87906380 case study cmva

7/27/2019 87906380 Case Study CmVA

1/41

Page1

I. INTRODUCTIONThe World Health Organization (WHO) definition of stroke is: rapidly developing clinical

signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or

longer or leading to death, with no apparent cause other than of vascular origin.

In the Philippines, deaths are mainly due to noncommunicable diseases, specifically of

the heart and vascular system. The eight leading causes of mortality are diseases of the heart,

stroke, cancer, accidents, pneumonia, tuberculosis, diabetes mellitus and chronic lower

respiratory diseases. The majority of these diseases are linked to common, preventable,

lifestyle-related risk factors that include tobacco use, unhealthy diet and physical inactivity.

Prevalence rates for obesity, diabetes and cardiovascular disease now surpass those of

most industrialized countries. Increasing rates of overweight and obesity, reduced physical

activity, smoking and, to some extent, the ageing of the population are factors contributing to

the rapidly growing burden of noncommunicable disease. Currently, 19.6% of Filipino adults are

overweight and 4.8% are obese. It is also reported that 60.5% of adults are physically inactive.

The prevalence of tobacco use among adults continues to be high and is rising, from 32.7% in

1999 to 34.8 in 2003. Around 56% of adult males and 12% of adult females are current smokers,

while 19.6% of adolescents smoke.

(http://www.wpro.who.int/countries/2007/phl/health_situation.htm)

A stroke is caused by the interruption of the blood supply to the brain, usually because a

blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients,

causing damage to the brain tissue.

The most common symptom of a stroke is sudden weakness or numbness of the face,

arm or leg, most often on one side of the body. Other symptoms include: confusion, difficultyspeaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking,

dizziness, loss of balance or coordination; severe headache with no known cause; fainting or

unconsciousness.

7/27/2019 87906380 Case Study CmVA

2/41

Page2

The effects of a stroke depend on which part of the brain is injured and how severely it

is affected. A very severe stroke can cause sudden death.

(http://www.who.int/topics/cerebrovascular_accident/en/)

Incidence

The steep increase in the burden of noncommunicable disease is currently a priority

health problem. Six of the top ten causes of mortality are due to noncommunicable diseases.

These include cardiovascular disease, cancer, chronic obstructive pulmonary disease, diabetes

and kidney disease. Hypertension and heart disease are among the 10 leading causes of

morbidity, with 22.5% of Filipino adults hypertensive.

(http://www.wpro.who.int/countries/2007/phl/health_situation.htm)

High blood pressure has been established as a major risk factor for stroke and the unfortunate

thing about it is that most hypertensive patients have no symptoms.

The statistics are grim:

Less than half of hypertensive patients are aware that they have high blood pressure.

Only about a quarter are taking antihypertensive medications.

Only about 10 percent, or even less, have adequately controlled high blood pressure.

According to the World Health Organization, 15 million people worldwide will suffer

from stroke in 2007. Five million will die and another five million will be permanently disabled.

In the Philippines, stroke affects 486 out of 100,000 Filipinos or roughly half a million Filipinos,

according to Dr. Navarro in his study published in The Philippine Journal of Neurology.

(Philippine Inquirer, 12/01/2007)

Vascular Disease which includes C.V.A. is the second leading cause of death in the

Philippines with a total of 51,680 according to DOH 2004. Along with this are 37,092 who

survived with it. (http://www.doh.gov.ph/kp/statistics/morbidity)
http://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaignshttp://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaignshttp://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaignshttp://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaigns

7/27/2019 87906380 Case Study CmVA

3/41

Page3

Current trends

Vaccine Prevents Stroke in Rats

A vaccine that interferes with inflammation inside blood vessels greatly reduces the

frequency and severity of strokes in spontaneously hypertensive, genetically stroke-prone rats,

according to a new study from the NIH's National Institute of Neurological Disorders and Stroke

(NINDS). If the vaccine works in humans, it could prevent many of the strokes that occur each

year.

In the study, researchers used a nasal spray to deliver a protein that, under normal

circumstances, contributes to inflammation of the cells that line the inner walls of blood vessels.

Exposing rats to this substance, called E-selectin, programs blood cells called lymphocytes to

monitor the blood vessel lining for the inflammatory protein. When these lymphocytes detect E-

selectin, they produce substances that suppress inflammation.

The vaccine is the first treatment to target inflammation in blood vessels as a possible

means of preventing stroke, says senior author John M. Hallenbeck, M.D., chief of the Stroke

Branch at NINDS. "Clinically, stroke is hard to treat. If we can prevent it from happening, that's

clearly the way to go," he adds. The study appears in the September 2002 issue of the journal

Stroke. (Retrieved at

http://www.ninds.nih.gov/news_and_events/news_articles/pressrelease_stroke_vaccine_0905

02.htm on September 26, 2010 at 8:10pm)

7/27/2019 87906380 Case Study CmVA

4/41

Page4

II. REVIEW OF ANATOMY AND PHYSIOLOGYMAJOR REGIONS OF THE BRAIN AND THEIR FUNCTIONS

The major regions of the brain (Figure 1.) are the cerebral hemispheres, diencephalon, brain

stem and cerebellum.

Figure 1. Major Regions of the Brain. (Reproduced from [Marieb 1991])

Cerebral hemispheres

The cerebralhemispheres (Figure 1), located on the most superior part of the brain, are

separated by the longitudinal fissure. They make up approximately 83% of total brain mass, and

are collectively referred to as the cerebrum. The cerebral cortexconstitutes a 2-4 mm thick grey

matter surface layer and, because of its many convolutions, accounts for about 40% of total

brain mass. It is responsible for conscious behaviour and contains three different functional

areas: the motor areas, sensory areas and association areas. Located internally are the white

7/27/2019 87906380 Case Study CmVA

5/41

Page5

matter, responsible for communication between cerebral areas and between the cerebral

cortex and lower regions of the CNS, as well as the basal nuclei (or basal ganglia), involved in

controlling muscular movement.

Diencephalon

The diencephalon is located centrally within the forebrain. It consists of the thalamus,

hypothalamus and epithalamus, which together enclose the third ventricle. The thalamus acts as

a grouping and relay station for sensory inputs ascending to the sensory cortex and association

areas. It also mediates motor activities, cortical arousal and memories. The hypothalamus, by

controlling the autonomic (involuntary) nervous system, is responsible for maintaining the

bodys homeostatic balance. Moreover it forms a part of the limbic system, the emotional

brain. The epithalamus consists of thepineal glandand the CSFproducing choroid plexus.

