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

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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.

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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.

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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

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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

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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.

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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.

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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

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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

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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

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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

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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

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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.

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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.

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(“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.)

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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

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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

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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.

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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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28

29

30

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.

31

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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33

34

35

36

37

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.

39

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