Case On Intracranial Hemorrhage

PATHOPHYSIOLOGY Predisposing Factor: Precipitating factor:

-

Age (53 years old)

Stress on work (technician)

-

Family history of Hypertension

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Cigarette smoking

-

Alcohol consumption

-

Kidney Failure

-

Kidney Failure

Chronic Hypertension

Failure of ReninAngiotensin IAngitension II Conversion

Increase Creatinine, UREA in Urinalysis

Increased blood flow to the brain

Compromise of the integrity of cerebral arterioles

Weakening of the walls

Formation of ChalcotBouchard aneurysm

Rupture of the anterior cerebral artery

- Fever - leukocytosis

Bleeding or hemorrhage on at the affected area Inflammation of the frontal lobe

Alteration in the cerebral component -ABG, Cerebral Angiography, MRI, CT SCAN,Subarachoid Screw, Ventriculostomy, Epidural ICP Monitoring.

Hematoma formation

Thrombus formation

Increase in the Intracranial pressure

Continuation………..

-Restlessness, drowsiness,confusion,

Presence of free blood in the interstitial areas

Cell membrane destruction

CT SCAN and MRI Decrease oxygen supply

Compression of the brain components

Stimulates further swelling and inflammation

-projectile vomiting, numbness of extremiities , visual disturbances

Ischemia

Cellular edema

Alteration in the frontal lobe function

Without Medical intervention

Vasospasm

Electrolyte imbalance

Stimulation of vasomotor centers

Scar Formation

X RAY, CT scan, MRI

-Broca’s aphasia, hemiparesis, hemianopsia, dysarthria, incapable of abstract thinking

Compensatory mechanism

Increase systemic pressure

- Increase BP

-SERUM ELECTROLYTE TEST (decrease Mg, K), ABG(Respiratory alkalosis) -changes in the v/s

With Medical Intervention

Acidosis

Management:

Brain stem herniation Comatose

SURGICAL: craniectomy, craniotomy MEDICAL: Pharmacologic Therapy (citicholine, mannitol, dilatin, captopril, Nitroglycerin, furosemide, remopain, Kalium Durule, MgSO4)

stupor

Worsening of the condition

Bad Prognosis

DEATH

Physical Assessment

Assessment of Body Parts Body odors Signs of illness

Normal Findings absence No illness noted

(skin color and breath)

Actual Findings (-) body odor

Analysis Normal

The client is obviouslyDeviation ill

Skin color

Light to deep brown, (+) paleness etc.

Paleness may be the result of decreased blood supply to the skin (cold, fainting, shock, hypoglycemia) or decreased number of red blood cells (anemia). (www.nlm.nih.gov/medline plus)

Skin moisture

Moisture in skin folds (+) skin dryness and axillae

The skin loses moisture and may crack and peel, or become irritated and inflamed. Bathing too frequently, especially with harsh soaps, may contribute to dry skin. Eczema may cause dry skin. (www.nlm.nih.gov/medline plus)

Skin Temperature

Uniform ;within normal range

A client with a temperature of 37.5 and above is positive for hyperthermia

Skin Turgor

Skin intact or springs (+) skin turgor back When pinched, the skin doesn’t return

39.0 temp

Skin turgor is an abnormality in the skin's ability to change shape and return to normal

immediately to its original state.

(elasticity). Decreased skin turgor is a late sign in dehydration. It occurs with moderate to severe dehydration. Fluid loss of 5% of the body weight is considered mild dehydration, 10% is moderate, and 15% or more is severe dehydration. (www.nlm.nih.gov/medline plus)

Lips

Pinkish, or darker, symmetric

The client’s lips are symmetrical but it is dry and dark.

A dark lip is due to varied reasons, such as, smoking, and excessive intake of caffeinated beverages. Dry lips are usually indicative of lack of moisture in the atmosphere. Our lips do not have inbuilt mechanisms which will help them secrete oil when there is a change in weather. (home-remedies-foryou.com)

Anterior Thorax Inspect breathing Quiet, rhythmic, and (+) dyspnea patterns effortless respirations. (+) prolonged expiratory phase

Jugular veins

Dyspnea is a difficulty in breathing, often associated with lung or heart disease and resulting in shortness of breath. Also called air hunger.

Inspect jugular veins

Veins not visible (-) jugular veins (indicating right side of heart is functioning normally).

Normal

Flat, rounded The abdomen is (convex) or scaphoid slightly rounded (concave). (-) striae.

Resulting from thinning or wasting of the skin due to lost of collagen and elastin.

