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I. INTRODUCTIONThe World Health Organization (WHO) definition of stroke is: rapidly developing clinical
signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or
longer or leading to death, with no apparent cause other than of vascular origin.
In the Philippines, deaths are mainly due to noncommunicable diseases, specifically of
the heart and vascular system. The eight leading causes of mortality are diseases of the heart,
stroke, cancer, accidents, pneumonia, tuberculosis, diabetes mellitus and chronic lower
respiratory diseases. The majority of these diseases are linked to common, preventable,
lifestyle-related risk factors that include tobacco use, unhealthy diet and physical inactivity.
Prevalence rates for obesity, diabetes and cardiovascular disease now surpass those of
most industrialized countries. Increasing rates of overweight and obesity, reduced physical
activity, smoking and, to some extent, the ageing of the population are factors contributing to
the rapidly growing burden of noncommunicable disease. Currently, 19.6% of Filipino adults are
overweight and 4.8% are obese. It is also reported that 60.5% of adults are physically inactive.
The prevalence of tobacco use among adults continues to be high and is rising, from 32.7% in
1999 to 34.8 in 2003. Around 56% of adult males and 12% of adult females are current smokers,
while 19.6% of adolescents smoke.
(http://www.wpro.who.int/countries/2007/phl/health_situation.htm)
A stroke is caused by the interruption of the blood supply to the brain, usually because a
blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients,
causing damage to the brain tissue.
The most common symptom of a stroke is sudden weakness or numbness of the face,
arm or leg, most often on one side of the body. Other symptoms include: confusion, difficultyspeaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking,
dizziness, loss of balance or coordination; severe headache with no known cause; fainting or
unconsciousness.
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The effects of a stroke depend on which part of the brain is injured and how severely it
is affected. A very severe stroke can cause sudden death.
(http://www.who.int/topics/cerebrovascular_accident/en/)
Incidence
The steep increase in the burden of noncommunicable disease is currently a priority
health problem. Six of the top ten causes of mortality are due to noncommunicable diseases.
These include cardiovascular disease, cancer, chronic obstructive pulmonary disease, diabetes
and kidney disease. Hypertension and heart disease are among the 10 leading causes of
morbidity, with 22.5% of Filipino adults hypertensive.
(http://www.wpro.who.int/countries/2007/phl/health_situation.htm)
High blood pressure has been established as a major risk factor for stroke and the unfortunate
thing about it is that most hypertensive patients have no symptoms.
The statistics are grim:
Less than half of hypertensive patients are aware that they have high blood pressure.
Only about a quarter are taking antihypertensive medications.
Only about 10 percent, or even less, have adequately controlled high blood pressure.
According to the World Health Organization, 15 million people worldwide will suffer
from stroke in 2007. Five million will die and another five million will be permanently disabled.
In the Philippines, stroke affects 486 out of 100,000 Filipinos or roughly half a million Filipinos,
according to Dr. Navarro in his study published in The Philippine Journal of Neurology.
(Philippine Inquirer, 12/01/2007)
Vascular Disease which includes C.V.A. is the second leading cause of death in the
Philippines with a total of 51,680 according to DOH 2004. Along with this are 37,092 who
survived with it. (http://www.doh.gov.ph/kp/statistics/morbidity)
http://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaignshttp://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaignshttp://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaignshttp://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20071201-104135/Stroke_prevention_campaigns7/27/2019 87906380 Case Study CmVA
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Current trends
Vaccine Prevents Stroke in Rats
A vaccine that interferes with inflammation inside blood vessels greatly reduces the
frequency and severity of strokes in spontaneously hypertensive, genetically stroke-prone rats,
according to a new study from the NIH's National Institute of Neurological Disorders and Stroke
(NINDS). If the vaccine works in humans, it could prevent many of the strokes that occur each
year.
In the study, researchers used a nasal spray to deliver a protein that, under normal
circumstances, contributes to inflammation of the cells that line the inner walls of blood vessels.
Exposing rats to this substance, called E-selectin, programs blood cells called lymphocytes to
monitor the blood vessel lining for the inflammatory protein. When these lymphocytes detect E-
selectin, they produce substances that suppress inflammation.
The vaccine is the first treatment to target inflammation in blood vessels as a possible
means of preventing stroke, says senior author John M. Hallenbeck, M.D., chief of the Stroke
Branch at NINDS. "Clinically, stroke is hard to treat. If we can prevent it from happening, that's
clearly the way to go," he adds. The study appears in the September 2002 issue of the journal
Stroke. (Retrieved at
http://www.ninds.nih.gov/news_and_events/news_articles/pressrelease_stroke_vaccine_0905
02.htm on September 26, 2010 at 8:10pm)
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II. REVIEW OF ANATOMY AND PHYSIOLOGYMAJOR REGIONS OF THE BRAIN AND THEIR FUNCTIONS
The major regions of the brain (Figure 1.) are the cerebral hemispheres, diencephalon, brain
stem and cerebellum.
Figure 1. Major Regions of the Brain. (Reproduced from [Marieb 1991])
Cerebral hemispheres
The cerebralhemispheres (Figure 1), located on the most superior part of the brain, are
separated by the longitudinal fissure. They make up approximately 83% of total brain mass, and
are collectively referred to as the cerebrum. The cerebral cortexconstitutes a 2-4 mm thick grey
matter surface layer and, because of its many convolutions, accounts for about 40% of total
brain mass. It is responsible for conscious behaviour and contains three different functional
areas: the motor areas, sensory areas and association areas. Located internally are the white
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matter, responsible for communication between cerebral areas and between the cerebral
cortex and lower regions of the CNS, as well as the basal nuclei (or basal ganglia), involved in
controlling muscular movement.
Diencephalon
The diencephalon is located centrally within the forebrain. It consists of the thalamus,
hypothalamus and epithalamus, which together enclose the third ventricle. The thalamus acts as
a grouping and relay station for sensory inputs ascending to the sensory cortex and association
areas. It also mediates motor activities, cortical arousal and memories. The hypothalamus, by
controlling the autonomic (involuntary) nervous system, is responsible for maintaining the
bodys homeostatic balance. Moreover it forms a part of the limbic system, the emotional
brain. The epithalamus consists of thepineal glandand the CSFproducing choroid plexus.
