CEREBROVASCULAR DISEASE

(BLEED)
CASE PRESENTATION

Prepare By: Aprille Anne C.Sagmit

JE Naw

INTRODUCTION

In this case study, the patient experienced

hemorrhagic stroke within the brain (intra-cerebral
bleeding) on the right temporo-parietal lobe. The
patient experienced severe headache, vomiting,
and slurring of speech 7 hours prior to admission.
Hes was admitted at the Intensive Care Unit of
Our Lady of Lourdes Hospital. As a CHSM student
nurses, well discuss the illness of the patient and
provide a systematic and appropriate nursing
interventions and management.

OBJECTIVES
General Objective:
To fully understand the underlying disease process of
cerebrovascular disease (bleed) and its nursing
management.
Specific Objectives:
1.To learn about the major etiologies of cerebrovascular disease
(bleed).
2.To determine the previous and present clinical history of the
patient.
3.To perform physical assessment with special attention on the
systems focus.
4.to show the laboratory examination results with the
corresponding normal values, actual result from the patient, and
its interpretation.

5.To understand the anatomy and physiology of the

blood supply in the brain and trace its
pathophysiology.
6.To learn the basic principle of nursing
management of cerebrovascular disease (bleed).
7.To use the nursing process to identify nursing
problems and understand the pharmacological
management set on the client and provide the
appropriate nursing care plan.
8.To identify the discharge plan for the patients
rehabilitation to conduct an evaluation of the clients
condition from admission to present

PATIENTS PROFILE
Patients Name : Patient S
Age : 68 years old 3 months 30 days
Address : 4927 INT. 2 Valenzuela St. Sta.
Mesa,
Manila
Gender : Male
Educational Attainment : College Graduate
Civil Status : Widower
Birthday : September 6, 1947
Religion : Catholic
Nationality : Filipino
Occupation : Retired Taxi Driver

Medical Data
Chief Complaint : Severe headache and vomiting
Admitting Diagnosis: Severe hemorrhagic stroke, Chronic
hypertension, Coronary Artery
Disease
Final Diagnosis : Cerebrovascular Disease (Bleed)
Time and Date Admitted: 10:29 PM / December 31, 2015
Attending Physician : Dra. Sadava
Surgeon : Dr. Debuque
Anesthesiologist : Dra. Guevarra
Preoperative Diagnosis : Intracerebral hemorrhage, right
temporo-parietal
Operation Performed
: Craniotomy and evacuation of
hematoma, Right frontotemporoparietal
Postoperative Diagnosis : Intracerebral hemorrhage, right
temporo-parietal R/O
Arteriovenous
Malformation (AVM)

Chief Complaint:
Sobrang sumasakit na yung ulo
niya nung gabi pa lang tapos bigla
na siyang nagsususuka as
verbalized by the patients daughter.

History of Present Illness

According to the daughter of the patient, 7 hours prior to
admission, Patient S started to have headache right side with a
pain scale of 10/10 radiating to right orbital area. This was
associated with 10 episodes of vomiting of previously ingested
food and water, left body weakness, slurring of speech and
with a blood pressure of 150/80 mm/hg. This prompted consult
hence admission.
Past Health History
The patient S was born September 6, 1947. Unrecalled
immunizations said by the daughter of the patient. He has a
history of hypertension and coronary disease for almost 7
years now with a maintenance medicine of Twynsta 80/5mg
once a day, Vastarel MR 35mg/tab once a day, Lipitor 20mg
once a day, Aspirin 100mg once a day and Metropolol 50mg
once a day. According to his daughter, he has a known allergy
to Ponstan, shrimp, and egg.

Personal/Social History
Patient S is the eldest in their family. Both
parents passed away. He has 1 brother and 3
sisters who are all married and settled. He has a
10 year gap to his second sister. He is a widower.
His wife died last 2014 due to Chronic Kidney
Disease. He has a son and a daughter, who are all
married and settled. He usually drinks liquor 2-3x
a week. Hes not really active in terms of exercise.
The only exercise he does is walking around the
neighborhood once in a while if he felt like
walking. According to his daughter, patient S has
no vices except for occasional drinking of alcohol.
Some morning he sweeps outside his house and
prepares breakfast for his grandchildren.

