REPUBLIC OF THE PHILIPPINES

CITY OF MAKATI
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J.P. RIZAL EXTENSION, WEST REMBO, MAKATI CITY
CENTER OF NURSING

CASE ANALYSIS

CVD BLEED

PRESENTED TO:
PROF. CLEMENT JOHN FERDINAND M. NAVARRETE, RN,MAN,PhD

PRESENTED BY:
RODADO, JESSICA B.
4-AN2

OCTOBER 20,2016

I.

INTRODUCTION

To function properly, the brain needs oxygen and nutrients that are provided by the blood.
However, if the blood supply is restricted or stopped, brain cells die, leading to brain damage and
possibly death.
According to World Health Organization 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.
Hemorrhagic stroke is one type of stroke which according to the American Stroke
Association, 13 percent of strokes are hemorrhagic. These are strokes that are caused by a
rupture in a weakened blood vessel in the brain. A hemorrhagic stroke occurs when a blood
vessel ruptures and blood accumulates in the tissue around the rupture. This produces pressure on
the brain and a loss of blood to certain areas. There are two types of hemorrhagic stroke
intracerebral and subarachnoid hemorrhage. Intracerebral stroke is when hemorrhagic stroke
occurs inside your brain while subarachnoid hemorrhage when the stroke occur in in the space
around your brain.
People most at risk for stroke are older adults, particularly those with high blood pressure
(hypertension), who are sedentary, overweight, smoke, or have diabetes. Older age is also linked
with higher rates of post-stroke dementia. Younger people are not immune, however. About 28%
of stroke victims are under age 65 (New York Times, March 11, 2016).
Signs and symptoms of hemorrhagic stroke include seizure, severe headache, confusion,
aphasia, dysphagia, muscle weakness, dyspnea and blurred vision.

There are 15 million people worldwide who suffer a stroke each year. According to the
World Health Organization (WHO, 2012), stroke is the second leading cause of death for people
above the age of 60 years, and the fifth leading cause in people aged 15 to 59 years old. Each
year, nearly six million people worldwide die from stroke. One in six people worldwide will
have a stroke in their lifetime. Every six seconds, stroke kills some. Stroke claims more than
twice as many lives as AIDS. In fact, stroke continues to be responsible for more deaths
annually than those attributed to AIDS, tuberculosis and malaria combined. The burden of stroke
now disproportionately affects individuals living in resource-poor countries. On the other hand,
According to the latest WHO data published in May 2014, stroke deaths in the Philippines
reached 63,261 0r 12.14% of total deaths. The age adjusted death rate is 119.21 per 100,000 of
population ranks Philippines number 54 in the world.

VI. PHYSICAL ASSESSMENT

Date: December 15, 2015

Time: 9:00 a.m

General Survey:

The patient is at sleep on bed. Upon assessment, patient appears restless has slurred
speech and patients left hand and feet is restraint on bed. Medical devices noted: heplock on the
right hand, IV line on right feet, nasal cannula (3LPM). The initial vital signs were taken as
follows:

Height

: 54

Weight

: 62 kg

BMI

: 23.4

BP

: 150/100

Temperature

: 36

Pulse Rate

: 65

Respiratory Rate

: 19

Organ/ System

Technique

Normal Findings

Actual Findings

Interpretation

Skin

Inspection

Color: Pinkish

Color: Pinkish

Normal

Palpation

Moisture: Moist

Dry

Due to lack of
hygiene

Pinched skin
goes back within
2-3 secs.

Pinched skin
goes back within
3-4 secs.

Due to lack of
oxygen supply

Normal
Head

Inspection

Warm to touch

Warm to touch

Symmetrical
facial features

Asymmetrical
facial features:
facial drooping
(left)

Red Birth mark

on Face

Inspection

Due to inborn
marks

no lesion

no lesion

no deformities

no deformities

No masses

No masses

Normal

Pink conjunctiva

Pale

Due to lack of
oxygen supply

No sunken eyes

No Sunken eyes

Normal

White sclera

White sclera

Pupils equal,
round

Pupils equal,
round

Palpation

Eyes

Due to right
basal ganglia
hemorrhage

Normal

Normal

Normal
Normal

Reactive to light

Reactive to light
Normal

Normal visual
acuity

Normal visual
acuity

No edema

No edema
Eyelids:

Palpation
Nose

Mouth and
Throat

Inspection

Inspection

Normal
Normal

Eyelids:
no masses

no masses

Symmetrically
aligned

Symmetrically
aligned

no discharge

no discharge

with flaring of
nose

with flaring of
nose

Due to dyspnea

no lesion

no lesion

Normal

Endotracheal
Tube

Due to difficulty
of breathing

Dry lips

Due to current
condition

Pinkish lips and

moist

Normal

Normal

Pink mucosa
Pink mucosa

Normal

Normal
no swelling

no swelling
Normal

No bleeding
no bleeding

Normal

No infection
No infection
Normal pharynx
and tonsilarfosa

White teeth, no
dentures

Upper
Extremities

Inspection

Palpation

Normal
Normal pharynx
and tonsilarfosa

Yellow teeth, no
dentures

Due to improper
hygiene

No rashes

No rashes

Normal

No bruises

Presence of
bruises in left
hand

Due to Injection
site and Heplock

Warm to touch

Skin pinch goes

Normal
Warm to touch
Normal
Skin pinch goes

back rapidly

back rapidly
Normal

Radial pulse
normal

Radial pulse
normal

VIII. DIAGNOSTIC
COMPLETE BLOOD COUNT
DATE: October 6, 2015
Normal
Values

TIME: 12:02 PM
Result

Interpretation

Analysis

REFERENCE:
Potassium

3.5-5.1

Date: October 8 , 2016

CBC PC

3.8

Normal

http://emedicine.medscape.com
/article/2054364-overview

TIME: 10:49 AM

Normal
Values

Result

Interpretation

Analysis

5.0-6.4g/dL

4.7g/dL

Normal

REFERENCE:
https://www.nlm.nih.gov/medli
neplus/ency/article/003647.htm

RBC count

14-18

13.5

Normal

REFERENCE:
http://emedicine.medscape.com
/article/2054364-overview

Hematocrit

0.40-0.54

0.42

Normal

REFERENCE:
https://www.nlm.nih.gov/medli
neplus/ency/article/003646.htm
REFERENCE:

(Mean cell
Volume)

80-96 fL

88.7 fL

Normal

(Mean
corpuscula
Hgb. Conc.)

32-36 g/L

32.2 g/L

Normal

Lymphocyt
e

20-40%

https://www.nlm.nih.gov/medli
neplus/ency/article/003646.htm

REFERENCE:
http://emedicine.medscape.com
/article/2054497-overview#a2

18%

Normal

REFERENCE:
https://www.nlm.nih.gov/medli
neplus/ency/article/003657.htm

Monocyte

2-5%

9%

Increased

An increased number of
monocytes in the blood
(monocytosis)
occurs
in
response to chronic infections,
in autoimmune disorders,
in
blood disorders, and in cancers.
REFERENCE:

http://www.diagnoseme.com/symptomsof/monocytes-elevated.html

eosinophils

2-4%

2%

Normal

REFERENCE:
http://emedicine.medscape.com
/article/2090595-overview#a2

X. ANATOMY AND PHYSIOLOGY

THE BRAIN
The brain and spinal cord form the central nervous system. These vital structures are
surrounded and protected by the bones of the skull and the vertebral column, as shown in the
drawing. The bones of the skull are often referred to as the cranium. In infants, the skull is
actually composed of separate bones, and an infants soft spot (anterior fontanel) is an area where

four skull bones nearly come together. The places where the bones meet and grow are called
sutures.
The brain consists of four main structures: the Cerebrum, the Cerebellum, the Pons,
and the Medulla.
The Cerebrum is the upper part of the brain and is arranged in two hemispheres called
cerebral hemispheres. The cerebrum is thought to control conscious mental processes. The outer
layer of the cerebrum is called gray matter, the inner portion, white matter.
The cerebral hemispheres are divided into four sections or lobes: the frontal lobe,
responsible for thinking, making judgments, planning, decision-making and conscious emotions,
the Parietal Lobe, mainly associated with spatial computation, body orientation and attention, the
Temporal Lobe, concerned with hearing, language and memory, and the Occipital Lobe, mainly
dedicated to visual processing.

The Pons is in front of the cerebellum and coordinates the activities of the cerebrum and
the cerebellum by receiving and sending impulses from them to the spinal cord.
The Medulla is part of the brainstem situated between the pons and the spinal cord and it
controls breathing, heartbeat, and vomiting.