Figure 2. Major Regions of the cerebral hemispheres. (Reproduced from [Marieb 1991]).
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Brain stem
The brain stem is similarly structured as the spinal cord: it consists of grey matter
surrounded by white matter fibre tracts. Its major regions are the midbrain, pons and medulla
oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways
between higher and lower brain centres, contains visual and auditory reflex and subcortical
motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the
regulation of respiration and cranial nerves. The medulla oblongata takes an important role as
an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in the
medulla regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves.
Moreover, it provides conduction pathways between the inferior spinal cord and higher brain
centres.
Cerebellum
The cerebellum, which is located dorsal to the pons and medulla, accounts for about
11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal
white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum
processes impulses received from the cerebral motor cortex, various brain stem nuclei and
sensory receptors in order to appropriately control skeletal muscle contraction, thus giving
smooth, coordinated movements.
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THE CEREBRAL CIRCULATORY SYSTEM
Blood is transported through the body via a continuous system ofblood vessels.Arteries
carry oxygenated blood away from the heart into capillaries supplying tissue cells. Veins collect
the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow
through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange
gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys.
All the circulation besides the heart and the pulmonary circulation are called the systemic
circulation.
Blood supply to the brain
Figure 3 Major cerebral arteries and the circle of Willis. (Reproduced from [Marieb 1991]).
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Figure 3 shows an overview of the arterial system supplying the brain. The major
arteries are the vertebral and internal carotid arteries. The two posterior and single anterior
communicating arteries form the circle of Willis, which equalises blood pressures in the brains
anterior and posterior regions, and protects the brain from damage should one of the arteries
become occluded. However, there is little communication between smaller arteries on the
brains surface. Hence occlusion of these arteries usually results in localised tissue damage.
Cerebral haemodynamics
The cardiac output is about 5 l/min of blood for a resting adult. Blood flow to the brain
is about 14% of this, or 700 ml/min. For any part of the body, the blood flow can be calculated
using the simple formula:
Blood flow = Pressure
Resistance
Pressure in the arteries is generated by the heart which pumps blood from its left
ventricle into the aorta. (Since pressure was historically measured with a mercury manometer,
the units are commonly expressed in terms of [mm Hg], although the official SI unit is the Pascal
[Pa].) Resistance arises from friction, and is proportional to the following expression
Resistance Viscosity x Vessel Length
(Vessel Diameter) 4
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Hence blood flow is slowest in the small vessels of the capillary bed, thus allowing time
for the exchange of nutrients and oxygen to surrounding tissue by diffusion through the capillary
walls.
Approximately 75% of total blood volume is stored in the veins which, because of their
high capacity, act as reservoirs. Their walls distend and contract in response to the amount of
blood available in the circulation. However, the function of cerebral veins, formed from sinuses
in the dura mater, is somewhat different from other veins of the body, as they are non-
collapsible.
Autoregulation
[Panerai 1998] describes autoregulation of blood flow in the cerebral vascular bed as
the mechanism by which cerebral blood flow (CBF) tends to remain relatively constant despite
changes in cerebral perfusion pressure (CPP). With a constant metabolic demand, changes in
CPP or arterial blood pressure that would increase or reduce CBF are compensated by adjusting
the vascular resistance. This maintains a constant O2 supply and constant CBF.
Therefore cerebral autoregulation allows the blood supply to the brain to match its
metabolic demand and also to protect cerebral vessels against excessive flow due to arterial
hypertension. Cerebral blood flow is autoregulated much better than in almost any other organ.
Even for arterial pressure variations between 50 and 150 mm Hg, CBF only changes by a few
percent. This can be accomplished because the arterial vessels are typically able to change their
diameter about 4-fold, corresponding to a 256-fold change in blood flow. Only when the brain is
very active is there an exception to the close matching of blood flow to metabolism, which can
rise by up to 30-50% in the affected areas. It is an aim of PET, functional MRI, near infrared
spectroscopy (NIRS), and, possibly, near infrared imaging, to detect or image such localized
changes in cortical activity and associated blood flow.
(Retrieved at http://www.medphys.ucl.ac.uk/research/borg/homepages/florian/thesis/pdf_files
/p25_34.pdfon September 27, 2010 at 8:44am)
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III. DIAGNOSTIC PROCEDURESNoncontrast Computed Tomography (CT) Scan
Intraparenchymal hemorrhage can be recognized on CT scans because blood appears
brighter than other tissue and is separated from the inner table of the skull by brain tissue. The
tissue surrounding a bleed is often less dense than the rest of the brain due to edema, and
therefore shows up darker on the CT scan. A computed tomography (CT) scan shows fresh
blood in the skull as a white spot on the film.
The risk of death from an intraparenchymal bleed in traumatic brain injury is especially
high when the injury occurs in thebrain stem. Intraparenchymal bleeds within themedulla
oblongataare almost always fatal, because they cause damage to cranial nerve X, thevagus
nerve, which plays an important role inblood circulationand breathing.This kind of hemorrhage
can also occur in thecortexor subcortical areas, usually in thefrontalortemporal lobeswhen
due to head injury, and sometimes in thecerebellum.
For spontaneous Intracranial Hemorrhage seen on CT scan, the death rate (mortality) is
3450% by 30 days after the insult,and half of the deaths occur in the first 2 days.
Sometimes a persons symptoms and clinical exam point to a subarachnoid hemorrhage,
but the CT scan cannot confirm the diagnosis because there is only a small amount of blood in
the space between the brain and the surrounding membranes. In this case, the physician usually
undertakes a lumbar puncture, or spinal tap, in order to detect any fresh blood cells in the
cerebrospinal fluid.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) may also detect fresh bleeding in the brain, but it is
even more useful in the search for possible underlying causes. It can detect vascular
malformations, tumors, evidence for congophilic amyloid angiopathy, and even aneurysms. A
specialized type of ultrasound called transcranial Doppler ultrasonography is another useful tool
for spotting larger malformations of blood vesselsits often used for follow-up evaluations of
people who have had a subarachnoid hemorrhage. The most reliable technique to confirm or
rule out the presence of aneurysms and other malformations of the blood vessels is a cerebral
angiogram; physicians inject contrast dye into the blood system to make arteries stand out on X-
ray films.
