Submitted to
Ma. Lilibeth Q. Icasiano, R.N.
Course Coordinator
In Partial Fulfilment
of the Requirements
for the 60th Batch
Post-Graduate Course in Critical Care Nursing
Submitted by
Monique Santos, R.N.
Rolando M. Santos Jr., R.N.
Korinna B. Selga, R.N.
Pamona Krysel Jean M. Seraspi, R.N.
Warly C.Soriano, R.N.
Joan Rae E. Tan, R.N.
Renea C. Torres, R.N
Enrico M. Tuazon, R.N.
Abigail L. Ty, R.N.
Ma. Angelie V. Velasco, R.N.
Kristine M. Viacrusis, R.N.
May U. Ydia, R.N.
Angeline Marie Zulueta, R.N.
SECTION 1: INTRODUCTION 1
SECTION 2: STATEMENT OF OBJECTIVES 4
SECTION 3: PROFILE OF THE PATIENT
3.1: DEMOGRAPHIC DATA AND HISTORY 5
3.2: NURSING CARE ASSESSMENT 8
3.3: INITIAL PHYSICAL EXAMINATION 10
3.4: NEUROLOGIC CRITICAL CARE ASSESSMENT 13
3.5: RISK ASSESSMENT 18
3.5: SIGNIFICANT LABORATORY AND DIAGNOSTIC 20
FINDINGS
SECTION 4: PATHOPHYSIOLOGY 24
SECTION 5: COURSE IN THE WARD
5.1: HIGHLIGHTS OF THE PATIENT’S STATUS 26
5.2: GENERAL MANAGEMENT FOR HEMORRHAGIC STROKE 31
5.3: PRE-OPERATIVE & ONGOING DIAGNOSTIC WORK-UPS 44
5.4: PRE-OPERATIVE AND POST-OPERATIVE MEDICAL 59
MANAGEMENT
5.5: SURGICAL MANAGEMENT 81
SECTION 6: NURSING CARE PLAN 85
SECTION 7: DISCHARGE CARE PLAN 104
SECTION 8: REFERENCES 116
SECTION 9: COPY OF PHYSICIAN’S CONSENT 119
3. Stroke is treatable
… optimally, through proven, affordable, culturally acceptable and
ethical means.
4. Stroke is preventable
… in a manner that could be implemented across all levels of society.
Look into this situation: You were busy preparing for the meeting the next day, when
numbness invades the left side of your body. You tried to call for help but then your
speech has slurred. You also lost your vision in one eye. The experience lasted for a few
minutes. Then, you brushed it off, not minding that a fatal attack may soon arise that
might leave you with permanent disability.
According to the World Health Organization, one in ten of the 55 million deaths that
occurs every year world wide is due to stroke and two-thirds of which occur among
people living in developing countries (www.who.org). In the Philippines, stroke remains
to be a leading cause of disability, afflicting 400,000 Filipinos yearly (Manila Bulletin, 13
September 2004) making it one of the leading causes of death together with vascular
diseases. Last September 1999, the former Health Secretary Alberto G. Romualdez said
But before a stroke occurs, one needs to understand its risk factors so that medical
intervention is administered early and aggressively. The non-modifiable risk factors for
stroke include age, sex, family history, race, and ethnicity – factors that we cannot
control. However there are modifiable risk factors for stroke which when eliminated or
controlled reduce the risk of stroke significantly. These are hypertension, cardiac disease
(particularly atrial fibrillation), diabetes, hyperlipidemia or elevated cholesterol, cigarette
smoking, alcohol abuse, physical inactivity, asymptomatic carotid stenosis, and transient
ischemic attack.
There is a growing concern that because of the lifestyle and diet of Asians, particularly
Filipinos, cholesterol levels are rising, resulting in an increased risk for stroke (brain
attack). In addition to being a leading cause of heart attacks, high cholesterol is emerging
as a major risk factor for what is known as ischemic stroke. In this type of stroke, the
blood supply to part of the brain is cut off because either atherosclerosis or a blood clot
has blocked a blood vessel.
With the growing concern on the prevalence of stroke among Filipinos, the contributors
intend to share a case of a 41 year old male who suffered from intracerebral hemorrhage
induced by uncontrolled hypertension not known by the patient.
When blood pressure has remained high for a significant period of time, the walls of
blood vessels change and become weak. Constant, high blood pressure wears away at the
A Case on Hemorrhagic CVA: Hypertension Stage II
vessel walls and can lead to blockage of the vessels or leakage of blood into the brain.
Blood irritates the brain tissues, causing swelling (cerebral edema). The blood collects
into a mass called a hematoma.
Brain tissue swelling and a hematoma within the brain put increased pressure on the brain
and can eventually destroy it.
Bleeding may occur in the hollow spaces (ventricles) in the center part of the brain or into
the subarachnoid space (the space between the brain and the membranes that cover the
brain). Such bleeding can cause symptoms of meningitis.
Symptoms depend on the location of the bleeding in the brain and how much damage has
occurred. Symptoms most commonly develop suddenly, without warning, and often
during activity. There is a rapid loss of function on one side of the body.
The symptoms can be the same as those that result from a typical stroke, and may include
decreased consciousness, comatose, lethargic, sleepy, stuporous, unconscious,
withdrawn, difficulty reading or writing, difficulty speaking or understanding others,
difficulty swallowing, headache that gets worse when changing positions (bending,
straining or coughing), loss of coordination & balance, movement changes, difficulty
moving any body part, loss of fine motor skills, nausea or vomiting, seizure, sensation
changes, numbness, tingling, weakness of any body part, and vision changes.
The symptoms vary depending on the location of the bleed and the amount of brain tissue
affected. Symptoms usually develop suddenly, without warning, and often during
activity. They may come and go (be episodic) or slowly get worse over time.
A neurologic exam is almost always abnormal. The patient may look drowsy and
confused. An eye examination may show abnormal eye movements and changes in the
back of the eye. The patient may have abnormal reflexes. However, these findings do not
necessarily mean a person is having a brain hemorrhage, and could be due to another
medical condition.
General Objective:
The contributors aim to delve on the increasing prevalence of people affected with
hemorrhagic CVA in the Philippines by providing the need to educate the public by
integrating the nurses’ role on the prevention, treatment and rehabilitation of stroke.
Specific Objectives:
Promotive
• Provide information on stroke, risk factors, lifestyle modification and regular
medical check-ups.
• Review the pathophysiology of hypertensive-induced hemorrhagic stroke.
Curative
• Promptly identify patient’s needs by performing proper health assessment with
emphasis on neurologic assessment techniques.
• Provide quality nursing care based on identified patient needs in collaboration
with other members of the health team, utilizing a holistic approach.
• Correlate the diagnostic findings to other pertinent data gathered and address
immediate deficits.
• Evaluate medical - surgical management in relation to patient recovery.
Preventive/Rehabilitative
• Focus on early rehabilitation and discharge planning.
• Assist in sustaining and maintaining patient’s healthy productive lifestyle.
Name: R.B.F.
