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Philippine Heart Center

Department of Nursing Education and Research

A Group Case Study on


Hemorrhagic CVA with Stage II Hypertension

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.

September 25, 2009


A Case on Hemorrhagic CVA: Hypertension Stage II
TABLE OF CONTENTS

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

A Case on Hemorrhagic CVA: Hypertension Stage II


SECTION 1: INTRODUCTION

STROKE: THINK GLOBALLY, ACT LOCALLY


- From the Stroke Society of the Philippines
Principles:
1. Stroke is a "brain attack"
… needing emergency management, including specific treatment and
secondary and tertiary prevention.
2. Stroke is an emergency
… where virtually no allowances for worsening is tolerated.

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.

This is a classic example of a mini-stroke or transient ischemic attack (TIA), which is


often an important warning sign for an impending fatal stroke. A stroke is an emergency
case, thus, it should be treated as such. Consequences are usually irreversible and fatal
depending on the section of the brain affected. Stroke often comes unexpectedly, as was
in the case of the former National Bureau of Investigation (NBI) Director Reynaldo
Wycoco who suffered a hemorrhagic stroke caused by a ruptured aneurysm in the brain
that left him in a deep coma for several days (Manila Times, 25 Nov 2005).

A stroke is similar to a heart attack. It is caused by the malfunction or “death” of a part of


the brain when there is a lack of blood supply to that certain part due to a clot or a
ruptured vessel. When stroke strikes, time lost is considered brain lost. The faster the
patient is able to receive medical intervention, the greater the chance for him to recover
from stroke

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

A Case on Hemorrhagic CVA: Hypertension Stage II


in a press release that the cost of treating uncomplicated stroke for 5-7 days range from
Php 15,000 to Php 20,000 (www.doh.gov.ph), making it not only a burden emotionally
but also economically to the family and community.

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.

A Case on Hemorrhagic CVA: Hypertension Stage II


SECTION 2: STATEMENT OF OBJECTIVES

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.

A Case on Hemorrhagic CVA: Hypertension Stage II


SECTION 3: PROFILE OF THE PATIENT

3.1: DEMOGRAPHIC DATA AND HISTORY

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:

I. History of Present Illness:

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).

A Case on Hemorrhagic CVA: Hypertension Stage II


II. Pertinent Family Medical History:
Mother & Father – HTN & CVD Grandmother - Ca (Breast)

III. Socio-Economic History:


The patient lives in an owned family house with his parents, niece and older brother. He
helps run the family business owned by his father while his mother is a full time
housewife.

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.

IV. Environmental History:


The patient has no known allergies to food or any medications. He prefers staying
indoors – drinking and bonding with family and friends. According to his mother, their
house is well-kept as to no pests are present and that garbage is collected 4-5 times a
week.

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.

A Case on Hemorrhagic CVA: Hypertension Stage II


Post operatively, he remained at the Neuro ICU for 4 ½ days until his parameters were
within acceptable limits to be transferred in the ward. He is currently on his 12 th hospital
day at the PHC and undergoing stroke rehabilitation at bedside.

A Case on Hemorrhagic CVA: Hypertension Stage II


3.2: NURSING CARE ASSESSMENT

Health-Perception/Health Management Patterns


The client does not seek consultation from a physician when dealing with minor ailments.
He relies on self care and over the counter medication such as bioflu for colds,
paracetamol for fever, etc. Few days prior to consultation, he manages his occipital
headache and fatigue by drinking a glass of pineapple juice daily. He does not wish to
share these symptom experiences with his family until he was found lying on the floor
with decreased sensorium and left side weakness. His mother believes that his good
prognosis will ensure a progressive recovery thus managing the residual symptoms of
stroke.

Nutritional/ Metabolic Pattern


The client usually eats 3 large meals and 1-2 snacks in a day. He drinks 5-8 glasses of
water a day. He prefers red meat over fruits and vegetables and wants his dishes prepared
either fried or grilled. His diet is now controlled – on low salt low fat diet. His skin is
warm. However, ever since he was hospitalized and was removed from NGT, his mother
shares that his appetite has decreased immensely. No various interruptions in skin
integrity are found but his present condition puts him to risk for pressure ulcers.

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.

Sleep/ Rest Pattern


The client has a regular sleeping pattern of 5-7 hours in a day. His usual sleeping time is
11 pm and wakes up at 5-6 am. Few days prior to consultation, the client had a hard time
sleeping due to recurrence of occipital headache. Presently in the ward, the patient has an
altered sleeping pattern. He is awake in the evening and is asleep in the morning –
irritable when awaken.

Cognition/ Perception Pattern


The client has a normal 20/20 vision prior to admission. His vision is altered due to the
presence of nystagmus upon looking to left and has a preferential gaze to the right.

A Case on Hemorrhagic CVA: Hypertension Stage II


Self perception/ Self control pattern
The client describes himself as God-fearing and often hears mass every Sunday.
However, for the past few months, he has not visited the church due to frequent social
occasions he took part in.

Role/ Relationship pattern


He lives with is parents and they have been so close and has a very harmonious
relationship. The patient lives with his parents, niece and his older brother. They have
good communication that serves as their foundation on settling serious problems in the
family. Their family is patriarchal but his father always makes sure that the rest of the
member is aware and in favor of every decision made. Client stated that his family goes
to Church every Sunday and believes in the power of faith.

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.

Sexuality/ Reproductive Pattern


The client prefers monogamous heterosexual when asked about his preferences on being
in relationship. He believes that having a homosexual relationship is simply
unacceptable. He is attracted to smart and witty women regardless of age.

Coping/ Stress Pattern


He is most comfortable in sharing his problems to his mother and God. Before, he used to
depend on his friends but when most of his peers got married, he got closer to his family.
His coping mechanism includes constant prayers, laughter and having a “me-time” for
reflection.

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.

A Case on Hemorrhagic CVA: Hypertension Stage II


3.3: INITIAL PHYSICAL EXAMINATION

(Performed at the 4th Hospital Day: NCU prior to Trans-in to Ward)

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

Skin and Nails


Patient’s skin is pallor and smooth with good skin turgor. The client’s skin is warm to
touch. Edema or lesions are not present. Nails and nail beds are whitish pink in color.
Capillary refill is less than 2 seconds.

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

A Case on Hemorrhagic CVA: Hypertension Stage II


noted at the ear canal. On otoscopic examination the tympanic membrane appears flat,
translucent and pearly gray in color. Tympanic membrane is intact. Gross hearing is
symmetrical.

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.

Chest and Lungs


Patient’s expiration is slightly longer than inspiration. Diaphragmatic breating is noted.
All the normal breath sounds are present; vesicular, bronchial and bronchovesicular.
There’s also presence of resonant sound upon percussion. Chest expansion is symmetrical
with no retractions. The anteroposterior diameter of the thorax is less than the transverse
diameter at approximately a ratio of 1:2; elliptical in shape.

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.

Breast and Axillae


Client’s breast is equal. Skin is uniform in color and intact. There is no tenderness.
Masses and nodules are not present. The nipples are round, everted and equal in size.

Abdomen
Client’s abdomen is uniform in color, symmetrical and no venous engorgement noted.
Umbilicus is sunken. Bowel sounds are audible but slightly hypoactive.

A Case on Hemorrhagic CVA: Hypertension Stage II


Genito-urinary System
Not Performed. Normal urine output of 30-50 ml per hour noted and is yellow to amber
in color.

Back and Extremities


Peripheral pulses are regular but slightly weak. Muscle tone normal; ROM limited at the
left upper and lower extremities due to hemiparesis. Motor function test is RUE & RLE
at 5/5 while LUE & RLE at 1/5. Spine is located midline and is vertically aligned.
Costovertebral angle tenderness is not noted.

Deviations

A Case on Hemorrhagic CVA: Hypertension Stage II


3.4 NEUROLOGIC CRITICAL CARE ASSESSMENT

A. Glasgow Coma Scale


Category Score 1st HD 4th HD 10th HD
Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1
Best Motor Response
Obeys 6
Localizes 5
Withdraws 4
Abnormal flexion 3
(decorticate)
Abnormal extension 2
(decerebrate)
None 1
Best Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Total Score 15 7 pts. 13 pts. 15 pts.

B. National Institute of Health (NIH) Stroke Scale


Items Scale Definition 1st HD 4th HD 10th HD
Ia. Level of 0 = Alert, keenly responsive 2 1 0
Consciousness 1 = Not alert, but arousable by
(LOC) minor stimulation to obey,
answer or respond
2 = Not alert, requires repeated
stimulation to attend, or is
obtunded and requires strong or
painful stimulation to make
movements (not stereotyped)
3 = Responds only with reflex
motor or autonomic effects or
totally unresponsive, or totally
unresponsive, flaccid, areflexic
Ib. LOC Questions 0 = Answers both questions 2 1 0
correctly
A Case on Hemorrhagic CVA: Hypertension Stage II
1 = Answers one question
correctly
2 = Answers neither question
correctly
Ic. LOC 0 = Performs both tasks 2 2 1
Commands correctly
1 = Performs one task correctly
2 = Performs neither task
correctly
2. Best gaze 0 = Normal 2 1 1
1= Partial gaze palsy. Gaze is
abnormal in one or both eyes but
forced deviation or total gaze
paresis is not present
2 = Forced deviation, or total
gaze paresis is not overcome by
oculocephalic maneuver
3. Visual 0 = No visual loss 0 0 0
1 = Partial hemianopsia
2 = Complete hemianopsia
3 = Bilateral hemianopsia (blind,
including cortical blindness)
4. Facial palsy 0 = Normal symmetrical 1 1 1
movement
1 = Minor paralysis (flattened
nasolabial fold, asymmetry on
smiling)
5. Motor (Arm) 0 = No drift; limb holds 90 (or A3 A3 A2
5 a. Left arm 45) degrees for full 10 seconds B0 B0 B0
5 b. Right arm 1 = Drifts; limb holds 90 (or 45)
degrees but drifts down before
full 10 seconds; does not hit bed
or other support
2 = Some effort against gravity,
limb cannot get up to or
maintain (if cued) 90 (or 45)
degrees; drifts down to bed, but
has some effort against gravity
3 = No effort against gravity;
limb falls
4 = No movement
9 = Amputation or joint fusion;
explain
6. Motor (Leg) 0 = No drift; leg holds 30-degree A3 A3 A2
6 a. Right leg position for full 5 seconds B0 B0 B0
6 b. Left leg 1 = Drifts; leg falls by the end of

A Case on Hemorrhagic CVA: Hypertension Stage II


the 5-second period but does not
hit bed
2 = Some effort against gravity;
leg falls to bed by 5 seconds but
has some effort against gravity
3 = No effort against gravity; leg
falls to bed immediately
4 = No movement
9 = Amputation or joint fusion;
explain
7. Limb ataxia 0 = absent 1 1 1
1 = Present in one limb
2 = Present in two limbs
9 = Amputation or joint fusion;
explain
8. Sensory 0 = Normal; no sensory loss 1 1 1
1 = Mild to moderate sensory
loss; patient feels pinprick is less
sharp or dull on the affected
side; or there is a loss of
superficial pain with pinprick,
but
patient is aware he/she is being
touched
2 = Severe or total sensory loss;
patient is not aware of being
touched in the face, arm or leg
9. Best Language 0 = No aphasia 1 1 1
1 = Mild to moderate aphasia;
some obvious loss of fluency or
facility of comprehension,
without significant
limitation on ideas expressed or
form of expression. Reduction of
speech and/or comprehension,
however, makes conversation on
provided material difficult
2 = Severe aphasia; all
communication is through
fragmentary expression; great
need for inference, questioning
and guessing by the listener.
Range of information that can be
exchanged is limited; listener
carries the burden of
communication

A Case on Hemorrhagic CVA: Hypertension Stage II


3 = Mute, global aphasia; no
usable speech or auditory
comprehension
10. Dysarthria 0 = Normal 9 1 1
1 = Mild to moderate; patient intubated
slurs at least some words and at per ET
worst, can be understood with A/C
some difficulty Mode,
2 = Severe; patient’s speech is FiO2 at
so slurred as to be unintelligible 60%, RR
in the absence of or out of at 14 per
proportion to any dysphasia, or minute,
is mute/anarthric 9 = intubated PEEP at
or other physical barrier; explain 5, and TV
of 600cc
11. Extinction & 0 = No abnormality 0 0 0
Inattention 1 = Visual, tactile, auditory,
spatial or personal inattention or
extinction to bilateral
simultaneous stimulation in one
of the sensory modalities
2 = Profound hemi-attention or
hemi-inattention to more than
one modality. Does not
recognize own hand or orients to
only one side of space.
Total Score 42 27 pts 14 pts 11 pts

C. Modified Rankin Scale


Score 10th HD
No symptoms at all 0
No significant disability despite symptoms; able to carry 1
out all usual duties and activities
Slight disability; unable to carry out all previous activities 2
but able to look after own affairs without assistance
Moderate disability; requiring some help but able to walk 3
without assistance
Moderately severe disability; unable to walk without 4
assistance and unable to attend to own bodily needs
without assistance
Severe disability; bedridden, incontinent and requiring 5
constant nursing care and attention

D. Barthel ADL Index Scale


A Case on Hemorrhagic CVA: Hypertension Stage II
Activity Score 1st HD 10th HD
FEEDING 0 = unable 0 5
5 = needs help cutting, spreading butter, etc., or
requires modified diet
10 = independent
BATHING 0 = dependent 0 0
5 = independent (or in shower)
GROOMING 0 = needs to help with personal care 0 0
5 = independent face/hair/teeth/shaving
(implements provided)
DRESSING 0 = dependent 0 0
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) 0 5
5 = occasional accident
10 = continent
BLADDER 0 = incontinent, or catheterized and unable to 0 5
manage alone
5 = occasional accident
10 = continent
TOILET 0 = dependent 0 0
USE 5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
TRANSFER 0 = unable, no sitting balance 0 5
S (BED TO 5 = major help (one or two people, physical), can
CHAIR AND sit
BACK) 10 = minor help (verbal or physical)
15 = independent
MOBILITY 0 = immobile or < 50 yards 0 0
(ON LEVEL 5 = wheelchair independent, including corners, >
SURFACES) 50 yards
10 = walks with help of one person (verbal or
physical) > 50 yards
15 = independent (but may use any aid; for
example, stick) > 50 yards
STAIRS 0 = unable 0 0
5 = needs help (verbal, physical, carrying aid)
10 = independent
Total 0-100 0 pts. 20 pts.

3.4: RISK ASSESSMENT


A Case on Hemorrhagic CVA: Hypertension Stage II
A. PHC Fall Risk Assessment Tool (Done on the 1st Hospital Day)

Category & Equivalent Score


Age
4: 0-6 years 1
2: 7-18 years
1: 19-64 years
2: 65-79
3: 80 years and above
Fall History
5: Fall within 3 mos. before admission 0
11: Fall during hospitalization
0: No history of fall
Mobility
4: Visual or auditory impairment affecting mobility 4
2: Ambulates or transfers with unsteady gait and no assistance or
assistive devices
2: Ambulates or transfers with assistance or assistive devices
0: Ambulates without assistance
Elimination
2: Urgency/Nocturia 2
5: Incontinence
0: Normal Pattern
Mental Status Changes
4: Affecting awareness of one’s physical limitation 4
2: Affecting awareness of environment
Medications
5: Two or more present; or sedated procedure within the past 24 hours 5
– Patient has taken anti-convulsants and anti-hypertensives
3: One present
0: No medication
IV and Other Equipment
2: >2 present: IV line, Chest tube, Indwelling catheter, etc. 2
1: 1 present
0: No equipment or gadget attached
Total points 18
Score legend: Risk
0-5 pts = Low risk level:
6-10 pts = Moderate risk HR
>10 pts = High risk

A Case on Hemorrhagic CVA: Hypertension Stage II


B. PHC Pressure Ulcer Risk Assessment Tool (Done on the 1st Hospital Day)

Category Equivalent Score


Level of Knowledge 1: Completely limited
2: Very limited
3: Slightly limited
4: No impairment
Moisture 1: Constantly moist
2: Very moist
3: Occasionally moist
4: Rarely moist
Activity 1: Bed rest
2: Chair bound
3: Walks occasionally
4: Walks frequently
Mobility 1: Completely immobile
2: Vey limited
3: Slightly limited
4: Not limited
Nutrition 1: Very poor
2: Probably inadequate
3: Adequate
4: Excellent
Friction and Shearing 1: Problem
Forces 2: Potential problem
3: No significant problem
Total Score 12
Risk Category HR
Risk Stratification:
15 or 16 = Low risk
13 or 14 = Moderate risk
12 or less = High risk

A Case on Hemorrhagic CVA: Hypertension Stage II


3.5: SIGNIFICANT LABORATORY AND DIAGNOSTIC FINDINGS

A. CT Scan of the Head

September 09, 2009


Clinical data: S/P right craniectomy for the evacuation of the intracerebral
hemmorrhage and subdural hematoma.

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.

Minimal subdural pneumocephalus is seen

Basal cisterns are open

The osseous structures, petromastoids and paranasal sinuses are unremarkable.

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.

September 17, 2009

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.

A Case on Hemorrhagic CVA: Hypertension Stage II


The previously noted thin subdural hemorrhage in the right posterior frontal area and the
subarachnoid hyperdensities in the vertex area of the lateral cerebral hemisphere are no
longer appreciated in this study.

Basal cisterns remain open.

The osseous structures, petromastoids and paranasal sinuses are unremarkable.

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.

B. Arterial Blood Gases

Vent/O2 pH PCO2 PO2 HCO3 CO2 BE O2 Impression


/BD Sat.
1st 60/600/1 7.43 27 263 17 18 -5.3 99.6 Normal ABGs
Hospital 4/5/SIM with more than
Day V adequate
oxygenation
2nd T-piece 7.45 38 160 26 27 2.3 99.8 Normal ABGs
Hospital with more than
Day adequate
oxygenation

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

2nd Hospital Day


Physical Examination
Specific Gravity 1.005 1.015 -1.025
Chemical Examination
Sugar glucose +1 Negative

A Case on Hemorrhagic CVA: Hypertension Stage II


Urine studies reflect a decreased specific gravity, indicative of changes in the kidney’s
ability to concentrate urine. This result may be associated to the patient’s hydration status
which resulted to urine dilution. This prompted keen monitoring of the patient’s intake
and output.

