A NURSING CASE ANALYSIS ON

HEMORRHAGIC STROKE

In Partial Fulfillment of the

Requirements in NCM-216 RLE
PC/OR NURSING ROTATION

Submitted to:
EREIN THERESE B. ACERO, RN, MN
Clinical Instructor

By:
Khrisha Nicole U. Abella, St. N
Jerah Mae N. Dechavez, St. N
Vince Lenard F. Mancera, St. N
Tanya Angela M. Quinones, St. N
Princess Kryzia H. Seroyla, St. N

BSN-3C Group 3 Subgroup 1

April 4, 2021
 2

CRITERIA
Introduction/Objectives---------------------------------------------------------------- ___/10%
Pathophysiology:
Etiology------------------------------------------------------------------ ___/10%
Symptomatology------------------------------------------------------- ___/10%
Disease Process-------------------------------------------------------- ___/5%
Management----------------------------------------------------------- ___/15%
Prognosis---------------------------------------------------------------- ___/10%
Discharge Planning--------------------------------------------------------------------- ___/10%
Nursing Theory-------------------------------------------------------------------------- ___/10%
Review of Related Studies------------------------------------------------------------ ___/10%
References--------------------------------------------------------------------------------- ___/5%
Promptness--------------------------------------------------------------------------------- ___/5%
TOTAL: ____/100%
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Table of Contents

Cover page …………………………………………………………………………......i

Criteria ……………………………………………………………..……………………ii
Table of Contents …………………………………………………………………..….iii
I. Introduction ......................................................................................... 4
II. Goals and Objectives ......................................................................... 5
III. Pathophysiology ................................................................................. 6
A. Etiology .......................................................................................... 6
B. Symptomatology ......................................................................... 12
C. Disease Process ......................................................................... 15
a. Diagram ...................................................................... 15
b. Narrative ..................................................................... 23
D. Diagnostic/Laboratory Confirmatory Test .................................... 25
a. Physical Assessment ................................................... 45
E. Management ............................................................................... 52
a. Medical Management .................................................. 52
b. Surgical Management .................................................. 73
c. Nursing Management .................................................. 76
IV. Discharge Planning .......................................................................... 83
V. Prognosis ......................................................................................... 86
VI. Nursing Theory ................................................................................. 87
VII. Review of Related Literature ............................................................ 91
VIII. References ....................................................................................... 98
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I. Introduction
The operating room is a complex environment in which individual team
members perform specific tasks according to their roles. Typically, with multiple
functions occurring simultaneously is a demanding environment in which to both
work and learn (Barnum, et al., 2017). Nurses play a critical role in ensuring the
health and safety of patients. Operating room nursing is a specialized field in which
nurses provide quality care to patients before, during, and after surgery. The
student nurses will further enhance their knowledge of clients with associated
problems in the nervous system. As a result, this branch of nursing is essential in
preparing students to work as perioperative nurses in the future (Royal College of
Nursing, 2020).
A stroke is a medical emergency. Stroke can be either ischemic or
hemorrhagic. Ischemic stroke is due to loss of blood supply to an area of the brain.
Hemorrhagic stroke is less the common type. According to Unnithan and Metha
(2021), Hemorrhagic stroke is due to bleeding into the brain by the rupture of a
blood vessel. Hemorrhagic stroke may be further subdivided into intracerebral
hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Hemorrhagic stroke is
associated with severe morbidity and high mortality.
According to the World Health Organization (2019), 15 million people suffer
stroke worldwide each year. Of these, 5 million dies, and another 5 million are left
permanently disabled. About 13% of stroke is of hemorrhagic type. According to
the Global Burden of Disease (GBD) study 2010, there were about 5.3 million
hemorrhagic stroke cases, out of which about 80% occurred in low and middle-
income countries. Over 3 million deaths occurred from hemorrhagic stroke (Habibi-
koolaee, et al., 2018). Nationally, stroke is the Philippines’ second leading cause
of death. It has a prevalence of 0.9%, ischemic stroke comprises 70% while
hemorrhagic stroke comprises 30% of it (Navarro, et al., 2016). Locally, the
Department of Health has not issued any recent statistical data posted online.
Nevertheless, one of the leading causes of morbidity in the city is poorly controlled
hypertension which is the most common cause of hemorrhagic stroke.
 5

There are implications that this case study can bring which also be
beneficial to us as student nurses. As future medical professionals, nurses must
be capable, educated, and trained to think critically, make nursing judgments
quickly, and most important to show empathy to the patients. Firstly, for nursing
practice, this will act as a reference in learning how to provide appropriate nursing
care or more specifically, when taking care of a client with a similar condition, to
administer particular strategies. Secondly, in nursing education, this case study
will provide nursing knowledge about hemorrhagic stroke, including its
management and treatment. Lastly, this case study will provide new information to
improve nursing research as this could be a basis for future research papers
associated with this topic.

II. Objectives
General Objectives
At the end of the 4-week clinical rotation, the student nurses of BSN 3C
Group 3 Subgroup 1 will be able to formulate a comprehensive case analysis about
hemorrhagic stroke, which can contribute to the improvement of knowledge and
skills of the student nurses and allows them to apply the principles and theories
specified by the study into the clinical setting.
Specific Objectives
In the span of 4-week for the PC/OR clinical rotation, the following will be
achieved:
a. Gather all the necessary data about hemorrhagic stroke that are needed to
be analyzed;
b. Present the concept and the statistics of the disease, and nursing
implications through the introduction;
c. Formulate general and specific objectives of the case analysis
d. Determine the etiology of Hemorrhagic stroke
e. Trace the pathophysiology of the disease process and symptomatology
presented in the schematic diagram;
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f. Determine the possible diagnostic or laboratory confirmatory tests for

clients with hemorrhagic stroke based on its signs and symptoms with its
rationale and clinical significance;
g. Search for the appropriate management for the diagnosis;
h. Identify the prognosis if treated or not;
i. Generate a discharge plan using METHOD;
j. Relate certain nursing theories for the client’s case;
k. Gather a certain review of related studies to support hemorrhagic stroke;
l. Formulate nursing care plans appropriate for clients with hemorrhagic
stroke;
m. Cite books, references, and the internet websites used as sources of
information; and
n. Present our case study through a zoom meeting.

III. PATHOPHYSIOLOGY
A. Risk Factors
PREDISPOSING FACTORS

FACTORS RATIONALE

Age Age is a relevant factor for hemorrhagic strokes as it affects in

numerous ways such as it changes functions of the
cardiovascular and central nervous system. It also increases
the risk of various chronic health conditions and comorbidities
like hypertension, diabetes, and anticoagulant medications
which contribute to the possible existence of hemorrhagic
stroke. It was stated by the National Center for Chronic Disease
Prevention and Health Promotion (2021) that as a person gets
older, the individual is more likely to have a stroke. It increases
after the age of 55 years old and doubles every 10 years.
 7

Although stroke is more common among older adults, a number

of people younger than 65 years old also have strokes.

Gender Both men and women are at risk of developing hemorrhagic

stroke. However, women suffer a stroke at older ages making
them vulnerable to die from stroke than men (Texas Heart
Institute, n.d.). Stroke is prevalent in the women population that
men and women of all ages are more likely to die early from
stroke (NCCDPHP, 2021).

Hormonal differences Estrogens are known to be cardioprotective in several ways. In

in men and women various studies, estrogen inhibits atherosclerotic plaque
formation by suppressing smooth muscle proliferation,
decreasing lipoprotein sequestration and oxidation as well as
preventing the formation of platelet thrombi. While, androgens
increase the proliferation of smooth muscle cells, which may
accelerate the progression of atherosclerosis, which may lead
to stroke (Galati, A., King, S. L., & Nakagawa, K.2015).

Race and Ethnicity According to Texas Heart Institute (n.d.), African- American
race have an increased risk of stroke than other populations.
While a study conducted by Mozzafarian D, Benjamin EJ, Go
AS, et al. (2016) mentioned that Blacks, Hispanics, American
Indians, and Alaska natives may be more likely to develop a
stroke than Non-Hispanic whites and Asians. Black people
have double the risk of having the first stroke than Whites, and
they are also more likely to die.

Family/ Heredity Members of the family share genes, behaviors, lifestyles, and
surroundings that may affect their health and disease risk. The
risk of stroke may be higher in some than in others. People with
a family history of stroke also likely to share common
 8

environments and other potentials that increase their risk

(CDC, 2021). Genetic also plays an important role in
hypertension, stroke, and other related conditions like sickle
cell disease.

Cerebral Amyloid Amyloid deposits can build up in the blood walls of

Angiopathy the brain, called amyloid angiopathy. The buildup of amyloid in
the blood vessels can cause to deteriorate over time,
eventually breaking down and bleeding (Vega, 2020).
Additionally, amyloid has also been linked to inflammation, is
the way the body deals with injury or infection. In
addition, particularly unnecessary or excessive inflammation
is a stroke.

PRECIPITATING FACTORS

FACTORS RATIONALE

Cerebral Aneurysm An aneurysm may increase in size, causing the arterial wall to
weaken. If an aneurysm bursts, uncontrolled bleeding can
occur (Medical News Today, 2019).

Arteriovenous In rare cases, intracerebral hemorrhage may occur due to a

Malformation leaky arteriovenous malformation, which is abnormal blood and
with a weak wall that connects one artery and one vein. This
weak blood vessel is present from birth, it is larger than a
capillary and blood may enter it at high pressure, possibly
causing the AVM to stretch or leak (Medical News Today,
2020).
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Hypercholesterolemia The level of high-density lipoprotein cholesterol is positively

associated with the risk of intracerebral hemorrhage.
Hyperlipidemia is caused by a diet's excessive intake of
cholesterol resulting in high blood lipid levels. With a high
cholesterol level, you can develop fatty deposits in your blood
vessels. Eventually, these deposits develop, making it difficult
for enough blood to flow through your arteries. Sometimes
these deposits can break suddenly and form a clot which
causes a heart attack or stroke (Mayo Clinic, 2019).

Diabetes Mellitus Diabetes means you have too much sugar in your blood, which
can make you more likely to have a stroke. This is because
having too much sugar in your blood damages the blood
vessels. This can make the blood vessels stiff and can cause
fatty deposits to build up (Medical News Today, 2020).
According to Chen, R., Ovbiagele, B., & Feng, W. (2016),
diabetes is a well-established risk factor. It can cause
pathological changes in the vessels in various places and can
lead to a stroke if the brain vessels are directly affected. People
with diabetes are more susceptible to hypertension, myocardial
infarction, and high cholesterol than people with diabetes. Even
prediabetes has been linked to a risk of stroke.

Hypertension According to American Heart Association (2021), high blood

pressure damages arteries throughout the body, conditions
where they can burst or easily blocked. The weakening of the
cerebral arteries, resulting from high blood pressure, puts you
at a much higher risk of stroke which is why management of
high blood pressure is essential to reduce your risk of having a
stroke. High blood pressure can also make a stroke more likely
to bleed. This can happen if you have an aneurysm in your
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brain. If this is damaged over time by arterial, it may leak or

burst, causing the brain to bleed.

Sleep Apnea Obstructive sleep apnea or OSA is a disease that involves a

repetitive pause in breathing during sleep. During sleep, when
the patient's breathing stops, prevents the body from getting
the necessary oxygen, which can low oxygen level. To
compensate, the body will increase blood flow, resulting in an
abnormal increase in blood pressure to the brain.

Blood Disorders or Diseases related to blood clotting make a person prone to the
Medications formation of blood clots, resulting in ischemic cerebrovascular
diseases. Bleeding disorders cause excessive bleeding, which
can cause hemorrhagic strokes.

Obesity Obesity is excess body fat. Obesity is linked to higher levels of

cholesterol and triglycerides and to lower levels of "good"
cholesterol. Obesity can also cause high blood pressure and
diabetes. Other than that, being overweight or diagnosed with
obesity based on the body mass index causes an increase in
high blood pressure or hypertension and fatty deposits in the
bloodstream contributing to the rupture of the artery.

Atrial Fibrillation If a blood clot forms in your heart, there is a risk that it will travel
through your circulation to the brain. If a clot blocks any of the
arteries leading to the brain, it could cause a stroke or TIA. If
you have atrial fibrillation, you are five more likely to have a
stroke and atrial fibrillation accounts for around 20% of all
strokes in the UK.

Physical Activity Not getting enough physical activity can lead to other health
outcomes which may increase the risk of stroke. These health
problems include obesity, high blood pressure, high
 11

cholesterol, diabetes. Regular physical activity can reduce your

risk of stroke.

Diet (High Fat, High Diets high in saturated fats, trans fat, and cholesterol have been
Cholesterol) linked to stroke and related conditions, such as heart disease.
Additionally, consuming too much salt in the diet can cause
blood pressure.

Use of cocaine and Cocaine can cause is internal bleeding, particularly in the brain.
other This is due to the dramatic and sudden increase in blood
sympathomimetic pressure. In addition, cocaine use can cause sudden or
drugs progressive spasms of the blood vessels in the brain.
Sympathomimetic drugs mimic or stimulate the adrenergic
nervous system, which can raise blood pressure to alarming
levels.

Smoking Smoking increases the risk of stroke. It can damage the heart
and blood vessels thus increasing your risk of stroke. The
nicotine in cigarettes increases blood pressure and the carbon
monoxide smoke reduces the amount of oxygen your blood can
carry. Even if you don't smoke, breathing second-hand smoke
can make you more likely to have a stroke.

Alcohol Use Drinking too much alcohol can increase blood pressure and the
risk of stroke. It also increases the levels of triglycerides, a fatty
form in your blood that can harden your arteries. Women should
have no more than one drink a day and men should have no
more than two drinks a day.
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B. Symptomatology

SYMPTOMS RATIONALE

Sudden weakness, Depending on what type of stroke it is, once an area is

Paralysis, or Numbness damaged in the brain, there is an effect on various types
of muscle groups and changes will range from minor to
major influence. This happens when the stimuli cannot
travel properly from the brain to the different muscles of
the body, causing paralysis and muscle weakness.
Weakness also contributes to movement and balance
problems (Healthline Media, 2020).

Dysphagia The damage to your brain caused by stroke will cause

trouble with some functions including eating and
swallowing. Hence, if the muscles in the mouth, tongue,
and throat are incapable of directing food down to the
esophagus, the liquid or food can get into the airway.

