Two

ASSESSMENASSESSMENTT

NURSING NURSING DIAGNOSISDIAGNOSIS

OBJECTIVOBJECTIVEE

PLANNINGPLANNING NURSING NURSING INTERVENTIONINTERVENTION

RATIONALERATIONALE EVALUATIEVALUATIONON

Subjective Cues:Subjective Cues:

>”tatlong araw >”tatlong araw na siyang na siyang nilalagnat” as nilalagnat” as verbalized by verbalized by the relatives.the relatives.

Objective Cues:Objective Cues:

>elevated body >elevated body temp of 39˚Ctemp of 39˚C

>flushing skin>flushing skin

>warm to touch>warm to touch

>increase RR >increase RR with a rate of 38 with a rate of 38 BpmBpm

>diaphoresis>diaphoresis

Hyperthermia Hyperthermia related to related to inflammation of inflammation of cerebral tissue as cerebral tissue as evidence by evidence by elevated body elevated body temp. temp.

Scientific EXP:Scientific EXP:

Body temperature Body temperature elevated above elevated above normal range, normal range, because of body’s because of body’s response to response to inflammation inflammation from hemorrhage from hemorrhage that result from that result from ruptured cerebral ruptured cerebral artery.artery.

>after 2 >after 2 hours of hours of nursing nursing interventions interventions the client’s the client’s temperature temperature will decrease will decrease to a normal to a normal range. range.

>Plan >Plan techniques in techniques in which the which the temperature temperature of the client of the client will decrease will decrease to a normal to a normal rage.rage.

>Identify under >Identify under lying causelying cause

>Promote surface >Promote surface cooling by means cooling by means of tepid sponge of tepid sponge bathbath

>Establish cool >Establish cool environment by environment by opening air vents opening air vents and window panesand window panes

>Advise relatives >Advise relatives not to cover the not to cover the client with a client with a blanket, and use blanket, and use less restrictive less restrictive clothing’s clothing’s

>To assess causative >To assess causative factors to the clients factors to the clients fever thus fever thus formulation of formulation of appropriate nursing appropriate nursing intervention.intervention.

>Heat loss by >Heat loss by evaporation and evaporation and conductionconduction

>Heat loss by >Heat loss by convection.convection.

>to avoid further >to avoid further increase of clients increase of clients temperature.temperature.

>after 2 >after 2 hours of hours of nursing nursing intervention intervention the client’s the client’s temperature temperature is decreased is decreased to a normal to a normal range range

> Administer > Administer antipyretics through antipyretics through

IV as prescribed.IV as prescribed.

> For immediate > For immediate alteration of body alteration of body

temperaturetemperature

ASSESSMENASSESSMENTT

DIAGNOSISDIAGNOSIS OBJECTIVEOBJECTIVE PLANNINGPLANNING INTERVENTIOINTERVENTIONN

RATIONALERATIONALE EVALUATIOEVALUATIONN

Objective Objective Cues:Cues:

>reddened >reddened skinskin

>poor skin >poor skin turgorturgor

>immobility>immobility

>friction>friction

>Risk for >Risk for impaired skin impaired skin Integrity Integrity related to related to physical physical immobilizationimmobilization..

Scientific Scientific Explanation:Explanation:

At risk for skin At risk for skin being being potentially potentially vulnerable to vulnerable to breakdown breakdown because of because of immobilizationimmobilization

>After 3 >After 3 hour s of hour s of nursing nursing intervention intervention the client the client relatives will relatives will identify risk identify risk factors for factors for impaired impaired skin integrity skin integrity , verbalize , verbalize understandinunderstanding of therapy g of therapy regimens and regimens and demonstrate demonstrate behaviors behaviors and and techniques to techniques to prevent skin prevent skin breakdown.breakdown.

>Plan >Plan strategies on strategies on how to how to eliminate eliminate the risk for the risk for impaired impaired skin skin

integrity.integrity.