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.

D. Complete Blood Count

1st Hospital Day 2nd Hospital 4th Hospital


Day Day
RBC 5.44 3.67 3.97 4.50 – 5.20
Hgb 178 121 128 140 – 170
Hct 0.51 0.35 0.37 0.42 – 0.51
Platelet count 327 164 228 200 – 400
Differential Count
Neutrophil 91% 87% 59% 55 – 65
Lymphocyte 4% 7% 26 25 – 35

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.

Other Laboratory/Diagnostic tests Performed


- Electrocardiogram (Normal Sinus Rhythm)
- Prothrombin Time (Within acceptable limits)
- Screening Tests (Hepa B, HIV, Malaria, Blood Typing and Crossmatching)

A Case on Hemorrhagic CVA: Hypertension Stage II


SECTION 4: PATHOPHYSIOLOGY OF HEMORRHAGIC STROKE

A Case on Hemorrhagic CVA: Hypertension Stage II


A Case on Hemorrhagic CVA: Hypertension Stage II
SECTION 5: COURSE IN THE WARD

5.1: HIGHLIGHTS OF THE PATIENT’S STATUS

Hospital Day Notes


Day 1 (Pre-op) Upon admission, patient was seen and examined, history was
reviewed, PE and CT Scan were also reviewed. Cranial CT scan
revealed presence of ICH right BG volume of 55 cc with
intraventricular extension. In response to this, a STAT order of
Mannitol 200 cc IV bolus was ordered. Patient also came in with an
elevated blood pressure, that of 270/120 mmHg hence was infused
with Nicardipine drip at 2 mg/hr to be titrated to maintain a MAP of
less than 130. Medications ordered were as follows: Citicholine 2g
STAT then 1g every 8 hours, Amlodipine 5 mg/tab 1 tab STAT then
OD, Mannitol 100cc IV Q4º, Tranexamic Acid 500 mg/IV Q8º for 2
doses, and Omeprazole 40 mg/IV STAT then OD. Orders were made
such as to keep the patient’s bed elevated at 30°, to be on complete
bed rest without bathroom privileges, to be on NPO temporarily and
to maintain on NGT. Furthermore, laboratory work-ups were
performed, namely PTPA, CBC, and ABO typing. Depakote 500
mg/tab 2 tabs per NGT STAT were ordered. Patient was noted to be
febrile with a temperature of 38.1 ºC. To address the fever, a STAT
order of Paracetamol 500 mg/tab 1 tab was ordered followed by a
Q4° PRN for it. Patient was seen by Dr. Gascon, was assessed, and
was found to be positive for lobar hemorrhage, volume of 50cc at
right tempoparietal area. Subsequently, patient’s GCS was 9,
(E2M5V2), pupils were 1-2 mm and equally reactive to light, noticed
to be spontaneously responsive, and positive for intraventricular
extension. The physician then ordered for a STAT Hemicraniectomy,
right, with evacuation of Intracerebral Hemorrhage BG, right, under
general anesthesia. Pre-op meds were as follows: Cefazolin 1g,
Omeprazole 40mg, and Ranitidine 50 mg.
Day 1(Post-op) Patient still on NPO with ongoing IVF PNSS regulated at 80 cc/hr.
He’s also hooked to a mechanical ventilator. Settings for the latter
were: A/C Mode, FiO2 at 60%, RR at 14 per minute, PEEP at 5, and
TV of 600cc. Patient’s ABG’s were obtained 30 minutes after. Still
infusing with Nicardipine drip which has to be titrated to maintain
BP of 130’s systolic. Head of bed was kept elevated at 30º, and
patient was turned side to side every 2 hours. Latest GCS was 10-11
(E3-4,V1M6). Noted to have isocoric pupils at 1 mm and reactive to
light, and positive for left hemiplegia. BP via arterial line was 160-
170/90-100 and 120/90 when a sphygmomanometer was used.
Hence, titration of Nicardipine was reinforced to maintain SBP
between 140-160 mmHg.

A Case on Hemorrhagic CVA: Hypertension Stage II


ABG results were within normal limits thus mechanical ventilator
settings were revised. The revisions were as follows: SIMV mode,
FiO2 at 30%, TV of 500cc, BUR of 14/min, and PEEP at 5.
Day 2 Serial neuro evaluation revealed the following results regarding the
patient’s staus: (+) spontaneous eye opening, obeys command,
isocoric pupils at 1-2 mm and reactive to light, still with left
hemiplegia (grade of 0/5 for left upper and lower extremities), (+)
spontaneous respirations, and BP maintained at 140-150/80-100.
Weaning of mechanical ventilator initiated with the provision of T-
piece regulated at 3 to 4 lpm. With orders to hook patient back to
mechanical ventilator once oxygen saturation drops below 90%.
CBC done and bladder training started. Suggestion pertaining to
provision of OF feeding and to discontinue CBG monitoring once
feeding is started were made. ABG STAT performed and results
were relayed at once because it will serve as the basis for a possible
extubation.

Latest GCS was 11 (E4M6V1) and patient was able to tolerate T-


piece the whole day. BP was at 180/100 which was obtained
manually. Subgaleal drain was emptied, with an output of 150 cc.
With orders to extubate patient, to shift to nasal cannula at 1-2 lpm,
to remove foley catheter, and to proceed to Prog 1 diet (sips of clear
liquids).
Day 3 Patient was extubated. Latest GCS was 14 (E4M6V4), pupils were at
2-3 mm, equal and both reactive to light, and BP was 180/100.
Consequently, Nicardipine drip was increased to 2.5 mg/hr. Cranial
CT Scan performed and patient was placed on condom catheter.
Moreover, Prog 2 diet was ordered.

CT scans results revealed no new presence of hemorrhage, a near


total resolution of intracerebral hemorrhage, right, (-) for
hydrocephalus, and (+) left hemiplegia.. New orders pertaining to the
need of oral anti-hypertensives to overlap Nicardipine drip were
made. Subsequently, patient is for trial of gelatin feeding tomorrow
and if tolerated, for removal of NGT as well. Subgaleal drain was
scheduled to be also removed therefore sterile blade and dressing set
was advised to be prepared. To address the hemiplegia, a suggestion
for patient to be referred to Rehab Medicine was ordered.

Before midnight arrived, changes in the patient’s medication regimen


were made. From OD, Norvasc was increased to BID, however the
dosage remains unchanged. Another anti-hypertensive was included
in the patient’s treatment plan, which was Aprovel 150 mg/tab 1 tab
to be given at lunchtime. A STAT of Norvasc 10 mg/tab 1 tab was
given to the patient and then Nicardipine drip was tapered to

A Case on Hemorrhagic CVA: Hypertension Stage II


consume.
Day 4 Patient complained of severe headache around 1 am thus a STAT
order of Tramadol 50mg/IV and Arcoxia 120 mg/tab OD was made.
The physician advised for patient to be trans-out by weekend, for
NGT to be removed and for patient to start on mechanically soft low
fat low salt diet. A STAT order of Nalbuphine/IV ½ ampule was
made around 10 am because patient still complained of persistence of
headache. Physician wanted patient to undergo stroke rehab once
trans-out orders are initiated.

Repeat CT Scan revealed a marked diminution in intraparenchymal


hemorrhage and a very minimal midline shift. Latest GCS was 15
(E4M6V5), however, is positive for low grade fever (temp of 37.8º
C) and postitive for headaches. Subgaleal drain was removed and
change of dressing performed. Patient put on high back rest during
waking hours and Cefazolin/IV discontinued as ordered.
Ciprofloxacin 500 mg/tab, 1 tab TID was started and patient is for
CBC and UA tomorrow morning. Diet was shifted to soft diet as
tolerated however must still be on low salt and low fat content.
Lastly, an order to give patient a round the clock Dolcet 1 capsule
every 6 hours was added..
Day 5 Patient presented with a GCS 15(E4M6V5), afebrile, and with
significant CBC results. Hgb was at 128, Hct at 0.37, and WBC at
8.00. Still with ongoing IVF at 80 cc/hr. With orders to decrease
Mannitol 20% to 100 cc IV fast drip Q6º the next day in the morning.
Serum sodium and potassium is to be performed tomorrow as well as
change of dressing.
Day 6 Serum sodium result turned out to be normal expect for potassium
which was at 3.4 mmol/L. As a result, patient was ordered to receive
Kalium durule TID for 6 doses only. Also, patient is for stroke rehab
program and still for rehab medicine.
Day 7 Patient was seen by rehab medicine and ordered for a bedside stroke
rehabilitation program to promote functional motor recovery.

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

A Case on Hemorrhagic CVA: Hypertension Stage II


then discontinue. Physician suggested addition of anti-hypertensive
medications.
Day 9 Patient presented with an altered sleep-wake cycle and still with a
grade of 0/5 for his left upper and lower extremities. Foot board
provided as ordered. Alprazolam (Xanor) 250 mg/tab, 1 tab at 9 pm
given as ordered also.
Day 10 Patient’s GCS was 15 (E4M6V5). PT facilitated. Alprazolam shifted
to Hydroxyzine (Iterax) 25 mg/tab, 1 tab 0-0-1 at 9 pm.
Day 11 Patient manifested a decrease in verbal output since yesterday.
Present BP ranged from 150-180 / 90-100. Repeat Cranial CT Scan
performed on patient to evaluate changes in the status. An increase in
the dose and frequency of Mannitol was ordered, from 100 cc every
8 hours, it was changed to 150 cc every 4 hours TIV. Inclusion of
Iterax in the patient’s medication regimen was temporarily put on
hold.

Result of CT Scan revealed internal improvement in cerebral edema


and midline shift. There were also no new hemorrhages and no
hydrocephalus observed. Change of dressing performed on patient.
The wound manifested improvements. Good wound co-adaptation
and negative for bleeding and discharge were the desirable outcomes
that were noticed. Afterwards, pressure dressing was applied. Patient
was also hooked to a supplementary oxygen particularly oxygen
inhalation per nasal cannula at 2 lpm.
Day 12 Patient had not passed stool for the last three days. Senokot 2 tabs
were ordered to be taken for today only. Physical therapy done at
bedside. Administration of Mannitol was decreased to 100 cc TIV
every 6 hours. Orders to discontinue Arcoxia, Dolcet, Toradol TIV,
oxygen inhalation, and IV line, although the order for the latter
would only take effect once Mannitol is consumed.
Day 13 Rehabilitation performed. Patient was able to sit with legs dangling
on bedside and able to turn to sides while on bed independently.

Patient complained of headache. Dolcet was given - as ordered,


accordingly and pain was relieved. For possible discharge on
Wednesday (September 23, 2009) from Neuro Surgery standpoint.
Day 14 Patient still has not passed out stool for the past 5 days. STAT
Dulcolax adult suppository, 2 suppositories were administered per
rectum. Furthermore, increase in fluid intake was reinforced.
Day 15 Other than Dulcolax, no other changes in medications were made.
Bowel movement of patient as verbalized was 5 times. Recurrence in
headache was again complained, therefore STAT Dolcet was
ordered. Pain was relieved.
Day 16 Latest GCS was 15 and with stable vital signs. May go home anytime
from Neuro Surgery Standpoint and already with orders of take home
medications. The medications patient has to take were the following:

A Case on Hemorrhagic CVA: Hypertension Stage II


Depakote 500 mg/tab 1 tab BID, Citicoline 500 mg/cap, and Dolcet 1
cap every 6 hours as needed for pain or headache. With specified
instructions to have patient come back on after 5 days for the
removal of his sutures, to observe seizure precautions, and to be alert
for manifestations of untoward signs and symptoms which would
necessitate patient to report immediately to the hospital
Day 17 Neurology made no objection to discharge. Latest GCS of patient
was at 15, vital signs were within normal limits, and still with left
hemiplegia. Discharge instructions, specifically those ordered by the
Neuro Surgery department, were given to patient. To verify
understanding of health teachings and instructions, patient’s family
was asked to reiterate what has been explained and to express their
understanding of each instruction. Reinforced the importance of
adherence to medication, of identifying untoward signs and
symptoms, and compliance to rehabilitation. Account settled. Patient
cleared and discharged.

A Case on Hemorrhagic CVA: Hypertension Stage II


5.2: GENERAL MANAGEMENT FOR HEMORRHAGIC STROKE

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

Slurred but intelligible


speech

Vertigo with
incoordination (e.g.,
gait disturbance,
unsteadiness or clumsy
hand)

Visual field defects alone


Combination of (a) and (b)

1. GUIDELINES FOR MILD HEMORRHAGIC STROKE

Management Ascertain clinical diagnosis of stroke or TIA (history and physical


Priorities exam are very important)
- Exclude common stroke mimickers (Supplement I)
Provide basic emergent supportive care (ABCs of resuscitation)
Monitor neuro-vital signs, BP, MAP, RR, temperature, pupils
Perform stroke scales (NIHSS, GCS) (Supplement II)
Monitor and manage BP; treat if SBP>220 or DBP>120 or
MAP>130 (Supplement III).
Precautions:
- Avoid precipitous drop in BP (BP not >20% of baseline
MAP) (Appendix III). Do not use rapid-acting sublingual
agents; when needed, use easily titratable IV or oral
antihypertensive medication

A Case on Hemorrhagic CVA: Hypertension Stage II


- Ensure appropriate hydration. If IVF is needed, use 0.9%
NaCl
Emergent - Complete blood count (CBC)
Diagnostics - Blood sugar (CBG, HGT or RBS)
- Electrocardiogram (ECG)
- PT/PTT
- Plain CT scan of the brain as soon as possible; computation
of hematoma volume (Supplement IV)
Early Specific - Early neurology and/or neurosurgeon consult for all ICH is
Treatment recommended
CT Scan - Monitor and maintain BP: MAP 110-130 mmHg (lower limit
Confirmed preferred) (Supplement III)
- Neuroprotection (Supplement V)
- Early rehabilitation once stable within 72 hours
- Give anticonvulsants only if with seizures
- Steroids are not recommended
- Monitor and correct metabolic parameters
- Correct coagulation/bleeding abnormalities
- Follow recommendations for neurosurgical intervention
CT Scan Not - No specific emergent drug treatment recommended
Available - Neuroprotection (Supplement V)
- Consult a neurologist or neurosurgeon
- Early supportive rehabilitation
Place of Admit to Hospital (Stroke Unit) Urgent Outpatient Work-up
Treatment 1. Stroke onset within 48 hours 1. Single TIA more than 2 weeks
2. Patients requiring any specific 2. Transient monocular blindness
active intervention, such as: alone
BP control, monitoring and 3. Stable mild strokes >48 hours
stabilization from ictus not requiring specific
3. Rapidly worsening deficits active intervention
4. Recurrent TIA within the past
2 weeks, especially those with Advise immediate re-consult or
increasing severity and duration admission if there is worsening
of deficits, cardiac arrhythmia, or of deficit
carotid bruit
Delayed - Long-term strict BP control and monitoring
Management - Consider angiogram if age <45 years, normotensive, no clear
cause of ICH, and/or is a candidate for surgery

2. GUIDELINES FOR MODERATE HEMORRHAGIC STROKE

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)

A Case on Hemorrhagic CVA: Hypertension Stage II


Neuro-vital signs, BP, MAP, RR, temperature, pupils
Perform stroke scales (NIHSS, GCS) (Supplement II)
Monitor and manage BP; treat if SBP>220 or DBP>120 or
MAP>130 (Supplement III).
Precaution: Avoid precipitous drop in BP (not >20% of baseline
MAP) (Supplement III). Do not use rapid-acting sublingual agents;
when needed use easily titratable IV or oral antihypertensive
medication.
Identify comorbidities (cardiac disease, diabetes, liver disease,
gastric ulcer, etc.)
Recognize and treat early signs and symptoms of increased ICP
(Supplement VIII)
- Ensure appropriate hydration. If IVF is needed, use 0.9%
NaCl
Emergent - Complete blood count (CBC)
Diagnostics - Blood sugar (CBG, HGT or RBS)
- Electrocardiogram (ECG)
- PT/PTT
- Serum Na+ and K+
- Plain CT scan of the brain as soon as possible; computation
of hematoma volume (Supplement IV)
Early Specific - Early neurology and/ or neurosurgical consult for all ICH is
Treatment recommended
CT Scan - Monitor and maintain BP: MAP 110-130 mmHg (lower limit
Confirmed preferred)
- Neuroprotection (Supplement V)
- Give anticonvulsants only if with seizures
- Steroids are not recommended
- Monitor and correct metabolic parameters
- Correct coagulation/bleeding abnormalities
- Follow recommendations for neurosurgical intervention
- Early rehabilitation once stable
CT Scan Not - Refer to neurologist/neurosurgeon for further diagnostic
Available work-ups and/or subsequent surgery
- Neuroprotection (Supplement V)
- Early supportive rehabilitation
Place of Hospital – Intensive Care Unit or Stroke Unit
Treatment
Delayed - Long-term strict BP control and monitoring
Management - Consider CT angiography, MRA, or 4-vessel angiography in
suspected cases of aneurysm, AV malformation or vasculitis

