I.

INTRODUCTION The 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, difficulty speaking 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.

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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)

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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 Eselectin, 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)

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II.

REVIEW OF ANATOMY AND PHYSIOLOGY

MAJOR 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 cerebral hemispheres (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 cortex constitutes 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

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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 the pineal gland and the CSFproducing choroid plexus.

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

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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.

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THE CEREBRAL CIRCULATORY SYSTEM Blood is transported through the body via a continuous system of blood 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]).

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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

Vessel Length (Vessel Diameter) 4

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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 noncollapsible. 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.pdf on September 27, 2010 at 8:44am)

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III.

DIAGNOSTIC PROCEDURES

Noncontrast 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 the brain stem. Intraparenchymal bleeds within the medulla oblongata are almost always fatal, because they cause damage to cranial nerve X, the vagus nerve, which plays an important role in blood circulation and breathing.This kind of hemorrhage can also occur in the cortex or subcortical areas, usually in the frontal or temporal lobes when due to head injury, and sometimes in the cerebellum. 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 Xray films.

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IV.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY (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 nuchal rigidity, headache and vomiting Seizures Changes in mental status Fever ECG changes

Intracerebral hemorrhage

Loss of blood supply

Brain cannot use anaerobic metabolism

Hypoxia

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Local Acidosis

Cerebral Ischemia

Influx of Ca and Na

Neurotoxins (O2 free radicals, nitric oxide, and glutamate) are released.

Membrane depolarization

Cytotoxic edema and cell death

Short term ischemia or TIA

Blood flow not restored within 3 to 10 minutes

Transient hemiparesis Loss of speech Hemisensory loss

Irreversible damage or infarction

Focal neurologic deficits lasting less than 24 hrs

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

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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.

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Risk Factors Modifiable a) Hypertension this is due to plaque deposits on the wall of the arteries which causes narrowing 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 which may cause thrombus formation leading to hypertension. c) Cigarette Smoking- nicotine content of cigarettes causes vasoconstriction there by resulting hypertension 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 and cerebral ischemia which may cause CVA. f) Obesity- this is due to increase cholesterol in the body which may contribute plaque formation 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 vessel wall may rupture causing hemorrhagic stroke. j) Atrial Fibrillation- pulling of blood from poorly emptying atrial which leads to formation of tiny clots in left atrium which can move on the cerebral circulation k) Type A personality- stress causes hypertension thereby increasing chance of having hemorrhagic stroke. l) Sedentary Lifestyle- increase of having DM and Obesity which one of the factors of having CV Non-modifiable a) Advancing Age- intracerebral hemorrhage is most often secondary to hypertension and is most common after age 50 years. Page

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b) Sex (Men)- Incidence of stroke in men is slightly higher than that of women c) Race (African Americans)- more prevalent among African Americans than whites or Hispanics d) History of transient ischemic attack or CVA e) Family History of DM- due to accelerated atherosclerosis Signs and Symptoms Clinical Manifestations a) Severe occipital or nuchal rigidity, Headache and vomiting due to an increase ICP which causes cerebral edema, and compressing the medulla oblongata b) Seizures due to hyper excitability of neurons because of irritation. c) d) e) Changes in mental status affectation in the Reticular Activating System Fever affectation in the hypothalamus ECG changes problem with the medulla oblongata

Warning Signs a) Transient hemiparesis b) Loss of speech c) Hemisensory loss d) Vertigo/syncope Specific Deficits a) Hemiparesis/Hemiplegia the former means weakness of one side of the body while the latter means paralysis of one side of the body. b) Aphasia defects on using and interpreting symbols of language c) Dysarthia imperfect articulation condition. d) Dysphagia- due to affectation of some cranial nerves e) 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 complex processes of vision. Page

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g) Homonymous Hemianopsia a defective vision or vision loss in the same half of the visual field h) Horners syndrome paralysis of sympathetic nerves to the eye causing sinking of the eyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the eye. i) j) Agnosia a disturbance in the ability to recognize familiar objects through the senses. 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 sensory strip 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 and emotions. People with stroke in the left cerebral or dominant hemisphere are frequently slow, cautious, and disorganized while on the right cerebral stroke or nondominant hemisphere, 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 to communicate.