Attending Physician: James O. Ho, MD
Age: 41 years old Sex: Male
Date of Birth:April 06, 1968 Place of Birth: Banawe, Quezon City
Civil Status: Religion: Roman Catholic
Ethnicity: Filipino
Home Address: Bagong Nayon, Galas, Quezon City
Educational Attainment: College graduate
Occupation: Business associate
Client Complaint:
Decreased sensorium, left side body weakness
Admitting Diagnosis:
Lobar hemorrhage, (R) temporo-parietal area with intraventricular extension
Final Diagnosis:
CVA Bleed, temporo-parietal area: hypertension stage 2
Procedure/Operation Performed:
Hemicraniectomy, (R) with evacuation of intracerebral hemorrhage (R)
Patient History:
A 41 year old male from Quezon City, came in due to decreased sensorium.
The Patient is not a known hypertensive, non diabetic who was noted to have left sided
weakness after patient was found on the bathroom floor 1 day PTA. He was rushed to a
local hospital where along the way he was noted to have vomiting and altered sensorium.
He was transferred to the PHC ER for further evaluation and management. At the ER he
was seen stuporous, with BP 270/120, CR 120, RR 21, temp 38.1. He has a pink
conjunctiva, anicteric sclera, SCE, vesicular breath sounds, AP, regular cardiac rhythm.
Flabby abdomen, NABS, soft, grossly normal extremities.
Ct scan was done which showed lobar hemorrhage at the right temporo-parietal area with
intraventricular extension. He underwent hemicraniectomy (R), with evacuation of ICH
(R).
Prior to symptom experience, he admits being a heavy alcoholic drinker ranging his
preferences from beer to whisky 4-6 times a week. He is also a cigarette smoker since his
college years – 1-2 packs a day.
Narrative Summary:
This is a case of a 42 year old male, born on 26 th of April 1968 at Bagong Nayon Galas
Quezon City. He is a single living with his parents, niece and older brother.
One day prior to admission, the patient experienced dizziness while taking a bath and
suddenly fell on the bathroom floor. He was noted to have left sided weakness. While on
the way to a local hospital, he had episodes of vomiting and alteration of sensorium.
The patient is not a known hypertensive and diabetic but has a family history of cancer,
hypertension and cardiovascular disease. He is a heavy alcoholic beverage drinker and
smokes cigarettes approximately 1-2 packs per day.
Upon receiving at the PHC ER, the patient is stuporous, no eye opening, localizes to pain
with sponstaneous respiration and spontaneous non-purposeful movement of the right
extremities. 1-2 mm pupils, nystagmus upon looking to the left – preferential gaze to the
right, positive doll’s sign, positive corneal reflex, no grimace to pain, nuchal rigidity with
positive brudzinski’s sign in the left.
Diagnostics performed were CT scan, electrolyte studies and CBC. Initial CT scan results
reveal Intracerebral hemorrhage, right basal ganglia of 55 cc lobar hemorrhage with
intraventricular extension and positive subfalcine herniation. These findings prompted the
consultant to immediately schedule an emergency hemicraniectomy, right with
evacuation of intracerebral hemorrhage, right. He was primarily managed in the ER with
the following medications: Mannitol, Omeprazole, Citicholine, and Cefazolin per IV. On
the other hand, Amlodipine, Paracetamol and Depakote were given per NGT. He also
received Nicardipine drip in D5 Water.
Elimination pattern
Prior to admission, the client has a regular urinary and bowel pattern. At present, his
urinary output is within acceptable limits but he has not resumed his normal bowel
movement for almost 5 days but with presence of flatus.
Activity/Exercise Pattern
The client rarely engages in physical activities. He used to play basketball as a
competitive sport during his high school to college years. He is currently unable to
perform activities of daily living and do self-care due to his present condition’s
limitations.
He is not in a relationship and does not see himself marrying someone anytime soon. He
is socially inclined and enjoys going to parties during his leisure time. He is very close to
his family and friends. He is currently helping his father run their family business.
Value-belief Pattern
The patient is a devout Roman Catholic and handles things by talking to God. Their
family value and fear God that serves as their guide in their everyday role and decision-
making.
General Information
The patient is a 41 year old male admitted to the PHC – ER due to lobar hemorrhage, (R)
temporo-parietal area with intraventricular extension via ambulance as referred by a local
hospital.
Vital Signs
Admitting vital signs: temperature is 38.1 per axilla – febrile, respiratory rate is 21
breaths/min – regular, blood pressure is greatly elevated at 270/120, cardiac rate is 120
bpm; at apical pulse. Current vital signs: temperature is 37.2 per axilla – afebrile,
respiratory rate is 18 breaths/min – regular, blood pressure is elevated at 150/100, cardiac
rate is 89 bpm; at apical pulse.
General Survey
The patient is observed lethargic; disoriented to person, place and time but persistently
calls his mother. Initial GCS is 7 (E1V1M5) stuporous to almost in coma upon admission
but has a current GCS of 13 (E4V4M5). He presently has left side body weakness and has
slurring of speech, thus making it difficult to comprehend what he is saying. His present
height and weight is 163 cm and 65 kg respectively with a normal BMI of 24.46
Head
Client’s head is normocephalic with prominences in the temporo-parietal area. Closed
fontanelles were noted. Hair is black, coarse to touch and evenly distributed. Scalp is
clean and intact. No lesions noted but with tenderness upon palpation in the right
temporo-parietal area.
Eyes
Eyelids are symmetrical. Conjunctiva is pale. Sclera is anicteric. Her cornea is smooth
and clear. Pupil size is equal (R=2-3mm; L= 2-3mm). Patient has nystagmus, primary
gaze OS – laterally deviated.
Ears
The patient has no ear piercings. The ear lobes are bean shaped, parallel, and
symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the
eye. Skin is same in color as in the complexion. No lesions noted. Auricles are firm.
External pinnae are normoset and symmetrical; recoils when folded. There is no pain or
tenderness on the palpation of the auricles and mastoid process. No discharges or lesions
Nose
Nasolabial fold is symmetrical. External nose is not tender and there’s no presence of
lesions. There is no discharge or nasal flaring. Air moves freely as the client breathes
through the nares. Mucosa is pinkish with clear, water discharge. There are no lesions.
Nasal septum is intact and in midline. The maxillary and frontal sinuses are not tender.
Client’s gross smell is symmetrical
Mouth
Outer lips are pale and dry. Gums are pale and with a moist and firm texture. He has an
incomplete set of teeth (2 tooth extractions), whitish to yellowish in color – dental status
is poor. The tongue is on central position. It moves freely and there is no presence of
tenderness. It is smooth with no palpable nodules. There is a asymmetry when the patient
is asked to smile. He also has slurring of speech.
Pharynx
The uvula is positioned in midline of soft palate. Client’s mucosa is pale. Tonsils are not
inflamed.
Neck
Neck is head centered and symmetrical. Lymph nodes are not palpable. Trachea is placed
in midline of the neck. The neck is straight with no jugular vein distention. Upon
admission, patient has nuchal rigidity with positive brudzinski’s sign in the left.
Heart
Heart sounds are distinct. S1 & S2 can be heard at all anatomic site. He has an adynamic
precordium, normal rate regular rhythm – slightly tachycardic (105 bpm), no murmurs.
Abdomen
Client’s abdomen is uniform in color, symmetrical and no venous engorgement noted.
Umbilicus is sunken. Bowel sounds are audible but slightly hypoactive.
Deviations
Non contrast axial CT images of the head show the following findings:
Multiple area of hyperdensities are seen in the right basal ganglia, representing
hemorrhage. Minimal hemorrhage is likewise noted in the right lateral ventricle.