Abdomen Inspect the abdominal contour (profile line from rib margin to the pubic bone) while standing at the clients side while the clients in dorsal recumbent position Test for the strength (neck)

* Fundamentals of Nursing by Kozier et al, pg. 537

(-) resistance

A comatose person cannot be awakened,and does not take voluntary actions. -wikipedia.org

Test for strength ( upper extremities)

(-) resistance

A comatose person cannot be awakened,and does not take voluntary actions. -wikipedia.org

Test for strength (lower extremities)

(-) resistance

A comatose person cannot be awakened,and does not take voluntary actions. -wikipedia.org

ECOLOGIC MODEL Hypothesis: There is a significant relationship between the disease process of Cerebrovascular disease and the Web Model being used

Predisposing Factors: •

• •

Host -Male - 53 years old -sedentary lifestyle -family history of hypertension -food intake (high fat high salt) -smoker -kidney failure -alcohol consumption Agent Environment

Ecologic Model: WEB MODEL

Analysis: Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most important cause; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure. A fall in blood pressure during sleep can then lead to a marked reduction in blood flow in the narrowed blood vessels causing ischemic stroke in the morning. Conversely, a sudden rise in blood pressure due to excitation during the daytime can cause tearing of the blood vessels resulting in intracranial hemorrhage. Cerebrovascular disease primarily affects people who are elderly or have a history of diabetes, smoking, or ischemic heart disease. The results of cerebrovascular disease can include a stroke, or occasionally a hemorrhagic stroke. Ischemia or other blood vessel dysfunctions can affect the person during a cerebrovascular accident. (http://en.wikipedia.org/wiki/Cerebrovascular_disease) Changes in the blood pressure are sensed by the renal barroreceptors . if the blood pressure is high release of rennin is decreased. Renin circulates in the blood and act as enzyme to convert the protein angiotensin to angiotensin I. Angiotensin II it is powerful vasoconstrictor that primarily causes con-

striction of the small arterioles . This causes an increase in resistance to blood flow and increase in blood pressure . Sedentary lifestyle and food intake greatly affect the blood vessel because of possible hyperlipidemia. If the client usually eat high salt and high fat food it will constrict the blood vessel. ( handbook of Pathophysiology by Elizabeth J. Corwin ) Interpretation: Web Model explains and related to Cerebrovascular Accident (Intracranial Hemorrhage) and its disease process. We used web model to easily define many factors that would affect and contribute to the patients underlying condition. Web model explains the multifactorial effect that could contribute to the patients condition. Factors such as a hereditary disease of hypertension. This is one of the big factor that could contribute to the patients condition because if there is a continues increase in blood pressure it will damage the blood vessel lining that could contribute to intracranial hemorrhage. Relatives also mentioned that there is a kidney failure that could impede in balancing hypertension. Conclusion and Recommendation: We therefore conclude that the disease process of Cerebrovascular disease is related to Web Model being used. Since it has different risk factor, we recommend that the goal of therapy must focus on Nursing management such measure of the client and medication regimen. The pharmacologic treatment on the other hand is based on the state of the disease, the existence of other conditions and the preference of the health professional/ physician.

Far Eastern University

Institute of Nursing

SUBMITTED BY: GROUP 85- BSN022

SUBMITTED TO: Prof. Josephine Robinos Clinical Instructor

INTRODUCTION 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. Cerebrovascular accident is commonly called Strokes.

Cerebrovascular accident may be caused by any of three mechanisms. • • •

Cerebral Thrombosis – blockage in the thrombus (clot) that has built up on the wall of the brain artery. Cerebral Embolism – blockage by an embolus (usually a clot) swept into the artery in the brain. Hemorrhage – Rupture of a blood vessel and bleeding within or over the surface of the brain.

Thrombosis and embolism both lead to cessation of blood supply to part of the brain thus to infarction (tissue death). Rupture of a blood vessel in or near the brain may cause an intracerebral hemorrhage or subarachnoid hemorrhage. The symptoms of a stroke usually develop over minutes or hours occasionally over several days. Depending on the site, cause and extent of damage, any or all of the symptoms at right may be present, in any degree of severity. The more serious cases lead to rapid loss of consciousness, coma, and death or to severe physical or mental handicap. The following are the symptoms of Cerebrovascular accident: • • • • •

Headache Dizziness and confusion Visual disturbance Slurred speech or loss of speech Difficulty of swallowing

Risk factors: • • •

Age High blood pressure – weakens the walls of arteries Atherosclerosis – narrowed artery channels

• •

• • •

Heart disease – cause blot clot in the heart that may break off and migrate to the brain. Diabetes mellitus – accelerated degeneration of small blood vessel Smoking – increase the risk ofhypertension Polycythemia – a raised level of red cells in the blood. Hyperlipidemia – high level of fatty substances in the blood