Environmental History (Living/Neighborhood/Circumstances)

According to patient Ss daughter, he is living with his son and
daughter including their own family. They live in a house which he
and his wife bought many years ago.
Their house is within a subdivision kind of type where usual
vehicles pass by. The patients daughter also said that their house is
a combination of cement and wood which is enough for his family
and grandchildren to live in. According to the daughter, cockroaches,
flies and mosquitoes are present at their house. They also own some
appliances like television, radio, electric fan, personal computer and
air conditioner. They have an electric and water connection. They live
in a place where houses are a little bit close but not closer to each
other. She also said that her fathers environment is a little bit noisy
and crowded.
Family History
Based on his daughter, there are histories of hypertension in her
fathers paternal side. She also said that patient S grew up close to
both mother and father side. She cannot recall any disease in both of
her fathers parents side.

V. GORDONS
FUNCTIONAL HEALTH
PATTERNS

Health Perception/Management Pattern

BEFORE
HOSPITALIZATION
According to patient
Ss daughter, he
perceived health as
being able to work,
fulfill his
responsibilities as a
good father and good
provider. She
believes that her
father thinks that
health is a very
important weapon to
live a long and
peaceful life. Based
on the daughter of
the patient, when
patient S feels like
hes going to have a

DURING
HOSPITALIZATION
Patient Ss
daughter realized
that its difficult to
be sick because of
the physical and
financial
constraints.
Patient S during
hospitalization is
conscious, calm
and lethargic. He
has plenty of
medications such
as
antihypertensive,
antibiotic, and
osmotic diuretic
drugs. Though

ANALYSIS AND
INTERPRETATION
Many people define and
describe health as:
Being free from
symptoms of disease
and pain as much as
possible, being able to
be active and to do
what they want or must,
and being good in spirits
most of the time.
(Kozier. Fundamentals of
Nursing, 8th ed.)
With him being in a
weakened state, he
cannot fulfill his role as
a father as long as his
illness continues. His
health is impaired and

 Nutritional/Metabolic Pattern
BEFORE
HOSPITALIZATION
Patient has known
food/drug allergies to
shrimp, egg and Ponstan.
According to the patients
daughter, he usually eats
food such as green leafy
vegetables, and fruits. His
usual diet in the house is
more on fish. He doesnt
like much fatty foods. He
eats 3 full meals a day:
breakfast, lunch,
sometimes a snack in the
afternoon and dinner. He
does drink alcohol 2 to 3
times a week and drinks 10
to 12 glasses of water
every day. He also doesnt
like too much sweet/salty
foods and crackers. He
perceived that eating

DURING
HOSPITALIZATION
Patient S has a
nasogastric tube
which acts as the
portal of entry of his
food and
medications. The
patients diet is liquid
osteurized feeding
1,500 Kcal divided
into 6 equal feedings
with an IV fluid of
PNSS 1L infusing well
at 20-21 drops/min.
Patient S also has an
endotracheal tube
connected to him
that makes eating
orally impossible.

ANALYSIS AND
INTERPRETATION
Health status greatly affects
ones eating habits and
nutritional status. Disease
process can disrupt
metabolism and caloric needs
of an old-aged. Alterations in
the clients diet are often
needed to treat a disease
process, to increase or
decrease weight, or to allow
an organ to rest and promote
healing. (Kozier.
Fundamentals of Nursing, 8th
ed.)
His current diet is
hypertensive diet which is low
at salt and low in fat and is
still the same as his normal
diet which involves a lot of
green leafy vegetables, fish

ELIMINATION PATTERN
BEFORE
HOSPITALIZATION
Patient Ss daughter
reported that he voids and
defecates regularly. He
passes out stool once a day.
Patient Ss daughter said he
did not have any difficulty
urinating or defecating.

DURING
HOSPITALIZATION

ANALYSIS AND
INTERPRETATION

Based on the nursing

assistant who did the
morning care
activities, patient S
did not pass any stool
for how many days
already. He has an
indwelling foley
catheter. There are
obvious signs of water
retention in his arms,
hands and feet.