Figure 2. Major Regions of the cerebral hemispheres. (Reproduced from [Marieb 1991]).

7/27/2019 87906380 Case Study CmVA

6/41

Page6

Brain stem

The brain stem is similarly structured as the spinal cord: it consists of grey matter

surrounded by white matter fibre tracts. Its major regions are the midbrain, pons and medulla

oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways

between higher and lower brain centres, contains visual and auditory reflex and subcortical

motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the

regulation of respiration and cranial nerves. The medulla oblongata takes an important role as

an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in the

medulla regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves.

Moreover, it provides conduction pathways between the inferior spinal cord and higher brain

centres.

Cerebellum

The cerebellum, which is located dorsal to the pons and medulla, accounts for about

11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal

white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum

processes impulses received from the cerebral motor cortex, various brain stem nuclei and

sensory receptors in order to appropriately control skeletal muscle contraction, thus giving

smooth, coordinated movements.

7/27/2019 87906380 Case Study CmVA

7/41

Page7

THE CEREBRAL CIRCULATORY SYSTEM

Blood is transported through the body via a continuous system ofblood vessels.Arteries

carry oxygenated blood away from the heart into capillaries supplying tissue cells. Veins collect

the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow

through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange

gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys.

All the circulation besides the heart and the pulmonary circulation are called the systemic

circulation.

Blood supply to the brain

Figure 3 Major cerebral arteries and the circle of Willis. (Reproduced from [Marieb 1991]).

7/27/2019 87906380 Case Study CmVA

8/41

Page8

Figure 3 shows an overview of the arterial system supplying the brain. The major

arteries are the vertebral and internal carotid arteries. The two posterior and single anterior

communicating arteries form the circle of Willis, which equalises blood pressures in the brains

anterior and posterior regions, and protects the brain from damage should one of the arteries

become occluded. However, there is little communication between smaller arteries on the

brains surface. Hence occlusion of these arteries usually results in localised tissue damage.

Cerebral haemodynamics

The cardiac output is about 5 l/min of blood for a resting adult. Blood flow to the brain

is about 14% of this, or 700 ml/min. For any part of the body, the blood flow can be calculated

using the simple formula:

Blood flow = Pressure

Resistance

Pressure in the arteries is generated by the heart which pumps blood from its left

ventricle into the aorta. (Since pressure was historically measured with a mercury manometer,

the units are commonly expressed in terms of [mm Hg], although the official SI unit is the Pascal

[Pa].) Resistance arises from friction, and is proportional to the following expression

Resistance Viscosity x Vessel Length

(Vessel Diameter) 4

7/27/2019 87906380 Case Study CmVA

9/41

Page9

Hence blood flow is slowest in the small vessels of the capillary bed, thus allowing time

for the exchange of nutrients and oxygen to surrounding tissue by diffusion through the capillary

walls.

Approximately 75% of total blood volume is stored in the veins which, because of their

high capacity, act as reservoirs. Their walls distend and contract in response to the amount of

blood available in the circulation. However, the function of cerebral veins, formed from sinuses

in the dura mater, is somewhat different from other veins of the body, as they are non-

collapsible.

Autoregulation

[Panerai 1998] describes autoregulation of blood flow in the cerebral vascular bed as

the mechanism by which cerebral blood flow (CBF) tends to remain relatively constant despite

changes in cerebral perfusion pressure (CPP). With a constant metabolic demand, changes in

CPP or arterial blood pressure that would increase or reduce CBF are compensated by adjusting

the vascular resistance. This maintains a constant O2 supply and constant CBF.

Therefore cerebral autoregulation allows the blood supply to the brain to match its

metabolic demand and also to protect cerebral vessels against excessive flow due to arterial

hypertension. Cerebral blood flow is autoregulated much better than in almost any other organ.

Even for arterial pressure variations between 50 and 150 mm Hg, CBF only changes by a few

percent. This can be accomplished because the arterial vessels are typically able to change their

diameter about 4-fold, corresponding to a 256-fold change in blood flow. Only when the brain is

very active is there an exception to the close matching of blood flow to metabolism, which can

rise by up to 30-50% in the affected areas. It is an aim of PET, functional MRI, near infrared

spectroscopy (NIRS), and, possibly, near infrared imaging, to detect or image such localized

changes in cortical activity and associated blood flow.

(Retrieved at http://www.medphys.ucl.ac.uk/research/borg/homepages/florian/thesis/pdf_files

/p25_34.pdfon September 27, 2010 at 8:44am)

7/27/2019 87906380 Case Study CmVA

10/41

Page10

III. DIAGNOSTIC PROCEDURESNoncontrast Computed Tomography (CT) Scan

Intraparenchymal hemorrhage can be recognized on CT scans because blood appears

brighter than other tissue and is separated from the inner table of the skull by brain tissue. The

tissue surrounding a bleed is often less dense than the rest of the brain due to edema, and

therefore shows up darker on the CT scan. A computed tomography (CT) scan shows fresh

blood in the skull as a white spot on the film.

The risk of death from an intraparenchymal bleed in traumatic brain injury is especially

high when the injury occurs in thebrain stem. Intraparenchymal bleeds within themedulla

oblongataare almost always fatal, because they cause damage to cranial nerve X, thevagus

nerve, which plays an important role inblood circulationand breathing.This kind of hemorrhage

can also occur in thecortexor subcortical areas, usually in thefrontalortemporal lobeswhen

due to head injury, and sometimes in thecerebellum.

For spontaneous Intracranial Hemorrhage seen on CT scan, the death rate (mortality) is

3450% by 30 days after the insult,and half of the deaths occur in the first 2 days.

Sometimes a persons symptoms and clinical exam point to a subarachnoid hemorrhage,

but the CT scan cannot confirm the diagnosis because there is only a small amount of blood in

the space between the brain and the surrounding membranes. In this case, the physician usually

undertakes a lumbar puncture, or spinal tap, in order to detect any fresh blood cells in the

cerebrospinal fluid.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) may also detect fresh bleeding in the brain, but it is

even more useful in the search for possible underlying causes. It can detect vascular

malformations, tumors, evidence for congophilic amyloid angiopathy, and even aneurysms. A

specialized type of ultrasound called transcranial Doppler ultrasonography is another useful tool

for spotting larger malformations of blood vesselsits often used for follow-up evaluations of

people who have had a subarachnoid hemorrhage. The most reliable technique to confirm or

rule out the presence of aneurysms and other malformations of the blood vessels is a cerebral

angiogram; physicians inject contrast dye into the blood system to make arteries stand out on X-

ray films.