I. Biographic Data Name: Mr. EPJ

Address: 17 Mabolo St., Signal Village Taguig City Age: 53 y/o

Gender: Male

Marital Status: Married

Religion: Roman Catholic Occupation: Mechanical technician

Room and Bed no.: Room 215 Bed 1 Chief Complaint: Dizziness and Weakness Provisional Diagnosis: Cardiovascular accident / intracranial hemorrhage

II. Nursing history A. Past Health History The past illnesses of the client include colds, cough, fever & flu. His wife added, “Ang alam ko hindi naman siya sakitin nung bata pa siya, pero siyempre di maiiwasan yung magkakaroon ng sakit paminsan minsan”. His wife stated that she is not sure with her husband’s childhood illnesses and immunizations. She also claimed that her husband is not allergic with any food. “Wala namang pagkain na nakakapagdulot ng allergy sa kaniya, pati alikabok o halaman wala din.” It is his first hospitalization. “Ito yung pinaka unang naconfine siya at nagpaospital, hindi naman kasi siya mahilig magpacheck up o magpadoktor, hanggat kaya pa niya, sariling paggamot na lang.” His wife said that he is not taking any maintenance medication or multivitamins for his daily use. When asked about the clients foreign travel, she reported that, “Hindi pa naman siya nakakaalis ng bansa, dito lang kami sa.” She added that her husband has no foreign travel for he is not interested in doing so nor he has money to finance for traveling.

B. History of Present Illness According to the client’s wife, her husband’s family have a hypertension disease. Few minutes prior to admission, the client go to comfort room and afterwards he complaint of having blurred vision and he said that he see things in opposite manner. He also asked, is there earthquake. From there, the family rushed the client to the nearest clinic but the clinic denied them and gives them medication. They decided to

bring the client to the hospital and diagnose him with cerebrovascular accident/ intracranial hemorrhage. C. FAMILY HISTORY According to his wife, her husband’s side has the following hereditary disease: Hypertension, Heart Disease, Kidney Failure and Hernia. She claimed that all her husband’s siblings have a hypertension.

PRIORITIZATION

RANK

1

NURSING PROBLEM Hyperthermia related to increased metabolic rate: illness

CUES S: (the client is in coma)

O: Skin warm to touch Flushed skin Temperature: 38.6

Increased blood S: “nakakataas daw pressure related to talaga na BP yung drugs administration gamut niya sabi ng doctor” as verbalized by SO

2

O: BP: 200/140

JUSTIFICATION This is our top priority because this problem is the most possible easy to deal with. If this is not intervened as soon as possible, it can lead to dehydration, hyperventilation, and tachycardia. Therefore, this is the fourth prioritized problem. This is the second problem because it according to ABC it is part of the circulation, for the blood is not distributed all through out the body and only concentrated at the upper part of the body. His medicines are the cause of this problem and is solved by administering anti high blood pressure drugs that is can only be orederd by

the phycisian Impaired skin integrity related to infiltration secondary to needle trauma

S: “

Impaired mobility related to neuro mascular impairment

S: ayan sabi ng doctor comatose sya”

3

O: the patient is not moving or even reacting

4 Self care deficit related to impaired mobility status

5

O: has many previous needle insertion

S: “comatose siya kaya kahapon pa siya ganyan, pinupunasan ko na lang minsan yung katawan niya pare presko siya”

O: the client is asleep Not reacting

This is the third priority in the nursing problem because it is also an actual problem that needs immediate action. It is not life threatening unlike the first problem but outweighs subordinating problems because it interferes or delays interventions needed for problem #1. This is the fourth problem because; it is not lifethreatening since he is in coma it is not the focus of our care but to other problems that is easier to manage This problem is in the fifth ranking because it is a problem, which is focusing on the patients hygienic needs, and also feeding. It is consequent to problem no. 1, because having good selfcare will lead to better wellness of self and

health. Uncooperative Comatose Activity intolerance related to immobility

S: “kahapon pa sya walang malay at hindi makagalaw kasi sabi nung doktos xempre kasi comatose siya”

O:

6

7

Risk for aspiration related to situation hindering elevation of upper body

S:

O: The patient is intubated

This is the sixth prioritized problem because if the patient cannot perform his activity like before there will be insufficient physiological and psychological energy to endure or complete required processes in the body. It also consequent with problem no.1 and when solved, will help solving the top problem This is the seventh prioritized problem because it is not an actual problem. It is only a risk. As the problem has not occur proper nursing interventions are directed at the prevention