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. Its 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 dont 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 1

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.

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.

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

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 parents 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 moms 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 5

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 doesnt 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. 6

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.

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

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 8:00 PM 10:00 PM 12:00 PM 2:00 AM BP 170/110 140/90 130/90 130/80 RR 26 26 24 27 HR 75 76 73 76 TEMP 36.5C 36.7C 35.9C 36.7C

March 26, 2014 Time 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM BP 130/80 130/80 130/70 120/70 120/70 130/80 120/80 120/70 130/90 RR 24 27 25 22 25 24 25 21 24 HR 74 74 73 75 74 76 78 76 78 TEMP 35.9C 36.5C 36.6C 36.9C 37.0C 36.5C 36.8C 36.7C 36.9C

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March 27, 2014 Time 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM BP 120/70 120/80 120/70 120/70 120/70 120/80 120/80 120/70 120/70 RR 22 24 22 22 20 22 25 24 25 HR 78 76 76 75 78 79 76 75 79 TEMP 36.5C 35.5C 35.6C 36.6C 36.4C 36.5C 36.8C 36.7C 36.9C

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 Gordons Functional Health Pattern

Health Management According to PCA (sister of patient PC), before the patients 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 doesnt 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 13

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 doesnt have any problems in urinary and bowel elimination before his hospitalization. Patient PC doesnt complain about any discomfort when urinating and doesnt notice blood in his urine. According to PCA, at night, the patients 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 doesnt 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 doesnt 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 doesnt 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 cant 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 doesnt have difficulty maintaining sleep although his sleep is usually disrupted because he needs to go to the comfort room and urinate. He doesnt use anything to help him go to sleep. He always experiences dreams but seldom experiences nightmares. 14

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 doesnt 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 cant do anything because of his status) Before hospitalization, his sleep at night is disrupted because he needs to go to the restroom. (He doesnt 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 o o o o o Putamen - Contralateral hemiparesis, contralateral sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, aphasia, neglect, or apraxia Thalamus - Contralateral sensory loss, contralateral hemiparesis, gaze paresis, homonymous hemianopia, miosis, aphasia, or confusion Lobar - Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, abulia, aphasia, neglect, or apraxia Caudate nucleus - Contralateral hemiparesis, contralateral conjugate gaze paresis, or confusion Brain stem - Quadriparesis, facial weakness, decreased level of consciousness, gaze paresis, ocular bobbing, miosis, or autonomic instability 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

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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 o o o o Clinical course and timing Patient's age and comorbid conditions Etiology Location of the hematoma Mass effect and drainage patterns

Surgical approaches include the following: o o o Craniotomy and clot evacuation under direct visual guidance Stereotactic aspiration with thrombolytic agents 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 bodys 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 bodys mass, but it receives 17% of the hearts output and consumes 20% of the bodys 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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Modifiable Factors
Hypertension Cigarette smoking (2packs/day) Poor diet(salty and fatty foods) Alcohol abuse Lack of exercise Lack of health maintenance

Chapter X Pathophysiology Non-Modifiable Factors

Atherosclerosis

Vertebrobasilar Artery and Carotid Syphons

Decreased blood flow

Increased pressure

Leaking of blood from the fragile vessel wall

Rupture

Dx: CT-SCAN
Results: acute intracranial hemorrhage, rt capsuloganglionic region

Intracranial hemorrhage
Signs and Symptoms: Left sided weakness, difficulty in ambulating, slurred speech

Atherosclerotic vertebrobasilar arteries

Increased ICP

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Chapter XII Course in the Ward

Day 1:February 25, 2014 Medical/Surgical Management 1. Diet: Low fat diet with strict aspiration precaution 2. Monitor VS q2 and record 4. IVF: PNSS 1L x 60 cc/hr Na K Creatinine Lipid profile 12 lead ECG Chest x-ray PA 7. Keep head elevated to 30. 8. Amlodipine 5 mg/tablet OD 9. Citicholine 1 gram IV now then q12. Rationale 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 clients 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.

3. Monitor I & O and record.

5. Diagnostic CBC

FBS

HBA1C,

6. Start Mannitol 100 g IV q8

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Day 2: February 26. 2014 Medical/Surgical Management 6:45 am 1. Please monitor VS q1 c/o MROD without fail and record. Rationale

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.

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.

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 1. Monitor VS q1 and record. 2. Continue Amlodipine 10 mg.

Rationale

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 1. Mannitol to be consumed. 2. Consume IVF once off Mannitol

Rationale

The client has a stable vital signs

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Chapter XV PROGNOSIS/EVALUATION

CRITERIA Health PerceptionHealth Management

POOR

FAIR

GOOD

JUSTIFICATION Patient failed to seek consultation early and does not

do anything to prevent the disease.

Patient does not have a healthy diet. He used to NutritionMetabolism 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 He does not exercise. He is immobile until now. Activity-Exercise He sleeps for about 7 to 8 hours only per day. He does Sleep-Rest not have an irregular sleeping pattern from the time when he was admitted until now. CognitivePerceptual Patient is oriented to time, date and place. Perceptual aspect is good and intact. Patient has a good relationship with family members. Roles-Relationship Self-Perception Self-Concept He also has a good relationship with his neighbours. Patient views his condition much better than before. He has a positive outlook towards his hospitalization. Patients coping ability is very good. He perceived his Coping-Stress hospitalization in a positive perception. Patient goes to church regularly and is an active Values-Beliefs
POOR- 3 FAIR- 0 GOOD- 7

Patient does not have a problem in defecation.

member of El Shaddai *** - Mark of choice.

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Chapter XVI Discharge Plan Educate the patient and relatives about the clients 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 [Link] [Link] [Link] [Link]

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