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IV. PATHOPHYSIOLOGYPATHOPHYSIOLOGY (BOOK-BASED)
MODIFIABLE RISK FACTORS
Hypertension Hyperlipidemia Cigarette Smoking Heavy Alcohol Consumption Drug Addiction (Cocaine) Obesity High Dose of estrogen OC Diabetes Mellitus Cardiovascular Disease Atrial Fibrillation Type A personality Sedentary Lifestyle
NON-MODIFIABLE RISK FACTORS
Advancing Age Sex (Men) Race (African Americans) History of transient
ischemic attack or CVA
Family History of DM
Severe occipital or nuchalrigidity, headache andvomiting
Seizures Changes in mental status Fever ECG changes
Intracerebral hemorrhage
Loss of blood supply
Brain cannot use anaerobic
metabolism
Hypoxia
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Influx of Ca and NaCerebral Ischemia
Neurotoxins (O2 free radicals,
nitric oxide, and glutamate) are
released.
Local Acidosis
Membrane
depolarization
Cytotoxic edema and cell death
Blood flow not restored
within 3 to 10 minutes
Short term ischemia or TIA
Irreversible damage or
infarction
Transient hemiparesis Loss of speech Hemisensory loss
Hemiparesis/ Hemiplegia Aphasia Dysarthria Dysphagia Apraxia Visual Changes Homonymous Hemianopia Horner Syndrome Agnosia Unilateral Neglect Sensory Deficits Behavioral Changes Incontinence
Focal neurologic deficits
lasting less than 24 hrs
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Synthesis of the Disease
Definition of the Disease
Stroke is a term used to describe neurologic changes caused by an interruption in the
blood supply to a part of the brain. The two major types of stroke are ischemic and
hemorrhagic. Ischemic stroke is caused by a thrombotic or embolic blockage of blood flow to
the brain. Bleeding into the brain or tissue or the subarachnoid space causes a hemorrhagic
stroke. Ischemic strokes account for about 83% of all strokes. The remaining 17% of strokes are
hemorrhagic.
Blood flow to the brain can be decreased in several ways. Ischemia occurs when the
blood supply to a part of the brain is interrupted or totally occluded. Ultimate survival of
ischemic brain tissue depends on the length of time it is deprived plus the degree of altered
brain metabolism. Strokes can also be large vessel and small vessel. Large vessel strokes are
caused by blockage of a major cerebral artery, such as the internal carotid, anterior cerebral,
middle cerebral, posterior cerebral, vertebral, and basilar arteries. Small vessel strokes affect
smaller vessels that branch off the larger vessels to penetrate deep into the brain.
Most intracerebral hemorrhages are caused by the rupture if arteriosclerotic and
hypertensive vessels, which causes bleeding into brain tissue. Intracerebral hemorrhage is most
often secondary to hypertension and is most common after age 50 years. Aneurysms are
another cause of hemorrhage. Aneurysms are weakened out pouching in a vessel wall. Although
cerebral aneurysms are usually small (2 to 6mm diameter), they can rupture. An estimated 6%
of all strokes are caused by aneurysm rupture.
Stroke secondary to bleeding often produces spasm of cerebral vessels and cerebral
ischemia because the blood outside of the vessels acts as an irritant to the tissue. Hemorrhagic
stroke usually produces extensive residual functional loss and has the slowest recovery of all
types of stroke. The overall mortality of intracerebral hemorrhage varies between 25% and 60%.
The volume of the hemorrhage is the single most important predictor of client outcome.
Therefore it is not surprising that hemorrhage into the brain causes the most fatalities of all
strokes.
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Risk Factors
Modifiable
a) Hypertension this is due to plaque deposits on the wall of the arteries which causesnarrowing of the blood vessel thereby causing hypertension which may lead to hemorrhagic
stroke
b) Hyperlipidemia- too much lipid in the blood may cause increase plaque formation whichmay cause thrombus formation leading to hypertension.
c) Cigarette Smoking- nicotine content of cigarettes causes vasoconstriction there by resultinghypertension which may lead to CVA
d) Heavy Alcohol Consumption- heavy alcohol consumption increases ones risk of a stroke,light or moderate alcohol may protect against ischemic stroke.
e) Drug Addiction (Cocaine) - this may cause vasospasm, hypertension, hypercoagulability andcerebral ischemia which may cause CVA.
f) Obesity- this is due to increase cholesterol in the body which may contribute plaqueformation that will narrow the blood vessel or may cause thrombus formation.
g) High Dose of estrogen OC- increases risk of stroke to women.h) Diabetes Mellitus- the mechanism is related to macrovascular changes in people with
diabetes mellitus. There is an increase viscosity of blood which may cause formation of
thrombus.
i) Cardiovascular Disease- such as aneurysms which are weakened out pouching in a vesselwall may rupture causing hemorrhagic stroke.
j) Atrial Fibrillation- pulling of blood from poorly emptying atrial which leads to formation oftiny clots in left atrium which can move on the cerebral circulation
k) Type A personality- stress causes hypertension thereby increasing chance of havinghemorrhagic stroke.
l)
Sedentary Lifestyle- increase of having DM and Obesity which one of the factors of havingCV
Non-modifiable
a) Advancing Age- intracerebral hemorrhage is most often secondary to hypertension and ismost common after age 50 years.
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b) Sex (Men)- Incidence of stroke in men is slightly higher than that of womenc) Race (African Americans)- more prevalent among African Americans than whites or
Hispanics
d) History of transient ischemic attack or CVAe) Family History of DM- due to accelerated atherosclerosisSigns and Symptoms
Clinical Manifestations
a) Severe occipital or nuchal rigidity, Headache and vomiting due to an increase ICP whichcauses cerebral edema, and compressing the medulla oblongata
b) Seizures due to hyper excitability of neurons because of irritation.c) Changes in mental status affectation in the Reticular Activating Systemd) Fever affectation in the hypothalamuse) ECG changes problem with the medulla oblongataWarning Signs
a) Transient hemiparesisb) Loss of speechc) Hemisensory lossd) Vertigo/syncopeSpecific Deficits
a) Hemiparesis/Hemiplegia the former means weakness of one side of the body while thelatter means paralysis of one side of the body.
b) Aphasia defects on using and interpreting symbols of languagec)
Dysarthia imperfect articulation condition.
d) Dysphagia- due to affectation of some cranial nervese) Apraxia - a condition in which a client can move the affected part but cannot use it for
purposeful actions.
f) Visual Changes- affectation of the several areas of the brain that control the complexprocesses of vision.