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V. DRUGS

MEDICAL MANAGEMENT AND SURGICAL PROCEDURE (IF ANY)

1. Dexamethasone Brand 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.

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2. Paracematol Brand 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 Nursing Responsibilities: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose. With caution used in patients with disorders of the liver and kidneys, with benign hyperbilirubinemia, as well as in elderly patients. With prolonged use of paracetamol is necessary to monitor patterns of peripheral blood and functional state of the liver. 3. Pantoprazole Brand Name: Pantoloc

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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. Nursing Responsibilities: Pantoprazole or Pantoloc seems to have a greater effect in the elderly, thus the dosage may have to be modified. Because the liver is involved in the metabolism and excretion of Pantoprazole or Pantoloc, people with liver disease may have to have a dosage modification.

4. Aluminum Hydroxide and Magnesium Hydroxide Brand Name: Maalox General Classification: Antacid Specific Action: This medication works only on existing acid in the stomach. It does not prevent acid production. It may be used alone or with other medications that lower acid production. Indication: stomach upset, heartburn, and acid indigestion Adverse Reactions:

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Upset stomach, vomiting, stomach pain, belching, constipation, dry mouth, increased urination, loss of appetite, metallic taste Nursing Responsibilities: Taken on an empty stomach, they only neutralize acid for 30 to 60 minutes because the 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 effect where 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 medications is always preferable but again is a nuisance and hard to comply with long-term. 5. Mannitol Brand 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

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Nursing Responsibilities: Mannitol may cause dizziness. These effects may be worse if you take it with alcohol or 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 extreme dizziness. Lab tests, including blood electrolytes, kidney function, lung function, heart function, 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. Nicardipine Brand 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. Nursing Responsibilities:

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Measure blood pressure frequently during initial therapy. Maximal response occurs about 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 on drug level, assess antihypertensive effect 8 hrs after dosing. Advise pt to report chest pain immediately.

7. Dopamine Brand 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. Nursing Responsibilities: Drug is not a substitute for blood or fluid volume deficit. If deficit exist, replace fluid before giving vasopressors. During infusion, frequently monitor ECG, BP, CO, CVP, pulmonary artery wedge pressure, PR, UO and color and temperature of the limbs. If diastolic pressure rises disproportionately with a significant decrease in pulse pressure, 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.

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VI.

SURGICAL MANAGEMENT

Surgeries for hemorrhagic stroke include:

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

A procedure (endovascular coil embolization) to repair a brain aneurysm that is the cause 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 (arteriovenous malformations) 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.

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VII.

NURSING CARE PLANS (NCPs)

1st Problem: Ineffective Cerebral Tissue Perfusion

Assessment S> O> The patient may manifest: >Headache >Vertigo >Visual Changes >Dizziness >Ataxia >Motor deficits >Paresthesia >Seizure activity >Coma >Bloody CSF >Positive radiologic findings Nursing Diagnosis Ineffective Cerebral Tissue Perfusion related to intracranial hemorrhage as evidenced by headache and sudden drop in level of consciousness. Scientific Explanation 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. Objectives 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. Nursing Interventions >Monitor and record neurologic status, usually Glasgow Coma Scale Rationale >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. Expected Outcome 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.

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.

>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

>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

>Monitor electrolytes >Monitor arterial blood gases and pulse oximetry

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 the need to increase ICP >Controlling fever reduces metabolic demands of the brain. Fever may be a result of hypothalamic irritation ot infection (bladder or respiratory).

>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.

> Administer the following meds: -Hyperosmotic -Albumin -Antihypertensives -Corticosteroids

-to decrease ICP -increases volume -control severe HPM -control intracranial inflammation

2nd Problem: Risk for Ineffective Airway Clearance

Assessment S> O> The patient may manifest: >Difficulty in breathing >O2 saturation less than 90% >Respiratory distress: patient complaints, cyanosis, restlessness, shortness of breath. Nursing Diagnosis Risk for Ineffective Airway Clearance related to neurologic dysfunction, obstruction or secretions. Scientific Explanation 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. Breathing center of the brain may be affected and so, difficulty in breathing may be experienced. Objectives Short Term: After 4 hrs of NI, the patient will maintain patent airway as evidenced by rate, rhythm and lung sounds within normal limits. Nursing Interventions >Monitor respiratory rate and rhythm, lung sounds, and ability to handle secretions. Rationale >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 Expected Outcome Short Term: The pt shall have maintained patent airway as evidenced by rate, rhythm and lung sounds within normal limits.

>Check presence of gag reflex.

Long term: After 3 days of NI, the patient will not exhibit any signs of respiratory distress.

Long term: The patient shall not have exhibited any signs of respiratory distress.