Vision problems Vision changes may occur if the parts of the brain that
communicate with the eyes are damaged. These
problems can include loss of vision, the one side, or parts
of the field of vision problems with moving the eyes. There
may also be having processing problems, which means
that the brain is not receiving information from the eyes.

Difficulty walking Foot drop is a common type of paralysis that makes it

difficult to lift the front part of the foot. This can cause you
to drag your toes on the floor when walking or bend at
knee level to lift the foot higher to prevent it from dragging.
The problem is usually caused by nerve damage can
improve with rehabilitation.
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Difficulty Breathing/ Coma Once a stroke damaged the brain stem which where the
body’s vital functions are located such as heartbeat,
breathing, and body temperature, it will now cause
breathing problems. Hemorrhagic stroke is more likely to
result in coma or death.

A sudden, severe When the blood flows into the cerebrospinal fluid, it puts
headache (Thunderclap) pressure on the brain, causing an immediate headache.
In the days immediately following the bleeding, a
chemical caused by the blood clot around the brain cause
spasms in the cerebral arteries near the area, which also
causes symptoms such as severe headache, dizziness,
and loss of balance (Harvard Health Publishing, 2019).

Loss of Consciousness The loss of consciousness at the time of bleeding is by

global ischemia, resulting from a lack of perfusion
pressure during an aneurysm rupture. The duration of
loss of consciousness could reflect the severity of these
perfusion deficits and ischemia (Wang, J., et. al., 2017).

Nausea and Vomiting According to Stoppler (2019), nausea and vomiting are
present once the cerebellar artery is affected which will
prohibit the supply of blood to the cerebellum. In addition,
it might be a common symptom if there is hemorrhagic
stroke due to excessive blood loss, bleeding, and pain in
the brain occur.

Dizziness Dizziness is present once there is an inadequate blood

supply to the brain (Healthline Media, 2020).

Confusion Confusion occurs when there is a Blockage of the normal

cerebrospinal (CSF) circulation which can cause
enlargement of the ventricles, thus, causing confusion,
 14

lethargy, and loss of consciousness (Mayfield Brain &

Spine, n.d.).

Seizure People are more likely to have a seizure if they have had
a bleeding stroke. Seizures may also be more likely if a
person has had a severe stroke or stroke in the cerebral
cortex, the large outer layer of the brain where vital
functions such as movement, vision, and emotions take
place (Stroke Association, 2020).
 C. Schematic Diagram

Predisposing Factors: Precipitating factors:

Age • Cerebral Aneurysm
Gender • AVM
Hormones • Hypercholesterolemia
Race & Ethnicity • DM
Family/ Heredity • Hypertension
Cerebral Amyloid • Sleep Apnea
Angiopathy • Blood Disorders/
Medications
• Obesity
• Atrial Fibrillation
Etiology • Physical Activity
• Diet
• Drugs, Smoking &
Alcohol

Intracerebral Subarachnoid

Primary Secondary A

Unknown Hypertension B
Drugs

Cerebral Traumatic
Amyloid Accelerates Vasospasm Injury
Angiopathy Arteriosclerosis
of large arteries
Increase Sudden
Blood increase in
Presence of pressure intravascular
proteins pressures
called hydrostatic
amyloid in pressure
the pushes Shears in
Brain proteins out blood
of blood direct damage to
vessels
vessels small veins or
arteries
 16
Amyloid deposits Proteins are scarring inside the A
build up on the pushed into the blood vessels
walls of blood interstitial space
vessels in the within the blood
brain vessels Arteriovenous
Blood vessels malformation
are weakened

Blood vessels Eosinophil and

are weakened fibroid deposits in Formation of
the brain blood abnormal
vessels tangled blood
(Lipohyalinosis) vessels

Blood vessels
are weakened Microaneursym Rapid blood
Blood vessels (Charcot- flow
became stiff and Bouchard through the
brittle Aneurysm) B artery
(Hyaline
arteriosclerosis)

Aneurysm Dilation of blood

vessels due to
continuous
pressure
Rupture of the Weakening and
Weakened Degeneration
Blood of a Blood
Vessels Vessel Wall
Weakening
and
thinning of
Aneurysm blood
Intracerebral Subarachnoid
expands due to vessels over
Hemorrhage Haemorrhage
increasing time
blood pressure

Intraparenchymal
Intraventicular Further
weakening of
the
Vessel Walls

C
 17
Headache Management:
• Consult physician to
detect cause of
headache
• Administer
analgesics such
acetaminophen
• Provide adequate
rest.

Loss of Management:
consciousness • Use of mechanical Diagnostic Tests:
ventilator for • MRI/ CT
oxygenation SCAN
• Give medications • EEG
such • Lumbar
as antihypertensive Puncture
medication and beta PA:
blockers. • GCS <15
• Encourage the • Pulse rates:
RR - >20 CPM
Management: CR & PR - <60
Nausea and BPM
• Acupuncture /
Vomiting
Acupressure
• Anti-histamine
• Small frequent
feeding

Mass of
blood
If bleeding continues forms and Formation of
grows blood clots

Blood goes into

Hemorrhage the Vasospasm of Lodges unto other
enlargement ventricles Tissues and cerebral arteries
Arteries
Intraventicular S/S: Management:
,
Obstruction of Dizziness • Consult
Subarachnoid CEREBRAL Headache physician
CSF
expansion
passageway HYPOPERFUSION Confusion • Pain
relievers
• Rest and
Comfort
 Impaired distribution Diagnostic Tests:
• Blood Tests 18
Accumulation of
oxygen and glucose • CT Scan
of CSF in • MRI
the ventricles • ECG
PA:
• GCS <15
Tissue hypoxia
• Vital signs
and
beyond
cellular starvation
Hydrocephalus normal value: RR;
below normal:
pulses
Ventricles dilate • Altered LOC
behind the
point of
obstruction Cerebral
Ischemia

Increased
Increased ICP
Anaerobic
Intracranial
metabolism by
Pressure
mitochondria

S/S: Production of
Headache E oxygen free
Nausea & radicals and other
Vomiting reactive
Restlessness Compression oxygen species
and irritability of
Fever brain tissues
Confusion/Lo
ss of Activates
alertness enzymes that
Further digest cell
Speech Increases
problems: proteins, lipids,
pressure to and nuclear
Ataxia brain
Pupillary/ material
tissues, cells
Vision and
changes blood vessels
Lethargy Total Depletion
Seizures of Energy in
cells and tissues
F

Death of brain Reperfusion

Bleeding into Hemorrhagic
tissues and
dead tissue Conversion
cells
 S/S:
Management Muscle weakness Diagnostic Tools:
19119
Headache Changes in vision Electroencephalogram
• Consultation Sensory loss Lumbar puncture
• Analgesics Dizziness/Loss of CT Scan/MRI
• Rest balance FAST test
Nausea and Vomiting Change in LOC
• Consultation Facial droop
• Anti-histamine Aphasia
• Small frequent feeding Management:
Restlessness and Irritability • Craniotomy, Stereotactic
• Oxygen therapy Aspiration, Aneurysm
• Provide comfort clipping, Endovascular
Fever coiling
• Consult doctor to detect • Antihypertensives and
Diagnostic Tools:
cause of fever Calcium Channel Blockers
• MRI
• Administer acetaminophen • Nursing management:
• CT SCAN
• Tepid Sponge bath - Rest and Comfort
• Blood Tests
Confusion - ROM exercises
• EEG
• Consultation - Provide safe
• ECG
• Rest and Comfort environment
Speech problems: Ataxia - Wear anti-embolic
• Speech therapy stockings
Vision changes
Lethargy
• Consult doctor for
underlying cause to treat it.
• Provide rest.
Seizures
• Administer anticonvulsant
or benzodiazepines.
• Assess physical
examination and mental
health status.
 Impaired perfusion and
F function 20

Middle Anterior Posterior Internal Carotid Vertebrobasilar Anteroinferior Posteroinferior

Cerebral cerebral artery CerebraI Artery Artery System Cerebellar cerebellar
Artery

Lateral Frontal Lobe Occipital lobe; Branches into Cerebellum and Cerebellum Cerebellum
hemisphere, anterior and ophthalmic, brain stem
frontal, medial portion of PCA, anterior
parietal and temporal lobe choroidal, ACA,
temporal MCA
lobes, basal
ganglia

Sx: Sx: Sx: Sx:

Contralateral Contralateral Mild contralateral
hemiparesis or hemiparesis, contralateral hemiparesis
hemiplegia, foot and leg hemiparesis, with facial
unilateral deficits greater intention asymmetry,
neglect, than the arm, tremor, diffuse contralateral
altered foot drop, gait sensory loss, sensory
consciousness disturbances, pupillary alterations,
, homonymous contralateral dysfunction, homonymous
hemianopsia, hemisensory loss of hemianopsia,
inability to turn alterations, conjugate ipsilateral
eyes toward deviation of gaze, periods of
affected side, eyes toward nystagmus, blindness,
vision changes, affected side, loss of depth aphasia if
dyslexia, expressive perception, dominant
dysgraphia, aphasia, cortical hemisphere is
aphasia, confusion, blindness, involved, Mild
agnosia, amnesia, flat homonymous Horner’s
memory deficits, affect, apathy, hemianopsia, syndrome,
shortened perseveration, carotid bruits
attention span, dyslexia,
loss of mental memory
acuity, apraxia, deficits, visual
incontinence hallucinations
 21

Sx: Sx: Sx:

Alternating Ipsilateral Ataxia,
If managed: Fair Prognosis:
Palliative care- The patient will be able motor ataxia, facial paralysis of
Frequent vital sign and to survived, however, the weaknesses, paralysis, the larynx and
neuro-vital signs, recovery will be slow and
intubation, mechanical only little chance of full ataxic gait, ipsilateral loss soft palate,
ventilation, vasodilators, recovery is expected. A dysmetria, ipsilateral loss
of sensation in
osmotic diuretics, stroke patients have an
ventriculostomy, ICP increase risk of acquiring contralateral face, sensation of sensation in
monitoring another episode of hemisensory changes on face,
stroke.
impairments, trunk and contralateral
double vision, limbs, on body,
homonymous nystagmus, nystagmus,
Poor cerebral perfusion
hemianopsia, Horner’s dysarthria,
nystagmus, syndrome, Horner’s
conjugate tinnitus, syndrome,
Poor improvement gaze, hearing loss hiccups and
paralysis, coughing,
dysarthria, vertigo,
memory loss, nausea and
Fair
Prognosis disorientation, vomiting
drop attacks,
If not managed:
tinnitus,
hearing loss,
vertigo,
dysphagia,
Continued insufficiency of blood
coma
flow

Herniation
E

Further compression of tissues

Coma

Loss of neural feedback Cessation of physiologic

Cerebral Death
mechanisms functions
F
 Cessation of physiologic 22
functions
F

Pulmonary
Cardiovascular GIT GUT Other systems
System
System

Loss of cardiac
muscle function
Loss of sphincter
control
Loss of lung
Relaxation of
movement
venous valves Relaxation of
Neurogenic
intestines and
Failure of bladder
sphincters
accessory
Bradycar muscles for
dia
breathing
Hypote
nsion

Loss of bowel
control

Apnea

Decreased cardiac
output

Cardiopulmonary
Arrest

Mgt:
• Midodrine
Systemic Failure
• Rest and Comfort
• VS monitoring
• Provide patent airway
• Ventilation Therapy
Death
 23

D. Narrative Discussion
Hemorrhagic stroke has various risk factors that affect the overall aspect
of the disease which is divided into two types: Predisposing and Precipitating
factors. For the predisposing factors, Age, Gender, Hormonal differences in men
and women, Race and Ethnicity, Family or Heredity and Cerebral Amyloid
Angiopathy are included. Precipitating factors consist of Cerebral aneurysm, AVM,
Hypercholesterolemia, DM, Hypertension, Sleep Apnea, Blood Disorders or
Medications, Obesity, Atrial Fibrillation, Physical Activity, Diet, Use of cocaine and
drugs, Smoking and lastly, Alcohol use.
According to Desai et al. (2018), hemorrhagic hemorrhage can be
classified as intracerebral and subarachnoid hemorrhage. The former occurs when
bleeding occurs inside the cerebrum while the latter occurs when bleeding occurs
between the pia mater and arachnoid mater of the meninges - the inner and middle
layers that wrap around the brain. Furthermore, there are two types of intracerebral
hemorrhage. An intraparenchymal hemorrhage occurs in the brain tissue alone,
while an intraventricular hemorrhage occurs when blood extends into the brain's
ventricles, which store cerebrospinal fluid.
There is no underlying deformity or coagulation disorder that induces a
primary ICH. Hypertensive arteriosclerosis and cerebral amyloid angiopathy
account for 80% of primary ICH cases (CAA). CAA patients are usually older and
have a high hemorrhagic volume. Factors can be unknown as well. On the other
hand, an underlying issue with the blood vessels causes secondary ICH.
Arteriovenous malformation, aneurysm and drugs can result to this type of
intracerebral hypertension (Shaffer, 2019).
According to Unnithan & Mehta (2021), the most common cause of
hemorrhagic stroke is hypertension. The pressure in the blood vessels rises in
tandem with the increase in blood flow to the brain. As a consequence, long-term
hypertension causes medial degeneration, elastic lamina breakage, and artery
smooth muscle fragmentation.
Hypertension causes acceleration of arteriosclerosis of the large arteries
which therefore increases the hydrostatic pressure which causes proteins to be
 24

pushed out of blood vessels. Proteins are then pushed into the interstitial space
within the blood vessels. Lipohyalinosis occurs in which there are eosinophil and
fibroid deposits in the brain blood vessels. This resulted in hyaline arteriosclerosis
which makes the blood vessels became stiff and brittle. Also, continuous
lipohyalinosis eventually creates microaneurysm also called Charcot-Bouchard
Aneurysm. Primary ICH can also be caused by cerebral amyloid angiopathy or the
presence and build-up of amyloids on the walls of blood vessels in the brain
causing it to weaken.
Meanwhile, subarachnoid hemorrhage can occur if there is a traumatic
injury and similar to secondary ICH caused by arteriovenous malformation and
aneurysms. All of which results in weakening of blood vessels increasing the risk
for rupture.
Furthermore, once a blood vessel in the brain ruptured. It can be classified
depending on where it occurred as mentioned in the earlier part of the paragraph.
The leaked blood from the ruptured blood vessels creates a mass of blood and
may potentially grow. This can lead to vasospasm of tissues and arteries and
formation of blood clots. Cerebral hypoperfusion occurs as the supply of oxygen
and glucose is impeded. This causes tissue hypoxia and cellular starvation. The
cells will try to cope up using anaerobic metabolism by the mitochondria.
However, this will lead to production of oxygen free radicals and other
reactive oxygen species, as time passes by activation of enzymes that lyses cell
proteins lipids and nuclear material occurs. The mitochondria had failed to sustain
and create ATP leading to death of the tissues.
In addition, once necrosis of the tissues occurs, the individual can feel
muscle weakness, changes in vision, sensory loss, dizziness or loss of balance.
Changes in the level of consciousness occurs and faces may droop and aphasia
can also be noticed to the person affected by hemorrhagic stroke. Multiple
managements can be done such as craniotomy, stereotactic aspiration, aneurysm
clipping and endovascular coiling. Medicines can also be given such as
antihypertensives and calcium channel blockers. Nursing interventions can also
be given such as rest and comfort.
 25

Secondary intracerebral hemorrhage may occur after an ischemic stroke.