Surroundings hypo densities are appreciated in the right fronto-temporal areas in which
might suggest post op changes or secondary changes from previous hemorrhage. There is
likewise compression of the right lateral ventricle, due to the ischemic changes or edema.
Very thin subdural hemorrhage is seen in the right posterior frontal area with maximum
thickness of 0.7 cm and length of 2.5 cm.
Subarachnoid hyperdensites are seen in the cortical sulci of the left cerebral hemisphere
in the vertex area.
A draining tube is seen in the right extra axial craniectomy space with subgaleal air.
Mucosal opacities are seen in the left maxillary antrum and left ethmuid sinus,
representing sinusitis.
Follow up non contrast axial CT images of the head after September 9, 2009 show the
following findings;
There is regression of the previously noted hemorrhage in the right basal ganglia and
right lateral ventricle. Subsequent regression of the surrounding edema is now
appreciated in the right fronto –temporal areas. Compression of the right lateral ventricle
is again seen but to a lesser degree.
There is significant regression in the volume of subgaleal emphysema seen in the extra
axial craniotomy space. The right draining tube is no longer seen.
Mucosal opacities are seen in the left maxillary antrum and left ethmoid sinus
representing sinusitis.
Although the Arterial Blood Gas results were considerably normal despite high PaO2
values, this may signify that the FiO2 and PEEP must be titrated since persistent elevation
of these values may delay weaning from mechanical ventilation, thus negatively
influencing outcome of the patient. Also, we cannot exclude that high PaO2 values were
achieved by more invasive ventilation strategies, potentially being more injurious to the
patient. Nevertheless, the patient was able to tolerate the weaning process and was
ordered for extubation immediately on the 3rd hospital day.
C. Urinalysis
Consequently, a minimal value of glucose was present in the urine. If the blood glucose
level exceeds the reabsorption capacity of the tubules, glucose will appear in the urine.
The sudden increase of glucose can be correlated to response of the body to stress. The
stressor being the hemorrhagic stroke stimulating the increase in cortisol levels and in
turn has increased the glucose levels in the body. This was managed by keen monitoring
and ensuring that the environment facilitates recovery to the patient thus decreasing the
effects of stress post-hemorrhagic CVA.
During the acute phase of the patient’s condition (1st hospital day), it was evident that the
patient has polycythemia and increased hemoglobin that may be associated with the
body’s means to compensate to the decreased tissue perfusion to the brain brought about
by the imbalance among the contents in the cranial vault (presence of 55 ml of blood
inside the brain – in excess). Also, it can be presumed that this is due to a decrease in the
circulating plasma volume which occurs in from stress causing spurious erythrocytosis.
However, on the 2nd and 4th hospital day, it was revealed that the patient has anemia, low
RBC and Hct . It can be assumed that with the patient being prescribed with NSAIDs,
particularly Arcoxia, it has a side effect of causing duodenal ulcers plus it is apparent that
the patient is also at risk for stress ulcers thus leading to GI bleeding. To counteract this
problem, Ranitidine and Sucralfate were prescribed to prevent ulcer formation and GI
bleeding.
The only anti-hemorrhagic agent prescribed to the patient was Tranexamic acid which is
not directly associated with the decrease in platelet count. On the 2nd hospital day, his
platelet count decreased placing the patient at risk for bleeding. Depakote, an anti-
convulsant and Cefazolin, an antibiotic taken by the patient has a side effect of
thrombocytopenia which may have suddenly decreased the number of circulating
platelets in the blood. However, this problem did not persist since on the 4th hospital day,
his platelet count returned to its acceptable limits.
A Case on Hemorrhagic CVA: Hypertension Stage II
Neutrophils constitute a primary defense against microbial invasion through the process
of phagocytosis. On the first two hospital days of the patient, he has an elevated
neutrophil count in response to potential invading organisms brought about by invasive
procedures particularly after undergoing brain surgery to evacuate the hematoma. With
the help of the prophylactic antibiotics, his neutrophil count went back to the normal
range on his 4th hospital day.
It is also evident that the patient has lymphocytopenia on his first two hospital days. This
may have occurred due to the high levels of stress that the patient is going through in the
acute phase of his condition. Subsequently, this problem was resolved on the 4 th hospital
day with the help of medical and surgical management.
E. Electrolytes
09/11/09
Potassium 3.4 3.5 – 4.8
Sodium 141 130 – 144
Upon electrolyte studies, it was found that the serum potassium is slightly decreased.
Although the value is not that alarming, this level must be corrected as soon as possible
to prevent prolonged hypokalemia and abrupt changes in the patient’s status particularly
ECG changes (depressed T waves, peaking of P waves) which may lead to fatal
arrhythmias.
The depletion of serum potassium may be associated with the patient’s medications. He
is currently taking Mannitol, an osmotic diuretic, indicated to decrease cerebral edema
and prevent increased intracranial pressure. One of its side effects involves the depletion
of electrolytes such as sodium and potassium. The mechanism of forced diuresis causes
K+ excretion of the renal glomeruli.
This sudden electrolyte changes prompted the physician to prescribe Kalium durule as a
prophylaxis during prolonged use of diuretics leading to hypokalemia.
Latest GCS was 15 (E4M6V5) and afebrile for 3 days. Still with
ongoing IVF PNSS 1L at 80 cc/hr. Change of dressing performed.
Day 3 of Ciprofloxacin and urinalysis noted to be within normal
limits. Physician ordered for patient to continue the abovementioned
antibiotics for 4 more days and then discontinue. Finally, Citicholine
was shifted to 500 mg/cap, 1 cap BID.
Day 8 Patient’s GCS was 15 (E4M6V5), afebrile but complains of occipital
headache, BP elevated to 160/100, thus prompting deferment of PT
schedule.
Orders made: decrease Mannitol 20% to 100 cc, IVF fast drip every
8 hours for 2 days then 100 cc IV fast drip every 12 hours for 1 day
STROKE CLASSIFICATION
Mild Moderate Severe
Alert patients with any of Awake patient with Comatose patient with
the following: significant motor and/or nonpurposeful response,
sensory and/or language decorticate, or decerebrate
Mild pure motor weakness and/or visual deficit posturing to painful stimuli
of one side of the body,
defined as: can raise or or
arm above shoulder,
has clumsy hand, or Disoriented, drowsy or Comatose patient with no
can ambulate without stuporous patient, but with response to painful stimuli
assistance purposeful response to
painful stimuli
Pure sensory deficit
Vertigo with
incoordination (e.g.,
gait disturbance,
unsteadiness or clumsy
hand)
Management Ascertain clinical diagnosis of stroke (history and physical exam are
Priorities very important)
- Exclude common stroke mimickers (Supplement I)
Basic emergent supportive care (ABCs of resuscitation)
Management Ascertain clinical diagnosis of stroke (history and physical exam are
A. The presence of any of the following should alert the physician to consider conditions
other than stroke:
- Gradual progressive course and insidious onset
- Pure hemi-facial weakness including forehead (Bell’s palsy)
- Trauma
- Fever prior to onset of symptoms
- Recurrent seizures
- Weakness with atrophy
- Recurrent headaches (migraine, tension-type headache)
Category Score
Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1
Best Motor Response
Obeys 6
Localizes 5
Withdraws 4
Abnormal flexion (decorticate) 3
Abnormal extension 2
(decerebrate)
None 1
Best Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Total Score 15
3. Allow “permissive hypertension” during the first week to ensure adequate CPP but
ascertain cardiac and renal protection
a. Treat if SBP>220 or DBP>120 or MAP>130
b. Defer emergency BP therapy if MAP is within 110-130 or SBP=185-220
mmHg or DBP=105-120 mmHg, unless in the presence of:
- Acute MI
- Congestive heart failure
- Aortic dissection
- Acute pulmonary edema
- Acute renal failure
- Hypertensive encephalopathy
4. Treat with small doses of IV antihypertensives patients who are potential candidates
for rtPA therapy who have persistent elevations in SBP >185 mmHg or DBP >110
mmHg. Maintain BP just below these limits.