7/27/2019 87906380 Case Study CmVA

11/41

Page11

IV. PATHOPHYSIOLOGYPATHOPHYSIOLOGY (BOOK-BASED)

MODIFIABLE RISK FACTORS

Hypertension Hyperlipidemia Cigarette Smoking Heavy Alcohol Consumption Drug Addiction (Cocaine) Obesity High Dose of estrogen OC Diabetes Mellitus Cardiovascular Disease Atrial Fibrillation Type A personality Sedentary Lifestyle

NON-MODIFIABLE RISK FACTORS

Advancing Age Sex (Men) Race (African Americans) History of transient

ischemic attack or CVA

Family History of DM

Severe occipital or nuchalrigidity, headache andvomiting

Seizures Changes in mental status Fever ECG changes

Intracerebral hemorrhage

Loss of blood supply

Brain cannot use anaerobic

metabolism

Hypoxia

7/27/2019 87906380 Case Study CmVA

12/41

Page12

Influx of Ca and NaCerebral Ischemia

Neurotoxins (O2 free radicals,

nitric oxide, and glutamate) are

released.

Local Acidosis

Membrane

depolarization

Cytotoxic edema and cell death

Blood flow not restored

within 3 to 10 minutes

Short term ischemia or TIA

Irreversible damage or

infarction

Transient hemiparesis Loss of speech Hemisensory loss

Hemiparesis/ Hemiplegia Aphasia Dysarthria Dysphagia Apraxia Visual Changes Homonymous Hemianopia Horner Syndrome Agnosia Unilateral Neglect Sensory Deficits Behavioral Changes Incontinence

Focal neurologic deficits

lasting less than 24 hrs

7/27/2019 87906380 Case Study CmVA

13/41

Page13

Synthesis of the Disease

Definition of the Disease

Stroke is a term used to describe neurologic changes caused by an interruption in the

blood supply to a part of the brain. The two major types of stroke are ischemic and

hemorrhagic. Ischemic stroke is caused by a thrombotic or embolic blockage of blood flow to

the brain. Bleeding into the brain or tissue or the subarachnoid space causes a hemorrhagic

stroke. Ischemic strokes account for about 83% of all strokes. The remaining 17% of strokes are

hemorrhagic.

Blood flow to the brain can be decreased in several ways. Ischemia occurs when the

blood supply to a part of the brain is interrupted or totally occluded. Ultimate survival of

ischemic brain tissue depends on the length of time it is deprived plus the degree of altered

brain metabolism. Strokes can also be large vessel and small vessel. Large vessel strokes are

caused by blockage of a major cerebral artery, such as the internal carotid, anterior cerebral,

middle cerebral, posterior cerebral, vertebral, and basilar arteries. Small vessel strokes affect

smaller vessels that branch off the larger vessels to penetrate deep into the brain.

Most intracerebral hemorrhages are caused by the rupture if arteriosclerotic and

hypertensive vessels, which causes bleeding into brain tissue. Intracerebral hemorrhage is most

often secondary to hypertension and is most common after age 50 years. Aneurysms are

another cause of hemorrhage. Aneurysms are weakened out pouching in a vessel wall. Although

cerebral aneurysms are usually small (2 to 6mm diameter), they can rupture. An estimated 6%

of all strokes are caused by aneurysm rupture.

Stroke secondary to bleeding often produces spasm of cerebral vessels and cerebral

ischemia because the blood outside of the vessels acts as an irritant to the tissue. Hemorrhagic

stroke usually produces extensive residual functional loss and has the slowest recovery of all

types of stroke. The overall mortality of intracerebral hemorrhage varies between 25% and 60%.

The volume of the hemorrhage is the single most important predictor of client outcome.

Therefore it is not surprising that hemorrhage into the brain causes the most fatalities of all

strokes.

7/27/2019 87906380 Case Study CmVA

14/41

Page14

Risk Factors

Modifiable

a) Hypertension this is due to plaque deposits on the wall of the arteries which causesnarrowing of the blood vessel thereby causing hypertension which may lead to hemorrhagic

stroke

b) Hyperlipidemia- too much lipid in the blood may cause increase plaque formation whichmay cause thrombus formation leading to hypertension.

c) Cigarette Smoking- nicotine content of cigarettes causes vasoconstriction there by resultinghypertension which may lead to CVA

d) Heavy Alcohol Consumption- heavy alcohol consumption increases ones risk of a stroke,light or moderate alcohol may protect against ischemic stroke.

e) Drug Addiction (Cocaine) - this may cause vasospasm, hypertension, hypercoagulability andcerebral ischemia which may cause CVA.

f) Obesity- this is due to increase cholesterol in the body which may contribute plaqueformation that will narrow the blood vessel or may cause thrombus formation.

g) High Dose of estrogen OC- increases risk of stroke to women.h) Diabetes Mellitus- the mechanism is related to macrovascular changes in people with

diabetes mellitus. There is an increase viscosity of blood which may cause formation of

thrombus.

i) Cardiovascular Disease- such as aneurysms which are weakened out pouching in a vesselwall may rupture causing hemorrhagic stroke.

j) Atrial Fibrillation- pulling of blood from poorly emptying atrial which leads to formation oftiny clots in left atrium which can move on the cerebral circulation

k) Type A personality- stress causes hypertension thereby increasing chance of havinghemorrhagic stroke.

l)

Sedentary Lifestyle- increase of having DM and Obesity which one of the factors of havingCV

Non-modifiable

a) Advancing Age- intracerebral hemorrhage is most often secondary to hypertension and ismost common after age 50 years.

7/27/2019 87906380 Case Study CmVA

15/41

Page15

b) Sex (Men)- Incidence of stroke in men is slightly higher than that of womenc) Race (African Americans)- more prevalent among African Americans than whites or

Hispanics

d) History of transient ischemic attack or CVAe) Family History of DM- due to accelerated atherosclerosisSigns and Symptoms

Clinical Manifestations

a) Severe occipital or nuchal rigidity, Headache and vomiting due to an increase ICP whichcauses cerebral edema, and compressing the medulla oblongata

b) Seizures due to hyper excitability of neurons because of irritation.c) Changes in mental status affectation in the Reticular Activating Systemd) Fever affectation in the hypothalamuse) ECG changes problem with the medulla oblongataWarning Signs

a) Transient hemiparesisb) Loss of speechc) Hemisensory lossd) Vertigo/syncopeSpecific Deficits

a) Hemiparesis/Hemiplegia the former means weakness of one side of the body while thelatter means paralysis of one side of the body.

b) Aphasia defects on using and interpreting symbols of languagec)

Dysarthia imperfect articulation condition.

d) Dysphagia- due to affectation of some cranial nervese) Apraxia - a condition in which a client can move the affected part but cannot use it for

purposeful actions.

f) Visual Changes- affectation of the several areas of the brain that control the complexprocesses of vision.

7/27/2019 87906380 Case Study CmVA

16/41

Page16

g) Homonymous Hemianopsia a defective vision or vision loss in the same half of the visualfield

h) Horners syndrome paralysis of sympathetic nerves to the eye causing sinking of theeyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the eye.

i) Agnosia a disturbance in the ability to recognize familiar objects through the senses.j) Unilateral neglect inability to respond to stimulus on the contralateral side of a cerebral

infarction.

k) Sensory Deficits- several types of sensory changes can result from a stroke in the sensorystrip of the parietal lobe supplied by the anterior and middle cerebral artery.

l) Behavioral changes- various portions of the brain assist with control of behavior andemotions. People with stroke in the left cerebral or dominant hemisphere are frequently

slow, cautious, and disorganized while on the right cerebral stroke or nondominanthemisphere, are frequently impulsive, overestimate their abilities and have a decreased

attention span which increases their risk of injury.

m) Incontinence due to inattention, memory lapses, emotional factors, and inability tocommunicate.

7/27/2019 87906380 Case Study CmVA

17/41

Page17

V. MEDICAL MANAGEMENT AND SURGICAL PROCEDURE (IF ANY)DRUGS

1. DexamethasoneBrand Name: Decadron

General Classification:Glucocorticoid

Specific Action:

Decreases inflammation mainly by stabilizing leukocyte lysosomal membranes; suppresses

immune response; stimulates bone marrow; and influences protein, fat and carbohydrate

metabolism.

Indication: Cerebral Edema

Adverse Reactions:

Euphoria, insomnia, seizures, peptic ulceration, immunosuppression

Nursing Responsibilities:

Determine sensitivity Give IM injection deeply into gluteal muscle. Rotate injection sites to prevent

muscle atrophy. Avoid SQ injection because atrophy and sterile abscesses may

occur.

Monitor pts weight, BP and electrolyte levels. Monitor pt for cushingoid effects, including moon face, buffalo hump, central

obesity, thinning hair, hypertension, and increased susceptibility to infection.

Watch for depression or psychotic episodes, especially in high-dose therapy. Diabetic client may need increased insulin; monitor blood glucose level. Inspect pts skin for petechiae. Gradually reduce dosage after long-term therapy.

7/27/2019 87906380 Case Study CmVA

18/41

Page18

2. ParacematolBrand Name: Aeknil

General Classification:Analgesic, Antipyretic

Specific Action:

It has analgesic, antipyretic and weak anti-inflammatory action. The mechanism of action is

associated with inhibition of prostaglandin synthesis, the predominant influence on the

thermoregulation center in the hypothalamus, enhances heat transfer.

Indication: Elevated temperature

Adverse Reactions:

Digestive system: rarely - dyspepsia

Long-term use at high doses - hepatotoxic effects, methemoglobinemia, renal dysfunction

and liver, hypochromic anemia

Hemopoietic system: rarely - thrombocytopenia, leukopenia, pancytopenia, neutropenia,

agranulocytosis.

Allergic reactions: rarely - skin rash, itching, hives


Many OTC and prescription products contain acetaminophen; be aware of this whencalculating total daily dose.

With caution used in patients with disorders of the liver and kidneys, with benignhyperbilirubinemia, as well as in elderly patients.

With prolonged use of paracetamol is necessary to monitor patterns of peripheralblood and functional state of the liver.

3. PantoprazoleBrand Name: Pantoloc

7/27/2019 87906380 Case Study CmVA

19/41

Page19

General Classification:Proton pump inhibitor

Specific Action:

Pantoprazole or Pantoloc inhibits proton pumps in the stomach which produce acid.

Indication:

Provides control of ulcer disease and reflux conditions; those under NPO status.

Adverse Reactions:

Pantoprazole or Pantoloc is well tolerated with most side effects being mild and transient.

Reported side effects include diarrhea, gas, constipation, abdominal pain, headache, and

dizziness.


Pantoprazole or Pantoloc seems to have a greater effect in the elderly, thus thedosage may have to be modified.

Because the liver is involved in the metabolism and excretion of Pantoprazole orPantoloc, people with liver disease may have to have a dosage modification.

4. Aluminum Hydroxide and Magnesium HydroxideBrand Name: Maalox

General Classification:Antacid

Specific Action:

This medication works only on existing acid in the stomach. It does not prevent acidproduction. It may be used alone or with other medications that lower acid production.

Indication: stomach upset, heartburn, and acid indigestion

Adverse Reactions:

7/27/2019 87906380 Case Study CmVA

20/41

Page20

Upset stomach, vomiting, stomach pain, belching, constipation, dry mouth, increased

urination, loss of appetite, metallic taste


Taken on an empty stomach, they only neutralize acid for 30 to 60 minutes becausethe antacid quickly leaves the stomach.

If taken with food, the protective effect may be 2 or 3 hours. To get as much acid reduction as prescription medicines produce is expensive as the

antacid must be taken frequently during the day and night. It is probably cheaper to

take an acid-reducing pill once or twice a day.

All antacids, but especially calcium carbonate, can result in an acid rebound effectwhere the stomach acid surges back after the antacid has left the stomach, another

reason for long-acting medications.

Antacids interfere with many drugs. Staggering the antacid away from medicationsis always preferable but again is a nuisance and hard to comply with long-term.

5. MannitolBrand Name: Osmitrol

General Classification:Osmotic Diuretic

Specific Action:

Mannitol is an osmotic diuretic. It works by increasing the amount of fluid excreted by the

kidneys and helps the body to decrease pressure in the brain and eyes.

Indication: To reduce intracranial pressure

Adverse Reactions:

Seizures, diarrhea

7/27/2019 87906380 Case Study CmVA

21/41

Page21


Mannitol may cause dizziness. These effects may be worse if you take it with alcoholor certain medicines. Use Mannitol with caution. Do not drive or perform other

possibly unsafe tasks until you know how you react to it.

Tell your doctor immediately if you have difficulty urinating or experience extremedizziness.

