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1
Chapter I
Introduction
A stroke or a cerebrovascular accident is one of the non-communicable diseases
most prominent in the Philippines. And according to the World Health Organization, these
non-communicable diseases are the leading cause of mortality in the world. It’s such an
invisible epidemic due to its unrecognizable prominence in countries that are under
poverty. Due to it being unrecognizable, the disease starts to go to family ties.
There are two major stroke classifications of stroke, ischemic stroke and
hemorrhagic stroke. Ischemic stroke, which may occur as a transient ischemic attack
(TIA), occurs when a clot, both of local or distant origin, blocks a cerebral artery and
causes oxygen deprivation with subsequent tissue damage. The term ischemic refers to
an insufficient blood supply. The most common extra cranial source of emboli is the
cervical bifurcation of the common carotid artery, while the most common sources of
intracranial thrombi are the main trunk and branches of the middle cerebral artery.
Hemorrhagic stroke occurs as a bleed within the brain, often causing tissue damage due
to pressure-related changes. Most commonly, intracerebral hemorrhages are caused by
rupture of vessels due to long-term atherosclerotic damage and arterial hypertension.
And what people don’t understand is that this disease is very preventable, by
simply staying away from tobacco and alcohol, having a regular exercise routine, and
managing ones diet. “It is known that 25% of Filipino adults, or about 14 million of current
adult population, have high blood pressure.” The problem with this is that people in the
Philippines tend to not have their annual check-ups, which leads them being unaware of
a probable disease they are at risk of or already possess. Heart disease and stroke
remains the leading causes of mortality, comprising 35% of total deaths, among Filipinos.
Philippine Health Statistics data show that in 2009, about 167,000 Filipinos died
from heart disease and stroke. Half of these tragic deaths are likely related to high blood
pressure. According to the latest WHO data published in April 2011, stroke deaths in the
Philippines reached 40,245 or 9.55% of total deaths. And in the Philippines it is reported
by a study done by Dr. Navarro entitled "The Philippine Journal of Neurology," that stroke
affects 486 Filipinos out of 100,000. Dr. Navarro also stated that in the Philippines and in
2
the world, the most common type of stroke was ischemic being 85% and hemorrhagic
being 15%.
In the United States, most strokes are ischemic and caused by the sudden
blockage of a cerebral artery. Ischemic strokes may occur in two ways, thrombotic stroke
and embolic stroke. Stroke is a serious health hazard. On the average, someone in the
United States has a stroke every 40 seconds (Go et al., 2013). One person dies of a
stroke every four minutes, and it is estimated that 1 of 19 people die of stroke (Roger et
al., 2012; Sidney et al., 2013). A recent study of Americans found that “25% of people
who had a stroke died within a year and 8% had another stroke within one year.
[Altogether,] 50% died or had another stroke or a heart attack within four years” (Feng,
2010).
Each year, almost 800,000 Americans suffer a stroke. For more than 600,000
Americans, this will be their first stroke, but almost 200,000 of the yearly strokes are
recurrences (Sidney et al., 2013).
In the United States, almost 3% of adults have had a stroke. For example, in 2005,
3.9 million American women and 2.6 million American men were survivors of a stroke. It
is estimated that approximately 17% of these survivors have residual difficulty performing
the basic functional activities of their daily lives (CDC, 2010a).
There are about 140,000 stroke deaths each year, and stroke is listed as a
contributing factor to an additional 100,000 deaths. Thus, stroke is the third leading cause
of death in this country, after heart disease and cancer (CDC, 2010a, b). From 1999 to
2009, however, the overall rate of death from stroke declined by 36.9% (Murphy et al.,
2013). The most common reason cited for this decrease is the presence of regional stroke
centers.
Within this case study, our patient is Mr. PC who was admitted to the Chinese
General Hospital diagnosed with Hemorrhagic CVA. In this case study, we discuss the
history of our patient which led up to him suffering from stroke.
3
Chapter II
Objectives of the Study
General Objectives:
To better understand the disease and its process as it affects the patient.
Specific Objectives:
To assess the physical state of the patient.
To gather data on the history of the patient.
To validate those manifestation that was manifested by the patient.
To formulate nursing care plan applicable to the patient.
To analyse what triggers the disease.
Show a Discharge Planning that the client may use upon discharge to the
hospital.
4
Chapter III
Demographic Profile
Name: PC
Age: 78 y/o
Gender: Male
Address: Samuel St. Brgy. Bungad Quezon City
Date of Birth: October 10, 1935
Nationality: Filipino
Religion: Roman Catholic
Educational Background: College Graduate
Occupation: Business man
Civil Status: Widowed
Chief Complaint: Left sided weakness of the body
Date of Admission: February 25, 2014
Time of Admission: 5pm
Place of Admission: Chinese General Hospital
Admitting Diagnosis: Hypertension
Final Diagnosis: Hemorrhagic Stroke
5
Chapter IV
Health History
I. History of Present Illness
Three months prior to admission
Patient PC experienced numbness on his left arm but it lasted for 3-5 minutes
only. He was experiencing it twice a week and there was no factor that aggravated
the numbness of his left arm. He did not consult for treatment for the past three
months.
Few hours prior to admission
He had left sided weakness, difficulty in ambulating and slurring of speech.