Several neuroprotective drugs have reached phase III clinical trials, butmost had negative
or disappointing results except for citicoline. Data-pooling analysis on four trials
involving 1,652 patients with ischemic stroke show that treatment with citicoline within
the first 24 hours increases the probability of global recovery (NIHSS, mRS, BI) by 30%
at 3 months.
B. Surgical Treatment
Its role depends on the size, extent and location of the hematoma, and patient factors.
a) There is evidence of increase in hematoma size by 33% within 24 hours of stroke
onset in 38% of cases.
b) Considerations for surgical intervention:
c) Non-surgical candidates
i. Patients with small hemorrhages (<10 mL) or minimal neurological
deficits
ii. Patients with GCS<5 except those who have cerebellar hemorrhage and
brainstem compression
iii. Patients with hematoma volume > 85 mL
d) Candidates for immediate surgery
i. Patients with cerebellar hemorrhage >3 cm who are neurologically
deteriorating or have brainstem compression and hydrocephalus from
ventricular obstruction
ii. Patients with bleed associated with a structural lesion such as an
aneurysm, AV malformation or cavernous angioma if there is a chance for
good outcome and the vascular lesion is surgically accessible
iii. Clinically deteriorating young patients with moderate or large lobar
hemorrhage.
iv. Ventricular drainage for patients with intraventricular hemorrhage with
moderate to severe hydrocephalus.
e) All other patients may benefit from surgery
i. Patients with basal ganglia or thalamic hemorrhage
ii. Patients with GCS >4
iii. Patients with supratentorial hematoma with volume >30 cc
General
1. Control agitation and pain with short-acting medications, such as NSAIDS
Specific
1. Elevate the head at 30 to 45 degrees to assist venous drainage.
2. Give osmotic diuretics: Mannitol 20% loading dose at 1 g/kg, maintenance
dose at 0.5-0.75 mg/kg) to decrease intravascular volume and free water.
3. Lost fluids must be replaced. Hypertonic saline is an option and has the
advantage of maintaining an effective serum gradient for a prolonged period with
lower incidence of rebound intracranial hypertension. Aim for serum
osmolarity=310 mOsm/L. (Serum osmolarity = 2 (Na) + Glucose/18 + BUN /2.8)
4. Hyperventilate only in impending herniation by adjusting tidal volume and
pCO2 between 25 to 30. This maneuver is usually effective only for
approximately 6 hours. Otherwise maintain normal pCO2 between 35 and 40.
5. Carefully intubate patients with GCS 8 or less, or those unable to protect
the airway.
6. Do CSF drainage in patients with intraventricular hemorrhage (IVH) or
hydrocephalus.
7. Use barbiturates if all other measures fail. Available locally is thiopental
(loading dose=10 mg/kg, maintenance dose titrated at 1-12 mg/kg/hour
continuous infusion to achieve burst suppression pattern in EEG)
8. Consider surgical evacuation for mass lesions.
9. Consider decompressive hemicraniectomy in cases of malignant middle
cerebral artery infarcts
1. Cranial CT-Scan
Definition:
Computed Tomography (CT) scanning
• also known as Computed Axial Tomography (CAT) Scanning
• is a noninvasive medical test that helps physicians diagnose and treat medical
conditions
• combine special x-ray equipment with sophisticated computers to produce
multiple images or pictures of the inside of the body. These cross-sectional
images of the area being studied can then be examined on a computer monitor or
printed
• provide greater clarity and reveal more details than regular x-ray exams
• provide more detailed information on head injuries, stroke, brain tumors and other
brain diseases than regular radiographs (x-rays)
Indications:
CT scanning of the head is typically used to detect:
• bleeding, brain injury and skull fractures in patients with head injuries
• bleeding caused by a ruptured or leaking aneurysm in a patient with a sudden
severe headache
• a blood clot or bleeding within the brain shortly after a patient exhibits symptoms
of a stroke
• a stroke, especially with a new technique called Perfusion CT
• brain tumors
Benefits of CT Scan:
1. CT scanning is painless, noninvasive and accurate.
2. A major advantage of CT is its ability to image bone, soft tissue and blood vessels
all at the same time.
3. Unlike conventional x-rays, CT scanning provides very detailed images of many
types of tissue as well as the lungs, bones, and blood vessels.
4. CT examinations are fast and simple; in emergency cases, they can reveal internal
injuries and bleeding quickly enough to help save lives.
5. CT has been shown to be a cost-effective imaging tool for a wide range of clinical
problems.
6. CT examinations are fast and simple; in emergency cases, they can reveal internal
injuries and bleeding quickly enough to help save lives.
7. CT has been shown to be a cost-effective imaging tool for a wide range of clinical
problems.
8. CT is less sensitive to patient movement than MRI.
9. CT can be performed if you have an implanted medical device of any kind, unlike
MRI.
10. A diagnosis determined by CT scanning may eliminate the need for exploratory
surgery and surgical biopsy.
11. No radiation remains in a patient's body after a CT examination.
12. X-rays used in CT scans usually have no side effects.
Risks of CT Scan:
• There is always a slight chance of cancer from excessive exposure to radiation.
However, the benefit of an accurate diagnosis far outweighs the risk.
• The effective radiation dose from this procedure is about 1 to 2 mSv, which is
about the same as the average person receives from background radiation in four
to eight months.
• Women should always inform their physician and x-ray or CT technologist if
there is any possibility that they are pregnant.
• CT scanning is, in general, not recommended for pregnant women unless
medically necessary because of potential risk to the baby.
• Nursing mothers should wait for 24 hours after contrast material injection before
resuming breast-feeding.
• The risk of serious allergic reaction to contrast materials that contain iodine is
extremely rare, and radiology departments are well-equipped to deal with them.
• Because children are more sensitive to radiation, they should have a CT study
only if it is essential for making a diagnosis and should not have repeated CT
studies unless absolutely necessary.
Overview:
Arterial Blood Gases is a means of assessing the adequacy of oxygenation and
ventilation, to evaluate acid base status by measuring the respiratory and non respiratory
components and to monitor effectiveness of therapy. They are also used to monitor
critically ill patients, to establish baseline values in the perioperative and postoperative
period, to detect and treat electrolyte imbalances, to titrate appropriate oxygen flow rates,
etc.