3. GUIDELINES FOR SEVERE STROKE

Management Ascertain clinical diagnosis of stroke (history and physical exam are

A Case on Hemorrhagic CVA: Hypertension Stage II


Priorities very important)
- Exclude common stroke mimickers (Supplement I)
Basic emergent supportive care (ABCs of resuscitation)
Neuro-vital signs, BP, MAP, RR, temperature, pupils
- Perform stroke scales (NIHSS, GCS) (Supplement II)
- Monitor and manage BP; treat if SBP>220 or DBP>120 or
MAP>130 (Supplement III).
- Precaution: Avoid precipitous drop in BP (not >20% of
baseline MAP) (Supplement III). Do not use rapid-acting
sublingual agents; when needed use easily titratable IV or
oral antihypertensive medication.
Identify comorbidities (cardiac disease, diabetes, liver disease,
gastric ulcer, etc.)
Recognize and treat early signs and symptoms of increased ICP
(Supplement VIII)
- Ensure appropriate hydration. If IVF is needed, use 0.9%
NaCl
Emergent - Complete blood count (CBC)
Diagnostics - Blood sugar (CBG, HGT or RBS)
- Electrocardiogram (ECG)
- PT/PTT
- Serum Na+ and K+
- Plain CT scan of the brain as soon as possible; computation
of hematoma volume (Supplement IV)
Early Specific Supportive treatment:
Treatment - Mannitol 20% 0.5 - 1 g/kgBW q 4-6 hours for 3-7 days
CT Scan - Neuroprotection (Supplement V)
Confirmed - Neurosurgery consult if:
o Patient not herniated; bleed located in putamen,
pallidum, cerebellum; family is willing to accept
consequences of irreversible coma or persistent
vegetative state and goal is reduction of mortality
- ICP monitoring is contemplated and salvage surgery is
considered
- Early supportive rehabilitation
CT Scan Not - No specific emergent drug treatment recommended
Available - Neuroprotection (Supplement V)
- Refer to neurologist
Place of Hospital – Intensive Care Unit or Stroke Unit
Treatment
Delayed - Long-term strict BP control and monitoring
Management - Consider CT angiography, MRA, or 4-vessel angiography in
and Treatment suspected cases of aneurysm, AV malformation or vasculitis
(Secondary
Prevention)

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Supplement I: Differential Diagnoses of Stroke

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)

B. Conditions that mimic stroke in the emergency department (according to decreasing


frequency):
1. Seizures
2. Systemic infection
3. Brain tumor
4. Toxic-metabolic
5. Positional vertigo
6. Cardiac
7. Syncope
8. Trauma
9. Subdural hematoma
10. Herpes encephalitis
11. Transient global amnesia
12. Dementia
13. Demyelinating disease
14. Cervical spine fracture
15. Myasthenia gravis
16. Parkinsonism
17. Hypertensive encephalopathy
18. Conversion disorder

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Supplement II: Stroke Scales

E. Glasgow Coma Scale

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

F. National Institute of Health (NIH) Stroke Scale

Items Scale Definition


Ia. Level of Consciousness (LOC) 0 = Alert, keenly responsive
1 = Not alert, but arousable by minor
stimulation to obey, answer or respond
2 = Not alert, requires repeated stimulation
to attend, or is obtunded and requires strong
or painful stimulation to make movements
(not stereotyped)
3 = Responds only with reflex motor or
autonomic effects or totally unresponsive,
or totally unresponsive, flaccid, areflexic
Ib. LOC Questions 0 = Answers both questions correctly
1 = Answers one question correctly
2 = Answers neither question correctly
Ic. LOC Commands 0 = Performs both tasks correctly
1 = Performs one task correctly
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2 = Performs neither task correctly
2. Best gaze 0 = Normal
1= Partial gaze palsy. Gaze is abnormal in
one or both eyes but forced deviation or
total gaze paresis is not present
2 = Forced deviation, or total gaze paresis
is not overcome by oculocephalic maneuver
3. Visual 0 = No visual loss
1 = Partial hemianopsia
2 = Complete hemianopsia
3 = Bilateral hemianopsia (blind, including
cortical blindness)
4. Facial palsy 0 = Normal symmetrical movement
1 = Minor paralysis (flattened nasolabial
fold, asymmetry on smiling)
5. Motor (Arm) 0 = No drift; limb holds 90 (or 45) degrees
5 a. Left arm for full 10 seconds
5 b. Right arm 1 = Drifts; limb holds 90 (or 45) degrees
but drifts down before full 10 seconds;
does not hit bed or other support
2 = Some effort against gravity, limb
cannot get up to or maintain (if cued) 90 (or
45) degrees; drifts down to bed, but has
some effort against gravity
3 = No effort against gravity; limb falls
4 = No movement
9 = Amputation or joint fusion; explain
6. Motor (Leg) 0 = No drift; leg holds 30-degree position
6 a. Right leg for full 5 seconds
6 b. Left leg 1 = Drifts; leg falls by the end of the 5-
second period but does not hit bed
2 = Some effort against gravity; leg falls to
bed by 5 seconds but has some effort
against gravity
3 = No effort against gravity; leg falls to
bed immediately
4 = No movement
9 = Amputation or joint fusion; explain
7. Limb ataxia 0 = absent
1 = Present in one limb
2 = Present in two limbs
9 = Amputation or joint fusion; explain
8. Sensory 0 = Normal; no sensory loss
1 = Mild to moderate sensory loss; patient
feels pinprick is less sharp or dull on the
affected side; or there is a loss of
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superficial pain with pinprick, but
patient is aware he/she is being touched
2 = Severe or total sensory loss; patient is
not aware of being touched in the face, arm
or leg
9. Best Language 0 = No aphasia
1 = Mild to moderate aphasia; some
obvious loss of fluency or facility of
comprehension, without significant
limitation on ideas expressed or form of
expression. Reduction of speech and/or
comprehension, however, makes
conversation on provided material difficult
2 = Severe aphasia; all communication is
through fragmentary expression; great need
for inference, questioning and guessing by
the listener. Range of information that can
be exchanged is limited; listener carries the
burden of communication
3 = Mute, global aphasia; no usable speech
or auditory comprehension
10. Dysarthria 0 = Normal
1 = Mild to moderate; patient slurs at least
some words and at worst, can be
understood with some difficulty
2 = Severe; patient’s speech is so slurred as
to be unintelligible in the absence of or out
of proportion to any dysphasia, or is
mute/anarthric 9 = intubated or other
physical barrier; explain
11. Extinction & Inattention 0 = No abnormality
1 = Visual, tactile, auditory, spatial or
personal inattention or extinction to
bilateral simultaneous stimulation in one of
the sensory modalities
2 = Profound hemi-attention or hemi-
inattention to more than one modality.
Does not recognize own hand or orients to
only one side of space.
Total Score 42

G. Modified Rankin Scale

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Score
No symptoms at all 0
No significant disability despite symptoms; able to carry 1
out all usual duties and activities
Slight disability; unable to carry out all previous activities 2
but able to look after own affairs without assistance
Moderate disability; requiring some help but able to walk 3
without assistance
Moderately severe disability; unable to walk without 4
assistance and unable to attend to own bodily needs
without assistance
Severe disability; bedridden, incontinent and requiring 5
constant nursing care and attention

Supplement III: Blood Pressure Management

A. BP management in Acute Ischemic Stroke

1. Use the following definitions:


Cerebral Perfusion Pressure (CPP) = MAP – ICP
MAP = 2 (diastolic) + systolic / 3
2. Check if patient is in any condition that may increase BP such as pain, stress, bladder
distention or constipation, which should be addressed accordingly.

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.

5. Use the following locally available intravenous anti-hypertensives in acute stroke:


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Drug Dose Onset of Duration Availability Stability Adverse Action
Nicardipine Action of Action /Dilution Reactions
1-15 5-10 1-4 (10 mg/ 10 1 to 4 Tachycardia, Inhibits calcium
mg/hour mins hours ml amp ); hours headache, ion from entering
10 mg in flushing, slow channel,
90 ml dizziness, producing coronary,
NSS/D5W somnolence, vascular, smooth
nausea muscle relaxation &
vasodilatation
Hydralazine

IV push 10- 10-20 3-8 25 mg/mL 4 days Tachycardia, Direct vasodilatation


20 mg/dose mins hours amp; 25 flushing, of arterioles &
q 4-6 hours mg/tab headache, decreased systemic
as needed, vomiting, resistance
may increased
increase to angina
40 mg/dose
Labetalol

5 mg IV 2-5 2-4 5 mg/ml in 72 Orthostatic Alpha- &


push over 2 mins hours 40 ml vial; hours hypotension, betablocker.
mins, repeat 250 mg in drowsiness, Beta-adrenergic
with 250 mL dizziness, blocking activity is
incremental NSS/D5W lightheadedness, 7x > than alpha-
dose of 10, dyspnea, adrenergic blockers.
20, 40, 80 wheezing & Produces dose
mg until bronchospasm dependent ↓ in
desired BP BP without
is achieved significant ↓ in
or a total dose HR or cardiac
of 300 mg has output
been
administered
Esmolol

0.25-0.5 mg/ 2-10 10-30 100 mg/ 48 Hypotension, Short-acting


kg IV push mins mins 10 ml vial; hours bradycardia, beta-adrenergic
1-2 mins 2,500 mg AV block, blocking agent.
followed by in 250 mL agitation, At low doses, has
infusion of D5W/NSS confusion, little effect on beta2
0.05 wheezing / receptors of
mg/kg/min. bronchoconstric bronchial &
If there is no tion, phlebitis vascular smooth
response, muscle
repeat 0.5
mg/kg bolus
dose & ↑
infusion to
0.10
mg/kg/min.
Maximum
infusion
rate=0.30
mg/kg/min

B. Blood pressure management in Acute Hypertensive ICH


Maintain MAP<130, but not lower than 110 mmHg
- Sustained hypertension may alter cerebral autoregulation, promote
progression of bleed and increase edema
- Hypotension may result in cerebral hypoperfusion especially in the setting
of increased intracranial pressure (ICP)
- Absence of penumbra allows for more aggressive BP management

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Supplement IV: Neuroimaging (CT and MRI)
- CT can accurately document the exact location of the hemorrhage and the
presence of mass effect, ventricular extension and hydrocephalus.
- In hypertensive ICH, a repeat plain CT scan after 24 hours of ictus is
recommended especially in cases showing clinical deterioration to document
hematoma enlargement and/or development of hydrocephalus.

Computation of Hematoma Volume (Kothari method)


Hematoma volume (in cc) = A x B x C
2
where: A= Largest diameter of hematoma (in cm)
B= Diameter perpendicular to A (in cm)
C= Number of slices on CT scan with hemorrhage x slice thickness (in cm)

- Count slice as 1 if size of hematoma is >75% of largest diameter


- Count slice as 0.5 if size of hematoma is 25-75% of largest diameter
- Disregard slice if size of hematoma is <25% of largest diameter
- In suspected cases of AV malformation, aneurysm or tumor bleed, a contrast CT
of the head may be warranted

Supplement V: Neuroprotection and Neuroprotectants

Neuroprotective Interventions: The 5 “H” Principle


Avoid hypotension, hypoxemia, hyperglycemia or hypoglycemia and hyperthermia
(fever) during acute stroke in an effort to "salvage" the ischemic penumbra
1) Avoid Hypotension
a) Aggressive BP lowering is detrimental in acute stroke.
b) Manage hypertension as per recommendation (Supplement III)
2) Avoid Hypoxemia
a) Routine oxygenation in all stroke patients is not warranted
b) Maintain adequate tissue oxygenation (target O2 saturation >95%)
c) Do arterial blood gases (ABG) determination or monitor oxygenation via pulse
oximeter
d) Give supplemental oxygen if there is evidence of hypoxemia or desaturation
e) Provide ventilatory support if upper airway is threatened or sensorium is impaired
or ICP increased.
3) Avoid hypoglycemia or hyperglycemia
a) Hyperglycemia can increase the severity of ischemic injury (causes lactic
acidosis, increases production of free radicals, worsens cerebral edema and
weakens blood vessels), whereas hypoglycemia can mimic a stroke
b) Prompt determination of blood glucose should be done in all stroke patients
c) Ensure tight glycemic control at 80-110 mg/dL
d) Avoid glucose-containing (D5) IV fluids. Use isotonic saline (0.9% NaCl)

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4) Avoid Hyperthermia
a) Fever in acute stroke is associated with poor outcome possibly related to
increased metabolic demand, increased free radical production and enhanced
neurotransmitter release.
b) For every 1°C increase in body temperature, the relative risk of death or disability
increases by 2.2.
c) Search for the source of fever.
d) Treat fever with antipyretics and cooling blankets.
e) Maintain normothermia.

Neuroprotectants are drugs that:


- Protect against excitotoxins and prolong neuronal survival
- Block the release of glutamate, free radicals, inflammatory cytokines, and the
accumulation of intracellular calcium cations.

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.

CDP–choline helps increase phosphatidylcholine synthesis and inhibition of


phospholipase A2 within the injured brain during ischemia. A number of phase III
clinical trials (e.g. SAINT II, FAST-MAG) are currently underway.

Supplement VI: Early Specific Treatment of Hypertensive Intracerebral


Hemorrhage

A. Medical Treatment for all ICH:


The goals are to prevent complications and careful manage BP.
a) Maintain MAP <130, but not lower than 110 mmHg
b) Manage increased ICP accordingly (see Appendix IX)
c) Start anticonvulsants only if with seizures
i. The incidence of seizures is higher in ICH, especially in lobar hematomas.
ii. The role of prophylactic anticonvulsants in deep hemorrhages is unclear. It
is justified to withhold anticonvulsants until clinically indicated.
d) Prevent and treat respiratory complications. Endotracheal intubation is performed
in patients to provide airway protection and in those in coma or with respiratory
failure.
e) Prevent and treat infections.
f) Maintain adequate nutrition.
g) Ensure proper fluid and electrolyte balance; maintain normothermia and
normoglycemia.
h) Rehabilitate early once stable.

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i) Practice bedsore precautions.
j) Deep-vein thrombosis and pulmonary embolism prophylaxis should be instituted
(use antiembolic stockings or intermittent pneumatic compression devices)

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

Supplement VII: Management of Increased Intracranial Pressure

A. Signs and symptoms of increased ICP


1. Deteriorating level of sensorium
2. Cushing’s triad
a. Hypertension
b. Bradycardia
c. Irregular respiration
3. Anisocoria

B. Management options for increased ICP

General
1. Control agitation and pain with short-acting medications, such as NSAIDS

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and opioids.
2. Control fever. Avoid hyperthermia.
3. Control seizures if present. May treat with phenytoin with a loading dose of
18-20 mg/kg IV then maintained at 3-5 mg/kg. Status epilepticus should be
managed accordingly.
4. Strict glucose control between 80-110 mg/dL
5. No dextrose-containing IVF. Hyperglycemia may extend ischemic zone
(penumbra) and further cause cerebral edema
6. Use stool softeners to prevent straining.

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

C. Sedatives and Narcotics Available Locally

Drug Usual Onset of Duration Availability Comments


Dose Action of Action /Dilution
Midazolam 0.025-0.35 1 to 5 min 2 hours 15 mg/3 mL amp; Unpredictable sedation
mg/kg 5 mg/5 mL amp;
50 mg in 100 mL
NSS/D5W
Diazepam 0.1-0.2 Immediate 20 to 30 (0.2-1 mg at 0.2 Sedation can be
mg/kg minutes mg/min at 20 min reversed with
interval, max flumazenil
dose 3 mg in one
hour) 10 mg/2 mL
amp; 50 mg in 250
mL NSS/D5W
Propofol 5-50 <40 secs 10 to 15 (10 mg/mL) 100 Expensive
ug/kg/min min mL
vial (premixed)

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Ketorolac 50-100 mg 1 hour 6 to 8 30 mg/mL amp NSAID
IV hours
Tramadol 50-100 mg 1 hour 9 hours 50 mg/ 2 mL amp; Centrally acting
IV 100 mg/2 mL amp synthetic
analgesic compound
not
chemically related to
opiates
but thought to bind to
opioid
receptors and inhibit
reuptake
of NE and serotonin
Fentanyl 50-100 1-2 mins >60 min 100 ug/2 mL; Can be easily reversed
ug/hour 2,500 ug in 250 with naloxone (0.4-2
mL NSS/D5W mg IVP; repeat at 2-3
min intervals, max
dose 10 mg) * 110x
more potent than
morphine

Morphine 2-5 5 mins >60 min 10 mg/mL gr 1/6; Opioid


mg/hour 16 mg/ mL gr 1/4

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5.3: PRE-OPERATIVE & ONGOING DIAGNOSTIC WORK-UPS

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

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• enlarged brain cavities (ventricles) in patients with hydrocephalus
• diseases or malformations of the skull

CT scanning is also performed to:


• evaluate the extent of bone and soft tissue damage in patients with facial trauma,
and planning surgical reconstruction.
• diagnose diseases of the temporal bone on the side of the skull, which may be
causing hearing problems.
• determine whether inflammation or other changes are present in the paranasal
sinuses.
• plan radiation therapy for cancer of the brain or other tissues.
• guide the passage of a needle used to obtain a tissue sample (biopsy) from the
brain.
• assess aneurysms or arteriovenous malformations through a technique called CT
angiography.

Nursing Care Prior to the Procedure:


• Wear comfortable, loose-fitting clothing prior to exam. The patient may be given
a gown to wear during the procedure.
• Metal objects including jewelry, eyeglasses, dentures and hairpins may affect the
CT images and should be left at home or removed prior to the exam. Hearing aids
and dentures will be asked to be removed.
• The patient may be asked not to eat or drink anything for several hours
beforehand, especially if a contrast material will be used in your exam.
• The physician must be informed of any medications the patient is currently taking
and the nurse must ask for the presence of any allergies. If there is known allergy
to contrast material, or "dye," the doctor may prescribe medications to reduce the
risk of an allergic reaction.
• Any recent illnesses or other medical conditions such as history of heart disease,
asthma, diabetes, kidney disease or thyroid problems must be relayed to the
physician. Any of these conditions may increase the risk of an unusual adverse
effect.
• The radiologist also must be informed if the patient hase asthma, multiple
myeloma or any disorder of the heart, kidneys or thyroid gland, or diabetes.
• Women should always inform their physician and the CT technologist if there is
any possibility that they are pregnant.