Afterwards, the patient slipped on the floor and suddenly lost consciousness which
resulted in nausea and vomiting. The patient was brought to Chinese General
Hospital. CT scan was done and showed CVA haemorrhagic. Patient was
subsequently admitted for further evaluation and management.
II. Family History
On the paternal side
There were no illnesses reported to run in the family.
On the maternal line
There is a trace of hypertension in their history. According to PCA (sister of
patient PC) both of their mothers’ parent’s side had a history of hypertension. “My
grandmother from my mother's side has hypertension, and she died from having a
stroke, and my grandfather from that same side died the same way. One of my
siblings also had a stroke and so did the oldest. Then my uncle, who's my mom’s
brother also has hypertension “as verbalized by PCA.
There is hypertension and stroke traced in the maternal line and no illness in
paternal line.
III. Social History
Patient PC lives with his sister when his wife died. Mrs. PD (wife of PC) and
patient PC only have one son who died of dengue at the age of 7. Patient PC has
6
been in their place since he and Mrs. PD got married. He owned an automobile
shop in their place. He also belongs to a Christian community in their place.
IV. Medical History
According to PCA, when the patient suffered from fever, and cough, patient
takes over the counter drugs like paracetamol, biogesic, alaxan and solmux.
Patient PC has never been hospitalized before his hospitalization in Chinese
General Hospital because every time he felt sick he would just rest and it would
make him feel better. He doesn’t go for any check-ups because he was capable of
tolerating the symptoms “He never goes to the doctor when he feels something
wrong within himself, even a check-up. His own solution for his recurrent
headaches is to just sleep it off" as verbalized by PCA. "As simple as getting his
blood pressure checked he's never done, which is why we just recently found out
he's already been living with high blood pressure and based on what I remembered
he told me that medical treatment would only make his disease or symptoms
severe and he was afraid also to die ” as verbalized by PCA.
PCA verbalized that patient PC has no allergies on medications and drugs.
PCA also added that patient PC has no allergies to any kinds of foods.
Patient PC did not experienced any major accidents according to PCA.
V. Developmental History
Developmental Level: Integrity vs. Despair
According to PCA patient PC describes his childhood as a very happy time for
him. Patient PC becomes excited and smiles as he relates stories of his childhood
on the farm. According to PCA patient PC shares his life story to his niece and
grandson. Patient PC stories focused heavily on his childhood and how happy he
was growing up. He later married, and even though his wife and son had all since
passed away, his stories barely touched on his wife and no regrets. He didn't say
anything negative about them at all, PCA added. Patient PC was satisfied in life
that was given to him by the Lord.
7
8
Chapter VI
Physical Assessment
Date Assessed: March 26, 2014, 4PM
Skin
Inspection reveals evenly pale skin tones without unusual or prominent
discolorations. Client has no odor of perspiration. Skin is normally thin with poor skin
turgor and warm temperature.
Head and Face
Upon inspection the head is symmetric, round, erect and in midline. No lesions are
visible. The face is symmetric with a round oval, elongated, with facial wrinkles and no
abnormal movements noted.
Upon palpation the head is hard, smooth and without lesions. The temporal artery
is elastic and not tender. There is no swelling and tenderness with movement of the
temporomandibular. Mouth opens and closes fully (3 to 6 cm between upper and lower
teeth). Lower jaw moves laterally 1 to 2 cm in each direction.
Neck
Upon inspection the neck is symmetric with head centered and without bulging
masses. Thy thyroid cartilage, cricoid cartilage and thyroid gland move upward
symmetrically as the clients swallows. C7 is usually visible and palpable. Neck is in full
range of motion.
Upon palpation trachea is in midline. The landmark of the thyroid gland are felt
lower in the neck.
Lymphnodes of the Head and Neck
Upon palpation there is no swelling and no tenderness noted.
Eyes
Upon performing corneal reflex test, corneal light reflex shows equal position of
reflexion. Extraocular movements smooth and symmetric with no nystagmus.
Upon inspection eyelids is in normal position with no abnormal widening. No
redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist
and smooth.
9
Eyeballs are symmetrically aligned in socket without protruding. With pinguecula
of the bulbar conjunctiva. Palpebral conjunctiva is free of swelling, foreign bodies or
trauma. No redness over lacrimal gland.
Cornea is transparent, smooth and moist with no opacities, lens is free of
opacities. Irises are round, flat and evenly colored. Pupils are equal in size and reactive
to light and accommodation. Pupils converge evenly. Red reflex present bilaterally. Both
optic disks visualized easily, creamy white in color, with distinct margins.
Upon palpation puncta is visible without swelling, no drainage noted when
nasolacrimal duct palpated.
Ear
Upon inspection the ears are equal in size bilaterally, auricles aligned with the
corner of each eye within a 10-degree angle of vertical position. Skin smooth, with small
amount of moist yellow cerumen in external canal ,no lesions, no lumps, no discharge.
Non tender on palpation and no nodules noted.
Mouth
Upon inspection lips are pink, smooth and moist without lesions. There is a missing
teeth (R and L proximal molars, R canine, L lower wisdom tooth). Buccal mucosa is pink,
moist and without exudate. Parotid ducts visible with no redness or swelling. Moist
bubbles are seen near ducts. Gums pink without redness. Protrudes geographic tongue
is deviated to the left. Varicose veins on the ventral surface of the tongue present. With
equal bilateral strength in tongue. Frenulum is in midline with visible submandibular ducts
on each side. Midline and symmetric elevation of uvula and soft palate with phonation.
Tonsillar pillars pink and symmetric, tonsils absent.
Nose
Upon inspection nose somewhat large but smooth and symmetric. Able to sniff and
blow through each nostril. Nasal septum slightly deviated to left but does not obstruct
airflow. Inferior and middle turbinates dark pink, moist and free of lesions. No purulent
discharge noted. Frontal and maxillary sinus trans illuminate and are non-tender to
palpation and percussion.
Thoracic and Lungs
10
Scapulae are symmetric and non-protruding shoulders. Scapulae are at equal
horizontal positions. Chest expansion symmetric. No retracting of intercostal spaces. No
pain or tenderness noted on palpation.
Percussion tones resonant over all lung fields. Vesicular breath sounds
auscultated over lung fields. No adventitious sounds present.
Heart and Neck Vessel
Upon auscultation of the carotid arteries there is no blowing or other sound heard.
Pulses are equally strong. Jugular venous pulsation disappears when upright. No visible
pulsations, heaves, or lifts on precordium. Apical impulse palpated in the fifth ICS at the
left MCL, approximately the size of the nickel, with no thrill. Apical heart rate auscultated,
72 beats/min, regular rhythm, S1 heard best at apex, S2 heard best at base. No S3 or S4
auscultated. No splitting of heart sounds or murmur noted.
Peripheral Vascular Assessment
Arms are equal in size, no swelling, pinkish skin tone, no clubbing of fingertips,
warm bilaterally. Capillary refill time less than 2 seconds, radial and brachial pulses strong
bilaterally, no epitrochlear lymph nodes palpated. Legs are pale from from toes to groin
bilaterally, normal distribution of hair, no ulcers or edema. Legs are warm bilaterally, 1
cm nontender inguinal lymph nodes palpated, femoral, popliteal, dorsalis pedis, and
posterior tibial pulses strongly palpated bilaterally. No apparent varicosities.
Abdomen
Upon inspection, skin of abdomen is free of striae, scars, lesions, or rashes.
Umbilicus is midline and recessed with no bulging. Abdomen is flat and symmetric with
no bulges or lumps. No bulges noted when patient raises head. Slight respiratory
movements and aortic pulsations noted. No peristaltic waves seen.
Upon auscultation, soft click and gurgles heard at a rate of 15 per minute. No bruits,
venous hums or friction rubs auscultated.
Upon percussion, percussion reveals generalized tympany over all four quadrants
with dullness over the liver, spleen, and descending colon. Percussion of liver span
reveals MCL 8cm and MSL 6cm. Percussion over spleen discloses a dull oval area
approximately 7cm wide near left tenth rib posterior to MAL. No tenderness elicited with
11
blunt percussion over liver and kidneys. No tenderness or guarding in any quadrant with
light palpation.
Upon palpation, no masses palpated. Umbilicus and surrounding area free of
masses, swelling, and bulges. Aortic pulsation moderately strong, regular, and
approximately 3.0 cm wide. Liver, spleen, kidneys, and urinary bladder not palpable. Test
for shifting dullness reveals constant borders between tympany and dullness throughout
position changes. No fluid wave test. All wave transmitted during ballottement test.
Upper and Lower Extremities
Upon inspection, both side of the body are equal in size, no contractures,
deformities and tenderness. Upper right arm and lower right leg has full ROM . Upper
left arm and lower left leg has limited ROM Muscle strength of right arm: 5/5; right leg:
5/5; left arm: 0/5; left leg:0/5.
Vital Signs
March 25, 2014
TIME BP RR HR TEMP
8:00 PM 170/110 26 75 36.5°C
10:00 PM 140/90 26 76 36.7°C
12:00 PM 130/90 24 73 35.9°C
2:00 AM 130/80 27 76 36.7°C
March 26, 2014
Time BP RR HR TEMP
6:00 AM 130/80 24 74 35.9°C
7:00 AM 130/80 27 74 36.5°C
8:00 AM 130/70 25 73 36.6°C
9:00 AM 120/70 22 75 36.9°C
10:00 AM 120/70 25 74 37.0°C
11:00 AM 130/80 24 76 36.5°C
12:00 PM 120/80 25 78 36.8°C
1:00 PM 120/70 21 76 36.7°C
2:00 PM 130/90 24 78 36.9°C
12
March 27, 2014
Time BP RR HR TEMP
6:00 AM 120/70 22 78 36.5°C
7:00 AM 120/80 24 76 35.5°C
8:00 AM 120/70 22 76 35.6°C
9:00 AM 120/70 22 75 36.6°C
10:00 AM 120/70 20 78 36.4°C
11:00 AM 120/80 22 79 36.5°C
12:00 PM 120/80 25 76 36.8°C
1:00 PM 120/70 24 75 36.7°C
2:00 PM 120/70 25 79 36.9°C
Summary
He was bed ridden.
Missing teeth was observable in the mouth.
Protrudes geographic tongue is deviated to the left.
