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SAINT LOUIS UNIVERSITY SCHOOL OF NURSING BSN IV C2

CASE PRESENTATION

CEREBRAL HEMORRHAGE

CLINICAL INSTRUCTOR: Mr. Gregorio Banglayan, RN

Submitted by: Tejada, Gian Ysmael Eleria, Jhessel Anne Guledew, Catherine Roselle K.
CASE PRESENTATION: CEREBRAL HEMORRHAGE

Date Submitted: August 22, 2011

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CEREBRAL HEMORRHAGE A cerebral hemorrhage or haemorrhage (or intracerebral hemorrhage, ICH) is a subtype ofintracranial hemorrhage that occurs within the brain tissue itself. Intracerebral hemorrhage can be caused by brain trauma, or it can occur spontaneously in hemorrhagic stroke. Non-traumatic intracerebral hemorrhage is a spontaneous bleeding into the brain tissue.[1] A cerebral hemorrhage is an intra-axial hemorrhage; that is, it occurs within the brain tissue rather than outside of it. The other category of intracranial hemorrhage is extra-axial hemorrhage, such as epidural, subdural, and subarachnoid hematomas, which all occur within the skull but outside of the brain tissue. There are two main kinds of intra-axial hemorrhages: intraparenchymal hemorrhage and intraventricular hemorrhages. As with other types of hemorrhages within the skull, intraparenchymal bleeds are a serious medical emergency because they can increase intracranial pressure, which if left untreated can lead to coma and death. The mortality rate for intraparenchymal bleeds is over 40%.[2]

High blood pressure, atherosclerosis (buildup of plaque in artery walls), and amyloid angiopathy (protein deposits in artery walls) can weaken blood vessel walls. Aneurysms, which are bulges in weakened areas, can form when blood vessels are damaged or they can be present at birth. Arteriovenous malformations, which are abnormal connections between arteries and veins that may be present at birth, are another vascular abnormality that can be a site of cerebral hemorrhage. SIGNS AND SYMPTOMS Patients with intraparenchymal bleeds have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed.[3] Other symptoms include those that indicate a rise in intracranial pressure due to a large mass putting pressure on the brain.[3] Intracerebral hemorrhages are often misdiagnosed as subarachnoid hemorrhages due to the similarity in symptoms and signs. A severe headeche followed by vomitting is one of the
CASE PRESENTATION: CEREBRAL HEMORRHAGE

symptoms of the disease. Common symptoms of cerebral hemorrhage include:


Change in level of consciousness or alertness such as passing out or unresponsiveness Difficulty swallowing Difficulty with thinking, talking, comprehension, writing or reading Loss of vision or changes in vision Numbness or weakness Paralysis Seizures Severe headache

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Serious symptoms that might indicate a life-threatening condition Cerebral hemorrhage is always an emergency and can be life threatening. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:

Change in level of consciousness or alertness such as passing out or unresponsiveness Change in mental status or sudden behavior change such as confusion, delirium, lethargy, hallucinations or delusions

Garbled or slurred speech or inability to speak Paralysis or inability to move a body part Seizure Sudden change in vision, loss of vision, or eye pain Trauma to the head Worst headache of your life

ASSESSMENT What causes cerebral hemorrhage? Cerebral hemorrhage can be due to head trauma or can occur as a result of weakened blood vessels, which can be present at birth or can occur due to processes that damage blood vessels. What are the risk factors for cerebral hemorrhage? A number of factors increase the risk of developing cerebral hemorrhage. Not all people with risk factors will get cerebral hemorrhage. Risk factors for cerebral hemorrhage include:

Amyloid angiopathy (deposits of protein in artery walls) Arteriovenous malformations (abnormal connections between arteries and veins) Atherosclerosis (buildup of plaque on the walls of the coronary arteries; atherosclerosis is a type of arteriosclerosis)
CASE PRESENTATION: CEREBRAL HEMORRHAGE

Cerebral aneurysms (life-threatening bulging and weakening of the wall of an artery that can burst and cause severe hemorrhage in the brain)

Head trauma Hypertension (high blood pressure)

DIAGNOSTIC TESTS 1. CT Scan or MRI Emergency neurodiagnostic imaging of the brain is required to emergently assess the possibility of bleeding into the brain substance. Once the location of the hemorrhage is identified by history, exam and neuroimaging, other direct diagnostic tests may be