Indication:
• used to evaluate respiratory diseases and conditions that affect the lungs
• help determine the effectiveness of oxygen therapy
• provide information about the body's acid/base balance, which can reveal
important clues about lung and kidney function and the body's general metabolic
state
Procedure
Observe standard precautions and follow agency protocols
1. Have the patient assume a sitting or supine position.
2. Perform the modified Allen’s test to assess collateral circulation before
performing a radial puncture as follows:
a. Use pressure to obliterate both radial and ulnar pulses
Overview
Electrolytes (ions) are critical for cellular reactions. These electrolytes provide the
necessary inorganic chemicals for a variety of cellular functions (eg, nerve impulse
transmission, muscular contraction, water balance). Typically, the concentration of
cations (positively charged electrolytes), eg, Na+, K+, Ca++, and Mg+, is higher in the
plasma than in the interstitial fluid owing to the Donnan effect (plasma proteins have a
net negative charge), whereas anions (negatively charged), eg Cl-, HPO4-, tend to be
higher in the interstitial fluid than the plasma.
Potassium is the major positive ion (cation) found inside of cells. The chemical notation
for potassium is K+. The proper level of potassium is essential for normal cell function.
Among the many functions of potassium in the body are regulation of the heartbeat and
the function of the muscles. A seriously abnormal increase in potassium (hyperkalemia)
or decrease in potassium (hypokalemia) can profoundly affect the nervous system and
On the other hand, Sodium is the major positive ion (cation) in fluid outside of cells. The
chemical notation for sodium is Na+. When combined with chloride, the resulting
substance is table salt. Excess sodium (such as that obtained from dietary sources) is
excreted in the urine. Sodium regulates the total amount of water in the body and the
transmission of sodium into and out of individual cells also plays a role in critical body
functions. Many processes in the body, especially in the brain, nervous system, and
muscles, require electrical signals for communication. The movement of sodium is
critical in generation of these electrical signals. Too much or too little sodium therefore
can cause cells to malfunction, and extremes in the blood sodium levels (too much or too
little) can be fatal.
Procedure
1. Collect a 5-ml venous blood sample using serum or heparinized Vacutainer tube.
Observe standard/universal precautions. Avoid hemolysis in obtaining the sample.
2. Deliver the sample to the laboratory and centrifuge immediately to separate cells
from serum. Potassium leaks out of the cell and levels in the sample will be
falsely elevated later than 4 hours after collection.
Overview
The process of UA determines the following properties of urine: color, odor, turbidity,
specific gravity, pH, glucose, ketones, blood protein, bilirubin, urobilinogen, nitrite,
leukocyte esterase, and other abnormal constituents revealed by microscopic examination
of the urine sediment. A 10 mL urine specimen is usually sufficient for conducting these
tests.
Overview
The CBC is used as a broad screening test to check for such disorders as anemia,
infection, and many other diseases. It is actually a panel of tests that examines different
parts of the blood and includes the following:
White blood cell (WBC) count is a count of the actual number of white blood cells per
volume of blood. Both increases and decreases can be significant.
• White blood cell differential looks at the types of white blood cells present. There
are five different types of white blood cells, each with its own function in
protecting us from infection. The differential classifies a person's white blood
cells into each type: neutrophils (also known as segs, PMNs, granulocytes, grans),
lymphocytes, monocytes, eosinophils, and basophils.
Red blood cell (RBC) count is a count of the actual number of red blood cells per volume
of blood. Both increases and decreases can point to abnormal conditions.
Definition:
Pulse oximetry is a non-invasive method allowing the monitoring of the oxygenation of a
patient's hemoglobin. This evaluates the pulsatile blood flow.
Indication:
- checks patient's oxygenation if unstable, including intensive care, critical care,
and emergency department areas of a hospital
- used to detect abnormalities in ventilation
Overview
Electrocardiography (ECG or EKG) is a transthoracic interpretation of the electrical
activity of the heart over time captured and externally recorded by skin electrodes.
Electrical impulses in the heart originate in the sinoatrial node and travel through the
intrinsic conducting system to the heart muscle.The impulses stimulate the myocardial
muscle fibres to contract and thus induce systole. The electrical waves can be measured
at selectively placed electrodes (electrical contacts) on the skin. Electrodes on different
sides of the heart measure the activity of different parts of the heart muscle. An ECG
displays the voltage between pairs of these electrodes, and the muscle activity that they
measure, from different directions, also understood as vectors. This display indicates the
overall rhythm of the heart and weaknesses in different parts of the heart muscle. It is the
best way to measure and diagnose abnormal rhythms of the heart, particularly abnormal
rhythms caused by damage to the conductive tissue that carries electrical signals, or
abnormal rhythms caused by levels of dissolved salts (electrolytes), such as potassium,
that are too high or low. In myocardial infarction (MI), the ECG can identify damaged
heart muscle. But it can only identify damage to muscle in certain areas, so it can't rule
out damage in other areas. The ECG cannot reliably measure the pumping ability of the
heart; for which ultrasound-based (echocardiography) or nuclear medicine tests are used.
Procedure
1. Have the patient assume a supine position; however, recordings can be taken
during exercise.
2. Prepare the skin sites and, if necessary, shave and place electrolodes on the four
extremities and on specific chest sites. Ensure that the right leg is the ground.
3. Remember that all 12 leads can be recorded simultaneously by newer ECG
machines.
4. Remember that a rhythm strip is a 2-minute recording from a single lead, usually
lead II. It is frequently used to evaluate dysrhythmias.
5. Follow safe, effective and informed intra-test care.
Renal: Increased
BUN and
creatinine levels,
renal failure
Local Reactions:
phlebitis
Other Reactions:
Genital and anal
pruritus (including
vulvar pruritus,
genital moniliasis,
and vaginitis).
Generic name: To reduce intra- Chemical effect: Contraindicated Pulmonary Monitor vital
Mannitol cranial pressure Increases osmotic in patients with congestion, fluid signs, CVP, and
and treat cerebral pressure of glomerular hypersensitivity and electrolyte fluid intake and
Brand name: edema infiltrate, inhibiting to the drug, and imbalance, output hourly.
Osmitrol tubular reabsorption of in those with acidosis,
Acute renal water and electrolytes. anuria, severe electrolyte loss, Insert urethral
Date Ordered: failure, oliguric This elevates blood pulmonary dryness of mouth, catheter in
1st hospital day phase (prophylaxis osmolality, enhancing congestion, frank thirst, marked incontinent patient
(09/07/09) and treatment) water and sodium flow pulmonary diuresis, urinary because therapy is
Instruct patient to
immediately report
pain in chest, back,
legs or shortness of
breath
Encourage patient
to comply with
other interventions
for hypertension
(weight reduction,
low-sodium diet,
smoking cessation,
moderation of
alcohol
consumption,
regular exercise,
and stress
management).
Medication
controls but does
not cure
hypertension
Advise patient to
take blood
pressure weekly
and to report
significant changes
to health care
professional.
Generic name: Reduced risk of Chemical effect: Contraindicated CNS: Headache Monitor liver
Esomeprazole gastric ulcers in Supresses gastric in patients GI: diarrhea, function test
sodium patients on secretion through proton hypersensitive to abdominal pain, results because in
continuous NSAID pump inhibition. any component nausea, flatulence, patients with
Brand name: therapy Reduces gastric acidity of esomeprazole dry mouth, hepatic
Nexium by blocking the finals or omeprazole vomiting, insufficiency, drug
Gastroesophageal step in acid production constipation increases liver
Date ordered: reflux disease, Use cautiously in function test
1st hospital day healing of erosive Therapeutic effect: patients with results
(09/07/09) esophagitis Decreases gastric acid severe hepatic
insufficiency Long term therapy
Long term- with omeprazole
Dosage: maintenance of has caused
40mg initially healing in erosive atrophic gastritis.
per IV OD esophagitis Be alert for
adverse reactions
Classification: Eradication of
Proton pump Helicobacter
Serious or fatal
hepatotoxicity may
follow nonspecific
symnptoms, such
as malaise, fever
and lethargy. If
patient has
suspected or
apparently
substantial hepatic
dysfunction, notify
the prescriber
immediately and
stop giving the
drug.