Upper right arm and lower right leg has full ROM . Upper left arm and lower left leg has
limited ROM Muscle strength of right arm: 5/5; right leg: 5/5; left arm: 0/5; left leg:0/5
13
Chapter VII
Gordon’s Functional Health Pattern
Health Management
According to PCA (sister of patient PC), before the patient’s hospitalization, patient
PC is satisfied with his health status. “ He would always say that his head hurts, but it was
nothing of concern because it was probably due to being tired, and it would usually hurt
three times a week. But yesterday, the pain didn't stop until both sides of his body started
to become weak” as verbalized by PCA.
According to PCA (sister of patient PC) patient PC has difficulty reading or seeing
objects, his hearing ability has somehow decline, but he doesn’t have problems in touch,
smell and taste. “He never exercises, all he does the entire is sit around the house with
he co-workers from the shop, drinking and eating food that's very unhealthy like lechon.
He especially doesn't eat vegetables, it's would always be meat. And when I would cook
something and he didn't like it, he'd make his own food" as verbalized by PCA. "Ever
since his younger years, he already knew how to drink and smoke, he was around 15 or
16 I think" as verbalized by PCA.
Nutrition
According to PCA (sister of patient PC) before the present hospitalization, patient
PC has a good appetite and does not have difficulty eating and swallowing. Before he
has been diagnosed with such health conditions, he used to consume high fat and high
salt diet. “The food he likes to eat the most is fat, especially if it's anything fried. And his
food has to be salty, otherwise he won't eat”, PCA added.
According to PCA patient PC eats 3 times a day excluding his snacks. His typical
daily intake consists of any of the following for breakfast, he usually eats, fried eggs, fried
pork, pandesal, and a cup of coffee; for lunch and dinner, the patient usually consumes
a cup of rice, chicken (tinola, adobo, afritada, grilled ,steam, chicken curry, etc.) , fish
(paksiw, steam, sarsyado, eskabeche, pesa, sinigang) ,pork (lechon kawali, sinigang,
adobo, kaldereta, etc , fruits (banana, mango) and a glass of water or juice. His typical
fluid intake is about 7-10 glasses a day and an intake of 1 liter of emperador. His usual
snacks consist of 1-2 slices of bread or a pack of biscuits (skyflakes, rebisco) and a glass
14
of water or a cup of coffee. “The entire day he'd always be drinking, I'd usually catch him
finishing an entire bottle of emperador and 2 packs of Marlboro cigarette, and that's just
in a day” as added by PCA.
Elimination
According to PCA patient PC doesn’t have any problems in urinary and bowel
elimination before his hospitalization. Patient PC doesn’t complain about any discomfort
when urinating and doesn’t notice blood in his urine. According to PCA, at night, the
patient’s sleep is usually disrupted because he needs to go to the comfort room and
urinate every now and then. PCA said, “He drinks a lot of water and a lot of alcohol, and
since I sleep on the couch, I always notice him waking up in the middle of the night (11pm)
and early in the morning (1am and 3am) just to go to the bathroom”.
With regards to his bowel elimination, he defecates at least 1 to 2 times a day, he
doesn’t have any discomfort or problem in control. Now, that he is in the hospital, he still
defecates once a day. He has not experienced urinary or bowel incontinence. Patient PC
has a foley catheter and is wearing a diaper.
Activity-Exercise
Before his hospitalization, the patient can complete a desired or required activity.
He doesn’t exercise. “He never exercises, all he does in a day is sit around watching TV,
drinking and smoking, and on occasion he visits the shop”. As verbalized by PCA.
According to PCA, patient PC doesn’t complain of feeling fatigue or weak, but kept on
saying to her that he often experienced headaches. Before hospitalization, the patient is
able to perform activities of daily living and self-care routines on his own, but now he can’t
do anything because of his status. He has no other history of falls other than what
happened before his admission.
Sleep-Rest
Prior to his hospitalization, according to PCA, the patient is generally rested and is
ready for daily activities. He usually sleeps from 9:00PM to 5:00AM. He doesn’t have
difficulty maintaining sleep although his sleep is usually disrupted because he needs to
go to the comfort room and urinate. He doesn’t use anything to help him go to sleep. He
always experiences dreams but seldom experiences nightmares.
15
Role-Relationship Pattern
According to PCA, patient PC was a loving father to his son and responsible to his
family. He provides their needs d sees to it that they are comfortable in their way of life.
Coping-stress Tolerance
Whenever problems come into their lives, they spend time to think, talk about it
and put in effort to resolve it, at the same time they pray and ask for guidance and help
from God. “Problems really come and go in life. But what's important is that you take
action against them to make it through” as what PCA verbalized.
Values and Beliefs
They get things they want from life. As what PCA said, “We don't really ask for
much from life, we just hope to go through it without getting badly ill”.
Summary
Patient PC often experiences headaches 3 months ago prior to his admission.
(“ He would always say that his head hurts, but it was nothing of concern because it was
probably due to being tired, and it would usually hurt three times a week. But yesterday,
the pain didn't stop until both sides of his body started to become weak” as verbalized by
PCA.)
He has problems in sight and hearing.
(According to PCA (sister of patient PC) patient PC has difficulty reading or seeing objects,
his hearing ability has somehow decline, but he doesn’t have problems in touch, smell and
taste.)
He does not exercise.
( “He never exercises, all he does in a day is sit around watching TV, drinking and smoking,
and on occasion he visits the shop”. As verbalized by PCA.)
He used to smoke cigarettes and drink alcohol.
( “The entire day he'd always be drinking, I'd usually catch him finishing an entire
bottle of emperador and 2 packs of Marlboro cigarette, and that's just in a day” as added
by PCA.)