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pursued as appropriate. Magnetic resonance imaging (MRI) is not used in the acute phase of injury but is useful after the initial 48 hours to assess the extent of injury to the brain. 2. Lumbar puncture If the CT is negative for bleeding is performed to determine if blood is present in the CSF. 3. Arteriography If a ruptured aneurysm is suspected, a complete vascular study of the carotid and cerebral arteries helps pinpoint the location of the ruptured aneurysm. 4. Angiography It may also be performed if subarachnoid hemorrhage is suspected. 5. ECG- atrial fibrillation, T wave changes, shortened PR interval, prolonged QT interval, PVC, sinus bradycardia and ventricular and supraventricular tachcardias. SAH can lead to ST segment and T wave abnormalities 6. chest x-ray 7. urinalysis 8. blood studies (complete blood count [CBC], prothrombin time [PT], erythrocyte sedimentation rate [ESR], blood glucose, electrolytes, and blood type). Expect an elevated homocysteine levels MEDICATIONS a. Warfarin (Coumadin) Warfarin is used to decrease the tendency for thrombosis or as secondary prophylaxis (prevention of further episodes) in those individuals that have already formed a blood clot (thrombus). Warfarin treatment can help prevent formation of future blood clots and help reduce the risk of embolism (migration of a thrombus to a spot where it blocks blood supply to a vital organ).

b. Aspirin Platelet inhibiting medications such as Aspirin decrease the incidence of cerebral infarction in patients who have experienced TIAs and stroke from suspected embolic or thrombotic causes. c. Simvastatins medications classified as 3-hydroxy-2-methyl-glutaryl-coenzyme reduce coronary events and strokes. d. Ace inhibitors Is also indicated for stroke preventions
CASE PRESENTATION: CEREBRAL HEMORRHAGE

e. Thiazide diuretics

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a "water pill" (diuretic) that decreases the amount of water in the body by increasing urination. It is used to decrease body fluid and swelling of the hands or feet (edema), and for high blood pressure.

f. Thrombolytic therapy T-pa: o a thrombolytic substance made naturally by the body. It works by binding fibrin and converting plasminogen into plasmin which stimulates fibrinolysis of the atherosclerotic lesion. Rapid diagnosis of stroke and initiantion of thromobolyitic therapy (within 3 hours) in patients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in fuctional outcome after 3 months. o the patient is weighed to determine the dose of T-pa. The dosage for tPA is 0.9 mg/kg with a maximum dose of90 mg. Ten percent of the calculated dose is administered IV bolus over 1 minute. The remaining dose is administered IV over 1 hour via an infusion pump. o Nursing responsibility for patients recieving t-PA: Monitor for bleeding (IV insertion sites, urinary catheter site, endotracheal tube, nasogastric tubes, urine, stool, emesis and other secretions) g. IV fluids Heparin IV Mannitol o Mannitol is used clinically in osmotherapy to reduce acutely raised intracranial pressure until more definitive treatment can be applied, e.g., after head trauma . It is administered intravenously, and is filtered by the glomeruli of the kidney, but is incapable of being and Na+ reabsorption via its osmotic effect. Consequently, mannitol increases water and Na+ excretion, thereby decreasing extracellular fluid volume. Hemorrhagic stroke a. vitamin K antidote for coumadin therapy if the bleeding is caused by anticoagulation of warfarin b. antiseizure agents such as diazepam to control seizures which may occur in hemorrhagic stroke
CASE PRESENTATION: CEREBRAL HEMORRHAGE

resorbed from the renal tubule, resulting in decreased water

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Intracerebral hemorrhage and Hematoma a. Mannitol o Mannitol is used clinically in osmotherapy to reduce acutely raised intracranial pressure until more definitive treatment can be applied, e.g., after head trauma . It is administered intravenously, and is filtered by the glomeruli of the kidney, but is incapable of being resorbed from the renal tubule, resulting in decreased water and Na+ reabsorption via its osmotic effect. Consequently, mannitol increases water and Na+ excretion, thereby decreasing extracellular fluid volume.

b. Acetaminophen o Acetaminophen relieves pain by elevating the pain threshold, that is, by requiring a greater amount of pain to develop before a person feels it. It reduces fever through its action on the heat-regulating center of the brain. Specifically, it tells the center to lower the body's temperature when the temperature is elevated

c. Anticonvulsants o Anti-convulsants are often prescribed to decrease the patient's chance of having a seizure. A health care provider should always check for therapeutic drug levels when using anticonvulsants such as phenobarbital or dilantin that can accumulate and become toxic to the patient. A sub-therapeutic drug level will not protect the patient from seizures. A high drug level may cause a variety of side effects

including a decreased level of consciousness. d. Barbiturate Coma


CASE PRESENTATION: CEREBRAL HEMORRHAGE

o Placing the patient is a barbiturate coma lowers ICP by lowering the rate of the body's metabolic process, oxygen consumption, and CO2 production. A lower metabolic rate will decrease the work of the brain during a recovery period. Barbiturate comas are only used when other methods to decrease intracranial hypertension fails. e. Sedatives o Sedating the patient will also lower the metabolic rate of the brain. The common sedative is a continuous infusion of propofol due to the short half-life of the drug. Turning off the drip will allow the patient to wake up within a few minutes to an hour. This is beneficial for