There are many other anatomical features of the brain which specialize in various
activities. The Meninges consist of three membranes which cover the brain and spinal cord
including the Dura mater, the arachnoid membrane and the pia mater. They completely
surround the brain and spinal cord.
Cerebrospinal fluid flows in the space between two of the layers in a space called the
subarachnoid space. CSF is essentially salt water, and it is in constant circulation and serves
several important functions. The brain floats in CSF.

THE BASAL GANGLIA

The basal ganglia form a set of interconnected nuclei in the forebrain. Overall the basal
ganglia receive a large amount of input from cerebral cortex, and after processing, send it back to
cerebral cortex via thalamus. This major pathway led to the creation of the popular concept of
cortico-basal ganglia-cortical loops. Inside the basal ganglia there are too many connections and
pathways to cover in this paragraph. Just briefly: The cortex sends excitatory input to the
striatum. The principle neuron of the striatum is the famous medium spiny neuron, which sends
its inhibitory output on to the globus pallidus. The globus pallidus can also be excited by cortical
activity, namely by a pathway that travels through the subthalamic nucleus first. The globus
pallidus is really divided into two segments, only one of which sends output (yet again
inhibitory!) to the thalamus and on to cortex, thus completing the loop. The larger segment of
globus pallidus (GPe) just inhibits the subthalamic nucleus and itself. The functional
significance of this connection is still quite mysterious. Similar to the cerebellum the basal
ganglia are also implicated in learning, and the system that is thought to be important here is the
dopaminergic input received from the Substantia nigra pars compacta. Probably the best known
fact regarding the basal ganglia is that a lesion of this dopaminergic pathway causes Parkinsons
disease.

Physiology:
Numerous research projects have recorded electrical activity in the basal ganglia.
Unfortunately for the experimentalists seeking clear answers, the recorded activity in behaving
animals can be related just about to any component of sensory input, motor preparation, and
movement execution. One thing is sure however: The medium spiny neurons are active only at
a very slow rate, and furthermore the connection to the GP takes more time than most pathways
in the brain. In contrast to cerebellum this system seems unsuitable for the fast feedback control
of ongoing movement. Neurons in GP in contrast are active at a very high rate. This could be
very useful, if both decreases and increases in activity need to be communicated accurately to the
thalamus. Since GP neurons are inhibitory in thalamus, a decrease in activity actually would
disinhibit the thalamus, and thus activate cortex. Single cell properties of various cell types in
the basal ganglia are also quite unique and interesting, and intracellular recordings in brain slices
and anesthetized animals have showed how specific features of single neuron properties could be
important in the ongoing function of the basal ganglia.
Function:
As is true for the cerebellum, the ultimate answers about the exact function of the basal
ganglia in the control of behaviour have yet to be established. One very good candidate is called
Action Selection Hypothesis. In this model the basal ganglia would be the arbiter of which of
the potential actions that cortex might be planning actually gets executed. This fits together well
with the idea that dopamine is a system mediating learning based on reward. This could train the
basal ganglia to choose behaviours that have been rewarding in the past. The overall lack of

action found in Parkinsons disease is also easily reconciled with the idea of action selection.
The other major symptom, namely movement tremor, however, is not. The presence of
movement tremor and other specific motor problems, have led some people to believe that the
basal ganglia may play a role in the planning and coordination of specific movement sequences.
Thus, the temporal sequencing of movements is another intriguing function of the basal ganglia.
XV. DISCHARGE PLAN
MEDICATION

Take them as directed:

TELMISARTAN
*Report any signs of infection (sore throat,
fever)
ATORVASTATIN
40 mg/tab ODHS
CITICOLINE SODIUM
*Contact the physician immediately if allergic
reaction such as hives, rash, or itching,
swelling in your face or hands, mouth or throat,
chest tightness or trouble breathing are
experienced.
OMEPRAZOLE
Patient teaching:
*Report headache
*Swallow capsules whole; do not chew
*Take prior to eating
SALBUTAMOL + IPRATOPIUM
1 Neb/ Inhalation/ every 4 hours
*Observe for paradoxical bronchospasm
(Wheezing). If Condition occurs, withhold
medication and notify physician or other
healthcare professional immediately.

EXERCISE
When youre ready, you should shoot for:

At least 30 minutes of exercise three to

four times a week more is better

Being active as often as possible for

example, parking a little further from

your destination to build in some

walking time

Bucking gravity: Try chair aerobics or

water sports

Using your cane or walker as part of

your routine. A physical therapist can
show you how to build an assistive
device into a healthy exercise program.