His diet was mainly high in fat and sodium.
16
(“The food he likes to eat the most is fat, especially if it's anything fried. And his food has
to be salty, otherwise he won't eat”, PCA added.)
Upon hospitalization, he cannot perform and self-care.
(Before hospitalization, the patient is able to perform activities of daily living and self-care
routines on his own, but now he can’t do anything because of his status)
Before hospitalization, his sleep at night is disrupted because he needs to go to the
restroom.
(He doesn’t have difficulty maintaining sleep although his sleep is usually disrupted
because he needs to go to the comfort room and urinate.)
17
Chapter VIII
COMPLETE MEDICAL DIAGNOSIS
BACKGROUND
Intracranial hemorrhage (ie, the pathological accumulation of blood within the cranial vault) may
occur within brain parenchyma or the surrounding meningeal spaces. Hemorrhage within the meninges or
the associated potential spaces, including epidural hematoma, subdural hematoma, and subarachnoid
hemorrhage, is covered in detail in other articles. Intracerebral hemorrhage (ICH) and extension of
parenchymal bleeding into the ventricles (ie, intraventricular hemorrhage [IVH]) are detailed here.
PRESENTATION
History
Onset of symptoms of intracerebral hemorrhage is usually during daytime activity, with progressive
(ie, minutes to hours) development of the following:
Alteration in level of consciousness (approximately 50%)
Nausea and vomiting (approximately 40-50%)
Headache (approximately 40%)
Seizures[3] (approximately 6-7%)
Focal neurological deficits
Lobar hemorrhage due to cerebral amyloid angiopathy may be preceded by prodromal symptoms of
focal numbness, tingling, or weakness.
A history of hypertension, trauma, illicit drug abuse, or a bleeding diathesis may be elicited.
Physical
Clinical manifestations of intracerebral hemorrhage are determined by the size and location of
hemorrhage, but may include the following:
Hypertension, fever, or cardiac arrhythmias
Nuchal rigidity
Subhyaloid retinal hemorrhages
Altered level of consciousness
Anisocoria
18
Focal neurological deficits
o Putamen - Contralateral hemiparesis, contralateral sensory loss, contralateral conjugate
gaze paresis, homonymous hemianopia, aphasia, neglect, or apraxia
o Thalamus - Contralateral sensory loss, contralateral hemiparesis, gaze paresis,
homonymous hemianopia, miosis, aphasia, or confusion
o Lobar - Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis,
homonymous hemianopia, abulia, aphasia, neglect, or apraxia
o Caudate nucleus - Contralateral hemiparesis, contralateral conjugate gaze paresis, or
confusion
o Brain stem - Quadriparesis, facial weakness, decreased level of consciousness, gaze
paresis, ocular bobbing, miosis, or autonomic instability
o Cerebellum - Ataxia, usually beginning in the trunk, ipsilateral facial weakness, ipsilateral
sensory loss, gaze paresis, skew deviation, miosis, or decreased level of consciousness
Causes
Possible causes are as follows:
Hypertension[4]
Arteriovenous malformation
Aneurysmal rupture
Cerebral amyloid angiopathy
Intracranial neoplasm
Coagulopathy
Hemorrhagic transformation of an ischemic infarct
Cerebral venous thrombosis
Sympathomimetic drug abuse
Moyamoya
Sickle cell disease
Eclampsia or postpartum vasculopathy
Infection
Vasculitis
Neonatal intraventricular hemorrhage
Trauma
Medical Care
19
Medical therapy of intracranial hemorrhage is principally focused on adjunctive measures to minimize
injury and to stabilize individuals in the perioperative phase. Recent clinical trial data suggests that
treatment with recombinant factor VIIa (rFVIIa) within 4 hours after the onset of intracerebral hemorrhage
limits the growth of the hematoma, reduces mortality, and improves functional outcomes at 90 days.[8]
However, further study of this medication in a broader cohort did not result in improved clinical outcomes.
This intervention may also result in a small increase in the frequency of thromboembolic adverse events.
The early use of rFVIIa in patients with head injury without systemic coagulopathy may reduce the
occurrence of enlargement of contusions, the requirement of further operation, and adverse outcome.[9]
Perform endotracheal intubation for patients with decreased level of consciousness and poor
airway protection.
Cautiously lower blood pressure to a mean arterial pressure (MAP) less than 130 mm Hg, but
avoid excessive hypotension. Early treatment in patients presenting with spontaneous
intracerebral hemorrhage is important as it may decrease hematoma enlargement and lead to
better neurologic outcome.[10]
Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan.
Intubate and hyperventilate if intracranial pressure is increased; initiate administration of mannitol
for further control.
Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion
without exacerbating brain edema.
Avoid hyperthermia.
Correct any identifiable coagulopathy with fresh frozen plasma, vitamin K, protamine, or platelet
transfusions.
Initiate fosphenytoin or other anticonvulsant definitely for seizure activity or lobar hemorrhage,
and optionally in other patients.
Facilitate transfer to the operating room or ICU.
While reducing SBP with intravenous nicardipine hydrochloride does not significantly reduce
hematoma expansion in patients with ICH, the Antihypertensive Treatment of Acute Cerebral
Hemorrhage study supports further studies to evaluate the efficacy of aggressive pharmacologic
SBP reduction.[11]
Surgical Care
Consider nonsurgical management for patients with minimal neurological deficits or with
intracerebral hemorrhage volumes less than 10 mL.