Nursing Care During and After the Procedure:


• The technologist or nurse, under the direction of a physician, may give a mild
sedative to help you tolerate the CT scanning procedure in cases of claustrophobia
or patients with chronic pain.
• If an intravenous contrast material is used, you will feel a slight pin prick when
the needle is inserted into your vein. You may have a warm, flushed sensation
during the injection of the contrast materials and a metallic taste in your mouth
that lasts for a few minutes. Some patients may experience a sensation like they
have to urinate but this subsides quickly.
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• You will be alone in the exam room during the CT scan. However, the
technologist will be able to see, hear and speak with you at all times.
• With pediatric patients, a parent may be allowed in the room but will be required
to wear a lead apron to prevent radiation exposure.
• After a CT exam, you can return to your normal activities. If you received
contrast material, you may be given special instructions.

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.

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2. Arterial Blood Gases

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

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b. Make the hand blanch, then release pressure over only the ulnar artery. In
a positive test, note flushing immediately; the radial artery may be used
for puncture.
c. If collateral circulation from ulnar artery is inadequate (negative test),
choose another site.
3. Elevate the patient’s wrist with a small pillow and ask the patient to extend the
fingers downward (this flexes the wrist and positions the radial artery closer to the
surface).
4. Palpate the artery and maneuver the patient’s hand back and forth until a
satisfactory pulse is felt.
5. Swab the area liberally with an antiseptic agent.
6. Optional: After assessing for allergy, inject the area with a small amount (<0.25
ml) of 1% plain lidocaine (Xylocaine) if necessary to anesthetize site. This allows
for a second attempt without undue pain.
7. Prepare a 20- or 21- gauge needle on a pre-heparinized self-filling syringe,
puncture the artery and collect a 3- to 5-ml sample. During the procedure, if the
patient feels a dull, sharp pain radiating up the arm, withdraw the needle slightly
and reposition it. If repositioning does not alleviate the pain, the needle should be
withdrawn completely.
8. Withdraw the needle and place a 4x4 inch absorbent bandage over the puncture
site. Maintain pressure over the site with two fingers for a minimum of 2 minutes
or until no bleeding is evident; it may be necessary to use a pressure dressing,
secured to the site with elastic tape, for several hours.
9. Meanwhile, ensure that all air bubbles in the blood sample are expelled as quickly
as possible. Air in the sample changes ABG values. Cap the syringe and gently
rotate to mix heparin with the blood.
10. Label the sample with patient’s name, identification number, date, time, mode of
O2 therapy and flow rate.
11. Place the sample on ice and transfer it to the laboratory. This prevents alterations
in gas tensions resulting from metabolic processes that continue after blood is
drawn.

Pretest Patient Care


1. Explain the purpose and procedure for obtaining arterial blood sample
2. If the patient is apprehensive, explain that a local anesthetic can be used.
3. Follow safe, effective, informed care.

Post test Patient Aftercare


1. Evaluate color, motion, sensation, degree of warmth, capillary refill time, and
quality of pulse in the affected extremity or at the puncture site.
2. Monitor puncture site and dressing for arterial bleeding for several hours. No
vigorous activity of the extremity should be undertaken for 24 hours.
3. Follow safe, effective, informed post test care.

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4. The nurse or physician may test the collateral circulation (Allen’s test) to the
hand before taking a sample of blood from the wrist area.
5. Patient can choose to have numbing medicine (anesthesia) applied to the site
before the test begins.
6. After the blood is taken, pressure is applied to the site for a few minutes to stop
the bleeding.
7. The health care provider will watch the site for signs of bleeding or circulation
problems.
8. The sample must be quickly sent to a laboratory for analysis to ensure accurate
results.

3. Electrolyte studies (Sodium and Potassium)

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

A Case on Hemorrhagic CVA: Hypertension Stage II


increases the chance of irregular heartbeats (arrhythmias), which, when extreme, can be
fatal.

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.

Pretest Patient Care


1. Explain test purpose and blood drawing procedure. Do not have patient
open and close fist while drawing blood.
2. Follow safe, effective and informed pretest care.

Post test Patient Aftercare


1. Interpret test results monitoring changes in body sodium and potassium as
appropriate.
2. Be aware that recognizing signs and symptoms of hypo/hyper
kalemia/natremia is very important.
3. Remember that potassium blood level rises 0.6 meq/L (0.6 mmol/L) for
every 0.1 decrease in blood pH.
4. Monitor for signs of edema or hypertension, and record and report these if
present.
5. Remember that IV therapy considerations are as follows:
a) Sodium balance is maintained in adults with an average dietary intake
of 90 to 250 meq/day. The maximum daily tolerance to an acute load is
400 meq/day. A patient who is given 3L of isotonic saline in 24 hours
will receive 465 meq of sodium. This amount exceeds the average,
healthy adult’s tolerance level. It will take 24 to 48 hours to excrete the
sodium.
b) After surgery, trauma or shock, there is a decrease in extracellular fluid
volume. Replacement of extracellular fluid is essential if water and
electrolyte balance is to be maintained. The ideal replacement IV
solution should have a sodium concentration of 140 meq/L.

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4. Routine Urinalysis

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.

Procedure (Single Random Urine Specimen)


1. Instruct the patient void directly into a clean, dry container or bedpan.
Transfer the specimen directly into an appropriate container. Disposable
containers are recommended.
2. Cover all specimens tightly, label properly, and send immediately to the
laboratory. Place the label on the cup, not on the lid.
3. Obtain a clean specimen using the same procedure as for bacteriologic
examination if a urine specimen is likely to be contaminated with drainage,
vaginal discharge.
4. If a urine specimen is obtained from an indwelling catheter, it may be
necessary to clamp off the catheter for about 15 to 30 minutes before obtaining
the sample. Clean the specimen port (in the tubing) with antiseptic before
aspirating the urine sample with a needle and syringe.
5. Observe standard precautions when handling urine specimens.
6. If the specimen cannot be delivered to the laboratory or tested within 1
hour, it should be refrigerated or have an appropriate preservative added.

Pretest Patient Preparation


1. Explain the purpose and procedure of the test to the patient.
2. Follow safe, effective and informed pre-test care.

Post test Patient Aftercare

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1. Interpret test outcomes, counsel and monitor appropriately for conditions
associated with altered urine results.
2. Ensure safe, effective and informed post test care.

5. Complete Blood Count

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.

• Hemoglobin measures the amount of oxygen-carrying protein in the blood.


• Hematocrit measures the percentage of red blood cells in a given volume of whole
blood.

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• The platelet count is the number of platelets in a given volume of blood. Both
increases and decreases can point to abnormal conditions of excess bleeding or
clotting. Mean platelet volume (MPV) is a machine-calculated measurement of
the average size of your platelets. New platelets are larger, and an increased MPV
occurs when increased numbers of platelets are being produced. MPV gives your
doctor information about platelet production in your bone marrow.
• Mean corpuscular volume (MCV) is a measurement of the average size of your
RBCs. The MCV is elevated when your RBCs are larger than normal
(macrocytic), for example in anemia caused by vitamin B12 deficiency. When the
MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in
iron deficiency anemia or thalassemias.
• Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of
oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large
so tend to have a higher MCH, while microcytic red cells would have a lower
value.
• Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the
average concentration of hemoglobin inside a red cell. Decreased MCHC values
(hypochromia) are seen in conditions where the hemoglobin is abnormally diluted
inside the red cells, such as in iron deficiency anemia and in thalassemia.
Increased MCHC values (hyperchromia) are seen in conditions where the
hemoglobin is abnormally concentrated inside the red cells, such as in burn
patients and hereditary spherocytosis, a relatively rare congenital disorder.
• Red cell distribution width (RDW) is a calculation of the variation in the size of
your RBCs. In some anemias, such as pernicious anemia, the amount of variation
(anisocytosis) in RBC size (along with variation in shape – poikilocytosis) causes
an increase in the RDW.

Pre-test Patient Care


1. Explain test procedure. Explain that slight discomfort may be felt when skin is
punctured.
2. Avoid stress if possible because altered physiologic status influences and changes
normal values.
3. Dehydration or over hydration can dramatically alter values; for example, large
volumes of IV fluids can dilute the blood and values will appear as lower counts.
The presence of either these states should be communicated to the laboratory.
4. Fasting is not necessary. However, fat-laden meals may alter some test results as a
result of lipidemia.

Post test Patient Aftercare


1. Apply manual pressure and dressings to the puncture site on removal of the
needle.
2. Monitor the puncture site for oozing or hematoma formation. Maintain pressure
dressings if necessary. Notify physician for unusual problems with bleeding.
3. Resume normal activities and diet.

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6. Pulse Oximetry

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

Pre-test Patient Care


Explain the purpose, benefits, and risks of non-invasive arterial blood measurement.
Assess the patient’s ability to comply with the procedure.

Post test Patient Aftercare


Interpret test outcomes. Assess, monitor, and intervene appropriately for hypoxemia and
other related problems.

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7. Electrocardiogram

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.

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Pre-test Patient Care
1. Explain test purpose, procedure and interfering factors. Emphasize that ECG is
painless and does not deliver electrical current to the body. A resting ECG is no
more than a 1-minute record of the heart’s electrical activity.
2. Have the patient completely relax to ensure a satisfactory tracing.
3. Be aware that ideally, the person should rest for 15 minutes before ECG
recording. Have the patient avoid heavy meals and smoking for at least 30
minutes before the ECG, and longer if possible.
4. Follow guidelines for safe, effective, informed pretest care.

Post-test Patient Aftercare


1. Recognize the limitations of an ECG. A normal ECG does not rule out coronary
artery disease or areas of cardiac ischemia. Conversely, an abnormal ECG in and of
itself does not always signify heart disease.
2. Interpret test results and counsel and monitor the patient appropriately. A resting
ECG is usually normal in those patients who experience only angina. It can provide
evidence of prior heart damage. The ECG is one diagnostic tool within a repertoire of
diagnostic modalities and should be viewed as such. The presence or absence of heart
disease should not be presumed solely on basis of ECG.
3. Follow guidelines for safe, effective, informed post-test care.

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5.4: PRE-OPERATIVE AND POST-OPERATIVE MEDICAL MANAGEMENT

1. Drugs Ordered in the Emergency Room and Neuro ICU

Drug Indications Mechanism of Action Precautions Adverse Effects Nursing


Considerations
Generic name: Perioperative Chemical effect: Contraindicated GI: Diarrhea, oral Assess the
Cefazolin prophylaxis in Inhibits cell-wall in patients candidiasis (oral patient’s infection
Sodium contaminated synthesis, promoting hypersensitive to thrush), vomiting, before therapy and
surgery: stat osmotic instability; other nausea, stomach regularly thereafter
Brand name: Hemicraniectomy, usually bactericidal cephalosporins cramps, anorexia
Ancef (R) with and pseudo- Obtain specimen
evacuation of Therapeutic effect: Use cautiously in membranous for culture and
Date Ordered: intracerebral Hinders or kills patients with a colitis. sensitivity tests
1st hospital day hemorrhage (R) susceptible bacteria history of before giving first
(09/07/09) sensitivity to Allergic: dose. Begin
Serious infections penicillin Anaphylaxis, therapy pending
Dosage: of respiratory, because of cross- eosinophilia, test results.
1 gram every 8 biliary and GU allergic reaction, itching, drug
hours (IV) tracts; skin, soft- and in patients fever, skin rash, Ask patient about
discontinued on tissue, bone and with renal Stevens-Johnson previous reactions
4th Hospital Day joint infections; impairment syndrome. to cephalosporins
(09/10/09) septicemia; or penicillins
endocarditis Hematologic: before
Classification: Neutropenia, administrering first
Cephalosporins, leukopenia, dose.
antibiotic thrombocytopenia,
thrombocythemia. If adverse GI
reactions occurs,
Hepatic: Transient monitor patient’s
rise in SGOT, hydration
SGPT, and
alkaline
phosphatase
levels.

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

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into extracellular fluid. edema, severe retention, edema,
Dosage: Toxicity, non heart failure, headache, blurred based on strict
Initial – 200 ml specific Therapeutic effect: severe vision, evaluation of fluid
every 8 hours Increases water dehydration, convulsions, intake and output.
(IV) then Hemolysis excretion, decreases metabolic edema, nausea, vomiting,
changed to 100 (prophylaxis) intracranial or progressive renal rhinitis, arm pain,
ml every 6 intraocular pressure, disease or skin necrosis, Monitor weight
hours prevents or treats kidney dysfunction, or thrombophlebitis, and kidney
09/15/09 – 100 dysfunction, and active chills, dizziness, function, as well as
ml every 12 promotes excretion of intracranial urticaria, serum and urine
hours for 1 day drug overdose bleeding except dehydration, sodium ands
then discontinue during hypotension, potassium levels,
craniotomy. tachycardia, fever daily
Classification: and angina-like
Osmotic diuretic chest pains. If patient’s oliguria
increases or has
adverse reactions,
notify prescriber
immediately

Instruct patient to
immediately report
pain in chest, back,
legs or shortness of
breath

Tell the patient


that he may feel
thirsty or have a
dry mouth, and
emphasize the
importance of
drinking only the
amount of fluid
provided.
Generic name: Management of Inhibits the transport of Contraindicated CNS: headache, Monitor blood
Amlodipine hypertension calcium into myocardial in: dizziness, fatigue. pressure and pulse
besylate and vascular smooth Hypersensitivity before therapy,
Angina pectoris muscle cells, resulting in Blood pressure CV: peripheral during dose
Brand name: inhibition of excitation- of <90 mmHg edema, angina, titration, and
Norvasc Vasospastic contraction coupling and bradycardia, periodically during
(Prinzmetal's) subsequent contraction Use cautiously hypotension, therapy.
Date Ordered: angina in: palpitations.
1st hospital day Therapeutic Effect(s): Severe hepatic Monitor ECG
(09/07/09) Systemic vasodilation impairment GI: gingival periodically during
resulting in decreased hyperplasia, prolonged therapy
Dosage: blood pressure Aortic stenosis nausea.
Initial –5 mg/tab Monitor intake and
per NGT then Coronary vasodilation History of CHF Derm: flushing. output.
withheld and resulting in decreased
resumed on the frequency and severity Assess for signs of
3rd hospital day of attacks of angina CHF
(5 mg/ tab PO
BID) Caution patient to
change positions
Classification: slowly to minimize
Calcium orthostatic
Channel hypotension
Blockers
Advise patient to
notify health care

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professional if
irregular
heartbeats,
dyspnea, swelling
of hands and feet,
pronounced
dizziness, nausea,
constipation, or
hypotension occurs
or if headache is
severe or
persistent.

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

Instruct patient and


family in proper
technique for
monitoring blood
pressure.

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

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inhibitor pylori to reduce
duodenal ulcer
occurrence
Generic name: Prevention of Chemical effect: Contraindicated Sedation, Before starting
Divalproex intra- and post- Unknown, may increase in patients emotional upset, drug and
sodium operative seizures brain levels of GABA, hypersensitive to depression, periodically
in craniectomy which transmits the drug or any psychosis, thereafter, monitor
Brand name: inhibitory nerve of its nystagmus, liver function
Depakote Simple and impulses in CNS components, and diplopia, nausea, studies, platelet
complex absence in patients with vomiting, counts and PT.
Date ordered: seizures, mixed Therapeutic effect: hepatic indigestion,
1st hospital day seizure types Prevents and treats dysfunction, or diarrhea, Give drug with
(09/07/09) (including absence certain types of seizure urea cycle pancreatitis, food or milk to
seizures) activity disorder hemorrhage, minimize adverse
Dosage: leucopenia, bone GI reaction.
500 mg/tab 2 Mania marrow
tabs per NGT suppression, Suddenly stopping
STAT then Prevention of thrombocytopenia, the drug may
changed to 1 tab migraine headache hepatotoxicity worsen seizures. If
PO BID adverse reaction
Complex partial develops, call
Classification: seizures prescriber
Anti-convulsant immediately

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

A Case on Hemorrhagic CVA: Hypertension Stage II


need. Never
share your
medicine with
others.

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

A Case on Hemorrhagic CVA: Hypertension Stage II


changes; weakness
or numbness in
arm or leg) occur.
Generic name: For short-term Inhibits calcium ion Contraindicated Symptoms Take each dose
Nicardipine treatment of influx across cell in: included marked with a full glass of
hydrochloride hypertension when membrane during hypotension, water.
oral therapy is not cardiac depolarization; hypersensitivity bradycardia,
Brand name: feasible or not produces relaxation of palpitations, Do not crush,
Cardene desirable. coronary vascular advanced aortic flushing,
break, or chew the
smooth muscle, stenosis because drowsiness,
Date ordered: Unstable angina peripheral vascular part of the effect confusion and extended-release
1st hospital day smooth muscle; dilates of Nicardipine is slurred speech. (SR) capsules.
(09/07/09) coronary vascular secondary to Lethal overdosage Swallow them
arteries; decreases reduced may cause whole. They are
Dosage: sinoatrial/atrioventricular afterload. progressive specially
2 mg/hr in D5W (SA/AV) node atrioventricular formulated to
09/09/09 – conduction. conduction block. release the
increased to 2.5 medication slowly
mg/hr, then in the body.
tapered to
consume
Nicardipine must
not be stopped
Classification:
Calcium abruptly without
Channel talking to the
Blocker physician, even if
the patient is
beginning to feel
better.

Grapefruit and
grapefruit juice
may interact with
nicardipine. The
interaction could
have potentially
dangerous effects.

Discuss the use of


grapefruit and
grapefruit juice
with the physician.
Instruct client not
to increase or
decrease the
amount of
grapefruit products
in your diet
without consulting
the physician.