An ischemic stroke occurs when blood flow to a portion of the brain is blocked, and
it normally results in brain tissue death within hours. Arteries within ischemic tissue
are made up of dying endothelial cells, which implies that if blood flow is restored,
the compromised blood vessel is more likely to burst, resulting in a hemorrhage.
This results in bleeding into dead tissue, which is known as hemorrhagic
conversion (Desai et al, 2018).
If bleeding still continues there is a possibility that blood may go into the
ventricles which enlarges the hemorrhage. Intraventicular hemorrhage then occurs
as it has already reached the ventricles. It can also lead to subarachnoid
expansion. There is now obstruction of cerebrospinal fluid pathway resulting in
accumulation of CSF in the ventricles creating the condition called hydrocephalus.
The ventricles will then dilate behind the point of obstruction leading to increased
intracranial pressure. Increased ICP can lead to herniation and compression of
brain tissues. Both of this lead to further increase of pressure on the brain tissues
and cells as well as blood vessels that will lead to impaired perfusion and function
of arteries.
According to Orozco & Manso (2020), the most common artery involved in
acute stroke is the middle cerebral artery (MCA). This artery is responsible for the
blood supply of a portion of the frontal lobe and the lateral surface of the temporal
and parietal lobes, including the primary motor and sensory areas of the face,
throat, hand and arm, and in the dominant hemisphere, the areas for speech. If not
managed the patient will lead to comma as there is further compression of tissues
and herniation. Eventually, cerebral death will occur. This will lead to cessation of
physiologic functions of each organ systems that will result to systemic failure and
lastly death.

DIAGNOSTIC TESTS

Diagnostic Tests Rationale Nursing Intervention

Computed tomography A CT scan uses X-rays to Before the procedure

 26

(CT) scan take pictures of your skull 1. Informed Consent.

and brain. The patient lies Obtain an informed
in a tunnel-like machine consent properly
while the inside of the signed.
machine rotates and takes 2. Look for allergies.
X-rays of the head from Assess for any
different angles. These history of allergies to
pictures are later used by iodinated dye or
computers to make an shellfish if contrast
image of a “slice” (or cross- media is to be used.
section) of the brain. CT 3. Get health history.
scans use computers and Ask the patient
rotating X-ray machines to about any recent
create images of slices, or illnesses or other
cross-sections, of the brain. medical conditions
Unlike other techniques, CT and current
scans (and MRI scans) can medications being
show the inside of the head, taken. The specific
including soft tissue, bones, type of CT scan
brains and blood vessels. determines the need
CT scans can often show for an oral or I.V.
the size and locations of contrast medium.
brain abnormalities caused 4. Check for NPO
by tumors, blood vessel status. Instruct the
defects, blood clots, and patient to not to eat
other problems. CT scans or drink for a period
are a primary method of amount of time
determining whether a especially if a
stroke is ischemic or contrast material will
hemorrhagic (The Internet be used.
 27

Stroke Center). 5. Get dressed up.

Instruct the patient to
Computed tomography wear comfortable,
(CT)-scan studies can also loose-fitting clothing
be performed in patients during the exam.
who are unable to tolerate a 6. Provide information
magnetic resonance about the contrast
examination or who have medium. Tell the
contraindications to MRI, patient that a mild
including pacemakers, transient pain from
aneurysm clips, or other the needle puncture
ferromagnetic materials in and a flushed
their bodies. Additionally, sensation from an
CT-scan examination is I.V. a contrast
more easily accessible for medium will be
patients who require experienced.
special equipment for life 7. Instruct the patient to
support (Liebeskind, 2019). remain still. During
the examination, tell
the patient to remain
still and to
immediately report
symptoms of itching,
difficulty breathing or
swallowing, nausea,
vomiting, dizziness,
and headache.
8. Inform about the
duration of the
procedure. Inform
 28

the patient that the

procedure takes
from five (5) minutes
to one (1) hour
depending on the
type of CT scan and
his ability to relax
and remain still.
After the procedure
9. Diet as usual.
Instruct the patient to
resume the usual
diet and activities
unless otherwise
ordered.
10. Encourage the
patient to increase
fluid intake (if a
contrast is given).
This is so to promote
excretion of the dye.

Magnetic Resonance Magnetic resonance Before the procedure

Imaging (MRI) imaging (MRI) is 1. Obtain an informed
increasingly being used in consent properly
the diagnosis and signed.
management of acute 2. Explain the
ischemic stroke and is procedure to the
sensitive and relatively patient. Explain the
specific in detecting MRI is an imaging
changes that occur after test that produces a
 29

such strokes. This test is clear and sensitive

useful for detecting a wide image.
variety of brain and blood 3. Patient may be
vessel abnormalities, and asked not to eat or
can usually determine the drink anything for 4 -
area of the brain that is 6 hours before the
affected. MRI can provide scan.
direct views of the body 4. Ask patient if they
from almost any direction, are afraid of close
while CAT scans only spaces or
provide images in an axial claustrophobia and
orientation (Sen, 2019) inform the doctor.
5. Remove all metallic
objects, including
jewelry, hairpins, or
watches must be
removed.

Cerebral angiography Cerebral angiography is a Before the procedure

diagnostic test that uses an 1. Obtain an informed
X-ray. It produces a consent properly
cerebral angiogram, or an signed.
image that can help your 2. Explain the
doctor find blockages or procedures to the
other abnormalities in the patient.
blood vessels of your head 3. Instruct patient stop
and neck. Blockages or taking medications
abnormalities can lead to a that can increase
stroke or bleeding in the bleeding risk as per
brain. For this test, a doctor doctor’s order.
injects a contrast medium 4. Assess for any
 30

into your blood. The history of medical

contrast material helps the conditions,
X-ray create a clear picture medications and
of your blood vessels so allergies to iodinated
that your doctor can identify contrast materials.
any blockages or 5. Do not eat or drink
abnormalities (Moores, after midnight the
2017). night before the test.
6. Do not eat or drink
after midnight the
night before the test.
7. Inform the
angiogram
technician if
pregnant or breast-
feeding. Also inform
the technician of any
of the following
conditions: asthma,
diabetes, and
allergies to iodine,
shellfish, drugs, or
latex.

Transcranial Doppler Transcranial doppler 1. Obtain an informed

Ultrasound ultrasound (TCD) is a non- consent properly
invasive ultrasound method signed.
used to examine the blood 2. Explain the
circulation within the brain. procedures to the
During TCD, inaudible patient. Instruct the
 31

(cannot be heard) sound patient that this test

waves are transmitted is used to evaluate
through the tissues of the blood flow.
skull. These sound waves 3. Remove all clothing
reflect off blood cells and jewelry in the
moving within the blood area to be
vessels, allowing the examined.
radiologist to interpret their 4. Reassure the patient
speed and direction. The that the test doesn’t
sound waves are recorded involve risk of
and displayed on a discomfort.
computer screen. TCD 5. Inform the patient
ultrasound images help in that the ultrasound
the diagnosis of a wide takes about 20 to 30
range of conditions minutes to complete.
affecting blood flow to the
brain and within the brain
(Cleveland, 2017).

Electroencephalogram An electroencephalogram 1. Obtain the signed

(EEG) (EEG) is a test used to informed consent
evaluate the electrical from the patient.
activity in the brain. Brain 2. Explain the
cells communicate with procedure to the
each other through patient.
electrical impulses. An EEG 3. Review the patient's
can be used to help detect health history
potential problems 4. Instruct the patient to
associated with this activity. eat a meal before
An EEG is used to detect the procedure and to
problems in the electrical avoid stimulants
 32

activity of the brain that may such as caffeine and

be associated with certain nicotine for 8 hours
brain disorders prior to the
(Weatherspoon, 2018). procedure.
5. Instruct the patient
to clean the hair and
to refrain from using
hair sprays, creams,
or solutions before
the test.
6. Instruct the patient to
avoid eating or
drinking anything
containing caffeine
for at least eight
hours before the
test.
7. Your doctor may ask
you to sleep as little
as possible the night
before the test if you
have to sleep during
the EEG. You may
also be given a
sedative to help you
relax and sleep
before the test
begins.

Echocardiogram Echocardiography uses Before the procedure

ultrasound waves to create 1. Explain the
 33

a picture of the heart, called procedure to the

an echocardiogram (echo). patient. Inform the
It is a noninvasive medical patient that
procedure that produces no echocardiography is
radiation and does not used to evaluate the
typically cause side effects size, shape, and
(Kohli, 2020). motion of various
cardiac structures.
Echocardiography (both Tell who will perform
transthoracic and the test, where it will
transesophageal) is a take place, and that
widely used and versatile it’s safe, painless,
technique that can provide and is noninvasive.
comprehensive information 2. No special
of thromboembolic risk in preparation is
patients with stroke. needed. Advise the
Echocardiography (both patient that he
transthoracic and doesn’t need to
transesophageal) is a restrict food and
widely used and versatile fluids for the test.
technique that can provide 3. Ensure to empty the
comprehensive information bladder. Instruct
of thromboembolic risk in patient to void prior
patients with stroke and to change into a
(Nakanishi, & Homma, gown.
2016). 4. Encourage the
patient to cooperate.
Advise the patient to
remain still during
the test because
 34

movement may
distort results. He
may also be asked
to breathe in or out
or to briefly hold his
breath during the
exam.
5. Explain the need to
darkened the
examination field.
The room may be
darkened slightly to
aid visualization on
the monitor screen,
and that other
procedure (ECG and
phonocardiography)
may be performed
simultaneously to
time events in the
cardiac cycles.
6. Explain that a
vasodilator (amyl
nitrate) may be
given. The patient
may be asked to
inhale a gas with a
slightly sweet odor
while changes in
heart functions are
 35

recorded.
During the procedure
7. Inform that a
conductive gel is
applied to the chest
area. A conductive
gel will be applied to
his chest and that a
quarter-sized
transducer will be
placed over it. Warn
him that he may feel
minor discomfort
because pressure is
exerted to keep the
transducer in contact
with the skin.
8. Position the patient
on his left side.
Explain that
transducer is angled
to observe different
areas of the heart
and that he may be
repositioned on his
left side during the
procedure.
After the procedure

9. Remove the
conductive gel from
 36

the patient’s skin.

When the procedure
is completed,
remove the gel from
the patient’s chest
wall.
10. Inform the patient
that the study will be
interpreted by the
physician. An official
report will be sent to
the requesting
physician, who will
discuss the findings
with the patient.
11. Instruct patient to
resume regular diet
and activities. There
is no special type of
care given following
the test.

Lumbar puncture One test for epilepsy is a Before the procedure

(spinal tap) spinal tap (also called a 1. Explain the
lumbar puncture). This is a procedure to the
procedure in which fluid patient. Explain to
surrounding the spinal cord the patient the
(called the cerebrospinal purpose of lumbar
fluid or CSF) is withdrawn puncture, how and
through a needle and where it’s done, and
 37

examined in a lab. A spinal who will perform the

tap may be performed to procedure.
rule out infections such as 2. Obtain informed
meningitis or encephalitis consent. Make sure
as the cause of epileptic the patient has
seizures (Robinson, 2020). signed a consent
form if required by
the institution.
3. Reinforce diet.
Advise the patient
that fasting is not
required.
4. Promote comfort.
Instruct the patient to
empty the bladder
and bowel before the
procedure.
5. Establish a baseline
assessment data.
Do vital signs
monitoring and
neurologic
assessment of the
legs by assessing
the patient’s
movement, strength,
and sensation.
6. Place the client in a
lateral decubitus
position. Assist the
 38

client to assume a
lateral decubitus
(fetal) position, near
the side of the bed
with the neck, hips,
and knees drawn up
to the chest. An
alternative position
is to have the patient
sit on the edge of the
bed while leaning
over a bedside table.
7. Instruct to remain
still. Explain that he
or she must lie very
still throughout the
procedure. Any
unnecessary
movement may
cause traumatic
injury.
After the procedure
8. Apply brief pressure
to the puncture site.
Pressure will be
applied to avoid
bleeding, and the
site is covered by a
small occlusive
dressing or band-
 39

aid.
9. Place the patient flat
on bed. The patient
remains flat on bed
for 4 to 6 hours
depending on the
physician. He or she
may turn from side to
side as long as the
head is not elevated.
10. Monitor vital signs,
neurologic status,
and intake and
output. Take vital
signs, measure
intake and output,
and assess
neurologic status at
least every 4 hours
for 24 hours to allow
further evaluation of
the patient’s
condition.
11. Monitor the puncture
site for signs of CSF
leakage and
drainage of blood.
Signs of CSF
leakage includes
positional
 40

headaches, nausea
and vomiting, neck
stiffness,
photophobia
(sensitivity to light),
sense of imbalance,
tinnitus (ringing in
the ear), and
phonophobia
(sensitivity to
sound).
12. Encourage
increased fluid
intake. An increased
amount of fluid
intake (up to 3,000
ml in 24 hours) will
replace CSF
removed during the
lumbar puncture.
13. Label and number
the specimen tube
correctly. Ensure all
samples are
properly labeled and
sent to the
laboratory
immediately for
further evaluations.
14. Administer
 41

analgesia as
ordered. Headaches
after the procedure
can last for a few
hours or days and is
usually treated with
analgesics.