Generic name: CVA in acute and Citicoline is an Contraindicated GI disturbances, Keep all
Citicoline recovery phase, interneuronal in para- anaphylaxis, medicine locked
symptoms and communication sympathetic elevated body up and away
Brand name: signs of cerebral enhancer. It increases the hypertonia temperature, from children.
insufficiency neuro transmission levels restlessness, and Store medicine
(dizziness, because it favors the • difficulty sleeping away from heat
Date ordered: memory loss, poor synthesis and production when taken in the and direct light.
1st hospital day concentration, speed of dopamine in the evening. Do not store
(09/07/09) disorientation, striatum, acting then as a your medicine in
recent cranial dopaminergic agonist the bathroom,
Dosage: trauma and their thru inhibition of near the kitchen
Initially 2g sequelae) tyrosine hydroxylase. sink, or in other
STAT then damp places.
changed to 1g Heat or moisture
every 8 hours may cause the
09/13/09 – medicine to
changed to 500 break down and
mg/ cap PO BID not work the way
it should work.
Classification: Throw away
CNS stimulant medicine that is
out of date or
that you do not
Citicoline may
interact with
other medicines
you may be
taking. Ask the
patient to consult
his/her physician
before taking
citicoline with
any other
medicine.
Generic name: Prevention or Chemical effect: Contraindicated CNS: dizziness. Observe site of
Tranexamic reduction of Inhibits activation of in: surgery for
Acid hemorrhage plasminogen, thereby EENT: visual excessive bleeding
following dental preventing the Hypersensitivity abnormalities.
Brand name: surgery in conversion of Instruct patient to
Cyklokapron hemophiliacs plasminogen to plasmin Active intra- CV: hypotension, take tranexamic
vascular clotting thromboembolism, acid as directed.
Date ordered: Therapeutic effect: Acquired thrombosis. Do not take more
1st hospital day Decreased defective color or less than
(09/07/09) bleeding following vision GI: diarrhea, directed. If a dose
dental surgery in nausea, vomiting. is missed, take as
Dosage: hemophiliacs Subarachnoid soon as possible
500 mg/IV Q8 hemorrhage unless almost time
for 2 doses Reduced need for for next dose; do
replacement therapy Use Cautiously not double doses
Classification: in:
Anti-fibrinolytic Advise patient to
Renal inform health care
impairment professional of any
changes in vision.
Hematuria
originating in the Caution patient to
upper urinary avoid products
tract containing aspirin
Conditions or NSAIDs
associated with without consulting
increased health care
thrombus professional.
formation
Instruct patient to
Pregnancy or notify health care
lactation (safety professional if
not established) signs and
symptoms of
thrombosis
(severe, sudden
headache; pains in
chest, groin, or
legs, especially
calves; sudden loss
of coordination;
sudden and
unexplained
shortness of
breath; slurred
speech; visual
Grapefruit and
grapefruit juice
may interact with
nicardipine. The
interaction could
have potentially
dangerous effects.
Store nicardipine
at room
temperature away
from moisture and
heat.
Generic name: Short-term Chemical effect: Contraindicated Headache, Assess patient’s
Ketorolac management of May inhibit in: transient stinging pain before and
tromethamine pain prostaglandin synthesis and burning, after drug therapy
hypersensitivity nausea, dyspepsia,
Caution patient to
avoid alcohol and
other CNS
depressant
medications while
using this
medication.
Generic name: Moderate to Unknown. A centrally Contraindicated Dizziness, Use in extreme
Tramadol moderately severe acting synthetic to patient weakness, caution in patients
hydrochloride + pain analgesic compound not hypersensitive to sleepiness, with severe cardiac
Paracetamol chemically related to drug and in those difficulty falling, disease. Use
opiates. Drug is thought with acute asleep or staying cautiously in
Brand name: to bind opioid receptors intoxication from asleep, patients with
Dolcet and inhibit reuptake of alcohol, headache, severe mental
norepinephrine and hypnotics, nervousness, depression,
Date ordered: serotonin. centrally active agitation, suicidal
1st Hospital Day analgesics, uncontrollable tendencies, or
(09/07/09) opioids, or shaking of a part history of drug
psychotropic of the body, abuse.
Dosage: drugs. muscle tightness,
30 mg q6 changes in mood, Alert: Note two
drowsiness, strengths of oral
Classification: heartburn or liquid form.
Analgesic indigestion, Double-check
nausea, dose, especially
vomiting, when giving to
diarrhea, children.
constipation,
itching, To minimize
sweating, unpleasant taste
chills, and stomach
dry mouth. irritation, dilute or
give with
liquid.drug should
be taken after
meals.
Monitor BUN
levels; large doses
may raise BUN
levels.
Don’t give drug
for 48 hours after
Special
populations:
Pediatrics:
Safety and
efficacy have not
been established
in children.
Generic name: Stress ulcer Chemical Use cautiously in CNS: vertigo, Assess patients GI
Ranitidine effect: patients with malaise condition before starting
Hydrochloride Intractable Competitively hepatic therapy and regularly
duodenal ulcer; inhibits action of dysfunction. EENT: blurred thereafter to monitor
Brand name: pathologic h2 at receptor Adjust dosage in vision drug’s effectiveness
hypersecretory sites of parietal patients with
conditions, such cells, decreasing impaired kidney Hematologic: Instruct patient to take
Date ordered: as Zollinger gastric acid function reversible drug with or without
4th Hospital Day Ellison secretions leucopenia, food
(09/10/09) syndrome, short- pancytopenia,
term therapy for Therapeutic thrombocytopenia Remind patient taking
Dosage: patients unable to effect: drug once daily to take it
300 mg OD tolerate oral form Relieves GI Hepatic: Jaundice h.s.
300mg/tab 1 tab discomfort
PO HS Duodenal and Other: anaphylaxis,
gastric ulcers angioedema
Classification:
H2 receptor Gastroesophageal
antagonist, anti- reflux disease
ulcerative
Erosive
esophagitis
To relieve
occasional
heartburn, acid
indigestion and
sour stomach
Generic name: Relief of acute Arcoxia reduces History of GI: Nausea, Etoricoxib may mask
Etoricoxib pain. pain and hypersensitivity diarrhea, dyspepsia fever and other signs of
inflammation by to the active and upper inflammation.
Brand name: Treatment of the blocking COX- substance or to abdominal pain.
Arcoxia signs and 2, an enzyme in any of the Caution should be
symptoms of the body. excipients Others: Edema, exercised when co-
Date ordered: osteoarthritis dizziness, administering etoricoxib
1st Hospital Day (OA) and Pregnancy and hypertension, with warfarin or other
(09/7/09) rheumatoid lactation headache, fatigue oral anticoagulants
arthritis (RA). and increases in
Dosage: Severe hepatic liver enzymes. The use of etoricoxib, as
120 mg/tab BID Treatment of dysfunction with any medicinal
stat on 1st acute gouty (serum albumin product known to inhibit
Hospital Day arthritis. <25 g/l or Child- cyclo-
then 120 mg/tab Pugh score 10). oxygenase/prostaglandin
PO OD on 4th Treatment of synthesis, is not
Hospital Day ankylosing Estimated renal recommended in women
spondylitis (AS). creatinine attempting to conceive.