Consider surgery for patients with cerebellar hemorrhage greater than 3 cm, for patients with
intracerebral hemorrhage associated with a structural vascular lesion, and for young patients with
20
lobar hemorrhage. The common hypertensive hemorrhages in the basal ganglia have not been
shown clearly to benefit from surgery, although case series with favorable outcomes after
stereotactic needle evacuation or endoscopic drainage have been reported. In the past, standard
craniotomy with evacuation of the hematoma did not appear to improve outcomes.
Other surgical considerations include the following:
o Clinical course and timing
o Patient's age and comorbid conditions
o Etiology
o Location of the hematoma
o Mass effect and drainage patterns
Surgical approaches include the following:
o Craniotomy and clot evacuation under direct visual guidance
o Stereotactic aspiration with thrombolytic agents
o Endoscopic evacuation
Medication Summary
Antihypertensive agents reduce blood pressure to prevent exacerbation of intracerebral
hemorrhage. Osmotic diuretics, such as mannitol, may be used to decrease intracranial pressure. As
hyperthermia may exacerbate neurological injury, acetaminophen may be given to reduce fever and to
relieve headache. Anticonvulsants are used routinely to avoid seizures that may be induced by cortical
damage. Vitamin K and protamine may be used to restore normal coagulation parameters. Antacids are
used to prevent gastric ulcers associated with intracerebral hemorrhage.
Accumulating data suggest that statins have neuroprotective effects; however, their association with
intracerebral hemorrhage outcome has been inconsistent.[12] Antecedent use of statins prior to
intracerebral hemorrhage is associated with favorable outcome and reduced mortality after intracerebral
hemorrhage. This phenomenon appears to be a class effect of statins.
21
Chapter IX
Anatomy and Physiology
The brain is a spongy organ made up of nerve and supportive tissues. It is located in the head and
is protected by a bony covering called the skull. The base, or lower part, of the brain is connected to the
spinal cord. Together, the brain and spinal cord are known as the central nervous system (CNS). The spinal
cord contains nerves that send information to and from the brain.
The CNS works with the peripheral nervous system (PNS). The PNS is made up of nerves that branch out
from the spinal cord to relay messages from the brain to different parts of the body.
The brain is the body’s control centre. It constantly receives and interprets nerve signals from the
body and responds based on this information. Different parts of the brain control movement, speech,
emotions, consciousness and internal body functions, such as heart rate, breathing and body temperature.
Brainstem
Connects the spinal cord to the remainder of the brain. It consists of the medulla oblongata, pons, and
midbrain and contains several nuclei involved in vital body functions such as the control of heart rate,
blood pressure, and breathing.
Medulla Oblongata
Is the most inferior portion of the brainstem and is continuous with the spinal cord. It extends from the
level of the foramen magnum to the pons. In addition to ascending and descending nerve tracts, the
medulla oblongata contains discrete nuclei with specific functions such as regulation of heart rate and
blood vessel diameter, breathing, swallowing, vomiting, coughing, sneezing, balance, and coordination.
Pons
It contains ascending and descending nerve tracts, as well as several nuclei. Some of the nuclei in the
pons relay information between the cerebrum and the cerebellum. Not only is the pons a functional bridge
between the cerebrum and the cerebellum, but on the anterior surface, it resembles an arched footbridge.
Several nuclei of the medulla oblongata, described earlier, extend into the lower part of the pons, so that
functions such as breathing, swallowing, and balance are controlled in the lower pons, as well as in the
medulla oblongata. Other nuclei in the pons control functions such as chewing and salivation
Midbrain
The dorsal part of the midbrain consists of four mounds called the colliculi. The two inferior colliculi are
major relay centers for the auditory nerve pathways in the CNS. The two superior colliculi are involved in
visual reflexes.
Cerebellum
The cerebellum is attached to the brainstem by several large connections called cerebella peduncles.
These connections provide routes of communication between the cerebellum and other parts of the CNS.
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Diencephalon
A part of the brain between the brainstem and the cerebrum. Its main components are the thalamus,
epithalamus, and hypothalamus.
Thalamus
It consists of a cluster of nuclei and is shaped somewhat like a yo-yo, with two large, lateral parts
connected in the center by a small interthalamic adhesion.
Epithalamus
A small area superior and posterior to the thalamus. It consists of a few small nuclei that are involved in
the emotional and visceral response to odors, and the pineal body.
Hypothalamus
The most inferior part of the diencephalon and contains several small nuclei, which are very important in
maintaining homeostasis. The hypothalamus plays a central role in the control of the body temperature,
hunger, and thirst. Sensations such as sexual pleasure, feeling relaxed and “good” after a meal, rage,
and fear are related to hypothalamic functions. Emotional responses, which seem to inappropriate to the
circumstances, such as “nervous perspirations” in response to stress or feeling hungry as a result of
depression, also involve the hypothalamus.
Cerebrum
The largest part of the brain. It is divided into left and right hemispheres by a longitudinal fissure. The
most conspicuous features on the surface of each hemisphere are numerous folds called gyri, which
greatly increase the surface area of the cortex, and intervening grooves called sulci. Each cerebral
hemisphere is divided into lobes, named for the skull bones overlying them. The frontal lobe is important
in the control of voluntary motor functions. The parietal lobe is the principal center for the reception and
conscious perception of most sensory information. The occipital lobe functions in the reception and
perception of visual input and is not distinctly separate from the other lobes. The temporal lobe is involved
in olfactory and auditory.
The brain comprises 2% of the body’s mass, but it receives 17% of the heart’s output and
consumes 20% of the body’s oxygen supply. The brain receives its blood through four main arteries:
Two large arteries, the right and left internal carotid arteries, ascend from the chest in the anterior
portion of the neck.
Two smaller arteries, the right and left vertebral arteries, ascend via the posterior portion of the
neck.
The carotid arteries supply blood to about 80% of the brain, including most of the frontal, parietal, and
temporal hemispheres and the basal ganglia. The vertebral arteries supply blood to the remaining 20% of
the brain, including the brainstem, cerebellum, and most of the posterior cerebral hemispheres.
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The anterior circulation of the brain is formed by those cerebral blood vessels that are branches
of the internal carotid arteries, while the posterior circulation of the brain is formed by those cerebral
blood vessels that are branches of the vertebral arteries. The anterior and posterior circulations connect
through a circular anastomosis of arteries called the Circle of Willis.
The functional anatomy of the cerebral arteries begins with a basic distinction between internal
carotid artery (anterior circulation) strokes and vertebral artery/basilar artery (posterior circulation)
strokes. In general, middle cerebral artery and internal carotid artery strokes cause contralateral motor
and eye dysfunction with speech and sensory deficits, while vertebral/basilar artery strokes cause
balance, vertigo, and cranial nerve dysfunction. (Dysfunction is possible in the cerebellar functions,
cranial nerve functions, and spinal sensory and motor functions.)
The Circle of Willis is frequently found to have aneurysms or congenital malformations.
Symptoms of a ruptured aneurysm in the Circle of Willis are similar to other hemorrhagic stroke
symptoms and can include a sudden headache, nausea, vomiting, neck pain, fainting, light sensitivity, or
a loss of consciousness and seizures.
Cerebral Aneurism
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Capsuloganglionic Hemorrhage
-hemorrhage into the basal ganglia and internal and external capsule of the brain
The basal ganglia (or basal nuclei) comprises multiple subcortical nuclei, of varied origin, in the
brains of vertebrates, which are situated at the base of the forebrain. Basal ganglia are strongly
interconnected with the cerebral cortex, thalamus, and brainstem, as well as several other brain areas.
The basal ganglia is associated with a variety of functions including: control of voluntary motor
movements, procedural learning, routine behaviors or "habits" such as bruxism, eye movements,
cognition and emotion.
Currently popular theories implicate the basal ganglia primarily in action selection; that is, it helps
determine the decision of which of several possible behaviors to execute at any given time. In more
specific terms, the basal ganglia's primary function is likely to control and regulate activities of the motor
and premotor cortical areas so that voluntary movements can be performed smoothly. Experimental
studies show that the basal ganglia exert an inhibitory influence on a number of motor systems, and that
a release of this inhibition permits a motor system to become active. The "behavior switching" that takes
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place within the basal ganglia is influenced by signals from many parts of the brain, including the
prefrontal cortex, which plays a key role in executive functions.
The main components of the basal ganglia are the striatum (caudate nucleus and putamen), the
globus pallidus, the substantia nigra, the nucleus accumbens, and the subthalamic nucleus.[5] Each of
these areas has a complex internal anatomical and neurochemical organization. The largest component,
the striatum, receives input from many brain areas beyond the basal ganglia, but only sends output to
other components of the basal ganglia. The pallidum receives input from the striatum, and sends
inhibitory output to a number of motor-related areas. The substantia nigra is the source of the striatal
input of the neurotransmitter dopamine, which plays an important role in basal ganglia function. The
subthalamic nucleus receives input mainly from the striatum and cerebral cortex, and projects to the
globus pallidus.
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Chapter X Pathophysiology
Modifiable Factors Hypertension
Cigarette smoking (2packs/day)
Poor diet(salty and
fatty foods)
Alcohol abuse
Lack of exercise
Lack of health
maintenance
Non-Modifiable Factors Age (78y/o)
Heredity(family history of hypertension)
Atherosclerosis
Decreased blood flow
Rupture
Intracranial
hemorrhage
Increased pressure
Leaking of blood from the fragile
vessel wall
Increased ICP
Vertebrobasilar
Artery and Carotid
Syphons
Signs and Symptoms: Left sided weakness, difficulty in ambulating, slurred speech
Dx: CT-SCAN
Results: acute intracranial hemorrhage, rt capsuloganglionic
region
Atherosclerotic vertebrobasilar
arteries
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Chapter XII Course in the Ward
Day 1:February 25, 2014
Medical/Surgical Management Rationale
1. Diet: Low fat diet with strict aspiration
precaution
2. Monitor VS q2 and record
3. Monitor I & O and record.
4. IVF: PNSS 1L x 60 cc/hr
5. Diagnostic
CBC
FBS
HBA1C,
Na
K
Creatinine
Lipid profile
12 lead ECG
Chest x-ray PA
6. Start Mannitol 100 g IV q8
7. Keep head elevated to 30°.
8. Amlodipine 5 mg/tablet OD 9. Citicholine 1 gram IV now then q12.
Low fat diet is intended for hypertensive to prevent the increase of LDL and BP.