The healthy body maintains a

balance between the amount
of fluid ingested and the
amount of fluid eliminated. The
excretory function of the
kidney diminishes with age,
but usually not significantly
below normal levels unless a
disease process intervenes.
The frequency of defecation is
highly individual; the amount
also varies from person to
person. Many older people
believe that regularity means
a bowel movement every day.
(Kozier. Fundamentals of
Nursing, 8th ed.)

His current urine output

indicates on how his body is
suffering from the disease. An
altered elimination pattern is
very detrimental to any
person.

Activity/Exercise Pattern
BEFORE
HOSPITALIZATION
According to patient Ss
daughter, hes not really
active in terms of exercise.
The only exercise he does is
walking around the
neighborhood once in a
while if he felt like walking
and every morning he
sweeps outside his house
and for her daughter its his
only exercise.

DURING
HOSPITALIZATION
Patient was admitted in
the intensive care unit.
Turning the patient
every 2 hours and
having bed bath was his
only activity and
movement.

ANALYSIS AND
INTERPRETATION
People often define their health
and physical fitness by their
activity because mental wellbeing and the effectiveness of
body functioning depend largely
on their mobility status. People
with mobility impairments may
feel helpless and burdensome to
others. (Kozier. Fundamentals of
Nursing, 8th ed.)
His condition has severely
impaired his daily activities and
even the most simple of those
tasks are important. It is difficult
to adjust into another
activity/exercise pattern just to
accommodate his limited
abilities in performing activities.

Sleep/ Rest Pattern

BEFORE

HOSPITALIZATION

Patient Ss daughter
verbalized that patient
S sleeps at around 9 to
10pm after watching
T.V. The late time he
sleeps is 11pm. He also
takes a nap in the
afternoon after lunch.
She said that his father
never experienced
sleeping late at night.
11pm is the maximum
time he can handle. He
wakes up 4 in the
morning to cook
breakfast to his
grandchildren and take
them to school. After

DURING
HOSPITALIZATION

During
hospitalization,
patient Ss only
activity was to sleep
and rest. There were
times when he was
not able to
sleep/rest aside
from his condition;
another factor is the
visitation of the
nurses who takes his
hourly vital signs,
medicines, and
occasional
suctioning.

ANALYSIS AND
INTERPRETATION

People require sleep in

order to cope with daily
stresses, to prevent fatigue,
to conserve energy, to
restore the mind and body,
and to enjoy life more fully.
Illness that causes pain,
physical distress personal
problems and stress can
result in sleep problems.
(Kozier. Fundamentals of
Nursing, 8th ed.)
Sleep deprivation being
present means that his
pattern was disrupted. His
current condition causes
pain and thus due to it he


Cognitive/ Conceptual Pattern
BEFORE

HOSPITALIZATION

Based on the patients

daughter, patient S did
experienced sensory
deficits such as slurring
of speech, difficulty of
breathing and
increased blood
pressure upon
admission. He did not
use hearing aid but he
uses eye glasses. He
knows how to speak
Tagalog and English.

DURING
HOSPITALIZATION

Patient S has an
endotracheal tube
connected to his
trachea which
makes talking or
speaking more
uncomfortable,
difficult and painful.
His only way of
communicating is
through little hand
gestures or
moaning. Patient S
was received
conscious,
responsive but
lethargic due to the

ANALYSIS AND
INTERPRETATION

The aged adults cognitive

and intellectual abilities
change very little. Cognitive
process includes reaction
time, memory, perception,
and learning. Problem
solving and creativity.
(Kozier. Fundamentals of
Nursing, 8th ed.)
The condition disables his
ability to properly recognize
and comprehend and verbal
or non-verbal cues.
Concentration a little bit
sluggish and he cannot
communicate properly due
to the endotracheal tube


Self-Perception Pattern
BEFORE
HOSPITALIZATION
Patient Ss daughter
perceived that her
father felt good about
himself before the
hospitalization because
he was able to work and
fulfill his
responsibilities. She
also reported that her
father is patient about
things and makes it a
point to resolve all
matters that annoys
him. She also thinks
that her father does not
have any negative
feelings about himself

DURING
HOSPITALIZATION
During
hospitalization and
during treatment,
patient was
conscious,
responsive and
lethargic. Patient S
was connected to an
endotracheal tube
that makes talking or
speaking, very
difficult and painful.