Classification: clearance <30
Treatment of ml/min. ARCOXIA tablets
Congestive heart
failure (NYHA
II-IV).
Patients with
hypertension
whose blood
pressure has not
been adequately
controlled.
Established
ischaemic heart
disease,
peripheral
arterial disease
and/or
cerebrovascular
disease
Generic name: Mild to moderate Chemical Contraindicated CNS: headache, Give oral form 2 hours
Ciprofloxacin UTI effect: in patient restlessness, after meals or 2 hours
Unknown. hypersensitive to seizures, confusion before or 6 hours after
Brand name: Severe or Bactericidal fluoroquinolones CV: taking antacids,
complicated UTI effects may Use cautiously in thrombophlebitis sucralfate, or products
result from patients with that contain iron. Food
Date ordered: Mild to moderate inhibition of CNS disorders, GI: nausea, diarrhea, doesn’t affect absorption
4th Hospital Day bone and joint bacterial DNA such as severe vomiting abdominal but may delay peak
(09/10/09) Last infections; mild gyrase and cerebral pain levels.
dose: 12th to moderate prevention of arteriosclerosis
hospital day respiratory tract replication in or seizure Hematologic: Have patient drink
(9/18/09) infections; mild susceptible disorders, and in leucopenia, plenty of fluids to reduce
to moderate skin bacteria those at neutropenia, risk of crystalluria
Dosage: and skin- increased risk for thrombocytopenia
500 mg/tab TID structure Therapeutic seizures. May Advise the patient to
infections; effect: cause CNS avoid caffeine while
Classification: infectious Kills susceptible stimulation. taking drug because of
Fluoroquinolone diarrhea; intra- bacteria potential for cumulative
, antibiotic abdominal caffeine effects
infection
Warn patient to avoid
hazardous tasks that
require alertness, such as
driving, until CNS
effects of drug are
known.
Generic name: Contraindicated Inform the physician
Alprazolam in: about any alcohol
consumption and
Brand name: Narrow-angle medicine you are taking
Xanor glaucoma; now, including
medication you may buy
Date ordered: Currently taking without a prescription.
9th hospital day itraconazole
Emphasize to
hypertensive patient
importance of other
modalities on BP:
weight control, regular
exercise, smoking
cessation, moderate
intake of alcohol and
salt.
Definition:
• Stroke rehabilitation is the process by which patients with disabling strokes
undergo treatment to help them return to normal life as much as possible by
regaining and relearning the skills of everyday living.
• It aims to help the survivor understand and adapt to difficulties, prevent secondary
complications and educate family members to play a supporting role.
Rehabilitation Team
• involves staff with different skills working together to help the patient
• includes nursing staff, physiotherapy, occupational therapy, speech and language
therapy, and usually a physician trained in rehabilitation medicine
• includes psychologists, social workers, and pharmacists since at least one third of
the patients manifest post stroke depression.
Activity Score
FEEDING 0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified
diet
10 = independent
BATHING 0 = dependent
5 = independent (or in shower)
GROOMING 0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided)
DRESSING 0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)
BOWELS 0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent
BLADDER 0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent
TOILET USE 0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
TRANSFERS (BED 0 = unable, no sitting balance
TO CHAIR AND 5 = major help (one or two people, physical), can sit
BACK) 10 = minor help (verbal or physical)
15 = independent
Stroke rehabilitation should be started as immediately as possible and can last anywhere
from a few days to over a year. Most return of function is seen in the first few days and
weeks, and then improvement falls off with the "window" to be closed after six months,
with little chance of further improvement. However, patients have been known to
continue to improve for years, regaining and strengthening abilities like writing, walking,
running, and talking. Daily rehabilitation exercises should continue to be part of the
stroke patient's routine. Complete recovery is unusual but not impossible and most
patients will improve to some extent: a correct diet and exercise are known to help the
brain to self-recover.
1. Hemicraniectomy
Photo © A.D.A.M.
Most strokes are small and cause insignificant brain swelling. A few of them, however,
cause such a large degree of swelling that with medical management alone they are
almost certain to cause death. For example, when a large stroke affects the blood flow
through the main middle cerebral artery, almost an entire side of the brain is completely
deprived of blood, causing the rapid death and swelling of nearly half of the brain.
Because the brain is encased by the walls of the bony skull, this swelling leads to an
increase in intracranial pressure (ICP), and results in an enlarged area of brain damage. In
the long run, the increased ICP prevents blood from flowing into most of the brain,
resulting in a rapid progression to brain death. In the majority of cases, the best way to
relieve the deadly ICP is through a life-saving surgery called a hemicraniectomy.
Definition:
• one of the most effective ways of relieving massive brain swelling
• performed in the operating room under anesthesia, consists of temporarily
removing a portion of the skull (sometimes up to one half or more) in order to
allow the swollen brain to expand beyond the confines of the skull bone, without
causing further elevations in brain pressure
• The part of the skull bone that is removed is typically frozen until the swelling has
resolved, at which point it can be sutured back onto its original place.
Definition:
A procedure wherein after evacuation of the hematoma through a single burr hole, a
Jackson Pratt drain is inserted into the subgaleal space, with suction facing the burr hole,
allowing for continuous drainage of the remaining hematoma.
Nursing Problem #2: Post-surgical pain on the operative site (Physiologic integrity – Pain/Discomfort)
Date Identified: 2nd Hospital Day
Nursing Problem #9: Compliance to Therapeutic Regimen (Health Promotion Maintenance – Teaching/Learning)
Date Identified: 10th day
5. Nurses will
ensure good
compliance to
medications and
provide options for
compliance to
outpatient follow-up
3. Nurses will
identify
appropriate lifestyle
modification suited
to the patient’s
current status.
4. Nurses will
involve patient in
diversion activities
that will enhance
self-esteem.
5. Nurses will
involve family
member in the care
plan.
DISCHARGE INSTRUCTIONS
MEDICATION
Nursing Responsibilities:
1. Prior to admission, assess for the patient or family members’ ability to understand
health teachings.
2. Reinforce importance of medication compliance to patient and her relatives; its
time, frequency, duration dosage and route.
3. Advise patient and relatives to keep a calendar of medication regimen.
4. Monitor and evaluate effectiveness of medication regimen as explained by the
physician.
5. Advice patient and relatives to keep track of their medication regimen through the
use of diaries or journals which will contain the effectiveness or side effects of the
drug taken.
6. Report unusual manifestations and side effects of drugs to physician.
7. Discuss with the patient different adverse effects that the patient may encounter
that will require further consultation to the physician.
8. Validate understanding of the health teachings that has been provided.
Exercise Promotion
Exercises should be properly coordinated with the rehabilitation team prior to Discharge:
1. A Warm Up phase of fifteen to twenty minutes should always be done prior to
any activity.
2. Initially, an exercise treatment program should comprise of
a. Passive range of motion exercise (flexion – extension of left upper and
lower extremities).
b. Assistive range of exercises.
c. Active-Assistive range of motion exercises.
d. Active range of motion exercises.
