INTRACEREBRAL HEMORRHAGE

A4C

Dayag, Decery

DEMOGRAPHIC DATA
Name:

Patient Mrs. EB Age: 66 years old Gender: Female Civil status: Married Address: Bulacan Birth Date: August 20, 1945 Birth Place: Ilocos Norte Nationality: Filipino Religion: Born Again Christian

 Occupation:

House wife Educational attainment: High school graduate Name of spouse: Mr. AB Occupation: Pastor or Priest Admission Date: August 28, 2011 Admission Time: 10:00pm Admitting Diagnosis: Cerebrovascular Accident Prob. Bleed Final Diagnosis: Intracerebral Hemorrhage Admitting Physician: Dr. Rafael Duran M.D. Hospital: East Avenue Medical Center in Acute Stroke Unit

HISTORY

OF PAST ILLNESS

The patient has an uncontrolled hypertension. In 1998 she had her first stroke attack and was brought to the hospital. She also had her second stroke attack last 2008 and was brought to the FEU hospital. She was diagnosed of CVA infarct. During that time, patient was admitted and underwent series of laboratory and diagnostic tests. Medication was prescribed such as simvastatin, losartan and amlodipine. Other drugs are not really remembered and maintained due to some financial problem because they believe that there are many necessities amend by medication.

They are seven(7) in the family. The youngest (34 yrs.old) is disabled. The 40 and 37 yrs. old havetheir own family. The 47 and 45 yrs. old are unemployed but they are active in church activities. According to husband of our client, from the previous hospitalization, medication was not financially and maintained because the basic needs was prioritized like foods, renting and the needs of her disabled son. She also accepts laundry works and after that she pressed it.

As we recall our lecture in Health Care II, there is transformatory and participatory approach on which they define that poverty is not God-given, rather it is rooted in the historical past and is maintained by the oppressive structure society and they also believe in miracle everything is in the hand of creator.

HISTORY

OF PRESENT ILLNESS

Three hours prior to admission, while cooking their dinner, the patient experienced dizziness and weakness on the right side of her body. Her son saw her as she was about to fall on the ground. The patient was rushed to East Avenue Medical Center. She was unconscious. She was admitted on the same day when attack occurs that was August 28, 2011 at 10:00pm with vital signs of Temp: 36.5, PR: 92 bpm, RR: 22 cpm, BP: 180/100 mmHg. Upon admission patient assisted on ER and transferred to ASU according to her son.

FAMILY HEALTH

HISTORY

Mrs. EBs father had hypertension and he died because of Myocardial infarction. Her second child also has Hypertension. One of her siblings which are the eldest has also Hypertension.

PATIENT SOCIAL AND ECONOMIC HISTORY

Patient EBs is from province of Bulacan.She is 66 years old. She is a high school graduate and has a stressful lifestyle. Due to the financial problem sometimes she wasnt able to buy her medication. She is housewife and his husband is a pastor.She is fond of eating fatty foods like pork and salty foods.

RISK FACTORS

Modifiable: Cigarette smoking, hypertension, hypercholesterolemia, obesity, heavy drinking, use of illicit drugs such as cocaine and methamphetamines, use of contraceptive pills, physical inactivity, stressrelated occupations are some of modifiable risk factors of stroke. In our patient, one of the modifiable risk factor is her uncontrolled hypertension. Another is stress because she worries easily especially on financial matters and the present situation of his youngest son. She is also fond of eating salty foods and chicharonbulaklak dip in sukang may sili at patis.

NON- MODIFIABLE
Male (gender), 50 years old and above (age), family history of stroke, and previous stroke attacks, cardiovascular diseases are some of the non-modifiable risk factors of stroke.

PHYSICAL ASSESSMENT

Cortez, Jeffmar Marron , Ferdinand

DEFINITION OF THE

DISEASE

Cruz, Paolo

A stroke or cerebrovascular accident (CVA) occurs when blood supply of the brain is disrupted, causing brain cells to die. When blood flow to the brain is impaired, oxygen and glucose cannot be delivered to the brain. Blood flow can be compromised by a variety of mechanisms. The main cause is blockage of an artery also called ischemic stroke. Another is the hemorrhagic stroke which is the bursting of blood vessel in the brain. It results from weakened vessels that rupture.

Hemorrhagic stroke has two types. First is the subarachnoid hemorrhage which is the bleeding into the space (subarachnoid space) between the inner layer (pia matter) and middle layer (arachnoid matter) of the tissue covering the brain (meninges). The most common cause is the rupture of a bulge (aneurysm) in an artery. The second type which is the case of our patient is the intracerebral hemorrhage. Intracerebral hemorrhage most often results when chronic high blood pressure weakens a small artery causing it to burst. Using cocaine or ampethamines can cause temporary but very high blood pressure and hemorrhage. In some older people, an abnormal protein called amyloid accumulates in arteries of the brain. This accumulation weakens the arteries and can cause hemorrhage.

Less common causes include blood vessel abnormalities present at birth, injuries, tumors, inflammation of blood vessels (vasculitis), bleeding disorders and use of anticoagulants in doses that are too high. Bleeding disorders and use of anticoagulants increase the risk of dying from an intracerebral hemorrhage.

An intracerebral hemorrhage begins abruptly. In about half of the people, it begins with a severe headache often during activity. However, in older people, the headache may be mild or absent. Symptoms suggesting brain dysfunction develop and steadily worsen as hemorrhage expands. Some symptoms such as paralysis, weakness, loss of sensation, and numbness often affect only one side of the body. People may be unable to speak or become confused. Loss of consciousness is common and may occur within seconds to minutes.

ANATOMY

AND PHYSIOLOGY

Cruz, Paolo

The heart is the organ that helps supply blood and oxygen to all parts of the body. It is divided by a partition or septum into two halves, and the halves are in turn divided into four chambers. The heart is situated within the chest cavity and surrounded by a fluid filled sac called the pericardium. This amazing muscle produces electrical impulses that cause the heart to contract, pumping blood throughout the body. The heart and the circulatory system together form the cardiovascular system.

Heart Anatomy: Chambers Atria - upper two chambers of the heart. Ventricles - lower two chambers of the heart. Heart Anatomy: Heart Wall Epicardium - the outer layer of the wall of the heart. Myocardium - the muscular middle layer of the wall of the heart. Endocardium - the inner layer of the heart. Heart Anatomy: Cardiac Conduction Cardiac Conduction is the rate at which the heart conducts electrical impulses. The following structures play an important role in causing the heart to contract: Atrioventricular Bundle - bundle of fibers that carry cardiac impulses. Atrioventricular Node - a section of nodal tissue that delays and relays cardiac impulses. Purkinje Fibers - fiber branches that extend from the atrioventricular bundle. Sinoatrial Node - a section of nodal tissue that sets the rate of contraction for the heart.

Heart Anatomy: Cardiac Cycle

The Cardiac Cycle is the sequence of events that occurs when the heart beats. Below are the two phases of the cardiac cycle: Diastole Phase - the heart ventricles are relaxed and the heart fills with blood. Systole Phase - the ventricles contract and pump blood to the arteries.

Heart Anatomy: Valves

Heart valves are flap-like structures that allow blood to flow in one direction. Below are the four valves of the heart: Aortic Valve - prevents the back flow of blood as it is pumped from the left ventricle to theaorta. Mitral Valve - prevents the back flow of blood as it is pumped from the left atrium to the left ventricle. Pulmonary Valve - prevents the back flow of blood as it is pumped from the right ventricle to the pulmonary artery. Tricuspid Valve - prevents the back flow of blood as it is pumped from the right atrium to the right ventricle.