Lab tests, including blood electrolytes, kidney function, lung function, heartfunction, and blood counts, may be performed to monitor your progress or to check

for side effects. Be sure to keep all doctor and lab appointments.

Use Mannitol with caution in the ELDERLY; they may be more sensitive to its effects.

6. NicardipineBrand Name: Cardene

General Classification:Calcium Channel Blocker

Specific Action: Nicardipine relaxes (widens) your blood vessels, which makes it easier for

the heart to pump and reduces its workload.

Indication:

It is used to treat hypertension (high blood pressure) and angina (chest pain)

Adverse Reactions:

Side effects of nicardipine include an increased heart rate due to the drop in blood

pressure. Other side effects include swelling of the feet (edema), dizziness, headaches,

flushing, palpitations, and nausea. Nicardipine sometimes can cause an increase in the

frequency and duration of angina. The reason for this side effect is not clearly understood.

Excessively low blood pressure can occur in rare instances, especially during initiation of

treatment or following adjustments of dosage.

http://www.medicinenet.com/script/main/art.asp?articlekey=12699http://www.medicinenet.com/script/main/art.asp?articlekey=97800http://www.medicinenet.com/script/main/art.asp?articlekey=20628http://www.medicinenet.com/script/main/art.asp?articlekey=57394http://www.medicinenet.com/script/main/art.asp?articlekey=437http://www.medicinenet.com/script/main/art.asp?articlekey=24732http://www.medicinenet.com/script/main/art.asp?articlekey=1950http://www.medicinenet.com/script/main/art.asp?articlekey=1950http://www.medicinenet.com/script/main/art.asp?articlekey=24732http://www.medicinenet.com/script/main/art.asp?articlekey=437http://www.medicinenet.com/script/main/art.asp?articlekey=57394http://www.medicinenet.com/script/main/art.asp?articlekey=20628http://www.medicinenet.com/script/main/art.asp?articlekey=97800http://www.medicinenet.com/script/main/art.asp?articlekey=12699

7/27/2019 87906380 Case Study CmVA

22/41

Page22

Measure blood pressure frequently during initial therapy. Maximal response occursabout 1 hour after giving the immediate-release form and 2 to 4 hours after giving

the sustained-release form.

Check for orthostatic hypotension. Because large swings in BP may occur based ondrug level, assess antihypertensive effect 8 hrs after dosing.

Advise pt to report chest pain immediately.

7. DopamineBrand Name: only generic name

General Classification: Dopamine is a vasopressor and inotropic agent.

Specific Action: It works by increasing the pumping strength of the heart and the kidney

blood supply.

Indication: Treating shock and low blood pressure due to heart attack, trauma, infections,

surgery, and other causes.

Adverse Reactions: Fast heartbeat; headache; nausea; vomiting.


Drug is not a substitute for blood or fluid volume deficit. If deficit exist, replace fluidbefore giving vasopressors.

During infusion, frequently monitor ECG, BP, CO, CVP, pulmonary artery wedgepressure, PR, UO and color and temperature of the limbs.

If diastolic pressure rises disproportionately with a significant decrease in pulsepressure, decrease infusion rate, and watch carefully for further evidence of

predominant vasoconstrictor activity, unless such an effect is desired.

Check UO often. If urine flow decreases without hypotension, notify prescriber. After the drug is stopped, watch closely for sudden drop in BP. Taper dose slowly to

evaluate stability of BP.

Acidosis decreases effectiveness of drug.

7/27/2019 87906380 Case Study CmVA

23/41

Page23

VI. SURGICAL MANAGEMENTSurgeries for hemorrhagic stroke include:

Surgery to drain or remove blood in or around the brain that was caused by a bleedingblood vessel (hemorrhagic stroke).

A procedure (endovascular coil embolization) to repair a brain aneurysm that is thecause of a hemorrhagic stroke. Endovascular coil embolization is becoming a standard

treatment option for people with a brain aneurysm. It may be used for people who are

at high risk for complications from a surgical repair of the aneurysm. Endovascular coil

embolization involves packing the aneurysm with a soft platinum coil that fills the

stretched and bulging section of blood vessel. This helps seal off the aneurysm and

reduces the risk of the aneurysm leaking blood or rupturing. The doctor uses X-rays to

identify the aneurysm and to guide the coil through the blood vessel to the

aneurysm.The success of this treatment depends on the size and location of the

aneurysm, the skill of the doctor, and the person's general health. Complications include

bleeding from the aneurysm or movement of the coils in the blood vessel.

Surgery to remove or block off abnormally formed blood vessels (arteriovenousmalformations) that have caused bleeding in the brain. An arteriovenous

malformation is a congenital disorder, which means it was present at birth. An

arteriovenous malformation causes an abnormal web of blood vessels and veins in the

brain, brain stem, or spinal cord. The vessel walls of an arteriovenous malformation may

become weak and leak or rupture.
http://www.webmd.com/hw-popup/aneurysmhttp://www.webmd.com/hw-popup/aneurysm

7/27/2019 87906380 Case Study CmVA

24/41

VII. NURSING CARE PLANS (NCPs)1

stProblem: Ineffective Cerebral Tissue Perfusion

Assessment Nursing DiagnosisScientific

ExplanationObjectives Nursing Interventions Rationale

Expected

Outcome

S>O> The patient

may manifest:

>Headache

>Vertigo

>Visual Changes

>Dizziness

>Ataxia

>Motor deficits

>Paresthesia

>Seizure activity

>Coma

>Bloody CSF

>Positive

radiologic findings

Ineffective

Cerebral Tissue

Perfusion related

to intracranial

hemorrhage as

evidenced by

headache and

sudden drop in

level of

consciousness.

Cerebrovascular

accident is the term

that refers to any

functional abnormality

of the Central Nervous

System that occurs

when the normal

blood supply to the

brain is disrupted, as

by a blood clot or a

ruptured blood vessel,

and vital brain tissue

dies. Hemorrhagic

stroke is the rupture of

a blood vessel and

bleeding within or over

the surface of the

brain.

Short Term:

After 4 hours of NI,

the pts cerebral

perfusion pressure

will be maintained

as evidenced by O2

saturation equal to

90% and above.

Long Term:

After 3 days of NI,

the pt will be able

to demonstrate

behaviors which

may improve

proper circulation

such as compliance

to health

management and

therapies provided.

>Monitor and record

neurologic status,

usually Glasgow Coma

Scale

>Assess past history of

systemic problems:

previous cardiac

disease, hypertension,

smoking, previous

pulmonary disease.