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,

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Brand name: Ocular itching Therapeutic effect: GI pain, renal Be alert for
Toradol caused by seasonal Relieves pain and history of nasal failure, purpura, adverse reaction
allergic rhinitis inflammation polyps, sweating and drug
Date Ordered: interactions
1st hospital day Postoperative angioedema,
(09/07/09) inflammation bronchospastic If pain persists or
following surgery reactivity, worsens, notify
Dosage: prescriber
50mg/IV stat allergic reactions
to aspirin or Teach patient to
Classification: other NSAIDS; recognize and
NSAIDs immediately report
advanced renal signs and
impairment symptoms of GI
bleeding. Explain
that serious GI
toxicity, even
witout any
symptoms, can
occur.
Generic name: Symptomatic Inhibits the synthesis of Contraindicated Hematologic: Use liquid form for
Acetaminophen relief of pain and prostaglandins in the in the presence of hemolytic anemia, children and
or Paracetamol fever. central nervous system allergy to neutropenia, patients who have
and peripherally blocks Paracetamol. leucopenia, difficulty
Brand name: pain impulse generation; pancytopenia. swallowing.
Tylenol produces antipyresis Use caution in
from inhibition of the presence of Hepatic: Jaundice In children, don’t
Date ordered: hypothalamic heat- impaired hepatic exceed five doses
1st hospital day regulating center. function, chronic Metabolic: in 24 hours.
(09/07/09) alcoholism, Hypoglycemia
pregnancy, Advise patient that
lactation. Skin: rash, drug is only for
Dosage: urticaria. short term use and
Initial 500 mg to consult the
per NGT stat physician if giving
followed by Q4 to children for
PRN longer than 5 days
or adults for
Classification: longer than 10
Analgesic, Anti- days.
pyretic
Advise patient or
caregiver that
many over the
counter products
contain
acetaminophen; be
aware
of this when
calculating total
daily
dose.

Warn patient that


high doses or
unsupervised long
term use can
cause liver
damage.
Generic name: Production of Chemical effect: Contraindicated CNS: dizziness, Assess location,
Nitroglycerine controlled Increases coronary blood in: headache, duration, intensity,
hypotension flow by dilating apprehension, and precipitating

A Case on Hemorrhagic CVA: Hypertension Stage II


Brand name: during surgical coronary arteries and Hypersensitivity restlessness, factors of patient's
Nitrostat procedures improving collateral weakness. anginal pain
flow to ischemic regions Severe anemia
Dosage: Acute and long- - Produces EENT: blurred Monitor blood
Nicardipine drip term prophylatic vasodilation (venous Pericardial vision. pressure and pulse
and NTG to management of greater than arterial) tamponade before and after
titrate once BP angina pectoris - Decreases left CV: hypotension, administration.
systolic is 130’s (for oral, ventricular end- Constrictive tachycardia,
sublingual and diastolic pressure pericarditis syncope. Patients receiving
Date ordered: transdermal) and left ventricular IV nitroglycerin
1st Hospital Day end-diastolic Concurrent use GI: abdominal require continuous
(09/07/09) Adjunct treatment volume (preload) of PDE-5 pain, nausea, ECG and blood
of CHF - Reduces myocardial inhibitor vomiting. pressure
Classification: oxygen (sildenafil, monitoring.
Antianginal, Adjunct treatment consumption tadalafil, Derm: contact Additional
nitrates of acute MI vardenafil) dermatitis hemodynamic
Therapeutic Effect(s): (transdermal or parameters may be
Treatment of CHF Relief or prevention of Use Cautiously ointment). monitored
associated with anginal attacks in:
acute MI Misc: alcohol Drug may cause
Increased cardiac output Head trauma or intoxication (large headache,
cerebral IV doses only), especially at start
Reduction of blood hemorrhage cross-tolerance, of therapy. Lower
pressure flushing, the dose
Glaucoma tolerance. temporarily.
Hypertrophic
cardiomyopathy Tolerance to drug
Severe liver without headache
impairment response may
Hypovolemia occur. Treat
(IV) headache with
Normal or acetaminophen as
decreased ordered
pulmonary
capillary wedge
pressure (IV)
Generic name: Management of Receptor studies show Nubain should CNS: Nubain is
Nalbuphine moderate to severe that nalbuphine exerts its not be Nervousness, associated with
Hydrochloride pain action via binding to mu, administered to depression, sedation and may
kappa, and delta patients who are restlessness, impair mental and
Brand name: Preoperative and receptors, but not to hypersensitive to crying, euphoria, physical abilities
Nubain postoperative sigma receptors. nalbuphine floating, hostility, required for the
analgesia hydrochloride, or unusual dreams, performance of
Date Ordered: Nalbuphine is primarily to any of the confusion, potentially
4th Hospital Day Supplement to a kappa agonist/partial other ingredients faintness, dangerous tasks
(09/10/09) stat balanced mu antagonist analgesic. in Nubain. hallucinations, such as driving a
anesthesia; dysphoria, feeling car or operating
Dosage: obstetrical Nubain should be of heaviness, machinery.
30 mg every 6 analgesia during administered as a numbness,
hours labor and delivery. supplement to tingling, unreality. Nubain is to be
stat IV ½ general used as prescribed
ampule anesthesia only CV: by a physician.
by persons Hypertension, Dose or frequency
Classification: specifically hypotension, should not be
Opioid trained in the use bradycardia, increased without
analgesic of intravenous tachycardia. first consulting
anesthetics and with a physician
management of GI: Cramps, since Nubain may
the respiratory dyspepsia, bitter cause
effects of potent taste. psychological or
opioids. physical
Respi: Respiratory dependence.

A Case on Hemorrhagic CVA: Hypertension Stage II


Naloxone, depression,
resuscitative and dyspnea, asthma. Advise patient or
intubation caregiver that
equipment and Derma: medication will
oxygen should be Itching, burning, usually be
readily available. urticaria. prepared and
administered by a
Miscellaneous: health care
Speech difficulty, provider in a
urinary urgency, health care setting.
blurred vision,
flushing and Advise patient or
warmth. caregiver to notify
health care
provider if
medication does
not adequately
control pain.

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

A Case on Hemorrhagic CVA: Hypertension Stage II


fluorometric test.

2. Drugs Ordered and Currently Taken in the Ward

Drug Indications Mechanism of Precautions Adverse Effects Nursing


Action Considerations
Depakote
Toradol
Mannitol
Citicoline Seen in the medications given in the ER and NCU
Amlodipine
Etoricoxib
Dolcet
Generic name: Stress ulcer Forms a Disease-related GI: Constipation, Teach patient to take
Sucralfate complex by concerns: diarrhea, nausea, recommended dose with
Stomatitis binding with vomiting, flatulence, water on an empty
Brand name: positively Duodenal headache, gastric stomach, 1 hour before
Iselpin Duodenal ulcer charged proteins ulceration: discomfort, or 2 hours after meals.
in exudates, because indigestion Take any other
Dosage: forming a sucralfate acts medications at least 2
16mg/tab PO viscous paste- locally at the Other: hours before taking
TID like, adhesive ulcer, successful hypersensitivity sucralfate. Do not take
substance. This therapy with (urticaria, antacids (if prescribed)
Date Ordered: selectively sucralfate should angioedema, facial within 30 minutes of
3rd Hospital Day forms a not be expected swelling, pruritus, taking sucralfate. May
protective to alter the post rash, laryngospasm) cause constipation
Classification: coating that acts healing (increased exercise,
Anti-ulcer locally to protect frequency of Respi: Respiratory fluids, fruit, or fiber may
the gastric lining recurrence or the difficulty, rhinitis help). If constipation
against peptic severity of persists, consult
acid, pepsin, and duodenal Muscu: Back pain prescriber for approved
bile salts ulceration. stool softener.
CNS: insomnia,
Renal dizziness, Use caution is presence
impairment: use sleepiness, vertigo, of renal failure. Assess
with caution in xerostomia potential for interactions
patients with with other
chronic renal pharmacological agents
failure; patient may be taking
sucralfate is an (eg, will affect
aluminum absorption of
complex, small concurrently
amounts of administered drugs).
aluminum are
absorbed Assess therapeutic
following oral effectiveness (reduction
administration. in clinical symptoms)
Excretion of and adverse reactions.
aluminum may
be decreased in Teach patient proper use
patients with (eg, timing of other
chronic renal medications), possible
failure. side effects (eg,
constipation) and
Concurrent drug interventions, and
therapy issues: adverse symptoms to
Altered report.
absorption:
Because of the

A Case on Hemorrhagic CVA: Hypertension Stage II


potential for
sucralfate to alter
the absorption of
some drugs,
separate
administration.

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

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NSAID primary contain lactose. Patients
dysmenorrhea. Children and with rare hereditary
adolescents problems of galactose
under 16 years of intolerance, the Lapp
age. lactase deficiency or
glucose-galactose
Inflammatory malabsorption should
bowel disease. not take this medicine.

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

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(9/15/09) (Sporanox) or Alcohol should
ketoconazole generally not be used
Dosage: (Nizoral); or during treatment with
250 mg/tab BID benzodiazepines.
Hypersensitivity
Classification: to alprazolam or Until you experience
Fluoroquinolone to other how this medication
, antibiotic benzodiazepines. affects you, do not drive
a car or operate
potentially dangerous
machinery, etc.

Do not increase the dose


even if you think the
medication "does not
work anymore" without
consulting your
physician.

Do not stop taking this


medication abruptly or
decrease the dose
without consulting your
physician, since
withdrawal symptoms
can occur.
Generic name: Treatment of Irbesartan is a Contraindicated Cardiovascular Advise patient to take
Irbesartan hypertension nonpeptide to patient Chest pain; prescribed dose once
angiotensin II hypersensitive to tachycardia; edema. daily, without regard to
Brand name: Treatment of antagonist that the drug. meals.
Aprovel diabetic selectively CNS: Headache;
nephropathy with blocks the anxiety/nervousness; Advise patient to try to
Date ordered: an elevated binding of dizziness. take each dose at about
4th Hospital Day serum creatinine angiotensin II to the same time each day.
(09/10/09) and proteinuria the AT1 GI: Diarrhea;
(>300 mg/day) in receptor. By dyspepsia/heartburn; Inform patient that drug
Dosage: patients with type blocking the abdominal pain; controls, but does not
150 mg/tab BID 2 diabetes and binding of nausea/vomiting. cure, hypertension, and
09/07/09- hypertension. angiotensin II to to continue taking drug
150mg/tab 1 tab the AT1 Respiratory: Upper as prescribed even when
at lunchtime receptor, respiratory tract BP is not elevated.
09/15/09- promotes infection; influenza;
300mg/tab OD vasodilation and pharyngitis; rhinitis; Caution patient not to
decreases the sinus abnormality change the dose or stop
Classification: effects of taking unless advised by
Angiotensin II aldosterone. Miscellaneous: health care provider.
Receptor Musculoskeletal
Blocker pain/trauma; fatigue; Instruct patient in BP
UTI; rash. and pulse measurement
skills.

Caution patient to avoid


sudden position changes
to prevent orthostatic
hypotension.

Caution patient that


inadequate fluid intake,
excessive perspiration,
diarrhea, or vomiting
can lead to excessive fall
in BP, resulting in

A Case on Hemorrhagic CVA: Hypertension Stage II


lightheadedness or
fainting.

Emphasize to
hypertensive patient
importance of other
modalities on BP:
weight control, regular
exercise, smoking
cessation, moderate
intake of alcohol and
salt.

Instruct patient to stop


taking drug and
immediately report any
of these symptoms to
health care provider:
fainting; swelling of the
face, lips, eyelids, or
tongue.
Generic name: Prevention of Chemical Contraindicated: CV: arrythmias, Give cautiously because
Potassium hypokalemia effect: Untreated heart block, cardiac different potassium
chloride Aids in Addisons arrest, ECG changes supplements deliver
Hypokalemia transmitting disease, CNS: paresthesia of varying amounts of
Brand name: nerve impulses, Adrenocortical limbs, flaccid potassium. Never switch
Kalium durule Severe contracting insufficiency, paralysis products without
hypokalemia cardiac and acute GI: GI ulcerations prescribers order
Date ordered: skeletal muscle, dehydration, heat (stenosis,
6th Hospital Day Acute MI and maintaining cramps, hemorrhage, Make sure powders are
(09/12/09) intracellular hyperkalemia or obstruction, completely dissolved
tonicity, cellular severe renal perforation) before giving
Dosage: metabolism, impairment with Respiratory:
1 tab TID acid-base oliguria, anuria respiratory paralysis Give potassium with or
balance, and or azotemia after meals with full
Classification: normal reanla Use cautiously in glass of water or fruit
Potassium function patient with juice to lessen GI
supplement cardiac disease distress
Therapeutic or renal
effect: impairment Drug is commonly given
Replaces and with potassium wasting
maintains diuretics to maintain
potassium level potassium levels

Don’t give potassium


postoperatively until
urine flow is established
Generic name: Essential, renal Chemical Contraindicated CNS: anxiety, Assess current use of
Clonidine and malignant effect: in patients somnolence, OTC drugs, such as
hydrochloride hypertension May inhibit hypersensitive to confusion, Aspirin or NSAIDs, and
central the drug. drowsiness, herbal remedies
Brand name: Severe pain vasomotor dizziness, fatigue,
Catapress centers, Use cautiously in sedation Assess patient for
Prophylaxis for decreasing patients with increased bleeding or
Date ordered: vascular sympathetic severe coronary CV: orthostatic bruising tendencies
9th hospital day headache outflow to heart, insufficiency, hypotension,
(09/15/09) kidneys, and recent MI, hypotension, Five days after stopping
Adjunctive peripheral cerebrovascular bradycardia, severe the drug, expect platelet
Dosage: therapy for vasculature, disease, and rebound aggregation to return to
75 mg/tab PO nicotine resulting in chronic renal or hypertension normal
TID withdrawal decreased hepatic
peripheral impairment. GI: constipation, dry Don’t give drug to a

A Case on Hemorrhagic CVA: Hypertension Stage II


Classification: Ulcerative colitis vascular mouth, nausea, patient with hepatic
Nitrates, resistance, vomiting impairment or at
antihypertensive decreased increased risk for
systolic and GU: urine retention, bleeding from trauma,
diastolic blood impotence, UTI surgery, or other
pressure, and pathologic conditions
decreased heart Metabolic: transient
rate glucose intolerance Instruct patient to inform
prescriber if unusual
Therapeutic Skin: pruritus and bleeding or bruising
effect: dermatitis with occurs
Lowers blood transdermal patch
pressure and Instruct patient that drug
decreases may be taken with or
neurogenic pain without food
Generic name: Anxiety Chemical Contraindicated CNS: drowsiness, Never give IV.
Hydroxyzine effect: in patients involuntary motor
Preoperative and Unknown; may hypersensitive to activity Warn patient to avoid
Brand name: postoperative suppress activity hydroxyzine or hazardous activities until
Iterax adjunct therapy in key regions of cetirizine GI: dry mouth CNS effects of the drug
subcortical area are known
Date ordered: Pruritus from of CNS Other: marked
10th hospital day allergies discomfort at IM Tell patient to avoid
(9/16/09) Therapeutic injection site, alcohol during drug
Psychiatric and effect: hypersensitivity therapy
Dosage: emotional Relieves anxiety reactions
25 mg/tab PO emergencies, and itching, Suggest sugarless hard
OD including acute promotes candy or gum to relieve
alcoholism calmness, and dry mouth
Classification: alleviates nausea
Antihistamine, Nausea and and vomiting
anxiolytic, vomiting
sedative,
antipruritic,
antiemetic,
antispasmodic
Generic name: Constipation. Chemical Containdicated GI: nausea, Assess history of bowel
Bisacodyl effect: in: Ileus, vomiting, abdominal disorder, normal patterns
Prep for Increases intestinal cramps, diarrhea, of elimination
Brand name: radiography; peristalsis, obstruction, (with high doses),
Dulcolax antepartum & probably by acute surgical burning sensation in Auscultate bowel sounds
postpartum care; acting directly abdominal rectum (with at least once per shift.
Date ordered: prep for on smooth conditions; suppositories), Check for pain and
15th Hospital sigmoidoscopy or muscle of severe protein-losing cramping
Day (9/21/09) proctoscopy; intestine. May dehydration. enteropathy (with
colonoscopy; irritate excessive use), Insert suppository as
Dosage: 2 adult hemorrhoids & musculature, Appendicitis & laxative dependence high as possible into
suppositories anal fissures. stimulate acute (with excessive use) rectum, and try to
then colonic inflammatory Metabolic: alkalosis, position suppository
discontinued All conditions intramural bowel diseases. hypokalemia, fluid against rectal wall.
w/c require plexus, and and electrolyte Avoid imbedding within
defacation to be promote fluid imbalance fecal material because
Classification facilitated. accumulation in Musculoskeletal: this may delay onset of
Laxative, colon and small muscle weakness action.
Purgative intestine (with excessive use)
Time administration of
Therapeutic drug so as not to
effect: interfere with scheduled
Relieves activities or sleep. Soft,
constipation formed stools usually is
produced 15-60 minutes
after P.R. administration

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Tablets and
suppositories are used
together to clean colon
before and after surgery
and before barium
enema

Store tablets and


suppositories below 86
˚F (30 ˚C)

Teach patient about


dietary sources of fiber,
including bran, and other
cereals, fresh fruit and
vegetables.

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3. Stroke Rehabilitation

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.

Instruments Used To Assess


• Barthel scale may be used to assess the likelihood of a stroke patient being able to
manage at home with or without support subsequent to discharge from hospital.

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

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MOBILITY (ON 0 = immobile or < 50 yards
LEVEL 5 = wheelchair independent, including corners, > 50 yards
SURFACES) 10 = walks with help of one person (verbal or physical) > 50
yards
15 = independent (but may use any aid; for example, stick) > 50
yards
STAIRS 0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent
Total 0-100

The Barthel ADL Index: Guidelines


1. The index should be used as a record of what a patient does, not as a record of
what a patient could do.
2. The main aim is to establish degree of independence from any help, physical or
verbal, however minor and for whatever reason.
3. The need for supervision renders the patient not independent.
4. A patient's performance should be established using the best available evidence.
Asking the patient, friends/relatives and nurses are the usual sources, but direct
observation and common sense are also important. However direct testing is not
needed.
5. Usually the patient's performance over the preceding 24-48 hours is important,
but occasionally longer periods will be relevant.
6. Middle categories imply that the patient supplies over 50 per cent of the effort.
7. Use of aids to be independent is allowed.