Blood Test ● Complete Blood 1. Verify the doctor's

Count. The CBC is order.
one of the most 2. Verify the client's
common blood tests. consent to the
It's often done as diagnostic test, as
part of a routine indicated.
checkup. The CBC 3. Provide the client
can help detect and/or significant
blood diseases and others with an
disorders, such as explanation of the
anemia, infections, diagnostic test, the
clotting problems, purpose of the
blood cancers, and diagnostic tests and
immune system the procedure that
disorders. This test will be followed for
measures many the specific
different parts of diagnostic test, in
your blood, as addition to any
discussed in the specific preparation
following such as NPO after
paragraphs. midnight, as
● Blood Chemistry indicated for the
Tests/Basic particular diagnostic
 42

Metabolic Panel. test.

The basic metabolic 4. Ensure adherence to
panel (BMP) is a universal
group of tests that precautions, medical
measures different or surgical asepsis
chemicals in the as indicated by the
blood. These tests type of the
usually are done on diagnostic test.
the fluid (plasma) 5. Ensure proper
part of blood. The handling, collection,
tests can give transportation, and
doctors information labeling of the
about your muscles specimen collected.
(including the heart),
bones, and organs,
such as the kidneys
and liver. The BMP
includes blood
glucose, calcium,
and electrolyte tests,
as well as blood
tests that measure
kidney function.
Some of these tests
require you to fast
(not eat any food)
before the test, and
others don't. Your
doctor will tell you
how to prepare for
 43

the test(s) you're

having.
● Coagulation Factor
Tests. A coagulation
factor test is used to
find out if you have a
problem with any of
your coagulation
factors. If a problem
is found, you likely
have a condition
known as a bleeding
disorder. There are
different types of
bleeding disorders.
Bleeding disorders
are very rare. The
most well-known
bleeding disorder is
hemophilia.
Hemophilia is
caused when
coagulation factors
VIII or IX are missing
or defective.
● Blood Lipid Tests.
A complete
cholesterol test also
called a lipid panel or
lipid profile is a blood
 44

test that can

measure the amount
of cholesterol and
triglycerides in your
blood. A cholesterol
test can help
determine your risk
of the buildup of
plaques in your
arteries that can lead
to narrowed or
blocked arteries
throughout your
body
(atherosclerosis).
A cholesterol test is
an important tool.
High cholesterol
levels often are a
significant risk factor
for coronary artery
disease.

Pulse Oximetry Pulse oximetry is a 1. Explain the

noninvasive and painless procedure to the
test that measures your client.
oxygen saturation level, or 2. Assess your
the oxygen levels in your patient’s baseline
blood. It can rapidly detect vital signs, and
even small changes in how tissue perfusion.
efficiently oxygen is being Determine if he has
 45

carried to the extremities an allergy to

furthest from the heart, adhesive and
including the legs and the explain the purpose
arms (Gotter, 2017). of pulse oximetry.
3. Choose an
application site;
finger, toe, nose,
forehead, or ear with
adequate circulation.
Remove polish or
artificial nails if
you’re using a finger
or toe, or position the
sensor parallel to the
nail.
4. Inform the patient
that he/she may feel
a small amount of
pressure, but there
is no pain or
pinching.
5. Keep the device for
as long as needed to
monitor the pulse
and oxygen
saturation.

PHYSICAL ASSESSMENT
General Survey
An endomorph body type with a body mass index of greater than 30 kg/m 2

and with central obesity has always been associated with an increased risk of
 46

stroke. Gait is also affected once a person experiences a stroke. Walking

dysfunction is prevalent for stroke survivors as evidenced by the damage to motor
cortices and muscle functions which leads to weakness. Hence, movements are
not rhythmic and uncoordinated, arms swing uncoordinated as well, and stride
length is inappropriate when asked to walk towards the nurse. Moreover, grooming
is affected since stroke patients cannot handle activities of daily living on their own
which means there is a need for nurse assistance. The patient may also
experience difficulty in sustaining eye contact, natural symmetry as well as
inappropriate smiling and frowning of the face. The stroke patient may feel
drowsiness and appears to be confused as well as disoriented when asked.
Vital signs are shown as follows:

Vital Signs Normal Vital Signs Recorded Value Remarks

Temperature 36.5 – 37. 5 ° C < 35.0 ° C Hypothermia

Cardiac Rate 60-100 bpm < 60 bpm Bradycardia

Respiratory 16-20 cycles per > 20 cycles per Tachypnea

rate minute minute

Pulse Rate 60-100 bpm <60 bpm Bradycardia

Head and Scalp

The facial features are affected if a patient has a stroke. It appears to be
asymmetrical in a movement when assessed through asking a patient to smile,
frown, and opening a mouth as well as involves a weakness in the mouth, eyes,
 47

and forehead, known as facial paralysis. The muscle strength in the face, including
the jaw, is decreased. The patient may also suffer severe headaches.

Eyes and Vision

The eye brows’ are asymmetrical and showed unequal movements when
asked to raise and lower the eyebrows. Patients suffering from hemorrhagic stroke
have a problem raising their eyebrows on the part of the affected area. Eyelids are
considered ptosis or the drooping of the upper lids is visible when a patient has a
hemorrhagic stroke, thus, impaired eyelid closure may be noted. Upon checking
visual acuity through Snellen’s Eye Chart, the patient is seen with a change of
vision or decreased visual acuity. After such, when tested for the extraocular
muscles, the patient experiences difficulty in moving the eyes, and a prominent
reaction is observed such as sensitivity to light. When assessed using the
tonometry, a stroke patient has abnormal results since there is an elevated
intraocular pressure as a result of increased intracranial pressure. When
measured, the normal eye pressure only ranges from 10-21 mmHg, however,
during this time, the patient experienced an eye pressure of greater than 21
mmHg.

Ear
Hemorrhagic stroke affects several parts of the brain including the
cerebellum and brainstem. Thus, a patient may suffer from tinnitus or a ringing of
one or both ears through hearing or movement exams. Other than that, the patient
may also experience hearing loss.

Mouth and Pharynx

Stroke patients may experience difficulty swallowing or problem with
speech since the muscles associated with the tongue, lips, and throat are affected.
There are cases when patients manifest paralysis of the larynx and soft palate.
Deviation of the tongue is also prominent in other patients.
 48

Neck
A patient suffering from hemorrhagic stroke manifests carotid bruits. These
bruits arise from the neck arteries and possibly to be auscultated. It is an indication
that there is a narrowing of the carotid arteries which can cause a stroke if it
becomes severe enough that blood flow is blocked. In addition, patients may also
experience nuchal rigidity or the stiffness of the neck. This symptom is observed
through Kernig’s sign and Brudzinski’s signs. A positive Kernig’s shows pain while
a positive Brudzinski’s creates an involuntary raise of the knee or hip flexion on the
patient.

Thorax and Lungs

Difficulty in breathing might be observed in patients with hemorrhagic
stroke as they try to work against the lack of oxygen in the body. But the respiratory
rate of the patient may also suddenly decrease as a late indication of increased
intracranial pressure.

Heart
Patients who suffered from increased intracranial pressure have decreased
heart rate because of the inability of the blood to flow normally towards the body
system.

Musculoskeletal and Extremities

The patients suffer from muscle weakness, which also results in a change
in muscle tone. There are signs of atrophy, flaccidity, spasticity, atrophy,
sometimes contractures or tremors are noted upon inspection and
palpation. When a patient is instructed to raise his right or left arms, the patient
may not be able to raise it properly or fully because of the weakness. The same
with the feet, a nurse instructs a patient to raise them up to 30 degrees, however,
a patient cannot fulfill the same command due to weakness or numbness. They
also have difficulty in resistance. Muscle strengths are unequal when compared
 49

from the left to the right side. Muscle strength may be scored below 4 depending
on the severity of the condition.

Joints

In assessing the joints, asymmetry is observed particularly there are

weaknesses on the affected parts. Some joints cannot perform full range of motion
due to numbness or paralysis.

NEUROLOGICAL ASSESSMENT

Mental Health Status

Patients with hemorrhagic stroke appear to be drowsy and unresponsive.
They are usually confused and disoriented to time, place, person, and situation.
When asked by the nurse, they provide incorrect and irrelevant answers. They are
also seen as irritable, lethargic and restless. Other than that, stroke patients have
slurred or incomprehensible speech. Upon checking the memory and
concentration, some patients manifest loss of memory and memory deficits. They
have a flat affect as well as appear to be irrational and incoherent.
The Glasgow Coma Scale scoring persistently shows a below 15 - grade
depending on the severity of their conditions. Nonetheless, when it comes to the
Reactive Level Scale, it is scored 2 or below, still depending on the severity of their
diseases.

Motor function and Balance

There are various tests to identify the motor function and balance of
patients with hemorrhagic stroke. It can be that a nurse may try to use resistance
by exerting opposing forces to the patients. The stroke patient may not be able to
resist the force exerted on the affected sides because of weakness or numbness.
The balance may also be determined by letting the patients stand, walk, or using
both techniques with the eyes closed. With this, patients with stroke may
 50

experience trouble in keeping their balance because they are often dizzy or a
particular part of the brain is affected such as the cerebellum.

Cranial Nerves

Cranial Name Function/ Result

Nerve Tests Done

I Olfactory Smell In some cases, patients present an

inability to sense smells or Anosmia
depending on the part of the brain
affected by hemorrhagic stroke.

II Optic Vision (Visual Vision changes may occur, hence,

Acuity and blindness, impaired vision, and even far
Visual Fields) (myopia) or near-sightedness
(presbyopia) is observed.

III Oculomotor Eye Patients with hemorrhagic stroke have a

movement hard time moving their eyes in the
(up, down, direction instructed by the nurse
inward because they have an absence of eye
PERRLA) movement control. An examiner also
observed slow pupil response when
tested using the penlight. Other than
that, there are also uneven pupils and
an absence of pupil constriction, which
means eyes cannot constrict properly
even when exposed to direct light. Some
of the patients may manifest CN III
paralysis or Horner’s syndrome.
 51

IV Trochlear Eye The patients have difficulty moving their

movement eyes when instructed to look upward or
(up, down) downward. There are impaired eye
movements and strabismus in some
cases.

V Trigeminal Facial Since the patients suffered from

sensation and hemorrhagic stroke, they tend to have a
movement loss of facial sensation and numbness
when assessed using cotton. Moreover,
there is a loss of ipsilateral corneal
reflex, wasting, and weakness of the
mastication muscles as well as deviation
of the jaw when opened to the ipsilateral
side.

VI Abducens Lateral eye When eyes are pulled inward, the eyes
movement cannot look out. They cannot move their
eyes from right to left or follow the
direction of the penlight.

VII Facial Facial The patients have difficulty moving their

Movement faces when asked to smile, frown and
show teeth. There is also an ipsilateral
paralysis of the facial muscles of which
eyes are unable to close, mouth corner
droops and difficulty in speech
articulation. For some facial paralysis is
seen due to the aftermath of stroke.

VIII Acoustic Hearing and The patients may experience dizziness

balance and tinnitus. For others, they experience
 52

hearing loss once this nerve is affected

by any kind of stroke.

IX Glossopharyngeal Swallowing, Hemorrhagic stroke causes patients to

taste sensory deal with difficulty in swallowing or
and gag reflex dysphagia.

X Vagus Taste, talking, There is an absence of gag reflex

swallowing

XI Accessory/Spinal Examine The nurse will apply resistance on the

muscle bulk muscles of the patient, hence, asked the
patient to move the head side to side
and shrug the shoulders. It was evident
that they have trouble in performing
such tests.

XII Hypoglossal Tongue The tongue of a patient with

movement hemorrhagic stroke appears to be
deviated. The patient talks sluggishly
and incoherent. There are cases of
atrophy or tongue fasciculations.

IV. MANAGEMENT
A. Medical Management
The treatment and management of patients with acute intracerebral
hemorrhage depend on the cause and severity of the bleeding. Management
begins with stabilization of vital signs. Basic life support, as well as control of
bleeding, seizures, blood pressure (BP), and intracranial pressure, are critical.
Medications used in the treatment of acute stroke include anticonvulsants to
prevent seizure recurrence, antihypertensive agents to reduce BP and other risk
 53

factors of heart disease, and osmotic diuretics to decrease intracranial pressure in

the subarachnoid space (Liebeskind, et al., 2019).
Intravenous Fluid
Fluids are given into a vein (intravenous, or iv) or under the skin
(subcutaneous) are commonly used in people with stroke, but there are no clear
guidelines on the best fluid management in such cases. There are a number of
possible different types of fluid that can be used: isotonic fluids or crystalloids are
solutions that contain similar amounts of dissolved salts as in normal cells and
blood, whilst hypertonic fluids, or colloids usually contain more (or larger) dissolved
particles than in normal cells and blood. Fluid can also be given in different
volumes, or for different durations. (Visvanathan, et al., 2015).
Emergency measures
A hemorrhagic stroke requires immediate medical attention. The goal of this
treatment is to stop the bleeding in the brain and reduce the pressure caused by
it. If you take a blood thinner to prevent blood clots, you may be given drugs or
blood transfusion to counteract the effects of the blood thinners. You may also be
given medications to lower intracranial pressure, blood pressure, prevent spams
of your blood vessels, and prevent seizures (Mayo Clinic, 2021).
Endotracheal Intubation
Perform endotracheal intubation with patients with a decreased level of
consciousness and poor airway protection. Intubate and hyperventilate if the
intracranial pressure is elevated, and initiate administration of mannitol for further
control (Liebeskind, 2019). Many patients with acute intracerebral hemorrhages
(ICHs) undergo endotracheal intubation followed by a mechanical ventilator for
“airway protection” to prevent aspiration, pneumonia, and its related mortality. On
the other hand, these procedures may promote pneumonia, laryngeal trauma,
dysphagia and adversely affect patient outcomes (Lioutas, 2018).
 54

MEDICATIONS

Generic Name Nifedipine

Brand Name Calcibloc

Drug Classification Calcium-Channel Blocker

Mechanism of Action Inhibits calcium ion influx across all membranes

during cardiac depolarization, produces relaxation
of coronary vascular smooth muscle and peripheral
vascular smooth muscle, dilates coronary arteries,
increases myocardial oxygen delivery in patients
with vasospastic.