>Monitor VS as

needed

>Monitor baseline

ECG and observe for

changes

>Monitor I and O and

Urine specific gravity

>Monitor to

determine effects of

stroke and prevent

life threatening

complications such as

severe hypertension

and increased

intracranial pressure.

>Hypertension seems

to be related to

hemorrhagic stroke.

>To assess for current

status

>Stroke can produce

cardiac electrical

changes and

dysrhythmias

>Because of cerebral

edema, fluid balance

must be regulated.

Fluids must be

restricted if pt has

significant increase in

ICP, or volume

expanders may be use

Short Term:

The pts

cerebral

perfusion

pressure shall

have been

maintained as

evidenced by

O2 saturation

equal to 90%

and above.

Long Term:

The pt shall

have been able

to demonstrate

behaviors which

may improve

proper

circulation such

as compliance

to health

management

and therapies

provided.

7/27/2019 87906380 Case Study CmVA

25/41

>Monitor electrolytes

>Monitor arterial

blood gases and pulse

oximetry

>Raise head of the

bed

>Keep head and neck

in neutral position

>Cluster activities

>Control body

temperature:

administer

antipyretics, initiate

topical cooling

methods, and

administer

hypothalamic

depressants as

prescribed.

if pt is hypotensive

with decreased

cerebral perfusion.

>For immediate

intervention

>Pulse oximetry

should be 90% or

greater for adequate

cerebral oxygenation.

>This diminishes

perfusion

(hemorrhage or

increased ICP). ICP

should be below

15mmHg. Cerebral

perfusion pressure

should be between 80

to 100 mmHg.

>This eliminates the

need to impinge

blood vessel and

circulation

>This eliminated theneed to increase ICP

>Controlling fever

reduces metabolic

demands of the brain.

Fever may be a result

of hypothalamic

irritation ot infection

(bladder or

respiratory).

7/27/2019 87906380 Case Study CmVA

26/41

> Administer the

following meds:

-Hyperosmotic

-Albumin

-Antihypertensives

-Corticosteroids

-to decrease ICP

-increases volume

-control severe HPM

-control intracranial

inflammation

7/27/2019 87906380 Case Study CmVA

27/41

2nd

Problem: Risk for Ineffective Airway Clearance



Expected

Outcome

S>O> The patient

may manifest:

>Difficulty in

breathing

>O2 saturation less

than 90%

>Respiratory

distress: patient

complaints,

cyanosis,

restlessness,

shortness of

breath.

Risk for Ineffective

Airway Clearance

related toneurologic

dysfunction,

obstruction or

secretions.

Cerebrovascular


that refers to any



System that occurs

when the normal blood

supply to the brain is

disrupted, as by

a blood clot or a



dies. Hemorrhagic


a blood vessel and


the surface of the

brain. Breathing center

of the brain may be

affected and so,

difficulty in breathing

may be experienced.

Short Term:

After 4 hrs of NI,

the patient will

maintain patent

airway as

evidenced by rate,

rhythm and lung

sounds within

normal limits.

Long term:

After 3 days of NI,

the patient will not

exhibit any signs of

respiratory distress.

>Monitor respiratory

rate and rhythm, lung

sounds, and ability to

handle secretions.

>Check presence of

gag reflex.

>Observe for evidence

of respiratory distress

that may result from

pulmonary edema:

patient complaints,

cyanosis, restlessness,

shortness of breath.

>Position upright.

Monitor ICP and BP

during position

changes.

>A stroke in evolution

may cause

neurological

deterioration,

including respiratory

dysfunction.

>Brainstem strokes

may diminish cranial

nerve function. Oral

feeding should not be

attempted if gag

reflex is absent to

prevent aspiration

and obstruction of

airway. When pt is

able to participate,

consult speech or

occupational therapy

to initiatle swallow

exercises.

> The use of volume

expanders to

promote cerebral

perfusion can also

cause pulmonary

edema.

>reduces the work of

breathing

Short Term:

The pt shall

have

maintained

patent airway

as evidenced by

rate, rhythm

and lung sounds

within normal

limits.

Long term:

The patient

shall not have

exhibited any

signs of

respiratory

distress.

7/27/2019 87906380 Case Study CmVA

28/41

>If pt is comatose, use

an oropharyngeal

airway.

>change position every

2 to 4 hours.

Encourage deep

breathing, coughing,

and use of incentive

spirometer (if able);

add humidity to

environment.

>Provide respiratory

support:

-Administer

supplemental oxygen

-Provide endotracheal

or tracheal care if

warranted.

-Avoid respiratory

measures that increase

ICP, such as frequentsuctioning, but keep in

mind that a patent

airway is first priority.

>keeps the tongue

form obstructing the

airway

>position changes

prevents pooling

secretions. Older

people are most

susceptible to

atelectasis and

pneumonia.

-This reduced

hypoxemia, which can

cause cerebral

vasodilation and

increased ICP.

-The patient in a

coma after 48hrs may

require intubation

7/27/2019 87906380 Case Study CmVA

29/41

3rd

Problem: Impaired Physical Mobility



Expected

Outcome

S>

O> The patientmay manifest:

>inability to move

purposefully

within physical

environment.

>limited range of

motion

>decreased muscle

strength, control

and/or mass

Impaired Physical

Mobility related

to paresis orparalysis, loss of

balance and

coordination and

increased muscle

tone.

The nervous system is

made up of nerve cells

called neurons thatserve as the

communication system

of the body. They carry

messages in the form

of electrical impulses.

The messages move

from one neuron to

another to keep the

body functioning.

Because neurons have,

limited ability to repair

themselves unlike

other body tissues that

is why nerve cells

cannot be repaired if

damaged due to injury

or disease.

Short Term:

After 4 hrs of NI,

the patient willmaintain maximum

level of function

and will reduce risk

of complications.

Long Term:

After 3 days of NI,

the pt will be able

to demonstrate

behaviors that

enable resumption

of activities.

>Assess pts degree of

weakness in both

upper and lowerextremities

>Assess ability: to

move and change

position, to transfer

and walk, for fine

muscle movement and

fro gross muscle

movement.

>determine active and

passive range of

motion capabilities.

>Observe activities or

situations that

increase or decrease

tone.

>monitor skin integrity

for areas of blanching

or redness as signs of

potential breakdown

>Change position of

the patient at least

every 2 hours, keeping

track of position

changes with a turning

schedule

>there may be

differing degrees of

involvement on theaffected side.

>paralysis, paresis,

and sensory loss are

contralateral to the

side of the brain

affected by stroke.

>initially muscles

demonstrate

hyporeflexia, which

later progresses to

hyperreflexia.

>Activities that cause

spastic response can

be postponed until

later in recovery

>to have immediate

treatment

>Patients may not

feel increases in

pressure or have the

ability to adjust

position.

Short term:

The patient

shall havemaintained

maximum level

of function and

will reduce risk

of

complications.

Long Term:

The pt shall

have been able

to demonstrate

behaviors that

enable

resumption of

activities.

7/27/2019 87906380 Case Study CmVA

30/41

>Perform active and

passive ROM exercises

in all extremities

several times daily.

>Increase functional

activities as strength

improves and the

patient is medically

stable

>Teach pt and family

exercises and transfer

techniques.

>Use pressure

relieving devices onthe bed and chair.

>Initiate rehabilitation

techniques in the

hospital setting as

soon as medically

possible.

>This preserves

muscle strength and

prevents

contractures,

especially in spastic

extremities.

>to gradually improve

muscle strength

>Once medically

stable, the pt may

have continuing

deficits such as

altered perception

and motor strength.

Exercise will increase

strength, promote

use of the affected

side and promote

transfer safety.

>This decreases the

risk of pressure ulcerdevelopment.

>this prevents further

systemic

deterioration.

7/27/2019 87906380 Case Study CmVA

31/41

4th

Problem: Risk for Impaired Verbal Communication



Expected

Outcome

S>O> The patient

may manifest:

>Inability to

recognize or

understand words

>Difficulty

vocalizing words

>Inability to recall

familiar words,

phrases or names

of known persons,

objects and places

>Unable to speak

dominant

language

>Problems in

receiving the type

of sensory input

being sent or

sending the type

of input necessary

for understanding.

Risk for Impaired

Verbal

Communicationrelated to brain

injury adversely

affecting the

transmission,

reception or

interpretation of

language and

other forms of

communication.

There is an affectation

of the certain brain

lobes that caused by

impaired cerebral

circulation that affects

its proper functions

that leads to

decreased, delayed or

absent ability to

receive, process,

transmit and use a

system of symbols in

communicating

resulting in impaired

verbal communication.

Short Term:

After 4 hrs of NI,

the patient will

maximize

remaining

communication.

Long term:

After 3days of NI,

the pt will be able

to use a form of

communication to

get needs met and

to relate effectively

with persons, and

his or her

environment.

>Assess speech-

language history:

determine primary

language, ability to

read, write, and

understand spoken

language; level of

education

>Assess speech-

language function:

automatic speech,

auditory

comprehension,

comprehension of

written language,

expressive ability,

ability to write.

>Approach the pt as an

adult.

>Enhance the

environment.

>These data provide a

baseline for

developing an

individualized

teaching plan.

>Depending on the

area of brain

involvement, patients

may experience

aphasia (receptive or

expressive),

dysarthria, or both,

Receptive aphasics

cannot understand

the spoken word.

Expressive aphasics

cannot use written

symbols.

>Inability to express

needs or feelings is

most distressing to

pts. Staff needs to be

sensitive to the

dignity of the pt.

>Communication can

be facilitated and

distractions

minimized by turning

Short term:

The patient

shall have

maximized

remaining

communication.

Long term:

The pt shall

have to used a

form of

communication

to get needs

met and to

relate

effectively with

persons, and his

or her

environment.

7/27/2019 87906380 Case Study CmVA

32/41

>Modulate personal

communication,

controlling body

language and

providing clear, simple

directions.

>Incorporate

multimodality input,

such as music, song

and visual

demonstration.

>Use written materials

(if appropriate)

>Use prompting cues,

such as gestures or

holding an object that

off the television,

radio or closing the

door.

> to maximize

communicating

ability.

>These enhance

function in intact

speech-language

areas.

>These supplement

auditory input (eg.

Communication

board with pictures,

numbers, words,

and/or alphabet). If

the pt has

homonymous

hemianopsia, placematerial in the

unaffected field of

vision. Homonymous

hemianopsia affects

the field vision in

both eyes, opposite

the side of the brain

affected by stroke.

>to enhance

communication

7/27/2019 87906380 Case Study CmVA

33/41

is being discussed.

>Allow adequate time

for patient response.

>Provide opportunities

for spontaneous

conversation.

>Anticipate pts needs

until alternative means

of communication can

be established.

>Provide reality

orientation and focusattention, but avoid

constantly correcting

errors.

>Collaborate with

speech-language

pathologist

>Encourage family to

attempt

communication with

pt; explain type of

>If the pt feels

rushed,

communication

problems worsened.

>This provides the pt

a chance to talk

without the

expectation of a

desired outcome

(decreases anxiety

about abilities.

>The nurse should set

aside enough time to

attend to all the

details of patient

care. Care measures

may take longer to

complete in the

presence of a

communication

deficit.

>Constant correction

increases frustrations,anxiety and anger.

>A comprehensive,

multidisciplinary plan

of care may be

required.

>to assume their

cooperation

7/27/2019 87906380 Case Study CmVA

34/41

aphasia and methods

of communication that

can be tried.

>Demonstrate to pt

any progress made

>this increases

confidence and

facilities ongoing

efforts.

7/27/2019 87906380 Case Study CmVA

35/41

5th

Problem: Risk for Disturbed Sensory Perception (Tactile)



Expected

Outcome

S>O> The patient

may manifest:

>numbness

>tingling sensation

or paresthesia

>pressure ulcers

>accidental

wounds or

punctures

>pallor/ cyanosis

Risk for Disturbed

Sensory

Perception(Tactile)

Cerebrovascular


that refers to any



System that occurs

when the normal blood

supply to the brain is

disrupted, as by

a blood clot or a



dies. Hemorrhagic


a blood vessel and


the surface of the

brain. Tactile stimuli

may not be felt by the

patient due to the

affection of the nerves

on the certain areas of

the brain.

Short Term:

After 4 hrs of NI,

the patient will

remain free from

injuries, including

pressure ulcers.

Long Term:

After 3 days of NI,

the patient will

continuously be

free from injuries.

>Assess pts ability to

sense light touch,

pinprick, and

temperature. Touch

skin lightly with a pin,

cotton ball or hot/cold

object and ask patient

to describe sensation

and point to where

touch occurred.

>Using pts toes or

fingers, assess position

sense (ability to sense

whether the joint is

moved in an upward or

downward position)

>Perform regular skin

inspections and

instruct pt in

techniques to do the

same. Explain

consequences of

prolonged pressure on

the skin.