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g) Homonymous Hemianopsia a defective vision or vision loss in the same half of the visualfield
h) Horners syndrome paralysis of sympathetic nerves to the eye causing sinking of theeyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the eye.
i) Agnosia a disturbance in the ability to recognize familiar objects through the senses.j) Unilateral neglect inability to respond to stimulus on the contralateral side of a cerebral
infarction.
k) Sensory Deficits- several types of sensory changes can result from a stroke in the sensorystrip of the parietal lobe supplied by the anterior and middle cerebral artery.
l) Behavioral changes- various portions of the brain assist with control of behavior andemotions. People with stroke in the left cerebral or dominant hemisphere are frequently
slow, cautious, and disorganized while on the right cerebral stroke or nondominanthemisphere, are frequently impulsive, overestimate their abilities and have a decreased
attention span which increases their risk of injury.
m) Incontinence due to inattention, memory lapses, emotional factors, and inability tocommunicate.
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V. MEDICAL MANAGEMENT AND SURGICAL PROCEDURE (IF ANY)DRUGS
1. DexamethasoneBrand Name: Decadron
General Classification:Glucocorticoid
Specific Action:
Decreases inflammation mainly by stabilizing leukocyte lysosomal membranes; suppresses
immune response; stimulates bone marrow; and influences protein, fat and carbohydrate
metabolism.
Indication: Cerebral Edema
Adverse Reactions:
Euphoria, insomnia, seizures, peptic ulceration, immunosuppression
Nursing Responsibilities:
Determine sensitivity Give IM injection deeply into gluteal muscle. Rotate injection sites to prevent
muscle atrophy. Avoid SQ injection because atrophy and sterile abscesses may
occur.
Monitor pts weight, BP and electrolyte levels. Monitor pt for cushingoid effects, including moon face, buffalo hump, central
obesity, thinning hair, hypertension, and increased susceptibility to infection.
Watch for depression or psychotic episodes, especially in high-dose therapy. Diabetic client may need increased insulin; monitor blood glucose level. Inspect pts skin for petechiae. Gradually reduce dosage after long-term therapy.
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2. ParacematolBrand Name: Aeknil
General Classification:Analgesic, Antipyretic
Specific Action:
It has analgesic, antipyretic and weak anti-inflammatory action. The mechanism of action is
associated with inhibition of prostaglandin synthesis, the predominant influence on the
thermoregulation center in the hypothalamus, enhances heat transfer.
Indication: Elevated temperature
Adverse Reactions:
Digestive system: rarely - dyspepsia
Long-term use at high doses - hepatotoxic effects, methemoglobinemia, renal dysfunction
and liver, hypochromic anemia
Hemopoietic system: rarely - thrombocytopenia, leukopenia, pancytopenia, neutropenia,
agranulocytosis.
Allergic reactions: rarely - skin rash, itching, hives
Nursing Responsibilities:
Many OTC and prescription products contain acetaminophen; be aware of this whencalculating total daily dose.
With caution used in patients with disorders of the liver and kidneys, with benignhyperbilirubinemia, as well as in elderly patients.
With prolonged use of paracetamol is necessary to monitor patterns of peripheralblood and functional state of the liver.
3. PantoprazoleBrand Name: Pantoloc
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General Classification:Proton pump inhibitor
Specific Action:
Pantoprazole or Pantoloc inhibits proton pumps in the stomach which produce acid.
Indication:
Provides control of ulcer disease and reflux conditions; those under NPO status.
Adverse Reactions:
Pantoprazole or Pantoloc is well tolerated with most side effects being mild and transient.
Reported side effects include diarrhea, gas, constipation, abdominal pain, headache, and
dizziness.
Nursing Responsibilities:
Pantoprazole or Pantoloc seems to have a greater effect in the elderly, thus thedosage may have to be modified.
Because the liver is involved in the metabolism and excretion of Pantoprazole orPantoloc, people with liver disease may have to have a dosage modification.
4. Aluminum Hydroxide and Magnesium HydroxideBrand Name: Maalox
General Classification:Antacid
Specific Action:
This medication works only on existing acid in the stomach. It does not prevent acidproduction. It may be used alone or with other medications that lower acid production.
Indication: stomach upset, heartburn, and acid indigestion
Adverse Reactions:
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Upset stomach, vomiting, stomach pain, belching, constipation, dry mouth, increased
urination, loss of appetite, metallic taste
Nursing Responsibilities:
Taken on an empty stomach, they only neutralize acid for 30 to 60 minutes becausethe antacid quickly leaves the stomach.
If taken with food, the protective effect may be 2 or 3 hours. To get as much acid reduction as prescription medicines produce is expensive as the
antacid must be taken frequently during the day and night. It is probably cheaper to
take an acid-reducing pill once or twice a day.
All antacids, but especially calcium carbonate, can result in an acid rebound effectwhere the stomach acid surges back after the antacid has left the stomach, another
reason for long-acting medications.
Antacids interfere with many drugs. Staggering the antacid away from medicationsis always preferable but again is a nuisance and hard to comply with long-term.
5. MannitolBrand Name: Osmitrol
General Classification:Osmotic Diuretic
Specific Action:
Mannitol is an osmotic diuretic. It works by increasing the amount of fluid excreted by the
kidneys and helps the body to decrease pressure in the brain and eyes.
Indication: To reduce intracranial pressure
Adverse Reactions:
Seizures, diarrhea
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Nursing Responsibilities:
Mannitol may cause dizziness. These effects may be worse if you take it with alcoholor certain medicines. Use Mannitol with caution. Do not drive or perform other
possibly unsafe tasks until you know how you react to it.
Tell your doctor immediately if you have difficulty urinating or experience extremedizziness.
Lab tests, including blood electrolytes, kidney function, lung function, heartfunction, and blood counts, may be performed to monitor your progress or to check
for side effects. Be sure to keep all doctor and lab appointments.
Use Mannitol with caution in the ELDERLY; they may be more sensitive to its effects.
6. NicardipineBrand Name: Cardene
General Classification:Calcium Channel Blocker
Specific Action: Nicardipine relaxes (widens) your blood vessels, which makes it easier for
the heart to pump and reduces its workload.
Indication:
It is used to treat hypertension (high blood pressure) and angina (chest pain)
Adverse Reactions:
Side effects of nicardipine include an increased heart rate due to the drop in blood
pressure. Other side effects include swelling of the feet (edema), dizziness, headaches,
flushing, palpitations, and nausea. Nicardipine sometimes can cause an increase in the
frequency and duration of angina. The reason for this side effect is not clearly understood.
Excessively low blood pressure can occur in rare instances, especially during initiation of
treatment or following adjustments of dosage.
Nursing Responsibilities:
http://www.medicinenet.com/script/main/art.asp?articlekey=12699http://www.medicinenet.com/script/main/art.asp?articlekey=97800http://www.medicinenet.com/script/main/art.asp?articlekey=20628http://www.medicinenet.com/script/main/art.asp?articlekey=57394http://www.medicinenet.com/script/main/art.asp?articlekey=437http://www.medicinenet.com/script/main/art.asp?articlekey=24732http://www.medicinenet.com/script/main/art.asp?articlekey=1950http://www.medicinenet.com/script/main/art.asp?articlekey=1950http://www.medicinenet.com/script/main/art.asp?articlekey=24732http://www.medicinenet.com/script/main/art.asp?articlekey=437http://www.medicinenet.com/script/main/art.asp?articlekey=57394http://www.medicinenet.com/script/main/art.asp?articlekey=20628http://www.medicinenet.com/script/main/art.asp?articlekey=97800http://www.medicinenet.com/script/main/art.asp?articlekey=126997/27/2019 87906380 Case Study CmVA
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Measure blood pressure frequently during initial therapy. Maximal response occursabout 1 hour after giving the immediate-release form and 2 to 4 hours after giving
the sustained-release form.
Check for orthostatic hypotension. Because large swings in BP may occur based ondrug level, assess antihypertensive effect 8 hrs after dosing.
Advise pt to report chest pain immediately.
7. DopamineBrand Name: only generic name
General Classification: Dopamine is a vasopressor and inotropic agent.
Specific Action: It works by increasing the pumping strength of the heart and the kidney
blood supply.
Indication: Treating shock and low blood pressure due to heart attack, trauma, infections,
surgery, and other causes.
Adverse Reactions: Fast heartbeat; headache; nausea; vomiting.
Nursing Responsibilities:
Drug is not a substitute for blood or fluid volume deficit. If deficit exist, replace fluidbefore giving vasopressors.
During infusion, frequently monitor ECG, BP, CO, CVP, pulmonary artery wedgepressure, PR, UO and color and temperature of the limbs.
If diastolic pressure rises disproportionately with a significant decrease in pulsepressure, decrease infusion rate, and watch carefully for further evidence of
predominant vasoconstrictor activity, unless such an effect is desired.
Check UO often. If urine flow decreases without hypotension, notify prescriber. After the drug is stopped, watch closely for sudden drop in BP. Taper dose slowly to
evaluate stability of BP.
Acidosis decreases effectiveness of drug.
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Page23
VI. SURGICAL MANAGEMENTSurgeries for hemorrhagic stroke include:
Surgery to drain or remove blood in or around the brain that was caused by a bleedingblood vessel (hemorrhagic stroke).
A procedure (endovascular coil embolization) to repair a brain aneurysm that is thecause of a hemorrhagic stroke. Endovascular coil embolization is becoming a standard
treatment option for people with a brain aneurysm. It may be used for people who are
at high risk for complications from a surgical repair of the aneurysm. Endovascular coil
embolization involves packing the aneurysm with a soft platinum coil that fills the
stretched and bulging section of blood vessel. This helps seal off the aneurysm and
reduces the risk of the aneurysm leaking blood or rupturing. The doctor uses X-rays to
identify the aneurysm and to guide the coil through the blood vessel to the
aneurysm.The success of this treatment depends on the size and location of the
aneurysm, the skill of the doctor, and the person's general health. Complications include
bleeding from the aneurysm or movement of the coils in the blood vessel.
Surgery to remove or block off abnormally formed blood vessels (arteriovenousmalformations) that have caused bleeding in the brain. An arteriovenous
malformation is a congenital disorder, which means it was present at birth. An
arteriovenous malformation causes an abnormal web of blood vessels and veins in the
brain, brain stem, or spinal cord. The vessel walls of an arteriovenous malformation may
become weak and leak or rupture.
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VII. NURSING CARE PLANS (NCPs)1
stProblem: Ineffective Cerebral Tissue Perfusion
Assessment Nursing DiagnosisScientific
ExplanationObjectives Nursing Interventions Rationale
Expected
Outcome
S>O> The patient
may manifest:
>Headache
>Vertigo
>Visual Changes
>Dizziness
>Ataxia
>Motor deficits
>Paresthesia
>Seizure activity
>Coma
>Bloody CSF
>Positive
radiologic findings
Ineffective
Cerebral Tissue
Perfusion related
to intracranial
hemorrhage as
evidenced by
headache and
sudden drop in
level of
consciousness.
Cerebrovascular
accident is the term
that refers to any
functional abnormality
of the Central Nervous
System that occurs
when the normal
blood supply to the
brain is disrupted, as
by a blood clot or a
ruptured blood vessel,
and vital brain tissue
dies. Hemorrhagic
stroke is the rupture of
a blood vessel and
bleeding within or over
the surface of the
brain.
Short Term:
After 4 hours of NI,
the pts cerebral
perfusion pressure
will be maintained
as evidenced by O2
saturation equal to
90% and above.
Long Term:
After 3 days of NI,
the pt will be able
to demonstrate
behaviors which
may improve
proper circulation
such as compliance
to health
management and
therapies provided.
>Monitor and record
neurologic status,
usually Glasgow Coma
Scale
>Assess past history of
systemic problems:
previous cardiac
disease, hypertension,
smoking, previous
pulmonary disease.
>Monitor VS as
needed
>Monitor baseline
ECG and observe for
changes
>Monitor I and O and
Urine specific gravity
>Monitor to
determine effects of
stroke and prevent
life threatening
complications such as
severe hypertension
and increased
intracranial pressure.
>Hypertension seems
to be related to
hemorrhagic stroke.
>To assess for current
status
>Stroke can produce
cardiac electrical
changes and
dysrhythmias
>Because of cerebral
edema, fluid balance
must be regulated.
Fluids must be
restricted if pt has
significant increase in
ICP, or volume
expanders may be use
Short Term:
The pts
cerebral
perfusion
pressure shall
have been
maintained as
evidenced by
O2 saturation
equal to 90%
and above.
Long Term:
The pt shall
have been able
to demonstrate
behaviors which
may improve
proper
circulation such
as compliance
to health
management
and therapies
provided.
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>Monitor electrolytes
>Monitor arterial
blood gases and pulse
oximetry
>Raise head of the
bed
>Keep head and neck
in neutral position
>Cluster activities
>Control body
temperature:
administer
antipyretics, initiate
topical cooling
methods, and
administer
hypothalamic
depressants as
prescribed.
if pt is hypotensive
with decreased
cerebral perfusion.
>For immediate
intervention
>Pulse oximetry
should be 90% or
greater for adequate
cerebral oxygenation.
>This diminishes
perfusion
(hemorrhage or
increased ICP). ICP
should be below
15mmHg. Cerebral
perfusion pressure
should be between 80
to 100 mmHg.
>This eliminates the
need to impinge
blood vessel and
circulation
>This eliminated theneed to increase ICP
>Controlling fever
reduces metabolic
demands of the brain.
Fever may be a result
of hypothalamic
irritation ot infection
(bladder or
respiratory).
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> Administer the
following meds:
-Hyperosmotic
-Albumin
-Antihypertensives
-Corticosteroids
-to decrease ICP
-increases volume
-control severe HPM
-control intracranial
inflammation
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2nd
Problem: Risk for Ineffective Airway Clearance
Assessment Nursing DiagnosisScientific
ExplanationObjectives Nursing Interventions Rationale
Expected
Outcome
S>O> The patient
may manifest:
>Difficulty in
breathing
>O2 saturation less
than 90%
>Respiratory
distress: patient
complaints,
cyanosis,
restlessness,
shortness of
breath.
Risk for Ineffective
Airway Clearance
related toneurologic
dysfunction,
obstruction or
secretions.
Cerebrovascular
accident is the term
that refers to any
functional abnormality
of the Central Nervous
System that occurs
when the normal blood
supply to the brain is
disrupted, as by
a blood clot or a
ruptured blood vessel,
and vital brain tissue
dies. Hemorrhagic
stroke is the rupture of
a blood vessel and
bleeding within or over
the surface of the
brain. Breathing center
of the brain may be
affected and so,
difficulty in breathing
may be experienced.
Short Term:
After 4 hrs of NI,
the patient will
maintain patent
airway as
evidenced by rate,
rhythm and lung
sounds within
normal limits.
Long term:
After 3 days of NI,
the patient will not
exhibit any signs of
respiratory distress.
>Monitor respiratory
rate and rhythm, lung
sounds, and ability to
handle secretions.
>Check presence of
gag reflex.
>Observe for evidence
of respiratory distress
that may result from
pulmonary edema:
patient complaints,
cyanosis, restlessness,
shortness of breath.
>Position upright.
Monitor ICP and BP
during position
changes.
>A stroke in evolution
may cause
neurological
deterioration,
including respiratory
dysfunction.
>Brainstem strokes
may diminish cranial
nerve function. Oral
feeding should not be
attempted if gag
reflex is absent to
prevent aspiration
and obstruction of
airway. When pt is
able to participate,
consult speech or
occupational therapy
to initiatle swallow
exercises.
> The use of volume
expanders to
promote cerebral
perfusion can also
cause pulmonary
edema.
>reduces the work of
breathing
Short Term:
The pt shall
have
maintained
patent airway
as evidenced by
rate, rhythm
and lung sounds
within normal
limits.
Long term:
The patient
shall not have
exhibited any
signs of
respiratory
distress.
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>If pt is comatose, use
an oropharyngeal
airway.
>change position every
2 to 4 hours.
Encourage deep
breathing, coughing,
and use of incentive
spirometer (if able);
add humidity to
environment.
>Provide respiratory
support:
-Administer
supplemental oxygen
-Provide endotracheal
or tracheal care if
warranted.
-Avoid respiratory
measures that increase
ICP, such as frequentsuctioning, but keep in
mind that a patent
airway is first priority.
>keeps the tongue
form obstructing the
airway
>position changes
prevents pooling
secretions. Older
people are most
susceptible to
atelectasis and
pneumonia.
-This reduced
hypoxemia, which can
cause cerebral
vasodilation and
increased ICP.
-The patient in a
coma after 48hrs may
require intubation
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3rd
Problem: Impaired Physical Mobility
Assessment Nursing DiagnosisScientific
ExplanationObjectives Nursing Interventions Rationale
Expected
Outcome
S>
O> The patientmay manifest:
>inability to move
purposefully
within physical
environment.
>limited range of
motion
>decreased muscle
strength, control
and/or mass
Impaired Physical
Mobility related
to paresis orparalysis, loss of
balance and
coordination and
increased muscle
tone.
The nervous system is
made up of nerve cells
called neurons thatserve as the
communication system
of the body. They carry
messages in the form
of electrical impulses.
The messages move
from one neuron to
another to keep the
body functioning.
Because neurons have,
limited ability to repair
themselves unlike
other body tissues that
is why nerve cells
cannot be repaired if
damaged due to injury
or disease.
Short Term:
After 4 hrs of NI,
the patient willmaintain maximum
level of function
and will reduce risk
of complications.
Long Term:
After 3 days of NI,
the pt will be able
to demonstrate
behaviors that
enable resumption
of activities.
>Assess pts degree of
weakness in both
upper and lowerextremities
>Assess ability: to
move and change
position, to transfer
and walk, for fine
muscle movement and
fro gross muscle
movement.
>determine active and
passive range of
motion capabilities.
>Observe activities or
situations that
increase or decrease
tone.
>monitor skin integrity
for areas of blanching
or redness as signs of
potential breakdown
>Change position of
the patient at least
every 2 hours, keeping
track of position
changes with a turning
schedule
>there may be
differing degrees of
involvement on theaffected side.
>paralysis, paresis,
and sensory loss are
contralateral to the
side of the brain
affected by stroke.
>initially muscles
demonstrate
hyporeflexia, which
later progresses to
hyperreflexia.
>Activities that cause
spastic response can
be postponed until
later in recovery
>to have immediate
treatment
>Patients may not
feel increases in
pressure or have the
ability to adjust
position.
Short term:
The patient
shall havemaintained
maximum level
of function and
will reduce risk
of
complications.
Long Term:
The pt shall
have been able
to demonstrate
behaviors that
enable
resumption of
activities.
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>Perform active and
passive ROM exercises
in all extremities
several times daily.
>Increase functional
activities as strength
improves and the
patient is medically
stable
>Teach pt and family
exercises and transfer
techniques.
>Use pressure
relieving devices onthe bed and chair.
>Initiate rehabilitation
techniques in the
hospital setting as
soon as medically
possible.
>This preserves
muscle strength and
prevents
contractures,
especially in spastic
extremities.
>to gradually improve
muscle strength
>Once medically
stable, the pt may
have continuing
deficits such as
altered perception
and motor strength.
Exercise will increase
strength, promote
use of the affected
side and promote
transfer safety.
>This decreases the
risk of pressure ulcerdevelopment.
>this prevents further
systemic
deterioration.
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4th
Problem: Risk for Impaired Verbal Communication
Assessment Nursing DiagnosisScientific
ExplanationObjectives Nursing Interventions Rationale
Expected
Outcome
S>O> The patient
may manifest:
>Inability to
recognize or
understand words
>Difficulty
vocalizing words
>Inability to recall
familiar words,
phrases or names
of known persons,
objects and places
>Unable to speak
dominant
language
>Problems in
receiving the type
of sensory input
being sent or
sending the type
of input necessary
for understanding.
Risk for Impaired
Verbal
Communicationrelated to brain
injury adversely
affecting the
transmission,
reception or
interpretation of
language and
other forms of
communication.
There is an affectation
of the certain brain
lobes that caused by
impaired cerebral
circulation that affects
its proper functions
that leads to
decreased, delayed or
absent ability to
receive, process,
transmit and use a
system of symbols in
communicating
resulting in impaired
verbal communication.
Short Term:
After 4 hrs of NI,
the patient will
maximize
remaining
communication.
Long term:
After 3days of NI,
the pt will be able
to use a form of
communication to
get needs met and
to relate effectively
with persons, and
his or her
environment.
>Assess speech-
language history:
determine primary
language, ability to
read, write, and
understand spoken
language; level of
education
>Assess speech-
language function:
automatic speech,
auditory
comprehension,
comprehension of
written language,
expressive ability,
ability to write.
>Approach the pt as an
adult.
>Enhance the
environment.
>These data provide a
baseline for
developing an
individualized
teaching plan.
>Depending on the
area of brain
involvement, patients
may experience
aphasia (receptive or
expressive),
dysarthria, or both,
Receptive aphasics
cannot understand
the spoken word.
Expressive aphasics
cannot use written
symbols.
>Inability to express
needs or feelings is
most distressing to
pts. Staff needs to be
sensitive to the
dignity of the pt.
>Communication can
be facilitated and
distractions
minimized by turning
Short term:
The patient
shall have
maximized
remaining
communication.
Long term:
The pt shall
have to used a
form of
communication
to get needs
met and to
relate
effectively with
persons, and his
or her
environment.
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>Modulate personal
communication,
controlling body
language and
providing clear, simple
directions.
>Incorporate
multimodality input,
such as music, song
and visual
demonstration.
>Use written materials
(if appropriate)
>Use prompting cues,
such as gestures or
holding an object that
off the television,
radio or closing the
door.
> to maximize
communicating
ability.
>These enhance
function in intact
speech-language
areas.
>These supplement
auditory input (eg.
Communication
board with pictures,
numbers, words,
and/or alphabet). If
the pt has
homonymous
hemianopsia, placematerial in the
unaffected field of
vision. Homonymous
hemianopsia affects
the field vision in
both eyes, opposite
the side of the brain
affected by stroke.
>to enhance
communication
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is being discussed.
>Allow adequate time
for patient response.
>Provide opportunities
for spontaneous
conversation.
>Anticipate pts needs
until alternative means
of communication can
be established.
>Provide reality
orientation and focusattention, but avoid
constantly correcting
errors.
>Collaborate with
speech-language
pathologist
>Encourage family to
attempt
communication with
pt; explain type of
>If the pt feels
rushed,
communication
problems worsened.
>This provides the pt
a chance to talk
without the
expectation of a
desired outcome
(decreases anxiety
about abilities.
>The nurse should set
aside enough time to
attend to all the
details of patient
care. Care measures
may take longer to
complete in the
presence of a
communication
deficit.
>Constant correction
increases frustrations,anxiety and anger.
>A comprehensive,
multidisciplinary plan
of care may be
required.
>to assume their
cooperation
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aphasia and methods
of communication that
can be tried.
>Demonstrate to pt
any progress made
>this increases
confidence and
facilities ongoing
efforts.
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5th
Problem: Risk for Disturbed Sensory Perception (Tactile)
Assessment Nursing DiagnosisScientific
ExplanationObjectives Nursing Interventions Rationale
Expected
Outcome
S>O> The patient
may manifest:
>numbness
>tingling sensation
or paresthesia
>pressure ulcers
>accidental
wounds or
punctures
>pallor/ cyanosis
Risk for Disturbed
Sensory
Perception(Tactile)
Cerebrovascular
accident is the term
that refers to any
functional abnormality
of the Central Nervous
System that occurs
when the normal blood
supply to the brain is
disrupted, as by
a blood clot or a
ruptured blood vessel,
and vital brain tissue
dies. Hemorrhagic
stroke is the rupture of
a blood vessel and
bleeding within or over
the surface of the
brain. Tactile stimuli
may not be felt by the
patient due to the
affection of the nerves
on the certain areas of
the brain.
Short Term:
After 4 hrs of NI,
the patient will
remain free from
injuries, including
pressure ulcers.
Long Term:
After 3 days of NI,
the patient will
continuously be
free from injuries.
>Assess pts ability to
sense light touch,
pinprick, and
temperature. Touch
skin lightly with a pin,
cotton ball or hot/cold
object and ask patient
to describe sensation
and point to where
touch occurred.
>Using pts toes or
fingers, assess position
sense (ability to sense
whether the joint is
moved in an upward or
downward position)
>Perform regular skin
inspections and
instruct pt in
techniques to do the
same. Explain
consequences of
prolonged pressure on
the skin.
>Provide tactile
stimulation to affected
limbs using rough cloth
or hand and instruct [t
or family in methods
used.
>Explain how stimulus
>This determines the
level of alteration and
identifies specific
areas of risk.
>to know extent of
sensory perception.
>Pressure on the
affected side should
last no longer than 30
minutes.
>This helps pts learn
to recognize
sensations.
>This improves pt
Short term:
The patient
shall remain
free from
injuries,
including
pressure ulcers.
Long Term:
The patient
shall have been
continuously be
free from
injuries.
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might feel.
>Instruct pt to
regularly move
affected limbs
>Enhance immediate
and home
environment
understanding.
>Movement
promotes circulation.
Impaired sensitivity to
pain or numbness
increases the
likelihood of
prolonged stationary
positioning.
>For optimum safety,
by regulating
temperature setting
on hot water heater,
moving sharp edged
furniture and lighting
hallways.
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6th
Problem: Risk for Unilateral Neglect
AssessmentNursing
Diagnosis
Scientific
ExplanationObjectives Nursing Interventions Rationale
Expected
Outcome
S>O> The patient
may manifest:
>Left or right
sided neglect due
to the affectation
of the opposite
hemisphere of
the brain.
Risk for
Unilateral
Neglect
Unilateral neglect
syndrome is a
neuropsychological
condition in which, after
damage to one hemisphere
of the brain, a deficit in
attention to and awareness
of one side of space is
observed
Short Term:
After 4 hrs of NI,
the patient will
have no injuries as
a result of deficit.
Long Term:
After 3 days of NI,
the pt will observe
and touch affected
side during ADLs.
>Conduct sensory
assessment
>Perform visual fields
confrontation test.
>Observe pts
performance of ADL.
>Observe pts
response to sounds
from affected side.
>Conduct paper
drawing test to test
for distorted spatial
relationships.
>Observe for remark
> This determines
the actual level of
sensation for
comparison with
how the pt uses the
senses in the
affected side. Use
may be different
from actual ability.
>Pt may not be able
to see on affected
side (hemianopsia).
The pt who
complains of diplopia
may benefit from
patching one eye.
>This provides
information on pts
recognition of
affected side. The pt
may not, for
example, bathe the
affected side; they
forget that it is here.
Short Term:
The patient
shall have no
injuries as a
result of
deficit.
Long Term:
The pt shall
observe and
touch affected
side during
ADLs.
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of denial of body
parts (anosognosia)
and degree to which
patient confuses
objects in space.
>Have pt point to
various body parts
(somatognosia)
>Approach pt from
unaffected side when
pt initially regains
consciousness. As the
pt becomes more
alert, approach from
the affected side
while calling the pts
name during the
rehabilitation phase.
>Provide tactile
stimulation to
affected side.
>Place all food in
small quantities,
arranged simply onplate.
> Attach watch or
bright bracelet to
affected arm.
>Practice drawing and
copying figures with
>Diminished
awareness is a safety
hazards.
>Pt may not
recognize body parts
on affected side.
>These decreases
anxiety and fear
while pt is unable to
interpret whole
environment.
>This will encourage
the pt to use
affected side of body
and environment.
>This stimulates
short-term memory
of sensation.
>This approach
diminishesspatial/visual
deficits. Small
quantities make it
easier to delineate
foods because of the
space between food
items.
>This draws pts
attention to the
affected side
>This helps develop
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patients.
>draw bright marks
on the sides of
newspaper or books
when pt is reading.
>teach compensatory
strategies such as
visual scanning
(turning head in order
to visualize entire
area)
fine motor skills and
relearn spatial
relationships.
>This cues the end of
a line and return for
next line.
>this reduces chance
of injury.
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Page40
VIII. CONCLUSIONAny hemorrhage affecting the brain or its adjacent spaces is a very serious condition.
Depending on the location and size of the mass of loose blood (called a hematoma), it may even
be life threatening.It is alarming to know that a simple manifestation such as headache has apossibility to lead to abrupt loss in level of consciousness. At the same time ambulatory patient
brought in a emergency room may end up in an intensive care unit, critically being cared.
A hemorrhagic stroke is caused by a sudden bleeding, or hemorrhage, into or next to
the brain. This problem accounts for about 20 percent of all people admitted to hospitals for
strokes. Most hemorrhagic strokes occur in the brain itself and are called intracerebral
hemorrhages. Smaller groups of people suffer bleeding into the fluid filled spaces located deep
in the brain (intraventricular hemorrhage) or into the small space between the brain and the
membranes that cover it (subarachnoid hemorrhage).
People who survive a hemorrhagic stroke and the critical period that immediately
follows often make a remarkable recovery. As the mass of the hematoma slowly decreases, the
actual disruption of brain tissue can turn out to be smaller than what doctors or family members
had feared. Early rehabilitation after strokes benefits most people.
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IX. REFERENCESBooks
Nursing 2008 Drug Handbook, Lippincott Williams and Wilkins Joyce M. Black and Jane Hokanson Hawks. Medical-Surgical Nursing Eighth Edition,
Volume 2, Saunders, 2009
Marilynn E. Doenges, Mary Frances Moorhouse, Alice Geissler-Murr; Nurses PocketGuide (11th Edition)Copyright 2006
Internet
http://www.wpro.who.int/countries/2007/phl/health_situation.htm http://www.who.int/topics/cerebrovascular_accident/en/ http://www.wpro.who.int/countries/2007/phl/health_situation.htm Philippine Inquirer, 12/01/2007 http://www.doh.gov.ph/kp/statistics/morbidity http://www.ninds.nih.gov/news_and_events/news_articles/pressrelease_stroke_vaccin
e_090502.htm
http://www.medphys.ucl.ac.uk/research/borg/homepages/florian/thesis/pdf_files/p25_34.pdf
http://www.drugs.com/
http://www.webmd.com/stroke/guide/stroke-surgery http://www.dana.org/news/brainhealth/detail.aspx?id=9824