Suggested Dose Dosage for hypertension (high blood pressure)

Adult dosage (ages 18–64 years)

• The starting dose is 30 mg or 60 mg by

mouth once per day. The dosage can be
increased every 7 to 14 days until the
maximum dosage of 90–120 mg per day is
reached.

Child dosage (ages 0–17 years)

 55

• This medication has not been studied in

children. It should not be used in people
younger than 18 years.

Senior dosage (ages 65 years and older)

• The kidneys of older adults may not work as

well as they used to. This can cause your
body to process drugs more slowly. As a
result, more of a drug stays in your body for
a longer time. This increases your risk of
side effects. Your doctor may start you on a
lowered dose or a different medication
schedule. This can help keep levels of this
drug from building up too much in your body.

Dosage for vasospastic angina

Adult dosage (ages 18–64 years)

• The starting dose is 30 mg or 60 mg by

mouth once per day. The dosage can be
increased every 7 to 14 days until the
maximum dosage of 180 mg per day is
reached.

Indications Treatment of vasospastic, angina, chronic stable

angina, hypertension (sustained release tablets
only.

Contraindications Hypersensitivity, cardiovascular shock,

combination with rifampicin contraindicated in
 56

unstable angina and after recent MI severe

hypotension, with systolic pressure less than 90
mmHg decompensated heart failure pregnancy
and lactation.

Side Effects Common: Headache, Nausea, Dizziness or

lightheadedness, Flushing, Heartburn, Fast
heartbeat, Muscle cramps, Constipation, Cough,
Decreased sexual ability
Severe: swelling of the face, eyes, lips, tongue,
hands, arms, feet, ankles, or lower legs, difficulty
breathing or swallowing, fainting, rash, yellowing of
the skin or eyes, increase in frequency or severity
of chest pain (angina)

Adverse Reactions Patients withdrawn from blockers while taking

nifedipine may experience increase angina

Drug Interactions Drug-drug:

Antibiotics (clarithromycin, erythromycin,
quinupristin/dalfopristin): Taking the antibiotic
rifampin can decrease the levels of nifedipine in
your body. This could make nifedipine less
effective. You shouldn’t take rifampin and
nifedipine together.
Antifungal drugs (fluconazole, itraconazole,
ketoconazole): drugs with nifedipine can cause
higher levels of nifedipine in your body. This can
increase your risk of side effects from nifedipine
Antiviral drugs (atazanavir, delavirdine,
fosamprenavir, indinavir, nelfinavir, ritonavir)
 57

Anti-seizure drugs (phenytoin, carbamazepine,

valproic acid)
Heart drugs (Digoxin) & Other drugs like Beta
Blockers (atenolol, metoprolol, nadolol,
propranolol, timolol): If you’re taking a beta-
blocker and your doctor has you stop taking it
before starting nifedipine, the beta-blocker should
be tapered slowly. Stopping it suddenly could
cause increased chest pains.

Nursing Responsibilities 1. Use caution in severe aortic stenosis or

severe hepatic impairment
R:
2. Assess potential for interactions with other
pharmacological agents or herbal products
patients is taking that may increase risk of
hypotension and toxicity
R:
3. Monitor blood pressure and pulse before
therapy, during dose Drug study 1filtration
and periodically during therapy monitor
ECG periodically during prolonged therapy
R:
4. Assess therapeutic effectiveness and
adverse reaction
R:
5. Assess location, duration intensity,
precipitating factor of patients’ angina pain
6.
 58

Generic Name Mannitol

Brand Name Osmitrol

Drug Classification Therapeutic: Diuretics

Pharmacologic: Osmotic diuretic

Mechanism of Action Increases the osmotic pressure of the glomerular

filtrate, thus inhibiting tubular reabsorption of water
and electrolytes. Drug elevates plasma osmolality
and increases urine output.

Dose and Route Acute Kidney Failure

• Adult:IV Test Dose: 0.2 g/kg or 12.5 g as a
15%–20% solution over 3–5 min
Positive Response: 30–50 mL of urine over
the next 2–3 h, may repeat test dose 1 time.
If still negative, do not use.
Treatment: 50–100 g as 15%–20% solution
over 90 min to several hours
• Child: IV Test Dose: 200 mg/kg (max: 12.5
g) over 3–5 min
 59

• Positive Response: Urine flow of 1 mL/kg/h

for 1–2 hours
• Maintenance: 0.25–0.5 g/kg q4–6 h
Edema, Ascites
• Adult IV: 100 g as a 10%–20% solution over
2–6 h
Elevated IOP or ICP
• Adult IV: 1.5–2 mg/kg as a 15%–25%
solution over 30–60 min
Acute Chemical Toxicity
• Adult IV: 100–200 g depending on urine
output
Measurement of GFR
• Adult IV: 100 mL of 20% solution diluted with
180 mL NaCl injection infused at a rate of 20
mL/min
Administration: Intravenous

Indications Adjunct in the treatment of:

● Acute oliguric renal failure
● Edema
● Increased Intracranial or intraocular
pressure
● Toxic overdose

Contraindications • Contraindicated in patients hypersensitive to

drug.
• It is also contraindicated in patients with
anuria; severe pulmonary congestion; frank
pulmonary edema; active intracranial
bleeding (except during craniotomy); severe
 60

dehydration; metabolic edema; previous

progressive renal disease or dysfunction
after starting drug, including increasing
azotemia and oliguria; previous progressive
HF or pulmonary congestion after treatment
with drug; or failure to respond to test dose.
• Dialyzable drug: YES
• Cautions; Overdose S&S: Increased
electrolyte excretion, orthostatic tachycardia
or hypotension, decreased central venous
pressure, impaired neuromuscular function,
intestinal dilation and ileus, HF, Pulmonary
edema or water intoxication if urine output is
inadequate.
• Pregnancy: Use only if clearly needed and
potential benefit justifies potential risk to the
fetus. Unknown if the drug appears in milk.
Use cautiously in breastfeeding women.

Side Effects Angina-like chest pains, Congestive heart failure,

Low blood pressure (hypotension), Phlebitis,
Convulsions, Chills, Dizziness, Headache,
Acidosis, Fluid/electrolyte imbalances, Thirst,
Nausea, Vomiting, Blurred vision, Urinary
retention, Runny nose, Skin rash, Hives, High
blood pressure (hypertension), Fever

Adverse Reactions Pulmonary congestion, fluid and electrolyte

imbalance, acidosis, electrolyte loss, dryness of
mouth, thirst, marked diuresis, urinary retention,
edema, convulsions
 61

Drug Interactions Drug-drug: Lithium: May increase urinary

excretion of lithium.
Nephrotoxic drug: (aminoglycosides &
cyclosporine) May increase risk of toxicity and renal
failure. Avoid use together.
Opioid analgesics: May increase diuretic-related
adverse effects and diminish therapeutic effects of
diuretics.
Sodium phosphates: May enhance nephrotoxic
effect of sodium phosphates. Consider therapy
modification.
Tobramycin: Mannitol (systemic) may enhance the
nephrotoxic effect of tobramycin (oral inhalation).
Avoid combination.

Nursing Responsibilities 1. Assess vital signs closely. Report significant

changes in BP and signs of CHF
2. Monitor CVP and fluid intake and output
hourly.
3. Assess patients for anorexia, muscle
weakness, numbness, tingling, confusion
and excessive thirst.
4. Monitor neurologic status and intracranial
pressure readings in patients receiving this
medication to decrease cerebral edema.
5. Check the patient’s weight daily
6. Monitor for possible indications of fluid and
electrolyte imbalance (e.g., thirst, muscle
cramps or weakness, paresthesia, and signs
of CHF)
 62

7. To relieve thirst, give frequent mouth care or

fluids.
8. Educate patient on drug therapy to
encourage cooperation.
9. Observe for any change in consciousness,
dizziness, fatigue, postural hypotension
10. In comatose or incontinent patient, use a
urinary catheter because therapy is based
on strict evaluation of fluid intake and output.

Generic Name Phenytoin

Brand Name Dilantin

Drug Classification Anticonvulsant, antiarrhythmic.

Mechanism of Action Phenytoin is often described as a non-specific

sodium channel blocker and targets almost all
voltage-gated sodium channel subtypes.7 More
specifically, phenytoin prevents seizures by
inhibiting the positive feedback loop that results in
neuronal propagation of high frequency action
potentials

Dose and Route Status Epilepticus

 63

• IV: ADULTS, ELDERLY, ADOLESCENTS:

Loading dose: 20 mg/kg at maximum rate of
50 mg/min. May repeat in 10 min after
loading dose with dose of 5–10 mg/kg.
• INFANTS, CHILDREN: Loading dose: 20
mg/kg at a maximum rate of 1 mg/kg/min.
May give an additional dose of 5–10 mg/kg
after loading dose.
Seizure Control (Maintenance)
• Note: Loading dose not used in pts with
history of renal/hepatic disease.
• PO: ADULTS, ELDERLY: Loading Dose: 1
g divided into 3 doses given at 2- hours
intervals. Maintenance (begins 24 hours
after loading dose): Initially 100 mg 3
times/day; adjust at no less than 7–10-day
intervals. Usual dose: 100 mg 3–4 times/day
up to 200 mg 3 times/day (may consider 300
mg once daily in pts established on 100 mg
3 times/day).
• CHILDREN: Initially, 5 mg/kg/day in 2–3
divided doses. Adjust dose at 7- to 10-day
intervals. Maintenance: 4–8mg/kg/day.
Maximum: 300 mg/day.
• Dosage in Renal/Hepatic Impairment: No
dose adjustment.

Indications Treat grand mal seizures, complex partial seizures,

and to prevent and treat seizures during or following
neurosurgery
 64

Contraindications Hypersensitivity to phenytoin, other hydantoins.

Concurrent use of delavirdine. IV (additional):
Second and third-degree AV block, sinoatrial block,
sinus bradycardia, Adams-Stokes syndrome.
Cautions: Porphyria, renal/hepatic impairment,
those at increased risk of suicidal
behavior/thoughts, elderly/debilitated pts, low
serum albumin, cardiac disease, hypothyroidism,
pts of Asian descent.
Pregnancy: This medication should be used only
when clearly needed. It may harm an unborn baby.
However, since untreated seizures are a serious
condition that can harm both a pregnant woman
and her unborn baby.

Side Effects Frequent: Drowsiness, lethargy, confusion, slurred

speech, irritability, gingival hyperplasia,
hypersensitivity reaction (fever, rash,
lymphadenopathy), constipation, dizziness,
nausea. Occasional: Headache, hirsutism,
coarsening of facial features, insomnia, muscle
twitching.

Adverse Reactions Abrupt withdrawal may precipitate status

epilepticus. Blood dyscrasias, lymphadenopathy,
osteomalacia (due to interference of vitamin D
metabolism) may occur. Toxic phenytoin blood
concentration (25 mcg/mL or more) may produce
ataxia, nystagmus, diplopia. As level increases,
extreme lethargy to comatose state occurs.
 65

Drug Interactions DRUG: Alcohol, other CNS depressants (e.g.,

Lorazepam, morphine, zolpidem): may increase
CNS depression.
Amiodarone, cimetidine, disulfiram, Fluoxetine,
isoniazid, sulfonamides: may increase
concentration/effects, risk of toxicity. Calcium-
containing antacids may decrease absorption:
may decrease effects of glucocorticoids (e.g.,
dexamethasone, prednisone) anticoagulants
(e.g., heparin, warfarin), oral contraceptives.
Lidocaine & propranolol may increase cardiac
depressant effects.

Nursing Responsibilities 1. Observe frequently for recurrence of seizure

activity.
2. Monitor ECG for cardiac arrhythmia.
3. Assist with ambulation if drowsiness and lethargy
occur.
4. Maintain good oral hygiene to prevent gingival
hyperplasia (bleeding, tenderness, swelling of
gums).
5. Advise patient to report for sore throat, fever,
glandular swelling, skin reaction (hematologic
toxicity).
6. Avoid tasks that require alertness, motor skills
until response to drug is established.
7. Do not abruptly withdraw medication after long
term use (may precipitate seizures).
8. Strict maintenance of drug therapy is essential
for seizure control, arrhythmias.
9. Avoid drinking alcohol.
 66

10.Report for any unusual in behavior.

Generic Name Nicardipine

Hydrochloride

Brand Name Perdipine

Drug Classification CHEMICAL CLASS: Dihydropyridine derivative

CLINICAL: Antianginal, antihypertensive

Mechanism of Action Inhibits calcium ion movement across cell

membranes, depressing contraction of cardiac,
vascular smooth muscle.

Indications / Dose and CHRONIC STABLE PO: Adults, Elderly:

Route ANGINA (Immediate-release):
Initially, 20 mg 3 times a
day.
Range: 20-40mg 3 times
a day (allow 3 days
between dosage
increase)

HYPERTENSION PO: Adults, Elderly:

(Immediate- Release):
Initially, 20 mg 3 times a
 67

day. Range: 20–40 mg 3

times a day (allow 3
days between dosage
increases). PO: Adults,
Elderly: (Extended-
Release): Initially, 30 mg
twice daily. Range: 30–
60 mg twice daily

IV: Adults, Elderly

ACUTE (gradual blood pressure
HYPERTENSION decreases): Initially 5
mg per hour. May
increase by 2.5 mg per
hour. Maximum: 15 mg
per hour. After blood
pressure goal is
achieved, adjust dose to
maintain desired blood
pressure.

Other Doses:

DOSAGE IN RENAL Adults, Elderly: (PO):

IMPAIRMENT Initially, give 20 mg
every 8 hours or 30 mg
twice daily, then titrate.
(IV): No dose
adjustment.
 68

DOSAGE IN HEPATIC Adults, Elderly: (PO):

IMPAIRMENT Initially, give 20 mg
twice daily, then titrate.
(IV): No dose
adjustment.

Contraindications Hypersensitivity to nicardipine and advanced aortic

stenosis.

Side Effects Frequent (10%–7%): Headache, facial flushing,

peripheral edema, light- headedness, dizziness.
Occasional (6%–3%): Asthenia, palpitations,
angina, tachycardia.
Rare (less than 2%): Nausea, abdominal cramps,
dyspepsia, dry mouth, rash.

Adverse Reactions Overdose produces confusion, slurred speech,

drowsiness, marked hypotension, bradycardia.

Drug Interactions DRUG: May increase concentration of

cyclosporine.
HERBAL: Ephedra, ginger, ginseng, yohimbe may
increase hypertension. Licorice may cause
retention of sodium, water; may increase loss of
potassium. St. John’s wort may decrease levels.
FOOD: Grapefruit products may alter absorption.
LAB VALUES: None significant.

Nursing Responsibilities 1. Concurrent therapy with sublingual nitroglycerin

may be used for relief of anginal pain.
2. Record onset, type (sharp, dull, squeezing),
radiation, location, intensity, duration of anginal
 69

pain, precipitating factors (exertion, emotional

stress).
3. Monitor blood pressure and heart rate during and
following IV infusion.
4. Assess for peripheral edema.
5. Assess skin for facial flushing, dermatitis, rash.
6. Question for asthenia and headache.
7. Monitor liver function test (LFT) results.
8. Assess electrocardiogram (EKG) and pulse for
tachycardia.
9. Monitor fluid intake and output.
10. Instruct patient to report if anginal pain is not
relieved or if palpitations, shortness of breath,
swelling, dizziness, constipation, nausea,
hypotension occurs.

Generic Name Acetaminophen

Brand Name Tylenol

Drug Classification PHARAMACOTHERAPEUTIC: Central analgesic

CLINICAL: Non-narcotic analgesic, antipyretic

Mechanism of Action Appears to inhibit prostaglandin synthesis in the

CNS (Cranial nerve system) and, to a lesser extent,
block pain impulses through peripheral action. Acts
centrally on hypothalamic heat-regulating center,
 70

producing peripheral vasodilation (heat loss, skin

erythema, diaphoresis).

Indications / Dose and Analgesia and Antipyresis

Route IV: ADULTS, ADOLESCENTS WEIGHING 50 KG
OR MORE: 1,000 mg every 6 hours or 650 mg
every 4 hours. Maximum single dose: 1,000 mg;
maximum total daily dose: 4,000 mg.

IV: ADULTS, ADOLESCENTS WEIGHING LESS

THAN 50 KG: 15 mg per kilogram every 6 hours or
12.5 mg per kilogram every 4 hours. Maximum
single dose: 750 mg; maximum total daily dose: 75
mg per kilogram per day.

IV: CHILDREN 2 to12 YEARS OLD: 15 mg per

kilogram every 6 hours or 12.5 mg per kilogram
every 4 hours. Maximum single dose: 750 mg.
Maximum: 75 mg per kilogram per day, not to
exceed 3,750 mg per day.

IV: INFANTS AND CHILDREN LESS THAN 2 YRS:

7.5–15 mg per kilogram every 6 hours. Maximum:
60 mg per kilogram per day.

PO: ADULTS, ELDERLY, CHILDREN 13 YRS AND

OLDER: Regular strength, 325 to 650 milligram
every 4 to 6 hours. Maximum: 3,250 mg per day
unless directed by health care provider.
 71

Extra Strength: 1000 mg every 6 hours. Maximum:

3,000 mg per day unless directed by health care
provider.

PO: CHILDREN 12 YRS AND YOUNGER: Weight

dosing preferred, however, if not available, age is
used. Doses may be repeated every 4 hours.
Maximum: 5 doses per day.

Contraindications Hypersensitivity to acetaminophen. (Ofirmev):

severe hepatic impairment or severe active liver
disease.

Side Effects Rare: Hypersensitivity reaction

Adverse Reactions Early Signs of Acetaminophen Toxicity: Anorexia,

nausea, diaphoresis, fatigue within first 12 to 24
hours.
Later Signs of Toxicity: Vomiting, right upper
quadrant tenderness, elevated LFTs (Liver
Function Test) within 48 to 72 hours after ingestion.

Drug Interactions DRUG: Alcohol (chronic use), hepatotoxic

medications (such as phenytoin), hepatic enzyme
inducers (such as phenytoin and rifampin) may
increase risk of hepatotoxicity with prolonged high
dose or single toxic dose. May increase risk of
bleeding with warfarin with chronic, high-dose use.
HERBAL: St. John’s wort may decrease blood
levels.
FOOD: Food may decrease rate of absorption.
 72

LAB VALUES: May increase serum ALT (alanine

transaminase), AST (aspartate transaminase),
bilirubin, and prothrombin levels which may indicate
hepatotoxicity.

Nursing Responsibilities 1. If given for analgesia, assess onset, type,

location, duration of pain. Effect of medication is
reduced if full pain response recurs prior to next
dose.
2. Assess for fever.
3. Assess LFT (Liver Function Test) in patients with
chronic usage or history of hepatic impairment and
alcohol abuse.
4. Assess for clinical improvement and relief of
pain, fever.
Therapeutic serum level: 10–30 microgram
per milliliters; toxic serum level: greater than 200
microgram per milliliter. Do not exceed maximum
daily recommended dose, which is 4 grams a day.
5. Observe for acute toxicity and overdose.
6. Caution parents or other caregivers not to give
acetaminophen to children younger than age 2
without consulting prescriber first.
7. Tell patient, parents, or other caregivers not to
use drug concurrently with other acetaminophen-
containing products or to use more than 4,000 mg
of regular-strength acetaminophen in 24 hours.
8. Inform patient, parents, or other caregivers not to
use extra-strength caplets in dosages above 3,000
mg (six caplets) in 24 hours because of risk of
severe liver damage.
 73

9. Advise patient, parents, or other caregivers to

contact prescriber if fever or other symptoms
persist despite taking recommended amount of
drug.
10. Inform patients with chronic alcoholism that
drug may increase risk of severe liver damage.

B. Surgical Management
An intracerebral hemorrhage (Hemorrhagic stroke) is an extreme medical
emergency that requires immediate treatment. Surgical intervention attempts to
evacuate the clot to restore normal intracerebral pressure and prevent worsening
neurologic injury (Wali, et al., 2017).

CRANIOTOMY
A craniotomy is a type of brain surgery. It involves removing part of the skull,
or cranium, to access the brain. The neurosurgeon removes a portion of the skull
and conducts open surgery to drain the hematoma and repair the ruptured blood
vessel. This is a major surgical procedure that is typically used when the
hematoma is very large, or when it’s compressing the brain stem, where critical
functions are controlled.
Before the procedure make sure that the patient undergoes various tests to
confirm that the patient can safely undergo the procedure. This will likely include a
physical exam, blood tests, neurological exam, and imaging of the brain (CT scan
or MRI). On the night before the surgery, the patient should fast (not to eat) after
midnight. Also, the patient should wash his or her hair with antiseptic shampoo on
the night before the procedure. During the procedure, the patient should remove
all his or her clothing and jewelry and wear a hospital gown. The patient will sit or
lie on the operating table and the position depends on the part of the brain being
operated on. The surgical team will insert an intravenous line into the patient arm
or hand, a urinary catheter into the bladder, and give general anesthesia to the
patient. Once the anesthesia makes the patient fall asleep, the surgeon will shave
 74

the hair on the surgical site of the patient and they will also clean the area to reduce
the risk of infection. The surgeon will make an incision on the scalp and they will
use a medical drill and saw to remove a piece of bone called a bone flap. Next, the
surgeon will cut the dura mater to access the brain. The dura mater is the brain’s
outermost membrane. The surgeon will perform the procedure and remove tissue
samples if needed. After the procedure, they will stitch the tissue back together.
Wires, stitches, or plates will be used to replace the bone flap. The surgeon will
stitch or staple the skin incision, then apply a sterile bandage. The procedure can
take up to 2 ½ hours.

SURGICAL CLIPPING
A surgeon places a tiny clamp at the base of the aneurysm, to stop the
blood flow to it. This clamp can keep the aneurysm from bursting, or it can keep
an aneurysm that has recently hemorrhaged from bleeding again. During this
surgical procedure, a tiny clip is attached to the base of the aneurysm to prevent
blood flow thereby decreasing the likelihood of it bursting or rupturing if it’s pre-
rupture or to treat a ruptured aneurysm. To reach the aneurysm, the neurosurgeon
performs a small craniotomy, which temporarily removes a portion of the skull, and
an incision in the brain covering called the dura mater allows the surgeon to
carefully retract the brain and trace the affected artery to the aneurysm. Once
there, the clip is placed on the neck of the aneurysm.
The patient will undergo general anesthesia with an anesthesiologist before
the procedure. The doctors, led by a surgeon will perform the clipping. Surgical
clipping is an open surgery, which means the skull is cut and microsurgery is
performed. Part of the preparation of the surgery includes shaving the hair on the
head of the patient. Depending on the location of the aneurysm, the neurosurgeon
makes an incision below the hairline or on the back of the head. From there, a
section of bone, or bone plate, is removed (craniotomy) from the skull to expose
the brain tissue. The aneurysm is approached through the opening between the
skull and the brain but does not go through brain tissue by the neurosurgeon. The
aneurysm is carefully separated from the normal blood vessels and the brain under
 75

a microscope so that the neurosurgeon can see it and treat it properly. After that,
the aneurysm is clipped with a device that looks like a tiny clothespin. The
aneurysm is totally sealed off with the clip in place, and no more blood can enter
it. If an aneurysm is quite large or involves a large section of the blood vessel it
may require special procedures, such as putting clips on either side of the
aneurysm or making a bypass around the aneurysm. After the surgery, the patient
will feel cold and slightly dizzy and may also experience nausea and a sore throat.
Teach the patient to do breathing exercises.

STEREOTACTIC RADIOSURGERY
This treatment uses precisely focused radiation to destroy the AVM. It is not
surgery in the literal sense because there is no incision. Using multiple beams of
highly focused radiation, stereotactic radiosurgery is an advanced minimally
invasive treatment used to repair blood vessel malformations. This treatment is
most appropriate for small AVMs that are difficult to remove with conventional
surgery and for those that haven't caused a life-threatening hemorrhage.

The preparation for this surgery may vary depending on the condition and
body area being treated. Teach the patient not to eat or drink anything after
midnight the night before the procedure. Ask the attending physician whether you
can take your regular medications the night before or the morning of the procedure.
The patient should wear comfortable, loose-fitting clothing. Avoid wearing jewelry,
eyeglasses, contact lenses, makeup, nail polish, dentures, and wigs or hairpieces.
For imaging tests and radiosurgery, children are often anesthetized. Adults are
normally conscious, although a mild sedative can be administered to aid relaxation.
The patient will lie on a bed that slides into the machine, and your head frame will
be attached securely to the bed frame. During surgery, the machine does not move
instead, the bed moves inside the machine. The procedure may take less than an
hour to about four hours, depending on the size and shape of the target. If treating
with LINAC stereotactic radiosurgery of the brain the treatment will be quicker.
 76

Coiling (endovascular embolization)

Considered a less invasive procedure than surgical clipping, coil
embolization is an endovascular procedure to insert a thin, flexible coil at the
aneurysm site to block the flow of blood to the aneurysm. . Using a catheter
inserted into an artery in your groin and guided to your brain, the surgeon will place
tiny detachable coils into the aneurysm that has recently hemorrhaged from
bleeding again.
Through the use of the initial catheter, a microcatheter is inserted. The
microcatheter is attached to the coil. An electrical current is used to detach the coil
from the catheter until the microcatheter has entered the aneurysm and been
inserted into the aneurysm. The coil seals off the aneurysm's opening. The coil is
left in the aneurysm permanently. Depending on the aneurysm's size, more than
one coil can be needed to fully seal it off. After surgery, a patient might expect to
return home after spending one night in the Neuro Intensive Care Unit, and may
expect to return to normal activities within 2 days.

NURSING MANAGEMENT
NURSING DIAGNOSIS
• Activity intolerance related to physical deconditioning as evidenced
by generalized weakness

Rationale
In hemorrhagic stroke, bleeding occurs directly into the brain parenchyma.
The usual mechanism is thought to be leakage from small intracerebral arteries
damaged by chronic hypertension (Liebeskind, 2019). Symptoms are numbness
or weakness of the face, arm, or leg (especially on one side of the body), sudden
trouble walking, dizziness, loss of balance or coordination, sudden severe
headache with no known cause, sudden confusion, trouble speaking or
understanding speech and sudden trouble seeing in one or both eyes.
 77

Nursing Interventions
1. Monitor vital signs for abnormalities.
R: Changes in vital signs with monitoring physiologic responses in activity.
2. Assess the physical activity level and mobility of the patient.
R: Provides baseline information for formulating nursing goals during goal setting.
3. Establish guidelines and goals of activity with the patient.
R: Motivation and cooperation are enhanced if the patient participates in goal
setting.
4. Evaluate the need for additional help at home.
R: Coordinated efforts are more meaningful and effective in assisting the patient
in conserving energy.
5. Have the patient perform the activity slowly, in a longer time mores rest or
pauses, or with assistance if necessary.
R: Helps in increasing the tolerance for the activity.
6. Gradually increase activity with active range-of-motion exercises in bed,
increasing to sitting and then standing.
R: Gradual progress of the activity prevents overexertion.
7. Assist with ADLs while avoiding patient dependency.
R: Assisting the patient with ADLs allow conservation of energy. Carefully balance
provision of assistance; facilitating progressive endurance will ultimately enhance
the patient’s activity tolerance and self-esteem.
8. Encourage verbalization of feelings regarding limitations.
R: This helps the patient to cope. Acknowledgement that living with activity
intolerance is both physically and emotionally difficult.
9. Gradually progress patient activity with the following:
- range-of-motion exercises in bed, gradually increasing duration frequency and
intensity to sitting and then standing
- deep breathing exercises three or more times daily
- sitting up in a chair 3 or more times daily
- walking in room 1 to 2 minutes three times a day
R: Duration and frequency should be increased before intensity.
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10. Teach energy conservation techniques such as: sitting to do tasks, frequent
position changes, pushing rather that pulling, sliding rather than lifting, working at
even pace, resting for atleast 1 hour after meals before starting a new activity and
organizing a work-rest-work schedule.
R: These techniques reduce oxygen consumption, allowing a more prolonged
activity.

• Ineffective cerebral tissue perfusion related to intracranial

hemorrhage as evidenced by aphasia, loss of alertness, and bloody
CSF

Rationale
A hemorrhagic stroke happens when a blood vessel bursts,
causing bleeding in the brain. As the blood presses on brain cells,
it damages them. This can lead to neurological symptoms such as aphasia, ataxia,
bloody CSF, dizziness, and more.

Nursing Interventions
1. Assess vital signs
R: To obtain base line data
2. Monitor neurological status
R: To determine location, extent and progression of damage
3. Evaluate pupil size, shape, equality and light reactivity.
R: To determine whether the brain stem is intact or not
4. Document changes in vision
R: Visual alterations reflect area of brain involved
5. Assess speech and alertness
R: Cognition and speech content indicate location and degree of cerebral
involvement
6. Assess for seizure activity
R: 5% of people will have a seizure within a few weeks after having a stroke
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7. Position with head slightly elevated

R: To promote venous drainage and improve cerebral perfusion
8. Provide quiet and relaxing environment
R: To prevent rebleeding
9. Restrict visitors and activities
R: Continuous stimulation can increase intracranial pressure.
10. Administer antihypertensives as ordered
R: To lower down blood pressure

• Impaired verbal communication related to cell and tissue damage in

the left hemisphere of the brain as evidenced by difficulty in vocalizing
words and incomprehensible verbal response with GCS score of 12

Rationale
In hemorrhagic stroke, there is rupture of blood vessels. This will create a
pool of blood that will eventually increase intracranial pressure that may
compress parts of the brain. Also, it can cause cerebral hypoperfusion that will
lead to impaired distribution of oxygen and glucose in the brain. This will lead to
tissue hypoxia and cellular starvation that can cause damage to the brain cells
and tissue. Since symptoms depend on the location of the stroke. It could involve
the brain’s Brocca’s area, which is primary responsible for communication through
facial expressions and speech. By causing damage to this area, the
patient’s communicating skills are greatly altered and affected.

Nursing Interventions
1.Establish means of communication, for example, maintain eye contact; ask
yes/no questions; provide magic slate, paper and pencil, or picture or alphabet
board; use sign language as appropriate; and validate the meaning of attempted
communications.
R: Eye contact assures clients of interest in communicating; if client is able to
move head, blink eyes, or is comfortable with simple gestures, a great deal can be
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done with yes/no questions. Pointing to letter boards or writing is often tiring to
client, who can then become frustrated with the effort needed to attempt
conversations. Use of picture boards that express a concept or routine needs may
simplify communication. Family members and other caregivers may be able to
assist and interpret needs.
2. Place call light or bell within reach and place note at central call station informing
staff that client is unable to speak
R: Alerts all staff members to respond to client at the bedside instead of over the
intercom
3. Anticipate and meet the needs of patients
R: Helpful in reducing frustration when dependent on others and cannot
communicate meaning.
4. Recognize subtle cues indicating the client is paying attention or attempting to
communicate.
R: Cues are often difficult to recognize (glancing out of the corner of the eye)
5. Describe for the client what is happening, and put into words what the client
might be experiencing.
R: Naming objects and describing actions, thoughts, and feelings helps the client
to use symbolic language.
6. Place important objects within reach
R: To maximize patient’s sense of independence
7. Speak slowly.
R: This approach provides the patient with more channels through which
information can be communicated.
8. Keep distractions such as television and radio at a minimum when talking to
patient
R: To keep patient focused, decrease stimuli going to the brain for interpretation,
and enhance the nurse’s ability to listen
9. Give the patient ample time to respond
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R: It may be difficult for patients to respond under pressure; they may need extra
time to organize responses, find the correct word, or make necessary language
translations
10. Offer alternative forms of communication such as: gestures or actions, pictures
or drawings, magic slate, word board, flash cards that translate words/phrases
R: Patients may have skills with many forms of communication. This will give
efficient communication skills without the need to verbalize.

• Impaired physical mobility related to neuromuscular involvement as

evidenced by slowed, uncoordinated movements and gait changes

Rationale
When a patient suffers from hemorrhagic stroke, there are common sites
involved or injured due to the rupture of the arterial walls in the brain. When the
artery ruptures and bleeds, it will increase the intracranial pressure, causing
damage to the brain cells and tissues. This will then lead to dysfunction of some
vital areas related with motor, balance and coordination control. So, the blood
usually bleeds into the cerebellum and the region of the putamen-external capsule,
of which putamen is associated with learning and motor functions including
cognitive control. Hence, once it is damaged, there will be a possible physical
mobility impairment causing a person to have uncoordinated movements and gait
changes.

Nursing Interventions
1. Review functional ability and reasons for impairment.
R: Identifies probable functional impairments and influences
choice of interventions.
2. Assess degree of immobility, using a scale to rate dependence
(0 to 4).
R: The client may be completely independent (0), may require minimal assistance
or equipment (1), moderate assistance or supervision and teaching (2), extensive
assistance or equipment and devices (3), or be completely dependent on
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caregivers (4). Persons in all categories are at risk for injury, but those in categories
2 to 4 are at greatest risk.
3. Instruct and assist client with exercise program and use of mobility aids.
Increase activity and participation in self-care as tolerated.
R: Lengthy convalescence often follows brain injury, and physical reconditioning
is an essential part of the program.
4. Position client to avoid skin and tissue pressure damage. Turn at regular
intervals, and make small position changes between turns.
R: Regular turning more normally distributes body weight and promotes circulation
to all areas. If paralysis or limited cognition is present, client should be repositioned
frequently.
5. Maintain functional body alignment—hips, feet, and hands. Monitor for proper
placement of devices and signs of pressure from devices.
R: Use of high-top tennis shoes, “space boots,” and T-bar sheepskin devices can
help prevent foot drop. Hand splints are variable and designed to prevent hand
deformities and promote optimal function. Use of pillows, bedrolls, and sandbags
can help prevent abnormal hip rotation.
6. Note emotional/behavioral responses to problems of immobility.
R: Feelings of frustration or powerlessness may impede attainment of goals.
7. Encourage adequate intake of fluids and nutritious foods.
R: Promotes well-being and maximizes energy production.
8. Inspect for localized tenderness, redness, skin warmth, muscle tension, or ropy
veins in calves of legs. Observe for sudden dyspnea, tachypnea, fever, respiratory
distress, and chest pain.
R: The client may be at risk for development of deep vein thrombosis (DVT) and
pulmonary embolus (PE), requiring prompt medical evaluation and intervention to
prevent serious complications.
9. Schedule activities with adequate rest periods during the day. Identify energy-
conserving techniques for ADLs.
R: Limits fatigue and maximizing participation.
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10. Encourage participation in self-care; occupational, diversional, or recreational

activities.
R: It enhances self-concept and sense of independence.

V. DISCHARGE PLANNING
Patient was advised to have a take home medication:

A. Anticonvulsants - To prevent seizure recurrence

B. Antihypertensive agents - To reduce blood
pressure and other risk factors of heart disease
C. Osmotic diuretics - To decrease intracranial
pressure

1. Inform the patient and the family regarding

indications, side effects, and adverse effects of the
medication.
Medicine R: For a better and effective management of the
medication.

2. Instruct patient and family to report occurrence of

adverse effects
R: To maximize optimum health of the patient whenever
they have taken the drug

3. Encourage patient to ask questions regarding the

drug.
R: Asking questions about one’s treatment or medicine is
important to help them understand their options.

4. Avoid anticoagulants and antiplatelet drugs.

R: These drugs increase bleeding; if the patient did take
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any of these drugs, special medications or blood clotting

factor transfusions may be administered to stop bleeding.

1. Encourage patient to take a walk every morning.

R: To increase oxygen uptake and reduce risk of
cardiovascular disease

2. Instruct patient to do stretching at least once a day

R: Stretching keeps the muscles flexible, strong, and
balanced, which is essential for maintaining joint range of
motion. Muscles shorten and become rigid without it.
Exercise
3. Encourage patient to do coordination and balance
activities
R: To improve level of safety when doing activities of daily
living.

4. Assessment and intervention relative to poststroke

physical activity and familial support should be done
R: It is important to assess these factors to help prevent a
cycle of diminished motivation, thus making it a barrier to
physical activity and exercise training of the patient.

1. Instruct family to ensure adequate lighting in all areas

inside and around the home.
R: To reduce the risk for falling

2. Instruct the patient to take medication as directed by the

physician
R: To promote a speedy recovery of the patient
Treatment
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3. Avoid nicotine and other illegal drugs

R: Cigarettes and cigars contain nicotine and other
substances that can destroy blood vessels. Both nicotine
and illicit medications raise the risk of a stroke.
4. Perform deep breathing exercises
R: To boost circulation and manage stress
1. Instruct patient to do washing or bathing regularly
R: To encourage the patient to handle their own needs,
increasing freedom and self-esteem while reducing
Hygiene dependency on others.

2. Urge significant others to assist the patient with

personal grooming.
R: Patients require empathy and assurance that
caregivers will be diligent in their aid.

1. Encourage compliance of follow-up checkups

R: To monitor the patient’s recovery

2. Instruct patient to practice communication skills daily

R: To find out what works best and facilitate sense of
confidence, independence and belongingness.

3. Monitor for new or worsening symptoms and

complications of such as:
a) sudden trouble with vision from one or both eyes;
b) sudden difficulties with walking, coordination,
Outpatient dizziness, and balance;
c) sudden trouble with speaking. Confusion,
memory, judgement or understanding;
d) sudden numbness or weakness of the face, arms,
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and legs;
e) sudden severe headache; and
f) difficulty swallowing.
R: People who have had stroke is at risk for developing
recurrent stroke. Recognizing the early signs will allow the
patient to be treated as early as possible with tissue
plasminogen activator (tPA), which can only be given
wihtin 3 hours that stroke symptoms occur.

1. Instruct patient to follow DASH (Dietary Approaches to

Stop Hypertension) diet
R: DASH diet allows the patient to consume a variety of
food high in nutrients that help lower blood pressure, such
Diet as potassium, calcium, and magnesium, while reducing
sodium intake.

2. Discourage alcohol intake

R: Drinking more than 30 drinks a month has been linked
to an increased risk of intracerebral hemorrhage.

VI. PROGNOSIS
When a blood vessel in the brain or on the surface of the brain leaks or
splits open, causing bleeding in or across the brain, this is referred to as
hemorrhagic stroke. This causes swelling and pain, which can damage brain cells
and tissue. Hemorrhagic strokes account for almost 25% of all stroke events.
Survivability of the aforementioned illness depends on how quickly the
patient is delivered to the hospital; when they survive long enough to reach the
hospital, bleeding has normally stopped by the time they see a doctor. Many
patients who have ruptured aneurysms or subarachnoid hemorrhages do not make
it to the hospital. Around half of those who do survive, die within the first month of
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therapy. The risk of mortality is just around 15% of individuals who have
subarachnoid hemorrhages caused by arteriovenous malformations. Many of the
25% of patients who survive an intracerebral hemorrhage have a significant
difference in their effects as their bodies eventually reabsorb the clotted blood
inside the brain. About half of people that survive a leaking aneurysm have long-
term neurological problems. Those who have a bleed from an aneurysm or an AVM
and will not have it managed are at risk of causing another bleed. If the defective
blood vessel is not healed nor removed, one out of every five survivors of
subarachnoid hemorrhage will experience bleeding within 14 days. A repeat bleed
happens in 50% of people who do not undergo surgical intervention within 6
months. There is a good chance of success whenever surgery is used to clip a
leaking aneurysm.

VII. RELATED NURSING THEORIES

Self-Care Deficit Theory

By (Dorothea Orem)

According to Gonzalo (2019), Dorothea Orem is a leading nursing expert in

the United States who developed the Self-Care Deficit Nursing Theory, also known
as the Orem Model of Nursing. It focuses on each person's "capacity to perform
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self-care," which is described as "the activity of activities that individuals initiate

and perform on their own behalf in sustaining life, fitness, and well-being."
Self-care is characterized as the conduct of practices that individuals
participate in to improve their personal health and well-being for the purposes of
this theory. The Self-Care or Self-Care Deficit Theory of Nursing is composed of
three interrelated theories: (1) the theory of self-care, (2) the self-care deficit
theory, and (3) the theory of nursing systems, which is further classified into wholly
compensatory, partially compensatory and supportive-educative.
Furthermore, patients with hemorrhagic stroke are often put in a vulnerable
situation. The amount of activities of daily living a client can perform varies per
individual. Patient care may be based on the stroke patient’s ability to perform
tasks like those that they conduct on their own behalf to sustain life, wellness, and
safety. Good hygiene is one factor in achieving complete health. Unfortunately,
patients with hemorrhagic stroke have trouble performing self-care. As a result,
we, nurses must aid our patients with self-care activities such as bathing, toileting,
feeding, and changing clothing, as this will benefit the patient's wellbeing while also
offering comfort.
In addition, hemorrhagic patients may suffer pain. Fortunately, there are
various techniques and medications that are now available for safe relief of pain.
As a result, health-care professionals must respond to patient demands for pain
relief with active information and awareness of the medication that has been used
to ease the discomforts of stroke patients.
Therefore, the Self-Care Deficit Nursing Theory is significant in this study
because it will aid in the development of a holistic approach to patient care. This
theory may aid both student nurses and nurses to train their clinical eye and
determine which aspects of patient care to be in a given situation, which may assist
in the formulation of a potential nursing diagnosis for the research, and it stresses
the importance of patients maintaining control over their own self-care process.
Through all this the client may eventually be able to function with less support from
others and promote independence in daily tasks.
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Nursing Need Theory

By (Virginia Henderson)

According to Gonzalo (2021), the Nursing Need Theory was founded by

Virginia Henderson to describe the unique focus of nursing practice. The theory
emphasizes the importance of increasing a patient's independence in order to
hasten their progress in the hospital. In addition, good health is a challenge
because it is affected by so many different factors, such as age, cultural
background, emotional balance, and others. Virginia Henderson's 14 components
of her Need Theory demonstrate a holistic nursing approach that addresses
medical, psychological, spiritual, and social needs. Henderson's philosophy
focuses on the most basic human needs and how nurses can help fulfill them.

Patients who suffer hemorrhagic stroke may suffer from various signs and
symptoms that are fit to the 14 basic needs of Henderson. A patient may suffer
from dyspnea, impairment to the skin integrity, hypertension, urinary dysfunction,
hyperthermia, loss of consciousness, impaired verbal communication, immobility
due to paralysis and poor hygiene. This is where nursing interventions come
through and promotes a varying holistic approach to solve each problem of the
basic human need that will eventually lead the patient to independence.
Once nursing interventions are given they are able to breathe normally, eat
and drink adequately, acquire enough sleep and rest, eliminate body wastes,
communicate using various non-verbal techniques, maintain regular vital signs
results, slowly restore regular body part motions and keep proper hygiene.
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In addition, hemorrhagic stroke clients not only need physiologic needs but
as well as spiritual and moral, psychological and sociological needs. Nurses can
impart health teachings and motivate patients in ways that are in line with reality
and the degree of his or her condition. Nurses need to stress the promotion of
health and prevention, as well as the curing of the disease.

THEORY OF COMFORT
by Katharine Kolcaba, RN

Kolcaba's Comfort Theory was first proposed in the 1990s. It is a philosophy

for health care practice, education, and science that is in the center of the
continuum. This theory puts emphasis to place the patient's comfort first in
healthcare. Relief, ease, and transcendence are three types of comfort, according
to Kolcaba.
Furthermore, when a patient's basic comfort needs are fulfilled, the patient
feels relieved and comforted. A patient who receives pain medication in post-
operative care is receiving relief comfort. Ease addresses comfort in a state of
contentment. For example, the patient’s anxieties are calmed. Transcendence is
described as a state of comfort in which patients are able to rise above their
challenges. The four contexts in which patient comfort can occur are: physical,
psychospiritual, environmental, and sociocultural. In the end, comfort is an
immediate desired outcome in nursing care.
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In relation to the case, the theory of comfort is applicable to the patient with
hemorrhagic stroke as one of the ultimate goals of nurses is to provide comfort.
During the first part of intervention, the student nurses evaluate the patient's
physical and psychological and spiritual needs by asking how they are feeling
about their condition and what they require to alleviate the problem. Following that,
the patients' other interests, such as their sociocultural and environmental needs,
are evaluated. Patients who may suffer from paralysis on one side of their body
can be repositioned every 2 hours taking note to position paralyzed area to only
30 mins and also position with pillows. In addition, when a patient has a headache
as a result of a hemorrhagic stroke, the nurse or student nurse may elevate the
head of the bed and administer the necessary drugs to alleviate the pain and
pressure. In this way, the student nurse approached the patient's physical comfort.
Another example is when the patient verbalizes to the student nurse her
frustration and concerns about the changes in her senses and the possible
complications brought about by the disease. In this scenario, the nurse or student
nurse may provide health teachings and information that will help her embrace and
adapt to change while also relieving her anxiety by assuring her of her strengths
and tools to help her cope.
Through all of these the patient can now feel enhanced comfort. This
strengthens patients to consciously or subconsciously engage in behaviors that
move them toward a state of well-being. After this, the patient can now engage
regularly in care-related behaviors, which is referred to as health-seeking activity.
The patient is now in his rehabilitation process, and his hospital stay has been
shortened, thanks to the patient's complete involvement and the help of nurses
and other members of the health team. Therefore, the theory of comfort is really
applicable in hemorrhagic stroke.

VIII. REVIEW OF RELATED LITERATURE

Stroke
A stroke is defined as a brain accident with "rapidly developing clinical signs
of focal or global disturbance to cerebral function, with symptoms lasting 24 hours
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or longer, or leading to death, with no apparent cause other than of vascular origin
and includes cerebral infarction, intracerebral hemorrhage, and subarachnoid
hemorrhage," according to the World Health Organization. Acute stroke is also
known as a cerebrovascular accident, which is not a term that most stroke
neurologists prefer. Stroke is NOT an unintentional occurrence. The better and
more meaningful term is "brain attack," which has the same meaning as "heart
attack."
It is mentioned in this article that there are 2 main types of stroke. The most
common type is an ischemic stroke, which is caused by a disruption in blood flow
to a specific area of the brain. Ischemic stroke is responsible for 85 percent of all
acute strokes. There are four major types of ischemic strokes, according to the
TOAST classification. Large vessel atherosclerosis, small vessel diseases
(lacunar infarcts), cardioembolic strokes, and cryptogenic strokes are examples of
these. While Acute hemorrhagic strokes account for 15% of all acute strokes and
are caused by the bursting of a blood vessel, i.e. acute hemorrhage. Hemorrhagic
strokes are classified into two types: intracerebral hemorrhage (ICH) and
subarachnoid hemorrhage, which account for approximately 5% of all strokes.
Moreover, every year, 15 million people worldwide suffer from stroke,
according to the World Health Organization (WHO). 5 million of these people die,
and another 5 million are permanently disabled. [2] Formalized paraphrase
According to the 2010 Global Burden of Disease Study, stroke is the world's
second leading cause of death and the third leading cause of premature death and
disability as measured by Disability Adjusted Life Years (DALY). Cerebrovascular
disease is the leading neurologic cause, accounting for 4.1 percent of total global
DALY.
Lastly, when a blood vessel in the brain ruptures and bleeds, this is referred
to as a hemorrhagic stroke. Intracerebral Hemorrhagic Stroke occurs when a blood
vessel within the brain bleeds. The most common cause of intracerebral
hemorrhagic stroke is high blood pressure while Subarachnoid hemorrhagic stroke
occurs when a blood vessel between the surface of the brain and the arachnoid
tissues that cover the brain bleeds. But some experts do not consider
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Subarachnoid Hemorrhage to be a Stroke because it presents differently than

Ischemic Stroke and Intracerebral Hemorrhagic Stroke.

Hemorrhagic Stroke
The article begins with an introduction mentioning that in hemorrhagic
stroke the bleeding enters the brain parenchyma directly. The most likely
mechanism is leakage from small intracerebral artery damage caused by chronic
hypertension. The article stated that the term intracerebral hemorrhage and
hemorrhagic stroke are interchangeably used and considered distinct entities from
a hemorrhagic transformation of ischemic stroke.
Hemorrhagic stroke occurs less frequently than ischemic stroke. (i.e., stroke
caused by thrombosis or embolism); according to epidemiological studies, only 8-
18% of strokes are hemorrhagic. Hemorrhagic stroke is more likely to result in
death than ischemic stroke. Patients with hemorrhagic stroke may present with
progressive neurological deficits similar to those seen in ischemic stroke, but they
are generally sicker. However, on the other hand, patients with intracerebral bleeds
are more likely to experience headaches, altered mental status, seizures, nausea,
vomiting, and severe hypertension.
Moreover, the pathophysiology of ICH stated in the article, when bleeding
occurs directly into the brain parenchyma in intracerebral hemorrhage. The most
likely mechanism is leakage from small intracerebral arteries damaged by chronic
hypertension. Bleeding diathesis, iatrogenic anticoagulation, cerebral amyloidosis,
and cocaine abuse are some of the other mechanisms. Intracerebral hemorrhage
has a predilection for certain sites in the brain, including the thalamus, putamen,
cerebellum, and brainstem. In addition to the area of the brain injured by the
hemorrhage, the surrounding brain can be damaged by pressure produced by the
mass effect of the hematoma. A general increase in intracranial pressure may
occur.

Stroke Risk Factors, Genetics, and Prevention

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Boehme, A. K., Esenwa, C., Elkind, M. S.V (2017) stated in this article that
Stroke is the leading cause of long-term adult disability and the fifth major cause
of death in the United States, accounting for 795000 stroke events annually. The
aging of the population, combined with a decrease in case fatality after stroke, is
expected to increase stroke prevalence by 3.4 million people between 2012 and
2030. Although stroke mortality in the United States has decreased over the last
two decades, recent mortality trends suggest that these decreases may have
dropped off and that stroke mortality might be starting to rise again. The reasons
for this are unknown, but they could be related to the obesity epidemic and
diabetes mellitus. Stroke morbidity remains high, with annual costs estimated at
$34 billion for health services, treatments, and missed work days.Estimates of
morbidity and cost burden, based on clinical stroke studies and traditional
measures such as physical disability and healthcare costs, are likely to
underestimate the burden of cerebrovascular disease.
The article also mentioned that in hemorrhagic stroke patients, after the age
of 45, the incidence rises. Some of the recent increases in incidence among
younger people may be due to changes in diagnostic testing, resulting in greater
sensitivity for detecting stroke among those with minor symptoms. The relationship
between sex and stroke risk varies with age. Women have the same or higher risk
of stroke as men when they are young, but men have a slightly higher relative risk
when they are older. The increased risk of stroke in younger women is most likely
due to risks associated with pregnancy and the postpartum state, as well as other
hormonal factors such as the use of hormonal contraceptives. Overall, more
strokes occur in women than in men, owing to women's longer life expectancy
compared to men.
Furthermore, it was mentioned here on the article that recent studies have
also found that HIV infection is associated with a modest increased risk of both
ischemic and hemorrhagic stroke, despite the availability of highly active
antiretroviral therapy. The mechanisms underlying this increase in risk are
unknown, but the risk appears to be higher in those with evidence of greater
immunosuppression, such as lower (200 cells/mm3) CD4+ T-cell counts and a
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higher number of HIV-1 RNA copies. HIV has the potential to cause direct damage
to the arterial wall. There is evidence, for example, that outward arterial
remodeling, or relative thinning of the arterial wall, occurs more frequently in HIV
patients who have long-term infections and a higher viral load before death.
In conclusion, the emphasis on different types of stroke has aided genetic
analyses in particular. Mutations in specific genes have been linked and replicated
in the subtypes of large vessel, cardioembolic, and small vessel stroke. Genetic
studies have also suggested new avenues to investigate in the quest to understand
stroke pathogenesis. According to the findings in this article, they are suggesting
that precision medicine will enable clinicians to better treatments for
cerebrovascular disease in the future. Meanwhile, several large clinical trials have
provided evidence of the benefits of various medical and behavioral therapies in
lowering stroke.

Acute intracerebral hemorrhage: diagnosis and management

Intracerebral hemorrhage (ICH) is responsible for half of all disability-
adjusted life years lost due to stroke globally. Care pathways for acute stroke
result in the rapid identification of ICH. But its management can prove challenging
because no individual treatment was been shown definitively to improve its
outcome. Despite this, acute stroke unit care improves outcomes after ICH. Patient
benefits from interventions to prevent complications, acute blood pressure-
lowering appears safe and may have an advantage, and implementing a bundle of
high-quality care is associated with a higher chance of survival.
Spontaneous intracerebral hemorrhage (ICH) refers to non-traumatic
bleeding in the brain parenchyma and is the deadliest form of stroke. The high 1-
month case-fatality rate of ~40% and poor long-term outcome make it a major
contributor to global morbidity and mortality, according to McGurgan, I.J., Ziai,
W.C., Werring, D.J, et al (2020). It is mentioned in the article that the Glasgow
Coma Scale (GCS) score is the most useful initial evaluation because of its similar
prognostic value to NIHSS, its simplicity and its incorporation in the ICH score.
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However, aphasia, like ischemic stroke, can reduce the verbal subdomain score,
causing the GCS can be underestimated.
In addition, management of the complications of ICH is a key focus of acute
care. Although there is no enough evidence to support the guide of this
management in ICH, measures used for raised ICP in other settings may help.
Which included raising the head of the bed to 30° (though there is no evidence to
support this in acute stroke), mild sedation, analgesia, and mannitol (or hypertonic
saline, depending on cardiac and renal comorbidities). Those with a GCS9 should
have intensive ICP monitoring. Cortical involvement, age younger than 65 years,
volume greater than 10 mL and early seizures within 7 days of ICH identify patients
at higher risk of subsequent late seizure development.
Lastly, there is more management mentioned in this article and this includes
neurosurgery. Neurosurgical intervention is generally recommended for
infratentorial bleeding despite a lack of randomized evidence, given the high risk
of brainstem compression and herniation syndromes in the confined space of the
posterior fossa. Clinical guidelines recommend posterior fossa decompressive
evacuation for cerebellar ICH>3 cm in diameter, or for smaller hematomas
associated with brainstem compression or hydrocephalus from ventricular
obstruction. Although ICH has the worst outcomes of any stroke subtype,
increased research interest in recent years has resulted in significant advances in
diagnosis and management. The focus of current treatment is on preventing
hematoma expansion, and advances in supportive care, blood pressure control,
and anticoagulation reversal have resulted in better outcomes. The involvement of
neurosurgery is still unclear, but the field is rapidly evolving. And with minimally
invasive techniques showing promise in selected groups, even in the context of
neutral trials so far.

Clinical nursing pathway improves the nursing satisfaction in patients with acute
cerebral hemorrhage: A randomized controlled trial protocol
In clinical practice, cerebral hemorrhage (CH) is a very common
cerebrovascular disorder. More and more studies have found that proper nursing
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care can increase the rate of treatment and improve the prognosis following
treatment. Clinical nursing pathway (CNP) refers to the original nursing mode that
has high quality, high efficiency, and low treatment costs. There have been few
studies on the effect of CNP in patients with acute CH. The program urgently
requires convincing evidence to demonstrate its dependability. As a result, we
conduct this randomized controlled trial protocol, hypothesizing that CNP is
associated with improved outcomes and nursing satisfaction, as well as fewer
adverse reactions in patients with acute CH.
It is mentioned here in this article that, aside from the various treatments,
an increasing number of studies have found that proper nursing care can
significantly improve the treatment rate and prognosis. Recent guidelines rarely
describe and analyze nurses' roles and the impact of nursing interventions on
health outcomes. With the rapid advancement of medical technology today, the
nursing method must be updated accordingly. Clinical nursing pathway (CNP) is a
unique nursing method with high quality, high efficiency, and low treatment costs.
Furthermore, the key to improving prognosis and curative rate is effective
treatment combined with appropriate nursing care. Formal paraphrase Because of
the backward concept of one-size-fits-all, the standard nursing model cannot fully
adapt to the development of the illness. As a result, the traditional nursing model
is inadequate for meeting patients' most critical clinical needs. To improve nursing
services for patients, CNP is an interdisciplinary, deeply integrated, and
progressive modern nursing model that emphasizes pre-admission hierarchy and
comprehensive hospital nursing courses. This method is intended to significantly
improve the quality of care by focusing on the patient.
In conclusion, this method is intended to greatly improve the quality of care
by establishing patient-centered roles in which nursing and medical personnel
focus their best efforts on meeting the needs of patients. The model can be
presented in the form of a table to help patients understand the content of their
self-care plan and the implications of active participation in disease rehabilitation.
CNP has the potential to improve clinical outcomes for patients with acute CH and
has a significant value in real-world applications.
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