>Provide tactile

stimulation to affected

limbs using rough cloth

or hand and instruct [t

or family in methods

used.

>Explain how stimulus

>This determines the

level of alteration and

identifies specific

areas of risk.

>to know extent of

sensory perception.

>Pressure on the

affected side should

last no longer than 30

minutes.

>This helps pts learn

to recognize

sensations.

>This improves pt

Short term:

The patient

shall remain

free from

injuries,

including

pressure ulcers.

Long Term:

The patient

shall have been

continuously be

free from

injuries.

7/27/2019 87906380 Case Study CmVA

36/41

might feel.

>Instruct pt to

regularly move

affected limbs

>Enhance immediate

and home

environment

understanding.

>Movement

promotes circulation.

Impaired sensitivity to

pain or numbness

increases the

likelihood of

prolonged stationary

positioning.

>For optimum safety,

by regulating

temperature setting

on hot water heater,

moving sharp edged

furniture and lighting

hallways.

7/27/2019 87906380 Case Study CmVA

37/41

6th

Problem: Risk for Unilateral Neglect

AssessmentNursing

Diagnosis

Scientific


Expected

Outcome

S>O> The patient

may manifest:

>Left or right

sided neglect due

to the affectation

of the opposite

hemisphere of

the brain.

Risk for

Unilateral

Neglect

Unilateral neglect

syndrome is a

neuropsychological

condition in which, after

damage to one hemisphere

of the brain, a deficit in

attention to and awareness

of one side of space is

observed

Short Term:

After 4 hrs of NI,

the patient will

have no injuries as

a result of deficit.

Long Term:

After 3 days of NI,

the pt will observe

and touch affected

side during ADLs.

>Conduct sensory

assessment

>Perform visual fields

confrontation test.

>Observe pts

performance of ADL.

>Observe pts

response to sounds

from affected side.

>Conduct paper

drawing test to test

for distorted spatial

relationships.

>Observe for remark

> This determines

the actual level of

sensation for

comparison with

how the pt uses the

senses in the

affected side. Use

may be different

from actual ability.

>Pt may not be able

to see on affected

side (hemianopsia).

The pt who

complains of diplopia

may benefit from

patching one eye.

>This provides

information on pts

recognition of

affected side. The pt

may not, for

example, bathe the

affected side; they

forget that it is here.

Short Term:

The patient

shall have no

injuries as a

result of

deficit.

Long Term:

The pt shall

observe and

touch affected

side during

ADLs.
http://en.wikipedia.org/wiki/Neuropsychologicalhttp://en.wikipedia.org/wiki/Neuropsychological

7/27/2019 87906380 Case Study CmVA

38/41

of denial of body

parts (anosognosia)

and degree to which

patient confuses

objects in space.

>Have pt point to

various body parts

(somatognosia)

>Approach pt from

unaffected side when

pt initially regains

consciousness. As the

pt becomes more

alert, approach from

the affected side

while calling the pts

name during the

rehabilitation phase.

>Provide tactile

stimulation to

affected side.

>Place all food in

small quantities,

arranged simply onplate.

> Attach watch or

bright bracelet to

affected arm.

>Practice drawing and

copying figures with

>Diminished

awareness is a safety

hazards.

>Pt may not

recognize body parts

on affected side.

>These decreases

anxiety and fear

while pt is unable to

interpret whole

environment.

>This will encourage

the pt to use

affected side of body

and environment.

>This stimulates

short-term memory

of sensation.

>This approach

diminishesspatial/visual

deficits. Small

quantities make it

easier to delineate

foods because of the

space between food

items.

>This draws pts

attention to the

affected side

>This helps develop

7/27/2019 87906380 Case Study CmVA

39/41

patients.

>draw bright marks

on the sides of

newspaper or books

when pt is reading.

>teach compensatory

strategies such as

visual scanning

(turning head in order

to visualize entire

area)

fine motor skills and

relearn spatial

relationships.

>This cues the end of

a line and return for

next line.

>this reduces chance

of injury.

7/27/2019 87906380 Case Study CmVA

40/41

Page40

VIII. CONCLUSIONAny hemorrhage affecting the brain or its adjacent spaces is a very serious condition.

Depending on the location and size of the mass of loose blood (called a hematoma), it may even

be life threatening.It is alarming to know that a simple manifestation such as headache has apossibility to lead to abrupt loss in level of consciousness. At the same time ambulatory patient

brought in a emergency room may end up in an intensive care unit, critically being cared.

A hemorrhagic stroke is caused by a sudden bleeding, or hemorrhage, into or next to

the brain. This problem accounts for about 20 percent of all people admitted to hospitals for

strokes. Most hemorrhagic strokes occur in the brain itself and are called intracerebral

hemorrhages. Smaller groups of people suffer bleeding into the fluid filled spaces located deep

in the brain (intraventricular hemorrhage) or into the small space between the brain and the

membranes that cover it (subarachnoid hemorrhage).

People who survive a hemorrhagic stroke and the critical period that immediately

follows often make a remarkable recovery. As the mass of the hematoma slowly decreases, the

actual disruption of brain tissue can turn out to be smaller than what doctors or family members

had feared. Early rehabilitation after strokes benefits most people.

7/27/2019 87906380 Case Study CmVA

41/41

IX. REFERENCESBooks

Nursing 2008 Drug Handbook, Lippincott Williams and Wilkins Joyce M. Black and Jane Hokanson Hawks. Medical-Surgical Nursing Eighth Edition,

Volume 2, Saunders, 2009

Marilynn E. Doenges, Mary Frances Moorhouse, Alice Geissler-Murr; Nurses PocketGuide (11th Edition)Copyright 2006

Internet

http://www.wpro.who.int/countries/2007/phl/health_situation.htm http://www.who.int/topics/cerebrovascular_accident/en/ http://www.wpro.who.int/countries/2007/phl/health_situation.htm Philippine Inquirer, 12/01/2007 http://www.doh.gov.ph/kp/statistics/morbidity http://www.ninds.nih.gov/news_and_events/news_articles/pressrelease_stroke_vaccin

e_090502.htm

http://www.medphys.ucl.ac.uk/research/borg/homepages/florian/thesis/pdf_files/p25_34.pdf

http://www.drugs.com/

http://www.webmd.com/stroke/guide/stroke-surgery http://www.dana.org/news/brainhealth/detail.aspx?id=9824

87906380 case study cmva

Documents