Good nursing care is fundamental in maintaining skin care, feeding, hydration,


positioning, and monitoring vital signs such as temperature, pulse, and blood pressure.
Stroke rehabilitation begins almost immediately.

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.

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Phase I. Acute Stroke Rehabilitation

A. Initial Brief Assessment


Assessment for complications and prior and current impairment:
1. Risk factors for recurrent stroke and coronary heart disease
2. Medical comorbidities (DM, hypertension, increase ICP, re-bleed, re-
stroke)
3. Consciousness and cognitive status
4. Brief swallowing assessment
5. Skin assessment and pressure ulcers
6. Mobility and need for assistance of movement
7. Deep-vein thrombosis (DVT) risk assessment

B. Assessment of Rehabilitation Needs


1. Prevention of complications: swallowing problems, skin breakdown,
DVT, bowel and bladder dysfunction, malnutrition, pain, contractures,
SHS/CRP, pulmonary.
2. Assessment of impairments: communication impairments, motor
impairment, cognitive deficits, visual and spatial deficiency, psychological
or emotional deficits, sensory deficits.
3. Psychosocial assessment and family or caregivers support
4. Assessment of function (e.g., functional independence measure or FIM).
5. Financial support.
A Case on Hemorrhagic CVA: Hypertension Stage II
Phase II. In-Patient Rehabilitation

A. Reassessment of Rehabilitation Progress


1. General (medical status)
2. Functional status (FIM, etc.): Mobility, activities of daily living (ADL)
and instrumental ADLs, communication, nutrition, cognition,
mood/affect/motivation, sexual function
3. Family support: Resources, caretaker, transportation
4. Patient and family adjustment
5. Reassessment of goals
6. Risk for recurrent cerebrovascular events

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Phase III. Outpatient Rehabilitation

A. Assessment of Discharge Environment


1. Functional needs
2. Motivation and preferences
3. Intensity of tolerable treatment: Equipment, duration
4. Availability and eligibility
5. Transportation
6. Home assessment for safety

A Case on Hemorrhagic CVA: Hypertension Stage II


Phase IV. Community Rehabilitation

A. Assessment of Discharge Environment


1. Functional needs
2. Motivation and preferences
3. Intensity of tolerable treatment: Equipment, duration
4. Availability and eligibility
5. Transportation
6. Home assessment for safety
7. Maximal patient functioning

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5.5: SURGICAL MANAGEMENT

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.

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Pre-operative Nursing Management
1. The pre-operative assessment serves as a baseline for post-operative status and
recovery. These include the evaluation of LOC, responsiveness to stimuli, and
identifying neurologic deficits.
2. Consideration of the patient’s and family’s understanding of and reactions to the
anticipated surgical procedure and its possible sequelae are assessed, as is the
availability of support systems for the patient and family.
3. Patient is assessed for neurologic deficits and their potential impact after surgery.
4. Preparation of the patient and family must include giving information on what to
expect during and after surgery.
5. Whatever the state of awareness of the patient, the family must be provided with
reassurance and support since they usually recognize the seriousness of the brain
surgery.

Post-operative Nursing Management

Collaborative Nursing Interventions


Problems
Reduction of - Use of Osmotic Diuretics and Corticosteroids to reduce the
Cerebral Edema swelling as prescribed by the physician.
- Evaluation of signs of increasing ICP with decreased LOC
as the first sign where the Cushing’s triad follows.
- Monitor fluid intake – avoiding overhydration.
- Elevate head if bed to reduce ICP and facilitate respirations.
- Avoid excessive stimuli.
- Maintain normothermia since hyperthermia increases the
metabolic demands of the brain.
Relieving pain and - Preventing seizures is essential to avoid further cerebral
preventing edema. Administer prescribed anti-convulsants and monitor
seizures its serum levels.
- Use of opioid analgesics as prescribed since headache
occurs after a brain surgery as a result of stretching and
irritation of nerves in the scalp during surgery.
Managing fluid - Serum electrolytes, BUN, blood glucose, weight and clinical
and electrolyte status must be monitored.
balances - Since the patient is prone to gastric ulcers, so histamine-2
receptor antagonists are prescribed to suppress the secretion
of gastric acid.
- The patient is also monitored for bleeding and assessed for
gastric pain.
- Fluid intake and output are monitored closely and since fluid
replacement must compensate for urine output, serum
potassium levels must be monitored.
Preventing - Incision site is monitored for redness, tenderness, bulging,
infection separation or foul odor.
- Since blood is an excellent culture medium for bacteria,

A Case on Hemorrhagic CVA: Hypertension Stage II


dressing must be reinforced with sterile pads so that
contamination and infection is avoided.
- Aseptic technique is used when handling dressings,
dressings, IV and arterial lines.
- Patient must be monitored for signs and symptoms of
infection and culture must be obtained if infection is
suspected.
Regulating - An elevated fever must be regulated vigorously since it
temperature affects brain metabolism and function.
- Monitor patient’s temperature and enforce measures such as
removing blankets, applying ice bag to axilla and groin areas
and administering prescribed medications to reduce fever.
Managing - Other complications occurs in the first 2 weeks or later thus
potential compromising the patient’s recovery. The most important
complications are thromboembolic complications, pulmonary and urinary
tract infection and pressure ulcers.
- These can be avoided with frequent changes in position,
adequate suctioning of secretions, thrombosis prophylaxis,
early ambulation and skin care.

2. Use of Subgaleal Drain

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.

Proper Way to Drain Fluid:

A Case on Hemorrhagic CVA: Hypertension Stage II


• Do hand hygiene. Wear gloves and prepare necessary materials.
• Empty the drain every 8 hours and if it is half full.
• Pull out the plug out of the bulb.
• Extract the fluid inside the bulb using a syringe.
• Clean the plug with alcohol. Make sure to squeeze the bulb flat so that the
vacuum suction can restart.
• Measure the amount of fluid collected. Document the amount, date and time it
was collected.
• Flush the fluid down the toilet.
• Wash your hands.

Care for Skin and Drain Site:


• Wash hands.
• Remove the dressing around the drain. Use triadine (povidone-iodine swab) to
clean the drain site and the skin around it. Clean the area once a day.
• When the drain site is clean and dry, put a new dressing around the drain. Put
surgical tape on the dressing to hold it down against the skin.
• Dispose the old dressing into the proper waste container (yellow).
• Wash hands.

A Case on Hemorrhagic CVA: Hypertension Stage II


SECTION 6: NURSING CARE PLAN

Nursing problem #1: Sudden Neurologic Deterioration (Physiologic Integrity - Circulation)


Date Discovered: 1st Hospital Day, upon Admission to PHC ER.

Focus Assessment Criteria Clinical Significance


1. Neurologic Assessment Findings (Glasgow Coma Scale) Provides baseline data to evaluate recovery or further deterioration. GCS
evaluates the client’s ability to integrate commands with conscious and
involuntary movements. Cortical function can be assessed by evaluating eye
opening and motor response.
2. Poor Cerebral Perfusion Presents deficiencies of cerebral blood supply caused by hemorrhage.

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Ineffective Cerebral Goal:
The mother of the patient Tissue Perfusion related to Goal/s Met.
verbalized: bleeding in the right Short Term
“Nung natagpuan ko siya sa tempo-parietal lobe of the - After 1 day of nurse – patient interaction, the client will The client exhibited
banyo, sabi niya biglang maintain improved level of consciousness, cognition, and improved level of cons-
brain.
nanghina ang kaliwang motor/ sensory function. ciousness, cognition and
bahagi ng katawan niya. motor/ sensory function
Nang makarating siya sa ER, Inference: as evidenced by non-
Disruption of blood supply to Long Term
parang mahimbing ang tulog Brain csused by hemor- - After 1 week of nursing intervention, patient will irritability, less pacing.
niya at di na makausap.” rhage demonstrate stable neuro vital signs and display no further He also demonstrated
↓ comprehension of simple
Imbalance between cranial vault
deterioration or recurrence of deficits.
Objective: content
commands like raising
↓ Nursing Interventions: his unaffected
• GCS 7 (E1V1M5) at ER brain com- extremities.
pression
• left hemiparesis with 0/5 ↓ Independent Interventions Rationale
left extremities motor Injury to brain paren- Monitor and document Assesses trends in level of
testing result chyma neurological status frequently consciousness and potential
↓ and compare with baseline. for increased ICP.
• slurring of speech Altered perfusion
• stuporous ↓ Monitor vital signs and note Fluctuations in pressure may
Innefective Cerebral tissue perfusion hypotension/hypertension. occur because of cerebral
• (+) spontaneous non- ↓ pressure/injury in vasomotor
purposeful movement of Neurologic
area of the brain. Hypertension
Deficit

A Case on Hemorrhagic CVA: Hypertension Stage II


the right extremities ↓ may have been a precipitating
Altered sensorium and may
• nystagmus upon looking manifests behavioral changes
factor.
to the left – preferential Evaluate pupils noting size, Pupil reactions are regulated
gaze to the right shape, equality and light by the occulo-motor(III)
• positive doll’s sign reactivity. cranial nerve and are useful in
• nuchal rigidity with determining whether the brain
positive brudzinski’s sign stem is intact. Response to
(left) light reflects combined
function of the optic (II) and
oculomotor(III) nerves.
Assess higher functions Changes in cognition
including speech if patient is & speech content are an
alert. indicator of degree/
location of cerebral
involvement.
Position with head slighty ele- Reduces arterial pressure by
vated and in neutral position. promoting venous drainage
and may improve cerebral
perfusion.
Maintain bed rest; provide a Continual stimulation and acti-
quiet environment. Provide rest vity may increase ICP. Abso-
periods between care activities. lute rest and quiet environ-
ment may be needed to pre-
vent rebleeding in the case of
hemorrhage.
Prevent straining at stool, hol- Valsalva maneuver increases
ding breath. ICP and potentiates risk for
rebleeding.
Collaborative Interventions Rationale
Administer supplemental Reduces hypoxemia, which
oxygen as indicated. can cause cerebral vaso-
dilation and increase pres-sure.
Prepare for surgery as May be necessary to resolve
appropriate. situation, reduce neurologic
symptoms/risks of recurrent
stroke.

A Case on Hemorrhagic CVA: Hypertension Stage II


Monitor laboratory studies as Provides information about the
indicated. effectiveness of medical and
pharmacological management.

Nursing Problem #2: Post-surgical pain on the operative site (Physiologic integrity – Pain/Discomfort)
Date Identified: 2nd Hospital Day

Focus Assessment Criteria Clinical Significance


1. Complaints of pain location, description, intensity and duration. Client is the best source of information about this pain and degree of relief
2. Effects of pain relief interventions obtained from interventions.
3. Source of pain: Surgical site Post-operative surgical site pain results from destruction of nerves and tissue
during surgery.
4. Physical signs of pain Client experiences and express pain in different ways. Objective signs may
alert the nurse to such pain.

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Acute Pain related to Goal: Goals met.
• Repeated complaints of compression of brain tissue
headache (occipital and increased intracranial Short Term The client appears
origin) pressure After two weeks of hospital stay, the client will report progressive relaxed, with restoration
reduction of pain and increase in activity by: of normal sleeping
Objective: Inference - Report effective pain relief patterns and is now
• Guarding Imbalance between cranial vault - Being able to appear relaxed, able to sleep and participate in participating in the PHC
content activities appropriately. Stroke Rehabilitation
• Facial grimacing ↓
Brain compression
Program.
↓ Nursing Interventions:
Altered cerebral perfusion
↓ Independent Interventions Rationale
Right hemicraniectomy and
evacuation of hematoma STAT Ascertain the location, nature, Pressure exerted on the
↓ and intensity of pain. baroreceptors in blood vessel
Prolonged surgery walls cause generalized
↓ headache. Other sources of
Compression of nerve fibers
↓ discomfort include dressings,
Pain IV lines, edema and poor
positioning.

A Case on Hemorrhagic CVA: Hypertension Stage II


If the pain is a headache, These measures may help
slightly raise the head of bed, reduce increased ICP and
reduce bright lights and room relieve headache.
noise, and loosen head dressings
if constrictive.
Assess vital signs noting Changes in these vital signs
tachycardia, hypertension, and often indicate acute pain and
increased respiration. discomfort.
Provide client privacy for his Privacy allows client to
pain experience (eg. Closed express pain in his own
curtains and room door, ask manner, which can help to
others to leave the room) reduce anxiety and ease pain.
Document effectiveness and Respirations may decrease on
adverse effects of analgesia. administration of narcotic, and
synergistic effects with
anesthetic agents may occur.
Collaborative Interventions Rationale
Administed medications as
indicated:
- Analgesics IV - Analgesics given IV
reach the pain centers
immediately provi-
ding more effective
relief with small
doses of medication.
- Provide round-the- - Research supports
clock analgesia with need to administer
intermittent rescue analgesics around the
doses clock initially to
prevent rather than
merely treat pain.
- Non-steroidal anti- - Useful mild to
inflammatory drugs moderate pain or as
adjuncts to opioid
therapy when pain is
moderate to severe.

A Case on Hemorrhagic CVA: Hypertension Stage II


Nursing Problem #3: Disruption of skull, skin layer and tissues: Wound Care (Safe amd Effective Care Environment - Safety)
Date Identified: 1st Hospital Day

Focus Assessment Criteria Clinical Significance


1. Surgical access through the skull Disruption of tissue integrity occurs to evacuate hematoma and when part of
the skull is removed.
2. Surgical site and drains Surgical interruption of skin integrity disrupts the body’s first line of defense
3. Type and progression of wound healing. against infection and allows direct entry of microorganism.

Cues Nursing Diagnosis Goal/s Evaluation


Objective: Impaired Skin/Tissue Integrity Goal: Goals met.
• Presence of dressing related to mechanical
around the skull interruption of skin/tissues Short Term The client has attained
• Part of the right skull has secondary to rght Throughout the hospital stay, the client will: timely wound healing
been removed hemicraniectomy and - Achieve timely wound healing and has prevented
evacuation of hematoma - Demonstrate techniques to promote healing and to prevent complications such as
• Presence of subgaleal
complications infection, etc.
drainage
Inference
Imbalance between cranial vault Nursing Interventions:
content

Brain compression
Independent Interventions Rationale
↓ Reinforce initial dressing as Protects wound from
Altered cerebral perfusion indicated. Use strict aseptic mechanical injury and
↓ techniques. comtamination.
Right hemicraniectomy and
evacuation of hematoma STAT Check tension of dressings. Prevent tape skin abrasions.
↓ Apply tape at center of incision Wrapping tape can impair
Prolonged surgery to outer margin of dressing. circulation.

Tissue interruption: part of the skull
Inspect incision regularly noting Early recognition of delayed
removed, evident hematoma characteristics and integrity. healing may prevent a more
evacuated Note clients at risk for delayed serious situation.
↓ healing.
Wound care measures must be
instituted
Assess amount and Decreasing drainage suggests
characteristic of drainage. evolution of healing process
Maintain patency of drainage; Facilitates approximation of
apply collection bag over drains wound edges; reduces risk of

A Case on Hemorrhagic CVA: Hypertension Stage II


in presence of copious drainage. infection.
Caution client not to touch Prevents contamination of
incision. area.
Elevate operative area as Decreases intracranial pressure
appropriate. and limits edema formation.
Collaborative Interventions Rationale
Monitor/maintain dressings. May be used to hasten healing
in large, draining
wound/fistula to reduce
frequency of dressing changes.
Administer prophylactic Prophylaxis prevents
antibiotics as prescribed. occurrence of post-operative
infections.

Nursing Problem #4: Impaired Elimination (Physiologic Integrity – Elimination)


Date Identified: 14th Hospital Day

Focus Assessment Criteria Clinical Significance


1. Pre-hospitalization elimination patterns These data help the nurse evaluate whether the client had any elimination
problem before admission.
2. Character of bowel sounds, presence and degree of abdominal Assessment helps the nurse monitor for the return of peristalsis.
distention.

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Constipation related to Goal: Goals met.
• “Napakahina niya kunain change in fluid and food
dito, ilan araw na rin intake Short Term Immediately after
siyang hindi makadumi” as After 3-5 of nursing intervention and follow-up the client will: laxatives as prescribed
verbalized by the patient’s Inference - Establish normal patterns of bowel functioning were given, he regained
mother. Stressed induced by condition his bowel movement –
↓ passing out 5 stools
Decreased food intake
Objective: ↓
Nursing Interventions: (Day 15).
• (-) bowel movement x 5 Hypoactive GI response
days ↓ Independent Interventions Rationale
Decreased gastric motility Auscultate bowel sounds These indicate nature of
• Hypoactive bowel sounds

A Case on Hemorrhagic CVA: Hypertension Stage II


↓ peristaltic activity.
Constipation
Implement measures to promote A well balanced diet high in
a balanced diet that promotes fiber content stimulates
regular elimination. peristalsis and regular
elimination.
Promote adequation fluid intake Adequate fluid intake helps
(8-10 glasses) per day at least 2 maintain proper stool
liters unless contraindicated. consistency in the bowel and
aids in regular elimination.
Collaborative Interventions Rationale
Administer medication as Promotes regularity by
prescribed (eg. bulk- increasing bulk and/or stool
providers/stool softeners). consistency.

Nursing Problem #5: Altered Sleep-Wake Cycle (Physiologic Integrity – Activity/Rest)


Date Identified: 9th Hospital Day

Focus Assessment Criteria Clinical Significance


1. Usual sleep requirements They vary among clients depending on age, lifestyle, activity level, stress, and
other factors.
2. Usual bed time stories, environment, position Bed time rituals may aid relaxation and promote sleep.
3. Quality of sleep Only the client can subjectively evaluate the quality of sleep and his
satisfaction/dissatisfaction with that quality.