>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.

>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

>keeps the tongue form obstructing the airway >position changes prevents pooling secretions. Older people are most susceptible to atelectasis and pneumonia.

-Provide endotracheal or tracheal care if warranted. -Avoid respiratory measures that increase ICP, such as frequent suctioning, but keep in mind that a patent airway is first priority.

-This reduced hypoxemia, which can cause cerebral vasodilation and increased ICP. -The patient in a coma after 48hrs may require intubation

3rd Problem: Impaired Physical Mobility

Assessment S> O> The patient may manifest: >inability to move purposefully within physical environment. >limited range of motion >decreased muscle strength, control and/or mass Nursing Diagnosis Impaired Physical Mobility related to paresis or paralysis, loss of balance and coordination and increased muscle tone.

Scientific Explanation
The nervous system is made up of nerve cells called neurons that serve 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.

Objectives Short Term: After 4 hrs of NI, the patient will maintain maximum level of function and will reduce risk of complications.

Nursing Interventions >Assess pts degree of weakness in both upper and lower extremities >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.

Rationale >there may be differing degrees of involvement on the affected side. >paralysis, paresis, and sensory loss are contralateral to the side of the brain affected by stroke.

Expected Outcome Short term: The patient shall have maintained 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.

Long Term: After 3 days of NI, the pt will be able to demonstrate behaviors that enable resumption of activities.

>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

>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.

>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.

>This preserves muscle strength and prevents contractures, especially in spastic extremities. >to gradually improve muscle strength

>Use pressure relieving devices on the bed and chair. >Initiate rehabilitation techniques in the hospital setting as soon as medically possible.

>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 ulcer development. >this prevents further systemic deterioration.

4th Problem: Risk for Impaired Verbal Communication

Assessment 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. Nursing Diagnosis Risk for Impaired Verbal Communication related to brain injury adversely affecting the transmission, reception or interpretation of language and other forms of communication. Scientific Explanation 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. Objectives 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. Nursing Interventions >Assess speechlanguage history: determine primary language, ability to read, write, and understand spoken language; level of education >Assess speechlanguage function: automatic speech, auditory comprehension, comprehension of written language, expressive ability, ability to write. Rationale >These data provide a baseline for developing an individualized teaching plan. Expected Outcome 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.

>Approach the pt as an adult.

>Enhance the environment.

>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

off the television, radio or closing the

door.
>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) > 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, place material 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

>Use prompting cues, such as gestures or holding an object that

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 focus attention, 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

aphasia and methods of communication that can be tried. >Demonstrate to pt any progress made

>this increases confidence and facilities ongoing efforts.

5th Problem: Risk for Disturbed Sensory Perception (Tactile)

Assessment S> O> The patient may manifest: >numbness >tingling sensation or paresthesia >pressure ulcers >accidental wounds or punctures >pallor/ cyanosis Nursing Diagnosis Risk for Disturbed Sensory Perception (Tactile) Scientific Explanation 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. Tactile stimuli may not be felt by the patient due to the affection of the nerves on the certain areas of the brain. Objectives Short Term: After 4 hrs of NI, the patient will remain free from injuries, including pressure ulcers. Nursing Interventions >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 Rationale >This determines the level of alteration and identifies specific areas of risk. Expected Outcome Short term: The patient shall remain free from injuries, including pressure ulcers.

Long Term: After 3 days of NI, the patient will continuously be free from injuries.

>to know extent of sensory perception.

Long Term: The patient shall have been continuously be free from injuries.

>Pressure on the affected side should last no longer than 30 minutes.

>This helps pts learn to recognize sensations.

>This improves pt

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.

6th Problem: Risk for Unilateral Neglect

Assessment S> O> The patient may manifest: >Left or right sided neglect due to the affectation of the opposite hemisphere of the brain. Nursing Diagnosis Risk for Unilateral Neglect Scientific Explanation 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 Objectives Short Term: After 4 hrs of NI, the patient will have no injuries as a result of deficit. Nursing Interventions >Conduct sensory assessment Rationale > 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. Expected Outcome Short Term: The patient shall 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.

>Perform visual fields confrontation test.

Long Term: The pt shall observe and touch affected side during ADLs.

>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

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 on plate.

>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 diminishes spatial/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

> Attach watch or bright bracelet to affected arm. >Practice drawing and copying figures with

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.

VIII.

CONCLUSION Any 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 a possibility 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.

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IX. Books

REFERENCES

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 Pocket Guide (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

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