Heart Anatomy: Blood Vessels Blood vessels are intricate networks of hollow tubes that transport blood throughout the entire body. The following are some of the blood vessels associated with the heart:

Arteries: Aorta - the largest artery in the body of which most major arteries branch off from. Brachiocephalic Artery - carries oxygenated blood from the aorta to the head, neck and arm regions of the body. Carotid Arteries - supply oxygenated blood to the head and neck regions of the body. Common iliac Arteries - carry oxygenated blood from the abdominal aorta to the legs and feet. Coronary Arteries - carry oxygenated and nutrient filled blood to the heart muscle. Pulmonary Artery - carries de-oxygenated blood from the right ventricle to the lungs. Subclavian Arteries - supply oxygenated blood to the arms.

Veins:

Brachiocephalic Veins - two large veins that join to form the superior vena cava. Common iliac Veins - veins that join to form the inferior vena cava. Pulmonary Veins - transport oxygenated blood from the lungs to the heart. Venae Cavae - transport de-oxygenated blood from various regions of the body to the heart.

THE BRAIN HAS THREE PRIMARY COMPONENTS. EACH IS RESPONSIBLE FOR DIFFERENT FUNCTIONS:

 The

Cerebrum: The cerebrum is the largest and most developmentally advanced portion of the brain. It controls a number of higher functions, including speech, emotion, the integration of sensory stimuli, initiation of the final common pathways for movement, and fine control of movement. It is divided into a left and a right hemisphere. The left hemisphere controls the majority of functions on the right side of the body, while the right hemisphere controls most of functions on the left side of the body. Thus, injury to the left cerebral hemisphere produces sensory and motor deficits on the right side, and vice versa.

The cerebrum is composed of the frontal, parietal, temporal, and occipital lobes: The frontal lobe is involved in planning, motor movements, organizing, problem solving and selective attention. The portion known as the prefrontal cortex controls personality and various higher cognitive functions such as behavior and emotions. The back of the frontal lobe consists of the pre-motor and motor areas, which produce and modify movement. The left and right parietal lobes contain the primary sensory cortex, which controls sensation (touch and pressure), and a large association area that controls fine sensation (judgment of texture, weight, size, and shape). Damage to the right parietal lobe can cause visuo-spacial deficits, making it hard for the patient to find his/her way around new or even familiar places. Damage to the left parietal lobe may disrupt a patients ability to understand spoken and/or written language.

 Structure

The brain contains various structures that have a multitude of functions. Below is a list of major structures of the brain and some of their functions.

The left and right temporal lobes, located around ear level, allow a person to differentiate smells and sounds. They also help in sorting new information and are believed to be responsible for short-term memory. The right lobe is primarily involved in visual memory (i.e., memory for faces and pictures). The left lobe is primarily involved in verbal memory (i.e., memory for words and names). The occipital lobe processes visual information. It is mainly responsible for visual reception and contains association areas that help in the visual recognition of shapes and colors. Damage to this lobe can cause visual deficits.

 The

Cerebellum: The cerebellum is the second largest area of the brain. It controls reflexes, balance and certain aspects of movement and coordination. Brain Stem: The brain stem is responsible for a variety of automatic functions that are critical to life, such as breathing, digestion and heart beat as well as alertness and arousal (the state of being awake).

The

 Basal

Ganglia Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's Brainstem Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons Broca's Area Speech production Understanding language

 Central

Sulcus (Fissure of Rolando) Deep grove that separates the parietal and frontal lobes Cerebellum Controls movement coordination Maintains balance and equilibrium Cerebral Cortex Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes

Limbic System Structures

Amygdala - involved in emotional responses, hormonal secretions, and memory Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and the regulation of aggressive behavior Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the hypothalamus Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrieves them when necessary

 Hypothalamus

- directs a multitude of important functions such as body temperature, hunger, and homeostasis Cortex - receives sensory information from the olfactory bulb and is involved in the identification of odors - mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum

Olfactory

Thalamus

Medulla Oblongata Lower part of the brainstem that helps to control autonomic functions Meninges Membranes that cover and protect the brain and spinal cord Olfactory Bulb Bulb-shaped end of the olfactory lobe Involved in the sense of smell Pineal Gland Endocrine gland involved in biological rhythms Secretes the hormone melatonin Pituitary Gland Endocrine gland involved in homeostasis Regulates other endocrine glands

 Pons

Relays sensory information between the cerebrum and cerebellum Reticular Formation Nerve fibers located inside the brainstem Regulates awareness and sleep SubstantiaNigra Helps to control voluntary movement and regulates mood

Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth ventricle Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the cerebellum Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow Wernicke's Area Region of the brain where spoken language is understood

PATHOPHYSIOLOGY

Lopez, Hennessy

DIAGNOSTIC PROCEDURE

Maala, Aizelle A.

CT

Mrs. EB

SCAN

66y/0 08/25/11

Multiple contiguous axial images of the brain were obtained. No intravenous contrast was given. There is an intraaxial hyper dense collection in the left hemispheric regions, measuring 2.2 x 2.1 cm (approximate volume : 7.1 cc) with minimal vasogenic edema. There is a mild compression of the frontal area. Calcific densities are seen in both ICA. The cistems, sella and CP angles are normal for the patients stated age. The visualized cranium is intact. Impression: Acute intracerbral hemorrhage with mild vasogenic edema, left region. Atherosclerotic disease in the ICA.

NURSING RESPONSIBILITY FOR HEMATOLOGY

Prior: Check the clients name or identification band Explain to the client the purpose of the procedure Inform the patient that the test requires a blood sample and who will perform the venipuncture Inform the patient how the procedure is performed Explain to the patient that he may feel some discomfort from the needle puncture Prepare the materials necessary for the test After: Apply direct pressure to the venipuncture site until bleeding stops Instruct patient that if hematoma results or developed at the venipuncture site apply warm compress

LABORATORY

Maala, Aizelle

NURSING

MANAGEMENT

Marfil, Mikhail

NURSING MANAGEMENT
Monitored vital signs every four hours. Assessed the patients neurological status. Observed for level of consciousness (LOC). Assessed Glasgow Coma Scale (GCS). Promoted nutrition. Intravenous fluid Administered osteorized feeding via nasogastric tube (NGT). Maintained proper positioning. Maintained on moderate high back rest to reduce intracranial pressure.

Promoted activity. Turned to sides every two hours. Performed range of motion (ROM) exercises. Exercised the affected extremities (right upper and right lower extremities) passively and carried out ROM exercises 4-5times daily to regain motor control and enhance circulation. Promoted elimination. Inserted indwelling foley catheter. Monitored intake and output. Promoted communication. Gave simple commands. Anticipated needs. Allowed the client to verbalize, no matter how long it took her.

Placed all belongings on the side of her unaffected side. Checked the patency of IV line/ tubing, infusion rate, assessed for any edema at the IV site. Checked for the patency of the NGT Aspirated gastric contents. Introduced air to the tube with the syringe while hearing the gurgling sound on the stomach. Checked for the patency of the foley catheter. Maintained the patency of the drainage system. Provided patient teaching. Encouraged to avoid stress. Identified lifestyle modification suited for the patients current status such as avoidance of foods that may increase blood pressure.

MEDICAL MANAGEMENT
Bed rest. Promoted adequate oxygenation. Maintained patent airway. Maintained on a moderate high back rest to facilitate adequate ventilation. Low-salt and low-fat diet. Inserted foley catheter. Inserted nasogastric tube.

 Inserted

intravenous line. Ensured adequate fluid and electrolyte balance. Intravenous fluids are maintained (1 L PNSS to run at KVO). Nasogastric tube feeding. Administered medications as ordered by the doctor.

DRUG STUDY

Marfil, Mikhail

STATEMENT OF NURSING PROBLEMS

Domingo, Donna

NURSING CARE PLAN (ACTUAL)

Melendrez, Jenifer

NURSING CARE PLAN (POTENTIAL)

Malabanan, Maurizze Ann

DISCHARGE PLANNING

Lozano , Raness Ann

THANK YOU,

GOD BLESS!