Strict aspiration precaution prevents aspiration pneumonia.
Monitoring vs updates the status of the client. Monitoring is essential to know if the client has increased BP and to provide intervention for it.
Monitoring intake and output helps evaluate client’s fluid and electrolyte balance.
To hydrate the client and prevent dehydration.
To detect or monitor different health conditions such as infection and blood disorders.
To test if the client has normal or increased blood sugar
To show the average level of blood sugar over the previous 3 months and screens if the patient is diabetic.
To check the water and electrolytes balance of the body
Check with hypertensive client who may have a problems with adrenal glands.
To assess the kidney function of the client.
To determine the LDL and HDL of the client since he is Hypertensive.
to identify arrhythmias and resultant clots in the heart which may spread to the brain vessels through the bloodstream);
An x-ray of the heart and lungs is a standard test for patients with acute medical problems. Abnormalities may alert your doctor to important problems such as pneumonia or heart failure.
Mannitol decreases ICP and the minimal edema of the client.
Elevating head improves venous outflow and lowers ICP of the client.
Amlodipine lowers the BP of the client.
It helps increase blood flow or brain metabolism.
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Day 2: February 26. 2014
Medical/Surgical Management Rationale
6:45 am
1. Please monitor VS q1 c/o MROD without fail and record.
11:10 am 2. Chart entries noted:
Seen asleep but arousable, intact hearing and oriented to person, tongue deviated to the L, L Hemiparesis at 3/5, CVA bleed Right basal. Inform me if BP > 140 mm/Hg
3. Make Amlodipine 10 mg/tab, 1 tab now then OD.
Monitoring VS updates the status of the client. Monitoring is essential to know if the client has increased BP and to provide intervention for it.
To prevent increase of BP that can aggreviate the increase in ICP.
The dosage is increase to control the BP of the patient.
Day 3: February 27, 2014
Medical/Surgical Management Rationale
1. Monitor VS q1 and record.
2. Continue Amlodipine 10 mg.
Monitoring the VS updates the status of the patient and to know if it deviates to normal.
To control the BP of the patient.
Day 4: February 28, 2014
Medical/Surgical Management Rationale
1. Mannitol to be consumed.
2. Consume IVF once off Mannitol
The client has a stable vital signs
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Chapter XV
PROGNOSIS/EVALUATION
CRITERIA POOR FAIR GOOD JUSTIFICATION
Health Perception-
Health
Management
√
Patient failed to seek consultation early and does not
do anything to prevent the disease.
Nutrition-
Metabolism
√
Patient does not have a healthy diet. He used to
consume a high fat and high salt diet and he does not
want to eat vegetables. He was an avid cigarette
smoker and alcohol drinker.
Elimination
√
Patient does not have a problem in defecation.
Activity-Exercise
√
He does not exercise. He is immobile until now.
Sleep-Rest
√
He sleeps for about 7 to 8 hours only per day. He does
not have an irregular sleeping pattern from the time
when he was admitted until now.
Cognitive-
Perceptual
√
Patient is oriented to time, date and place.
Perceptual aspect is good and intact.
Roles-Relationship
√
Patient has a good relationship with family members.
He also has a good relationship with his neighbour’s.
Self-Perception –
Self-Concept
√
Patient views his condition much better than before.
He has a positive outlook towards his hospitalization.
Coping-Stress
√
Patient’s coping ability is very good. He perceived his
hospitalization in a positive perception.
Values-Beliefs
√
Patient goes to church regularly and is an active
member of El Shaddai
POOR- 3 *** √ - Mark of choice.
FAIR- 0
GOOD- 7
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Chapter XVI Discharge Plan
Educate the patient and relatives about the client’s illness/status.
Instruct the relatives to follow medication regimen.
Encourage relatives to do some range of motion exercises in the affected and
unaffected site parts of the body of the client.
Inform the relatives about the importance of proper hygiene from head to toe.
Instruct relatives to turn patient every 2 hours to avoid bed sores.
Inform the family of the patient to have a regular check-up for the continuity of
treatment.
Instruct the family of the patient to monitor if there is sudden change to the
patient and report immediately.
Instruct the relative to feed the client on time with nutrition food that is low in
sodium, low cholesterol, low in fat and give citrus food, moderate in fluid intake
and increase in fiber diet to improve health.
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Bibliography
Essentials of Anatomy & Physiology 6th Edition, Seeley Stephens Tate, McGraw-Hill
International Edition, 2007
Pathophysiology Concepts of Altered Health States 6th Edition, Carol Mattson Porth,
Lippincott, 2002
Physical Examination & Health Assessment 4th Edition, Carolyn Jarvis, Saunders, 2004
Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span 7th
Edition, Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr, 2006
Health Assessment in Nursing 3rd Edition, Janet Weber & Jane Kelley, Lippincott
Williams & Wilkins, 2007
Understanding Pathophysiology 2nd Edition, Sue E. Huether, Kathryn L. McCance, 2004
http://en.wikipedia.org/wiki/Basal_ganglia
http://en.wikipedia.org/wiki/Basilar_artery
http://en.wikipedia.org/wiki/Circle_of_Willis
http://www.wildirismedicaleducation.com/courses/422/index_cm.html