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neurological exams necessary to assess the progress or decline of the patients status. f. Hypertensive/Hypotensive Therapy o Blood pressure control needs to be closely managed to keep ICP within normal limits. Remember that MAP-ICP = CPP. A patient needs a CPP 60-75; therefore, the systolic blood pressure needs to be at a range where ischemia is not occurring Increased blood pressure may increase intracranial pressure, decrease cerebrial blood flow or worsen bleeding. Intravenous drip medications such as: Nipride, Nicardipine, or Labetalol may be given to lower the patients blood pressure (Lavin, 1986). In addition, if the MAP is too low,

intravenous medications such as neosynephrine, levophed, or vasopressin may be ordered to increase the MAP and thereby increasing the CPP

g. Coagulation o If increased ICP is a result of intracranial hemorrhage from

anticoagulation use, reversal agents may be necessary. Fresh frozen plasma, Vitamin K, platelets, and other factors may need to be given h. Intravenous (IV) Fluids o Hypertonic or isotonic IV fluids are usually used for patients with ICH. Hypotonic solutions will increase the amount of edema.

Examples of hypertonic or isotonic IV fluids include: Normal saline : o A sterile solution of sodium chloride that is isotonic to body fluids, used to maintain living tissue temporarily and as a solvent for parenterally administered drugs.
CASE PRESENTATION: CEREBRAL HEMORRHAGE

o Normal Saline is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment. o It is indicated as a source of water and electrolytes. Lactated ringers o Isotonic Solution. When provide sources administeredintravenously, and electrolytes. these Their solutions electrolyte

of water

contentresembles that of the principal ionic constituents of normal plasma and the solutions therefore aresuitable for parenteral replacement of extracellular losses of fluid and electrolytes. Calcium chloride inwater

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dissociates to provide calcium (Ca++) andchloride (Cl) ions. They are normal constituents of the body fluids and are dependent on

various physiologic mechanisms for maintenance of balance between intake and output. Approximately 80% of body calcium is excreted in the feces as insolublesalts;urinaryexcretion chloride in accounts for the

remaining20%. Potassium

water dissociates

to provide

potassium (K+) and chloride (Cl) ions.Potassium is found in low concentration in plasmaand extracellular fluids (3.5 to 5.0 mEq/liter in ahealthy adult). It is the chief cation of body cells(160 mEq/liter of intracellular water). Potassium plays an important role in electrolyte balance Albumin o Serum albumins are important in regulating blood volume by maintaining the oncotic pressure (also known as colloid osmotic pressure) of the blood compartment. They also serve as carriers for molecules of low water solubility this way isolating their hydrophobic nature, including lipid soluble hormones, bile salts, unconjugated bilirubin, free fatty

acids (apoprotein),calcium, ions (transferrin), and some drugs like warfarin, phenobutazone, clofibrate & phenytoin. For this reason, it's sometimes referred as a molecular "taxi". Competition between drugs for albumin binding sites may cause drug interaction by increasing the free fraction of one of the drugs, thereby affecting potency. INTERVENTIONS & MANAGEMENT Reducing your risk of cerebral hemorrhage / Interventions You may be able to lower your risk of cerebral hemorrhage by:

Controlling your blood pressure Eating a healthy diet Exercising regularly Quitting smoking Taking precautions against falling Using safety devices such as helmets and seatbelts when necessary
CASE PRESENTATION: CEREBRAL HEMORRHAGE

Medical Management 1. Identify stroke early 2. Maintain Cerebral Oxygenation 3. Restore cerebral flow (thrombolytic therapy)

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4. Prevent Complications 5. Rehabilitation after stroke 6. Physical therapy 7. Occupational therapy 8. Speech therapy Nursing Management 1. Serial Assessments of these data may be required as oten as every 15 minutes for unstable clients to every 2 to 4 hours for stable clients 2. Notify physician if client is deteriorating neurologically 3. Maintain the clients blood pressure within normal range 4. Maintain perfusion without promoting cerebral edema 5. Maintain normothermia to reduce cerebral glucose and oxygen consumption 6. Cluster nursing interventions to reduce unneeded movement and stimulation 7. Elevate the head of the bed 30 degrees to reduce cerebral edema 8. Maintain clients head in neutral position to improve venous drainage 9. Administer medications to improve cerebral tissue perfusion as prescribed.

Anticoagulants or antiplatelet agents will be used to decrease risk further thrombus formation. Nimodipine, a Ca channel blocker, is used to treat vasospasm secondary to SAH. 10. Delirium and restlessness should be controlled with sedatives 11. Restraitns should be avoided because it increase agitation and ICP. 12. Straining at stool or with excessive coughing, vomiting, lifting, or use of the arms to change position should be avoided, because the valsalva maneuver increases ICP.

CASE PRESENTATION: CEREBRAL HEMORRHAGE