>Note for >Note for general general debilitation, debilitation, reduced reduced mobility, mobility, changes in skin changes in skin and muscle and muscle mass, poor mass, poor nutritional status nutritional status and problems of and problems of self care self care

> Maintain strict > Maintain strict skin hygiene, skin hygiene, using mild non-using mild non-detergent soap, detergent soap, drying gently drying gently and thoroughly. and thoroughly. and lubricating and lubricating with lotionwith lotion

> To assess > To assess aggravating aggravating factor to skin factor to skin breakdown breakdown and make and make appropriate appropriate intervention intervention to it.to it.

> To prevent > To prevent

skin irritationskin irritation

After two After two hours of hours of nursing nursing intervention intervention the the possibilities possibilities for impaired for impaired skin integrity skin integrity of the client is of the client is

eliminated.eliminated.

Nursing Care Plan ThreeNursing Care Plan Three

>Instruct the >Instruct the relative to turn relative to turn the patient every the patient every two hourstwo hours

> Avoid friction > Avoid friction when changing when changing positionposition

>Provide >Provide protection by protection by use of use of pads,pillows, pads,pillows, foam mattress. foam mattress.

>Observe for >Observe for reddened or reddened or blanched areas blanched areas and give proper and give proper management if management if there is any.there is any.

>To reduce >To reduce tissue pressure tissue pressure and prevent and prevent pressure sore.pressure sore.

> To prevent a > To prevent a shearing force shearing force on the skin. on the skin.

>To increase >To increase circulation and circulation and eliminate eliminate excessive tissue excessive tissue pressure.pressure.

>Reduces >Reduces likelihood of likelihood of progression to progression to skin breakdown.skin breakdown.

Discharge Plan

MM >Nifedipine must be given 10mg once a day by sublingual as >Nifedipine must be given 10mg once a day by sublingual as prescribed.prescribed.

>Instruct the relative to follow medication regimen.>Instruct the relative to follow medication regimen.

EE

>Encourage the relative to do some exercises like a passive range of >Encourage the relative to do some exercises like a passive range of motion in affected and unaffected parts of the body of the client.motion in affected and unaffected parts of the body of the client.

TT > Educate & instruct the family to monitor the blood pressure and > Educate & instruct the family to monitor the blood pressure and pulse rate before administering medication.pulse rate before administering medication.

HH

>Inform the relative the importance of proper hygiene of the patient >Inform the relative the importance of proper hygiene of the patient from head to toe.from head to toe.

>regular inspection of the diaper of the patient and change if there a >regular inspection of the diaper of the patient and change if there a presence of fecal material, urine or even redness that would lead to skin presence of fecal material, urine or even redness that would lead to skin rashes.rashes.

>Educate and instruct the relatives on how to feed the client through >Educate and instruct the relatives on how to feed the client through nasogastric tube.nasogastric tube.

>Instruct them to turn the client every 2 hrs to avoid pressure sores.>Instruct them to turn the client every 2 hrs to avoid pressure sores.

OO

>Inform the family of the patient to have a regular check-up for the >Inform the family of the patient to have a regular check-up for the continuity of treatment.continuity of treatment.

>Instruct the family of the patient to monitor if there is any sudden >Instruct the family of the patient to monitor if there is any sudden change to the patient and report immediately.change to the patient and report immediately.

DD

>Instruct the relative to feed the client on time with nutrition food that >Instruct the relative to feed the client on time with nutrition food that is low in sodium, low in cholesterol, low in fat and give citrus fruits, is low in sodium, low in cholesterol, low in fat and give citrus fruits, moderate in fluid intake and increase fiber diet to improve health.moderate in fluid intake and increase fiber diet to improve health.

>Follow the diet prescribed by the doctor.>Follow the diet prescribed by the doctor.

Documents

Case Presentation of Hemorrhagic Stroke (Subarachnoid Hemorrhage)