3. Prior to discharge, the immediate caregiver should be oriented to proper
monitoring of the patient during home exercises.
4. Patient compliance should be reinforced to accelerate patient's recovery by
adjusting regimen according to patient's individuality.
5. Discuss with patient and relatives that although cooperation in the exercise
regimen is vital to the recovery of the patient, he must not over exhaust himself.
Extreme exercise, to the point that it is already beyond one’s capacity, is also
detrimental to one’s health.
6. The exercise program should always be functional and have a target of
resumption of ADL‘s.
7. Educate patient and family members of untoward signs and symptoms that patient
might encounter that would necessitate prompt intervention.
A Case on Hemorrhagic CVA: Hypertension Stage II
Progressive Ambulation
Before ambulation exercises can begin, you The goal of ambulation exercises is to
must be able to stand. establish and maintain a safe gait, not to
Start to learn first the standing from sitting restore a normal gait. Most hemiplegic
position. patients have a gait abnormality, which is
The height of the seat may need to be caused by many factors (eg, muscle
adjusted. weakness, spasticity, distorted body image)
Stand with the hips and knees fully and is thus difficult to correct. Also,
extended, leaning slightly forward and attempts to correct gait often increase
toward the unaffected side. spasticity, may result in muscle fatigue, and
Use of parallel bars is the safest way to may increase the already high risk of falls
practice standing.
During ambulation exercises, place the feet Patients who begin walking without the
> 15 cm (6 in) apart and grasp the parallel parallel bars may need physical assistance
bars with the unaffected hand. from and, later, close supervision by the
Take a shorter step with the hemiplegic leg therapist. Generally, patients use a cane or
and a longer step with the unaffected leg. walker when first walking without the
parallel bars. The diameter of the cane
handle should be large enough to
accommodate an arthritic hand.
For stair-climbing, ascent starts with the If possible, patients ascend and descend
better leg, and descent with the affected leg with the railing on the unaffected side, so
(good leads up; bad leads down). that they can grasp the railing. Looking up
During descent, use a cane. The cane the staircase may cause vertigo and should
should be moved to the lower step shortly be avoided.
before descending with the bad leg.
Lean on the affected side against the Patients must learn to prevent falls, which
railing. Do strengthening exercises for are the most common accident among
weak muscles particularly in the trunk and stroke patients and which often result in hip
legs. fracture. Usually, patients explain the fall
by saying that their knees gave way.
TREATMENT
Wound Care
1. Do handwashing and observe cleanliness at all times.
2. Clean wound daily with the prescribed antiseptic medication.
3. If there are any signs of redness, discharge, foul smell & pain, visit the nearest
clinic immediately.
Safety
Follow up check ups can gauge the patients’ improvement and this can be used to
ascertain if the patient will change assistive devices or change from assistive devices to
adaptive devices which are more permanent.
Suggested assisted devices by the physician are the following: Patient can begin using a
walker, followed by crutches then canes as tolerated. Physical therapist must validate the
patient’s readiness towards motor recovery.
HYGIENE
Regular follow-up appointments are usually scheduled with the doctor and sometimes
with rehabilitation professionals. The purpose of follow-up is to check on the stroke
survivor's medical condition and ability to use the skills learned in rehabilitation. It is also
important to check on how well the stroke survivor and family are adjusting. The stroke
survivor and caregiver can be prepared for these visits with a list of questions or
concerns.
Schedule: 1st Follow-up visit on the 5th post-discharge day at the Dr. Rondilla’s clinic
Room 401.
Such services are usually multidimensional and can include emotional and social support,
assistance with referral to other services, and the provision of information to people with
stroke and their families. The evidence is difficult to interpret and no one service has
been shown to be clearly beneficial. A follow up service provided by a physician or
physiotherapist resulted in higher function compared to standard aftercare.
DIET
Spirituality
Family and relatives should be advised to seek spiritual support.
Sexuality
Immediate relatives should be oriented on ways on showing affection, care and support to
further encourage the patient’s motivation on recovery.
AHA guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002
Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients.
Circulation. 2002;106:388. Retrieved on September 19, 2009 from
http://circ.ahajournals.org/cgi/content/full/106/3/388.
Adams H, Adams R, del Zoppo G, Goldstein L. Guidelines for the early management of
patients with ischemic stroke. 2005 Guidelines update, a scientific statement from the
Stroke Council of the American Heart Association. Stroke 2005; 36:916-923.
Broderick JP, Adams HP, Barsan W, et al. Guidelines for the management of
spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a
special writing group of the Stroke Council of the American Heart Association. Stroke
1999;30:905-915.
Doenges, M., Moorhouse, M. & Murr, A. 2006. Nursing Care Plans: Guidelines for
Individualizing Client Care Across Life Span. 7th edition. FA Davis Company.
Fogelholm R, Avikainen S and Murros K. Prognostic value and determinants of first day
mean arterial pressure in spontaneous supratentorial intracerebral hemorrhage. Stroke
1997;28:1396-1400.
Goldstein LB, Bartels C. Davis JN. Interrater reliability of the NIH Stroke Scale. Arch
Neurol 1989;46:660-662.
Guyton A and Hall J. Guyton and Hall’s Textbook of Medical Physiology, 11th ed.
USA: WB Saunders; 2005.
Jon Zonderman & Rita Doyle. 2006. Springhouse Nurse’s Drug Guide 2006 Seventh
Edition Lippincott Williams and Wilkins.
Kothari RU, Brott T, Broderick JP, et al. The ABCs of measuring intracerebral
hemorrhage volumes. Stroke 1996;27:1304-1309.
Libman RB, Wirkowski E, Alvir J, Rao H. Conditions that mimic stroke in the
emergency department. Arch Neurol 1995;52:1119-1122.
Nettina, S. 2001. The Lippincott Manual of Nursing Practice. 7th edition. Lippincott
Williams & Wilkins.
Powers WJ, Zazulia AR, Videen TO, et al. Autoregulation of cerebral blood flow
surrounding acute (6-22hours) intracerebral hemorrhage. Neurology 2001; 57:18-24.
Rankin J. Cerebral vascular accidents in patients over the age of 60. Scot Med J
1957;2:200-215.
Van Swieten JC, Koudstaal JP, Visser MC, et al. Interobserver agreement for the
assessment of handicap in stroke patients. Stroke 1988;19:604-607.
Wijdicks EFN. The Clinical Practice of Critical Care Neurology. 2nd ed. USA: Oxford
University Press; 2003.
Greetings!
We, the participants of the 60th Batch of Critical Care Course are conducting a case study
on neurologic conditions. This is to provide effective nursing care and also to give
reference for the benefit of health care practitioners managing such case. As your
attending physician, we humbly ask for your consent if we can have Patient Regino Flora,
a 41 year old male currently admitted at Petal 4-D to become our primary reference for
our case study. The patient is currently diagnosed with Right Intracerebral Hemorrhage
with Intraventicular Extension S/P Hemicraniectomy with Evacuation of Hematoma at
the Right Fronto-Temporal Lobe.
Data gathering will involve the following methods: chart review, physical assessment,
neurologic assessment and patient/family interview. We ensure that no form of harm will
be done and that patient confidentiality is strictly observed.
Aware of your concern for the growth and development towards the provision of quality
care, we are hopeful that you will give us your favorable response.
Respectfully yours,
Noted: