CASE STUDY:

CVA –
CEREBROVASCULAR ACCIDE
NT, HEMORRHAGIC STROKE
ALMIN, RAZELLE S.
BSN3Y2-2
 HISTORY OF PRESENT ILLNESS:

This 50-year-old female has not seen a doctor in a number of years and reports headaches
over the past 2 weeks, which she treated at home with ibuprofen. The night of admission, she
went to bed but woke around midnight to get some water and ibuprofen, and fell. Her
husband heard her fall and when he arrived at her side he noted she was not moving her left
side and was confused and disoriented. She also had garbled speech and was complaining of
headache by holding her head and moaning. The husband called 911 and EMS arrived
approximately 5 to 10 minutes after the fall. The paramedics stated that she vomited on way
to the hospital and again in the emergency department (ED). Her blood pressure on way was
208 over palpable, she was in sinus rhythm, and her blood sugar was 91. The EMS
assessment also noted confusion, garbled speech, and absence of movement on her left side to
painful stimuli. EMS called the ED on way to initiate a “stroke alert.” The estimated time
elapsed from the fall to the patient’s arrival in the ED is 15 to 20 minutes.
 CONT………

Due to the rapid decline of this patient’s neurological status, the patient was intubated in the ED.
IVF’s with Normal Saline solution initiated. Her blood pressure was severely elevated on admission
so intravenous hydralazine was administered. Citicoline 1gm intravenously as loading dose started.
Further physical examination and diagnostic evaluation was done. Stat ECG shows normal sinus
rhythm. A stat non-contrast computed tomography (CT) scan of head and CT angiography followed.
The patient’s CT scan shows a large 6-cm right-sided intraparenchymal hemorrhage with a 16-mm
leftward midline shift. While CT angiography results did not identify an aneurysm.
Hemorrhagic stroke was the initial diagnosis and pertinent stroke management followed due to
rapidly declining neurological status, she was rushed to the operating room for an emergent right
craniotomy and hemorrhagic clot removal. She was then admitted to the ICU for further monitoring
and management.
 MEDICAL HISTORY:

 (-) diabetes, hypertension, heart disease, cancer, and seizure.

 (-) recent fevers, chills, nausea, vomiting, dyspnea, cough, pain
in the chest, abdomen, or back.
 (-)complained of numbness, tingling, paresthesia, or edema of
the extremities.
 (-) history of fall and trauma to the head for the past 2 weeks
 (+) recurrent headaches mildly relieved with ibuprofen .
 PHYSICAL ASSESSMENT UPON ADMISSION:

 Elevated blood pressure - 251/136

 Rapidly deteriorating neurological examination
 Opens eyes to verbal and tactile stimuli
 Deconjugated gaze
 Left hemiparesis
 Positive left Babinski
 Able to follow commands on arrival but rapidly declined to unresponsive.
 HEMORRHAGIC STROKE

Doctors may also use the term “intracranial hemorrhage” when talking about
hemorrhagic stroke.

A stroke that leads to hemorrhage (too much blood in the brain) is called a hemorrhagic
stroke. If you have a hemorrhagic stroke caused by a slow accumulation of blood, you may
experience symptoms such as headaches, lethargy, and nausea or vomiting.
Your chances of experiencing a hemorrhagic stroke are higher if you are older (over age
65), have a family or personal history of stroke, have uncontrolled diabetes, high
cholesterol, or high blood pressure, smoke, are obese, do not exercise, or have a poor diet.
.
 SIGNS AND SYMPTOMS
 Sudden, severe headache near the back of the head. Many people have described this as the “worst headache of
your life.”
 Losing consciousness
 Inability to move or feel
 Confusion and irritability
 Muscle pain in neck and shoulders
 Nausea and vomiting
 Sensitivity to light
 Seizure
 Vision problems
 Drooping eyelids
 One eye pupil larger than the other
 TREATMENT

We treat hemorrhagic stroke by locating the source of the bleed

and surgically “clipping” it, draining the skull to decrease pressure in
the brain, blocking off any sources of bleeding, and/or performing
minimally invasive “burr hole” removal of the intracerebral
hemorrhage.
After we perform a procedure, we typically give you medications
to reduce blood pressure, pain, anxiety, headaches, and/or seizures.
 DIAGNOSTIC / LABORATORY TESTS 

 Physical examination and diagnostic evaluation was done.

 Stat ECG shows normal sinus rhythm.
 A stat non-contrast computed tomography (CT) scan of head and
CT angiography followed.
 The patient’s CT scan shows a large 6-cm right-sided
intraparenchymal hemorrhage with a 16-mm leftward midline
shift. While CT angiography results did not identify an aneurysm.
 CRANIOTOMY 
 A craniotomy is the surgical removal of part of the bone from the skull to expose
the brain. Specialized tools are used to remove the section of bone called the
bone flap. The bone flap is temporarily removed, then replaced after the brain
surgery has been done.
 Some craniotomy procedures may use the guidance of computers and imaging
(magnetic resonance imaging [MRI] or computerized tomography [CT] scans)
to reach the precise location within the brain that is to be treated. This
technique requires the use of a frame placed onto the skull or a frameless
system using superficially placed markers or landmarks on the scalp. When
either of these imaging procedures is used along with the craniotomy
procedure, it is called stereotactic craniotomy.
DRUG STUDY
 NAME, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS NURSING RESPONSIBILITY
CLASSIFICATION OF ACTION
DRUG, DOSAGE,
FRQUENCY, ROUTE

Name: Citicoline is CVA in acute and • Hypertonia of the • Headache • Monitor bloodpres

CITICOLINE derivative of recovery phase. parasympathetic •  Dizziness sure, pulse rate
choline and Symptoms and nervous system •  Shaking of hands and heart rate.
cytidine signs of cerebral or feet
Brand Name:
involved in the insufficiency i.e., •  Sleepiness • Monitor for advers
Brainact, biosynthesis of dizziness •  Change in pulse e effect; instruct
Cholinerv, lecithin. It is headache, poor rate patient to report
Nicholin claimed to concentration, •  Change in blood immediately if she
increase blood memory loss, pressure develops chest
Drug flow and disorientation,. •  Diarrhea tightness, tingling
Classification oxygen Recent cranial •  Nausea in mouth and
: Nootropic agent consumption trauma and their •  Stomach pain throat, headache,
in the brain. sequence •  Blurred vision diarrhea and
blurring vision.
Dosage: 1gm

Route: IV
NAME, CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS NURSING
OF DRUG, DOSAGE, ACTION RESPONSIBILITY
FRQUENCY, ROUTE

Name: May inhibit Mild to moderate pain contraindicated for use in Common side effects • Check renal and hepatic
Brand Name: Addaprin, prostaglandin synthesis. fever. function periodically in
Advil, Advil Cold and Sinus, To produce anti- patients with: known of ibuprofen include: patients on long-term
Advil Congestion Relief, Advil inflammatory, hypersensitivity or • Dizziness  therapy.
PM, Advil Sinus Congestion analgesic, and idiosyncratic reaction to • Stomach and • NSAIDS may mark signs
and Pain, Alivio, Caldolor, antipyretic effects. and symptoms of infection.
Cedaprin, Children's ibuprofen (or any of the other abdominal pain • Blurred or diminished
Ibuprofen,  ingredients in the product) • Heartburn vision and changes in color
known hypersensitivity to • Constipation vision may occur.

Drug Classification:   aspirin and other NSAIDs • Nausea

• Full anti-inflammatory
effects may take 1 or 2
NSAIDs;  • Rash weeks to develop.
Patent Ductus • Ringing in the ears
Arteriosus Agents • Swelling (edema)
• Fluid retention
• Headache
• Vomiting
• Skin peeling
• Sun sensitivity (
photosensitivity
 reactions)
 NAME, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS NURSING
CLASSIFICATION OF ACTION RESPONSIBILITY
DRUG, DOSAGE,
FRQUENCY, ROUTE

Name: hydralazine (Rx) Acts directly on Hypertension- Concentration CNS” Before

vascular smooth muscle - Check BP Arrange for CBC,
Eclampsia - hypersensitivity Headache, peripheral neuritis,
LE cell preparations and ANA
Brand Name: to cause - CAD dizziness, tremors, psychotic
titers before therapy.
vasodilation, primarily  - mitral valvular rheumatic heart disease reactions characterized by
- - Assess for contraindicated
Drug Classification:   arteriolar, decreasing Precautions
depression, disorientation,
conditions.- Observe the 15
Vasodilators peripheral resistance.- - with CAV’s- increased ICP-
anxiety rights of drug administration.-
CV : Assess bowel sounds.- Assess
maintains or increases - severe hypertension with uremia  Palpitations, tachycardia,
- advanced renal damage voiding pattern.
Dosage: renal and cerebral flow angina pectoris, During
- slow acetylators
injectable solution - lactation
hypotension, paradoxical pressor - Give oral drug with food.
response, orthostatic hypotension - - Use parenteral drug
20mg/mL - pregnancy GI: immediately after opening
- pulmonary hypertension  Anorexia, nausea, vomiting, ampule.- Instruct to take drug
tablets Drug Interaction Drug to drug diarrhea, constipation, paralytic exactly as prescribed.
• increased pharmacologic effects ileus After
10mg of  beta-adrenergic blockers and GU - Withdraw drug gradually
25mg hydralazine when given concomitantly : Difficult micturition, impotence - Discontinue if blood
dyscrasias occur.- Arrange for
50mg Drug to Food Hematologic
pyridoxine therapy if pt.
• increased bioavailability of oral : Blood Dyscrasias
100mg Hypersensitivity: develops symptoms of
hydralazine given with food. peripheral neuritis.
Rash, urticaria, pruritus, fever,
- Monitor for orthostatic
chills, arthralgia, eosinophilia,
hypotension.- Report
rarely, hepatitis,
Route: obstructive jaundice
persistent or severe
constipation, unexplained
Other fever or malaise, muscle or
: Nasal congestion, flushing, joint aching, chest pain, rash,
edema, muscle cramps, numbness, tingling.
splenomegaly, dyspnea, lupus- - do proper documentation.
like syndrome.
NURSING CARE
PLAN