In- and Outpatient Exercise Therapy OR

Rehabilitation

Aerobic exercises that include largemuscle activities (e.g., walking,

graded walking, stationary cycle
ergometry, arm ergometry, arm-leg
ergometry, functional activities
seated exercises) if appropriate. for 35 days/week, 20-60 min/session

Muscular Strength/Endurance
activities include resistance training
of upper and lower extremities, trunk
using free weights, weight-bearing or
partial weight-bearing activities,
elastic bands, spring coils, pulleys,
circuit training, and functional
mobility.

Flexibility should also be a focus that

involves static stretching of the trunk
and upper- and lower extremities.
Holding each stretch for 10-30
seconds, with the stretches performed
2-3 days/week (before or after
aerobic or strength training).

Neuromuscular activities such as

balance and coordination activities,
Tai Chi, Yoga, recreational activities
(paddles/sport balls to challenge
hand-eye coordination), and activeplay video gaming and interactive
computer games. Employ 2-3
days/week as a complement to
aerobic, muscular strength/endurance
training, and stretching activities.

TREATMENT
If the area of bleeding is large, your doctor may
perform surgery to remove the blood and
relieve pressure on your brain.
Surgical blood vessel repair. Surgery may be
used to repair blood vessel abnormalities
associated with hemorrhagic strokes. Your
doctor may recommend one of these
procedures after a stroke or if an aneurysm or
arteriovenous malformation (AVM) or other
type of vascular malformation caused your
hemorrhagic stroke:

Surgical clipping. A surgeon places a

tiny clamp at the base of the aneurysm,
to stop blood flow to it. This clamp can
keep the aneurysm from bursting, or it
can prevent re-bleeding of an aneurysm
that has recently hemorrhaged.

Coiling (endovascular embolization).

In this procedure, a surgeon inserts a
catheter into an artery in your groin and
guides it to your brain using X-ray
imaging. Your surgeon then guides tiny
detachable coils into the aneurysm
(aneurysm coiling). The coils fill the
aneurysm, which blocks blood flow into

the aneurysm and causes the blood to

clot.

HYGEINE

Surgical AVM removal. Surgeons

may remove a smaller AVM if it's
located in an accessible area of your
brain, to eliminate the risk of rupture
and lower the risk of hemorrhagic
stroke. However, it's not always
possible to remove an AVM if its
removal would cause too large a
reduction in brain function, or if it's
large or located deep within your brain.

Intracranial bypass. In some unique

circumstances, surgical bypass of
intracranial blood vessels may be an
option to treat poor blood flow to a
region of the brain or complex vascular
lesions, such as aneurysm repair.

Stereotactic radiosurgery. Using

multiple beams of highly focused
radiation, stereotactic radiosurgery is an
advanced minimally invasive treatment
used to repair vascular malformations.
Always take a bath.
Advice the patient to wash hands
before and after meal at least 10
minutes
Advice the patient to brush her teeth 2-3
times a day.

OUT PATIENT

For stroke patients who have

difficulty getting to the bathroom,
a three-in-one commode chair will
be helpful

Maintain a good hygiene.

Get enough sleep/rest.
Consult your doctor if symptoms
persist.

DIET
SPIRITUAL

Maintain a low salt low fat diet.

Continue to pray and ask for the
guidance of our Almighty God.

MEAL PLAN
BREAKFAST

1 cup cooked

LUNCH

DINNER

oatmeal= 160

kcal
1 piece

of

1 serving/40g
porridge = 142

kcal
1

cup

banana bread=

mushroom

79 kcal
1 slice Whole

soup

grain bread =

128kcal
1 small orange

fruit= 45 kcal
1 cup of milk=

103 kcal
1 cup of water
(250mL)=
kcal.

kcal
1

kcal
1

serving

scrambled
129

small

corn=

eggs

kcal.
1 cup yogurt =
243 kcal

101

kcal
1 cup grape

juice=154 kcal
1 cup of water
(250mL)=

59 kcal
2 cups of water
(500mL)=

1 serving/40g
porridge = 142

hardboiled
sweet

TOTAL CALORIES

kcal
1 cup chicken
corn soup =
189 kcal

TOTAL CALORIES:
TOTAL CALORIES:
515 kcal

573 kcal

1674 kcal

TOTAL CALORIES:
586 kcal