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Disturbed Sleeping Pattern Goal: Goals met.
• Mother of the patient related to emotional stress
states: “Sa umaga tulog Short Term The patient was able to
ang anak ko, sa gabi Inference After 3-5 days of nurse-patient interaction, the client will report a complete at least 4 hours
naman siya gising.” Imbalance between cranial vault satisfactory balance of rest and activity. of undisturbed sleep and
content acknowledges that when

Objective: Brain compression
Nursing Interventions: lights are already dim, it
• Labile mood ↓ is nearing his bedtime.
• Irritable if awaken in the Altered cerebral perfusion Independent Interventions Rationale
↓ Institute measures to promote Sleep is difficult without
afternoon

A Case on Hemorrhagic CVA: Hypertension Stage II


Right hemicraniectomy and relaxation: relaxation. The unfamiliar
evacuation of hematoma STAT

- Maintain dark quiet hospital environment can
Prolonged surgery environment hinder relaxation.
↓ - Allow client to choose
Situational Crises/Emotional Stress pillows, linens as

Altered sleep wake cycle
approprtiate
- Provide a regular
bedtime ritual
- Ensure good room
ventilation.
Schedule procedures to In order to feel rested, a
minimize the times you need to person usually must complete
wake the client at night. If an entire sleep cycle (70-100
possible plan for at least 2 hour minutes) four to five times a
periods of uninterrupted sleep. night.
Assist with usual bed routines as A familiar bed time ritual may
necessary such as personal promote relaxation and sleep.
hygiene, snack or music for
relaxation.
Teach client and significant
other sleep promoting measures:
- Eating a high protein - Digested protein
snack produces tryptophan,
which has a sedative
effect.
- Avoiding caffeine - Caffeine stimulates
metabolism and
deters relaxation.
- Attempting to sleep - Frustration may result
only when feeling if the client attempts
sleepy to sleep when not
sleepy or relaxed.
- Irregular sleeping
- Trying to maintain pattern can disrupt
sleep habits. normal circadian
rhythms.
Nursing Problem #6: Ability to perform ADL (Health Promotion Maintenance – Hygiene)

A Case on Hemorrhagic CVA: Hypertension Stage II


Date Identified: 1st Hospital Day

Focus Assessment Criteria Clinical Significance


1. Self-feeding abilities A baseline is needed to assess improvement in self care activities.
2. Self-bathing abilities
3. Self-dressing abilities
4. Self-toileting abilities
5. Motivation
6. Endurance

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Self-care Deficit related to Goal: Goals met.
• Mother of the patient neuromuscular impairment
states: “Tinutulungan secondary to right Short term: Patient exhibited some
namin siya kumain, intracerebral hemorrhage. Throughout the patient’s hospital stay, he will achieve the following: techniques in meeting
magbihis, inaalalayan ng - Demonstrate techniques to meet self-care needs. self care needs such as:
PT siya maglakad, atbp.” Inference - Identify personal resources that can provide assistance as using knife-fork
Hemorrhage at right side of the brain needed. combinations,

Objective: extensions for picking
Imbalance between cranial vault
• Barthel index scale results content Long term: things up.
↓ - Perform self-care activities within level of own activity
on 1st Hospital Day
Brain compression ADL score improved
(0/100) and on the 10th ↓ Nursing Interventions:
Hospital Day (25/100) Injury to brain parenchyma
from 0/100 to 20/100 on
the 10th day requiring
• Needs assistance in ↓
Altered perfusion Independent Interventions Rationale assistance to meet self-
feeding, bathing ↓ Assess abilities and level of Aids in anticipating/planning care needs.
grooming, dressing, Neurologic Deficit deficit (eg. Barthel’s ADL for meeting individual needs.
elimination, transferring ↓
Neuromuscular involvement
index) for performing ADLs.
from one place to another, ↓ Avoid doing things for patient These patients may become
etc. Weakness of the face, arm, and leg that patient can do for self, but fearful and dependent, and
of the opposite side of the body provide assistance as necessary. although assistance is helpful
↓ in preventing frustration, it is
Inability to provide self care

important for patient to do as
Self-care deficit much as possible for self to
maintain self-esteem and
promote recovery.
Maintain a supportive, firm Patients need empathy and to

A Case on Hemorrhagic CVA: Hypertension Stage II


attitude. Allow patient sufficient know caregivers will be
time to accomplish tasks. consistent in their assistance.
Provide self-help devices, eg. Enables patient to manage for
button/zipper hook, knife-fork self, enhancing independence
combinations, long-handled and self-esteem; reduces
brushes, extensions for picking reliance on others for meeting
things up from floow; toilet own needs; and enables patient
riser, leg bag for catheter; to be more socially
shower chair. Assist and active.
encourage good grooming and
make-up habits.
Assess patient’s ability to Patient may have neurogenic
communicate the need to void bladder, be inattentive, or be
and/or ability to use urinal, unable to communicate needs
bedpan. Take patient to the in acute recovery phase, but
bathroom at frequent/periodic usually is able to regain
intervals for voiding if independent control of this
appropriate. function as recovery
progresses.
Identify previous bowel habits Assists in development of
and reestablish normal regimen, retraining program and aids in
increase bulk in the diet, preventing constipation and
encourage fluid intake and impaction.
increased activity.
Encourage significant other to Reestablishes sense of
do as much as possible for self. independence and fosters self-
worth and enhances
rehabilitation process.
Collaborative Interventions Rationale
Administer suppositories and May be necessary at first to
stool softeners. aid establishing regular bowel
function.
Consult with rehabilitation Provide assistance in
team/physical/occupation developing a comprehensive
therapists. therapy program identifying
special equipment needs that
can increase client’s
participation in self-care.

A Case on Hemorrhagic CVA: Hypertension Stage II


Nursing Problem #7: Problems in Mobility (Safe and Effective Care Environment – Activity/Rest)
Date Identified: 1st Hospital Day

Focus Assessment Criteria Clinical Significance


1. Motor function; range of motion and strength in hands, arms and legs. 1. These assessments provide baseline data to determine the assistance
2. Mobility: ability to turn, sit, stand, transfer and ambulate. needed and to evaluate progress.

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Impaired Physical Mobility Goal: Goals Met.
• “Natagpuan na lang related to decreased motor
naming siya sa banyo, function Short Term The client was able to
nakaupo sa bath tub, demonstrate techniques
hilong-hilo at hindi Inference - After 1 day of nurse-patient interaction, the client will that enable resumption
maigalaw ang kaliwang Hemorrhage at right side of the maintain agreeable physical appearance and skin integrity. of activities such as
bahagi ng kanyang brain moving from bed to

katawan.” Imbalance between cranial vault Long Term chair with assistance of a
content physical therapist.
Subjective: ↓ - After 2 weeks of nursing intervention The patient will
Brain compression He has maintained and
• Results of motor arm maintain and increase the strength & function of affected or

testing of left extremities Injury to brain parenchyma compensatory body part. slightly increased the
reveal no effort against ↓ - The patient will maintain optimal position of function strength and function of
gravity – limb falls (0/5) Altered perfusion as evidenced by absence of contractures, footdrop. the left side of his body
↓ as manifested by
• Pressure ulcer risk Neurologic Deficit
assessment findings: High ↓ Nursing Interventions: movement of the left
risk for pressure ulcer Neuro muscular involvement side of his body from
formation ↓ Independent Interventions Rationale time to time as
Weakness of the face, arm, and leg evidenced by a motor
• Use of supportive devices of the opposite side of the body Assess functional ability/ extent Identifies strengths/
testing from 0/5 to 1/5.
such as pillows and folded ↓ of impairment on a regular deficiencies and may provide
Inability to move independently basis. information regarding
towels in bed.

recovery. Contractures did not
Immobility become a problem
Reposition at least every 2 hours Decreases chance of pressure
and ensure that bed linens are sores and promotes proper particularly foot drop
always intact. body alignment. Affected with the enforcement of
side has poorer circulation & a footboard.

A Case on Hemorrhagic CVA: Hypertension Stage II


reduced sensation and is more
predisposed to skin break-
down.
Observe affected side for color, Edematous tissue is more
edema, or other signs of comp- easily traumatized and heals
romised circulation. more slowly.
Inspect skin regularly, particu- Pressure points over bony
larly over bony prominences. prominences are most at risk
Gently massage any reddened for decreased perfusion.
areas.
Encourage early and complete Self-care increases
participation in ADLs Independence and a
sense of well-being
Begin active/passive ROM to all Minimizes muscle atrophy,
extremities on admission. promotes circulation and helps
Encourage exercises such as prevent contractures. Reduces
quadriceps/gluteal exercise, risk of hypercalciuria and
squeezing rubber ball, extension osteoporosis if underlying
of fingers and legs/feet. problem is hemorrhage.
Teach and encourage the patient To further strengthen the
to exercise the right part of his mobile part of the body so as
body by always moving it. to compensate the immobile
part.
Provide written information on Written materials can serve as
activity instructions and a valuable resource for
restrictions post discharge care at home.
Collaborative Interventions Rationale
Provide egg-crate mattress, Promotes even weight
water bed, flotation device or distribution, decreasing
specialized bed as indicated. pressure on bony points and
helping to prevent skin
breakdown.
Consult with physical therapist Individualized program can be
regarding active, resistive developed to meet particular
exercises and client ambulation. needs/deal with deficits in
balance, coordination and

A Case on Hemorrhagic CVA: Hypertension Stage II


strength.
Assist with electrical stimulation May assist muscle
as indicated. strengthening and increase
voluntary muscle control.

Nursing Problem #8: Problems in Articulation (Physiologic Integrity-Neurosensory)


Date Identified: Hospital Day 1

Focus Assessment Criteria Clinical Significance


1. Slurred speech 1. Damaged cells in the frontal lobe near the motor cortex and cranial
nerves that control movement of lips, jaw, tongue, soft palate and
vocal cords.

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Impaired Verbal Goal: Goal Met.
• The patient calls his Communication related to
mother “MaMaaarma” impaired cerebral circulation Short Term: The client was able to
(the only word he can After 3-5 days of nurse-patient interaction, the client will: understand problems in
utter on the 9th hospital Inference: - Demonstrate improved ability to express self and understand communication by
Brain swelling due to hemorrhage nodding after
day. others

Subjective: - Indicate an understanding of the communication problems. explanation.
Compromised cerebral perfusion
• slurred speech ↓ - Establishing method of communication in which needs can be
Damaged cells in the frontal lobe Nurse and patient
• impaired articulation of ↓ expressed. established method of
words Slurred speech - Use resources appropriately. communication in which
needs can be expressed
Nursing Interventions: as evidenced by using
hands and gestures to
Independent Interventions Rationale communicate needs (eg.
Have client produce simple Identifies dysarthria because pointing, thumbs-up with
sounds such as “sh”, “cat.” motor components of speech the use of the right
(tongue, lip movement, breath hand).
control) can affect articulation.
Provide notice at nurses’ station Allays anxiety related to Used resources appro-

A Case on Hemorrhagic CVA: Hypertension Stage II


and client’s room about speech inability to communicate and priately.
impairment. Provide a special fear that needs will not be met
call bell if necessary. promptly.
Provide alternative methods of Provides communication of
communication with client such needs based on individual
as reading mail, discussing situation or underlying deficit.
family happenings, etc. Provide
visual clues.
Talk directly to client, speaking Reduces confusion at having
slowly and distinctly. Use to process and respond to large
yes/no questions to begin with, amount of information at a
progressing in complexity as time.
client responds.
Anticipate and provide for Helpful in decreasing
client’s needs/ frustration when dependent on
others and unable to
communicate desires.
Encourage family and visitors to Reduces client’s isolation,
persist in efforts to communicate promotes establishment of
with the client. effective communication and
maintain sense of
connectedness with family.
Respect client’s pre-injury Enables client to feel esteemed
capabilities. because intellectual abilities
often remain intact.
Collaborative Intervention Rationale
Consult with/refer to speech Assesses individual verbal,
therapist. capabilities and sensory, motor
and cognitive functioning to
identify deficits/therapy needs.

A Case on Hemorrhagic CVA: Hypertension Stage II


Nursing Problem #9: Impaired emotional response (Psychosocial Integrity – Neurosensory)
Date Identified: 10th day

Focus Assessment Criteria Clinical Significance


1. Behavioral changes This will provide baseline data as to how deficits in perception will be dealt
with.

Cues Nursing Diagnosis Goal/s Evaluation


Subjective: Disturbed Sensory Goal: Goal/s Met.
The mother of the patient Perception related to
verbalized, “Kahapon psychologic stress (narrow Short Term The client has
kinakausap pa niya kami perceptual deficits caused After the 3-5 days of nurse – patient interaction, client will be able maintained/preserved his
pero ngayon ayaw na niya by anxiety) to: level of cognition and
magpahawak, biglang Inference - Maintain usual level of cognition and prevent further prevented further
naging bugnutin siya.” Disruption of blood supply to deterioration as evidenced
deterioration
Brain csused by hemorrhage
- Acknowledge changes in ability and presence of residual by: decreased restlessness

Objective: Imbalance between cranial vault involvement. and irritability (decreased
• Labile mood content pacing, able to have
↓ adequate periods of rest
• Irritable Nursing Interventions:
brain compression
• Restlessness ↓
and sleep)
• Does not obey commands Injury to brain parenchyma Independent Interventions Rationale
↓ Observe behavioral responses. Individual responses are He has acknowledged
Altered perfusion changes in ability and
↓ variable, but commonalities
Neurologic Deficit such as emotional lability, presence of residual
↓ lowered frustration, threshold, involvement through
Narrowed perceptual fields apathy and impulsiveness may nodding when SO/staff
↓ nurses are giving care and
Behavioral changes complicate care.
Assess vital signs. Provide baseline data. by pointing the extremity
Assess ability to speak and Provide Baseline data and to with weakness/paralysis.
respond to simple commands note degree of impairment
Continued verbal therapeutic To prevent sensory
communication, especially deprivation and provide
during procedure and/or auditory stimulation.
activities.
Speak in a calm, quiet voice, Clients have limited attention
using short sentences and span. These measures can help

A Case on Hemorrhagic CVA: Hypertension Stage II


maintain eye contact. client attend to
communication.
Reorientation to person, time, Prevent confusion and
place, events and staff as anxiety. In addition, it
necessary promotes familiarization.
Assess sensory awareness: Provide baseline data
visual acuity/hearing. Detect sensorineural
Impairment.
Provide undisturbed rest and Promote comfort and
sleep periods. minimize restlessness.
Provide safety measures: use of To promote safety and prevent
call light, side rails& blanket. injury.
Collaborative Intervention Rationale
Administer medications as Promote wellness and
ordered. minimize symptoms.
Facilitate stroke rehabilitation Promote activity and augments
program. senses.

Nursing Problem #9: Compliance to Therapeutic Regimen (Health Promotion Maintenance – Teaching/Learning)
Date Identified: 10th day

Focus Assessment Criteria Clinical Significance


1. Readiness and ability to learn and retain information A client or family failing to meet learning goals requires a referral for
assistance post discharge.

Cues Nursing Diagnosis Goal/s Evaluation


Risk for Ineffective Goal: Goal/s Met.
Therapeutic Regimen
Management related to Short Term The client or family
insufficient knowledge of Before discharge, the client or family will be able to: member exhibited
wound care, signs and - Explain surgical site care understanding on the
symptoms of complications, - Discuss management of activities of daily living discharge health
restrictions and follow up - Verbalize precautions to take for medication use teachings provided and
care. - State signs and symptoms that must be report to a health stated important things to

A Case on Hemorrhagic CVA: Hypertension Stage II


professional the nurse that must be
Inference considered in the
Disruption of blood supply to Nursing Interventions: recovery of stroke.
Brain csused by hemorrhage

Imbalance between cranial vault Independent Interventions Rationale
content Explain that mild headaches will Knowing what to expect can
↓ persist but gradually decrease. reduce client’s anxiety
brain compression
↓ associated with headache.
Injury to brain parenchyma Explain surgical site care: This knowledge enables client
↓ and family to participate in
Altered perfusion care.

Neurologic Deficit - Wear a cap after - This helps to protect
↓ bandages are removed. the incision site.
Narrowed perceptual fields - Hair can be shampooed - Hair re-growth
↓ after suture removal, indicates adequate
Teaching/Learning needs not yet met
↓ but avoid scrubbing wound closure.
Assess needs near the incision.
- Pat the incision dry. - Vigorous rubbing can
separate the wound
edges.
Explain the need to avoid hair Direct heat can burn the
dryers until hair has regrown. unprotected surgical site.
Teach the client no to do the These activities activate
following: Valsalva’s maneuver, which
- Hold breath impairs venous return by
- Strain during compressing the jugular veins
defecation and can increase ICP.
- Lift heavy objects
- Blow nose
- Cough, sneeze
Teach client to exhale during Exhaling causes the glottis to
certain activities (eg. defecating, open which prevents the
turning, or bending). Valsalva maneuver.
Teach client and family to watch Early detection enables prompt
for and report the following: intervention to prevent serious
- Drainage from surgical complications.

A Case on Hemorrhagic CVA: Hypertension Stage II


site, nose, or ear - Leakage may be CSF,
which represents an
entry route for
microorganisms.
- Increasing headaches
- Increasing headaches may point to
increasing ICP.
- These signs may
- Elevated temperature, indicate infection or
stiff neck, photophobia, meningitis.
hyperirritability
Discuss with client and family Evaluation of client’s personal
their perceptions of cognitive system is essential to plan
and behavior changes. interventions.
Depending on client’s and Family caregivers who are
family’s readiness for more more informed are prepared to
information, explain the help the patient compensate
following: (eg. mother).
- Decreased
concentration
- Difficulty with multiple
stimuli
- Emotional lability
- Easy fatigability
- Decreased libido
- Allusiveness
Discuss need to evaluate the The negative impact of deficits
effect of changes on the can be decreased by
following: identifying strategies to be
- Safety used at home.
- Self-care ability
- Communication
- Family system
Collaborative Intervention Rationale
Expand community services that Promote wellness and
may be indicated: minimize symptoms.
- Home health care

A Case on Hemorrhagic CVA: Hypertension Stage II


- Counseling
- Stroke Groups: Stroke
Society of the
Philippines, etc.
- PHC Stroke
Rehabilitation
- Speech Therapists and
PT/OT

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A Case on Hemorrhagic CVA: Hypertension Stage II
SECTION 7: DISCHARGE CARE PLAN

7.1: GOALS IN REHABILITATIVE AND PROMOTIVE NURSING CARE

Goal/s Objectives Process Outcome


1. Nurses will 1. Assist the 1. Nurses will 1. Performance
focus on patient towards initiate of simple ROM
early maximum rehabilitation upon exercises and
rehabilitation functional admission. ADLs by patient
and capacity. with minimal or no
discharge 2. Nurses will assist supervision.
planning. 2. Discuss the the patient in
care plan with performing ADLs 2. Maintenance
the patient and in collaboration of sexual function.
significant with other health
others. team members. 3. Performance
of simple nursing
3. Involve the 3. Nurses will procedures by
patient’s family educate patient on significant others
and significant alternative, with minimal or no
others in physiologically safe supervision from
decision making sexual practice (as nurses.
and the care indicated).
plan. 4. Compliance
4. Nurse will to treatment
include significant regimen and
others in providing adherence to
specific nursing outpatient follow-up
care, such as
provisions of 5. Active
hygiene, nutrition, participation of
turning, positioning, patient and family in
ROM exercises, and care plan.
other care.

5. Nurses will
ensure good
compliance to
medications and
provide options for
compliance to
outpatient follow-up

6. The nurse will


collaborate with the

A Case on Hemorrhagic CVA: Hypertension Stage II


family & significant
others in the care
plan.
2. Nurses will 1. Provide 1. Nurses will 1. Adherence of
assist in guidelines for provide a discharge patient and family to
sustaining and home care. care plan prescribed discharge
maintaining containing the care plan.
patient’s 2. Guide patient following:
healthy, in lifestyle a. Activity and 2. Compliance
productive modification exercise to alternative life-
lifestyle. based on identified b. Medication style.
risk factors. regimen
c. Symptoms 3. Motivation and
3. Assist patient needing stimulation of
in accepting and referral patient’s interest in
adapting to d. Prescribed diet self enhancing
disability. e. Medical follow- activities.
up schedule
f. Special care to be 4. Maximal patient
provided potential.

2. Nurses will 5. Active


facilitate participation of
referrals to family
community members.
resources.

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.

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7.2: DISCHARGE PLAN CHECKLIST

Plan and Outcome Target Nursing Interventions Date


Date: Achieved:
(_) The patient/family's 3rd (_) Assess needs of patient/family
discharge planning will Hospital beginning on the day of
begin on day of admission Day admission and continue
including preparation for assessment during
education and/or hospitalization.
equipment.
(_) Anticipated needs/services:
(_) On the day of
discharge, patient/family • Respiratory equipment
will receive verbal and • Hospital bed
written instructions • Wheel chair
concerning: • Walker
• Home health nurse
• Medications • Home PT/OT/ST
• Environment /
Exercise (_) Involve the patient/family in
• Treatment / the discharge process.
Rehabilitation
• Health Teachings (_)Discuss with physician the
• Outpatient Follow- discharge plan and obtain orders
Up if needed.
• Diet
• Spiritual / Sexual (_) Contact appropriate personnel
with orders.
• Other
(_)Provide written and verbal
instructions at the patient/family's
level of understanding.

(_) Verbally explain instructions


to patient/family prior to
discharge and provide
patient/family with a written
copy.

(_) Ascertain that patient has


follow-up care arranged at
discharge.

(_) Provide verbal and written


information on what signs and
symptoms to observe and when to

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contact the physician.

(_) Assess if any community


resources should be utilized (i.e.:
Home Health Nurse), and contact
appropriate personnel.

(_) Document all discharge


teaching on Discharge Instruction
Sheet and Nursing notes.

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.

Medications Dosage/Route Timing Actions Precautions


Aprovel 300 mg/tab 9 am Medications that
(oral) can lower your
Catapress 75 mg/tab (oral) 9 am, 6 pm BP PRN for BP ≥160
Norvasc 5 mg/tab (oral) 9 am, 6 pm
Omeprazole 20 mg/cap 9 pm To reduce risk of
gastric ulcer
Nursing considerations seen at the Medical Management (Pharmacologic Therapy)

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ENVIRONMENT/ EXERCISE

Promotion of a Safe and Effective Care Environment


Environmental modifications at home will be done such as:
• Prior to discharge, demonstrate together with the physical therapist, the proper
and approved exercises for the patient.
• Remove unnecessary clutter and possibly hazardous appliances or furnitures to
provide safer environment and clearer pathways for mobility of the patient during
ambulation and exercise.
• Reduce or control possible stimuli in the patient's immediate environment to
promote rest and relaxation
• Store utensils and other household objects that have sharp edges in proper and
safer places to avoid accidental contacts. Secure appliances that may be prone to
tipping over.
• Instruct the client to use non-skid slippers.
• Provide safety handrails or grips in the comfort room or any other areas in the
home that may be usually wet and become slippery.
• Relocate Patient’s room to the lower floor if applicable.
• Provide inclines in places of elevation as in a flight of stairs or a raised part of the
flooring.
• Provide comfortable temperature.
• Observe positional precaution to prevent increase in intracranial pressure when
sitting or lying down in any house furniture.

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

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1. Turn to sides every two hours to avoid skin irritation and respiratory
complication.
2. Do not hesitate to ask for assistance in performing any activity.
3. In getting from the bed, make sure to dangle leg first for a few minutes to avoid
dizziness.

Use of Assistive Devices


Upon discharge assistive devices may be used initially immediately for patient comfort,
resumption of ADL’s and also to generally improve the patients confidence regarding
recovery

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.

Characteristic Walker Crutches Canes


Stability Very good Good Least stable
Walking speed Slowest Slow Can be fast
Use on steps None Training needed Easy
Strength of arms required
Normal Moderate strength Normal
for use
Number of hands required
2 Usually 2 Usually 1
for use
Requires
Possibility of carrying
attachment of None Possible
objects
basket
Relatively Least
Cost Most expensive
inexpensive expensive

HYGIENE

Maintain cleanliness at all times


- Take a bath daily (the incision line should be tightly covered with a plastic
- Practice good oral hygiene by regularly brushing your teeth
- Keep finger/toe nails properly trimmed
- Make sure that the perineal area is cleaned daily.
- Wear clean and comfortable clothing and footwear.

A Case on Hemorrhagic CVA: Hypertension Stage II


OUT PATIENT FOLLOW UP

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.

A number of follow-up services have been evaluated including:


• social work;
• specialist nurse support;
• the Stroke Transition After Inpatient Care (STAIR) program/Stroke Rehabilitation
Program of the PHC
• stroke family care worker;
• mental health worker;
• home visits by physician or physiotherapist; and
• stroke family support organizers

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

The 2006 AHA Guidelines recommend a well-balanced diet containing ≥5 servings of


fruits and vegetables per day to reduce stroke risk. The DASH diet, which emphasizes
fruit, vegetables and low-fat dairy products and is reduced in saturated and total fat, also
lowers BP and is recommended (Class I- A).

Some pointers to observe in planning meals:


1. Choose freely from fruits, vegetables, cereals, root crops, bread, dried beans and
nuts.
2. Eat fish as main dish at least three times a week.
3. May eat chicken meat as a substitute to fish at least three to four times a week.
4. For other kinds of meat, use lean parts and prepare as boiled, baked, broiled, or
A Case on Hemorrhagic CVA: Hypertension Stage II
roasted. Trim off any visible fat.
5. Use evaporated filled milk or skimmed milk instead of whole milk and avoid
whole milk products such as cheese, butter, cream, etc. Use margarine made with
allowed vegetable oil.
6. Use unsaturated fats and oils such as corn oil, soybean oil, peanut butter, etc.
7. Limit eggs to only three per week.
8. Avoid rich desserts such as cakes, pastries, cookies, pies, ice cream and
chocolates.
9. Always read the nutrition labels of packaged/processed foods.

Food Selection Guide


Food Group Allowed Restricted/Avoided
Fats and oils In prescribed amounts: Olive, Fats and oils from animal foods,
canola, corn, soybean, palm, butter. Hydrogenated vegetable
sunflower and peanut oils. oils (e.g., margarine, lard,
Coconut oil. shortening, spread)

Meat and chicken fat drippings


used for sauces, bacon fat,
“chicharon”
Meat, fish, poultry, Eat frequently*: Fish (fresh, Fish roe, crabfat “aligui” shrimp
eggs, milk, dry beans frozen or canned in water, head, oyster, clams.
tomato or vinegar); chicken
breast without skin or fat. Fatty meats: cold cuts, canned
Dried beans, lentils, fresh or or frozen meats, sausages.; fatty
frozen sweetpeas; “vege- poultry with skin; internal
meat”, tokwa, taho, tofu & organs (liver, kidney, heart,
other bean products; tripe, sweetbreads)

Eat occasionally**: Very lean, Whole milk/cow’s milk and


well-trimmed cuts of beef, cheese made from whole milk
pork, veal, lamb; crabmeat,
shrimp without head; whole
eggs up to 3 pieces per week,
eggwhite as desired, may be
cooked in allowed fat;
Skimmed milk or low fat milk
or cheese.
Vegetable All vegetables prepared Buttered, creamed, fried
without fat or with allowed fats vegetables in restricted fats or
only. cooked with fatty meat and
sauces.
Eat frequently*: Green leafy
and yellow vegetables (they
are good sources of
betacarotene, vitamin C,

A Case on Hemorrhagic CVA: Hypertension Stage II


calcium, iron and dietary fiber
among others)
Fruit All fruits; adjust fat allowance Avocado in moderation (due to
when using avocado. its
high fat content)
Eat frequently*: Vitamin C-
rich fruits and deep colored
fruits
Rice, corn, All cereals, roots/tubers, Croissants, muffins, crackers,
rootcrops, noodles, certain noodles/pasta, wheat biscuits, waffles, pancakes,
bread and cereals bread, “pan de sal” except doughnut, rolls made with
those restricted whole egg, butter, margarine or
fat of unknown composition
Eat frequently*: Oatmeal, cold
cereals, corn and Fresh mami or miki noodles
sweet potato
Potato chips, french fries,
popcorn
Desserts Fat-free/low-fat/light dessert. Rich dessert especially those
Fresh or canned fruits in light made with cream, butter, solid
syrup only. Plain cakes with no shortening, lard, whole egg,
icing (angel or sponge cakes), chocolate cookies and pies
meringue, yogurt, sherbet. made from cream fudge, ice
cream; pastillas from whole
milk, yema
Soups Fat-free broths made from Cream soups, fatty broth or
meat or chicken stock. Soups stock
prepared with skimmed/low-
fat milk.
Beverage Coffee (not more than 3 cups Soda fountain beverages such as
black), decaffeinated coffee, milkshake, malted milk and
tea, carbonated beverages in chocolate drinks.
moderation.
Alcoholic drinks in moderation.
Alcoholic drinks: not more
than 1 jigger for women and
not more than 2 jiggers for
men.
Miscellaneous Nuts (peanuts, walnut, almond, Sauces and gravies with
cashew, pili, etc.) preferably restricted fats or milk; regular
boiled, roasted/baked, mayonnaise.
consume in moderation.
Butter-dipped foods.
Non dairy cream in
moderation. Packed dinners or instant foods
of unknown fat content.

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Spices and seasonings in
moderation. Sauce made with
allowed fats and skimmed mil,
vinegar, pickles, mustard,
catsup, banana sauce.
*Eat frequently – at least 4 to 5 times a week.
**Eat occasionally – at most, once a month.

SPIRITUAL / SEXUAL / STRESS MANAGEMENT

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.

Tips for Reducing Stress


The following tips for reducing stress are for both caregivers and stroke survivors.
• Take stroke recovery and care giving one day at a time and be hopeful.
• Remember that adjusting to the effects of stroke takes time. Appreciate each small
gain as you discover better ways of doing things.
• Care giving is learned. Expect that knowledge and skills will grow with
experience. Experiment. Until you find what works for you, try new ways of
doing activities of daily living, communicating with each other, scheduling the
day, and organizing your social life.
• Plan for "breaks" so that you are not together all the time. This is a good way for
family and friends to help on occasion. You can also plan activities that get both
of you out of the house.
• Ask family members and friends to help in specific ways and commit to certain
times to help. This gives others a chance to help in useful ways.
• Read about the experiences of other people in similar situations. Your public
library has life stories by people who have had a stroke as well as books for
caregivers.
• Join or start a support group for stroke survivors or caregivers. You can work on
problems together and develop new friendships.
• Be kind to each other. If you sometimes feel irritated, this is natural and you don't
need to blame yourself. But don't "take it out" on the other person. It often helps
to talk about these feelings with a friend, rehabilitation professional, or support
group.
• Plan and enjoy new experiences and don't look back. Avoid comparing life as it is
now how it was before the stroke.

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SECTION 8: REFERENCES

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.

All Refer.com . Retrieved on September 19, 2009 from http://health.allrefer.com/health.

American Heart Association. Retrieved on September 18, 2009 from


http://www.americanheart.org

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.

Brott T, Adams H. Olinger CP, et al. Measurements of acute cerebral infarction: a


clinical e Bronner L, et al. Primary Prevention of Stroke. The New England Journal of
Medicine. 23 November 1995. Vol. 333: 1392-1400. Retrieved on September 20, 2009
from http://content.nejm.org/cgi/content/short/333/21/1392.

Smeltzer, S. et al. 2008. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.


11th edition. Lipincott Williams & Wilkins.

Carpenito-Moyet, L. 2004. Nursing Care Plans and Documentation.4th edition. Lipincott


Williams and Wilkins.

Chua, Philip S. Heart to Heart Talk. Cebu Cardiovascular Center. Retrieved on


September 18, 2009 from http://www.cdc-cdh.edu/hospital/cardio/chua173.html.

Davis’s Drug Guide, FA Davis Company. Retrieved on September 20, 2009


http://www.Drugguide.com

Department of Health. Retrieved on September 19, 2009 from


http://www.doh.gov.ph/press/09271999.pdf.

Doenges, M., Moorhouse, M. & Murr, A. 2006. Nursing Care Plans: Guidelines for
Individualizing Client Care Across Life Span. 7th edition. FA Davis Company.

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Fischbach, F. 2004. A Manual of Laboratory and Diagnostic Tests. 7th edition. Lippincott
Williams & Wilkins.

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.

Heart Attacks/Sudden Cardiac Death. 2002 American Heart Association. Retrieved on


September 19, 2009from http://www.americanheart.org/presenter.jhtml?
identifier=3000996

Internet Stroke Center. Retrieved on September 20, 2009 from


http://www.strokecenter.org/pat/ais.htmxamination scale. Stroke 1989;20:864-870.

Hand P, Kwan J, Lindley R, et al. Distinguishing a stroke and mimic at the


bedside. Stroke 2006;37:769 – 775.

Jon Zonderman & Rita Doyle. 2006. Springhouse Nurse’s Drug Guide 2006 Seventh
Edition Lippincott Williams and Wilkins.

Kidwell CS, Saver JL, Mattiello J, et al. Diffusion perfusion MR evaluation of


perihematomal injury in hyperacute intracebral hemorrhage. Neurology 2001;57:1611-
1617.

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.

Medline Plus: Hemorrhagic Stroke. 2008. Retrieved on 20 September 2009 from


http://www.nlm.nih.gov/medlineplus/ency/article/000761.htm

MIMS Philippines. Retrieved on September 20, 2009 http://www.mims.com/index/aspx

Nettina, S. 2001. The Lippincott Manual of Nursing Practice. 7th edition. Lippincott
Williams & Wilkins.

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Philippine Council for Health Research and Development: Stroke Alert. 2006. Retrieved
on September 20, 2009 from http://www.pchrd.dost.gov.ph/news-archive/225.html

Powers WJ, Zazulia AR, Videen TO, et al. Autoregulation of cerebral blood flow
surrounding acute (6-22hours) intracerebral hemorrhage. Neurology 2001; 57:18-24.

Qureshi A, Wilson D, Hanley D, Traystman R. No evidence for an ischemic penumbra in


massive experimental intracerebral hemorrhage. Neurology 1999;52:266-272.

Rankin J. Cerebral vascular accidents in patients over the age of 60. Scot Med J
1957;2:200-215.

Ropper A, Daryl G, Diringer M et al. Neurological and Neurosurgical Intensive Care.


4th ed. USA: Lippincott Williams & Wilkins; 2003.

RxList – The Internet Drug Index. Retrieved on September 20, 2009


http://www.rxlist.com/script/main.hp.asp

Schellinger P, Fiebach J, Hoffman K, et al. Stroke MRI in intracerebral hemorrhage: is


there a perihemorrhagic penumbra? Stroke 2003; 34:1647-1680.

Stroke Society Philippines Handbook. Retrieved on 18 September 2009 from


http://www.strokesocietyphil.org/files/SSPHandbook.pdf

The Philippine Star. 2009. Retrieved on 19 September 2009 from


http://www.philstar.com/Article.aspx?articleId=477921&publicationSubCategoryId=80

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.

A Case on Hemorrhagic CVA: Hypertension Stage II


SECTION 9: COPY OF PHYSICIAN’S CONSENT

Philippine Heart Center


East Avenue, Quezon City
Department of Nursing Education and Research

September 10, 2009

James O. Ho, M.D.


Adult Cardiology Specialist
Philippine Heart Center
East Avenue, Quezon City

Dear Dr. Ho:

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,

Angeline Marie A. Zulueta, RN


Staff Nurse – Petal 3D
Group 5 Representative, Critical Care Course

Noted:

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A Case on Hemorrhagic CVA: Hypertension Stage II