ANALYSIS AND
INTERPRETATION
A positive self- concept is
essential to a persons
mental and physical health.
Self- concept also extends to
the choices people make and
perceptions they have about
their health. People respond
to stressors such as illness
and alterations in function
related to aging in variety of
ways. Individuals with poor
self-concept may express
feelings of worthlessness,
self-dislike or even selfhatred. They may feel sad,
or hopeless, and may state
they lack energy to perform

Role/Relationship Pattern
BEFORE
HOSPITALIZATION

DURING
HOSPITALIZATIO
N
According to the
During
daughter of the
hospitalization,
patient, patient S
the siblings and
lives with his son and the daughter of
daughter including
the patient stays
their families.
with him in the
Patient Ss daughter hospital but stays
also said that her
only at the back of
father has good
the room because
relationship with his patient S was
friends, neighbors
admitted in an
and family. She also
intensive care
thinks that her father unit. They only
is a very caring and
got to visit him

ANALYSIS AND
INTERPRETATION
Throughout life, people
undergo numerous role
changes. Each person
usually has several roles.
Failure to master a role
creates frustrations and
feelings of inadequacy,
often with consequent
lowered self-esteem.
(Kozier. Fundamentals of
Nursing, 8th ed.)

Sexuality/Reproductive
Pattern
BEFORE
HOSPITALIZATION
Based on the patients
daughter, patient Ss
wife died last 2014 due
to Chronic Kidney
Disease. Ever since his
wife died, he never
looked for another
woman because for
him, her mother was
his life, strength and
happiness. According
to the daughter,
sometimes she can feel
and notice that her
father is sad and lonely
thats why she let her
children sleeps at her

DURING
HOSPITALIZATION
During
hospitalization,
patient S is under
supervision of
nurses and doctors
due to his condition.
His sexual pattern
remained the same.

ANALYSIS AND
INTERPRETATION
Regardless of gender, age,
race, socioeconomic status,
religious beliefs, physical
and mental health, or other
demographic factors,
people express their
sexuality in a variety of
ways throughout their lives.
Sexual health is the
integration of the somatic,
emotional, intellectual and
social aspects of sexual
being, in ways that are
positively enriching and
that enhance personality,
communication and love.
(Kozier. Fundamentals of


Coping/Stress Tolerance Pattern

BEFORE
HOSPITALIZATION
According to the
patients daughter,
when faced with
problems, he talks to
the person involved to
resolve it in a peaceful
manner. He prays to
God whenever he felt
like everythings falling
apart. The daughter
also said that he
doesnt hold grudges
from other people.

DURING
HOSPITALIZATION
During
hospitalization, it is
very obvious that
the patient just
sleeps and rest.
Lately, he does
encounter stress
physically due to the
endotracheal tube
that is connected to
a mechanical
ventilator
nasogastric tube,
and the operation
that has been done
to him which causes
him pain and stress;
emotionally due to
the inability to

ANALYSIS AND
INTERPRETATION
Coping strategies vary
among individuals and are
often related to the
individual\s perception of
the stressful event. A
persons coping strategies
often change with a
reappraisal of a situation. If
the duration of the stressors
is extended beyond the
coping powers of the
individual, that person
becomes exhausted and
may develop increased
susceptibility to health
problems. (Kozier.
Fundamentals of Nursing,
8th ed.)

Value/Belief Pattern
BEFORE

HOSPITALIZATION

The daughter said

that her father felt a
little bit satisfied
with his life but
there are parts of
him that she thinks
her father regrets.
He is a Roman
Catholic and goes to
church every Sunday
and visits Quiapo
church on a Friday.

DURING
HOSPITALIZATION

Because of the
patients
condition, the
chaplain of the
hospital does his
rounds and thats
the only time, the
patient receives
holy sacrament.
Plus the holy
mass that was
being played all
over the hospital
rooms.

ANALYSIS AND
INTERPRETATION

Spiritual health as
defined by the Nursing
Outcomes Classification
protect (Moorhead,
Johnson, & Maas, 2004
p.519), is the
Connectedness with
self, others, higher
power, all life, nature
and the universe that
transcends and
empowers the self.
(Kozier. Fundamentals of
Nursing, 8th ed.)

VI. Physical Assessment

General Appearance:
Patient was received awake, responsive but lethargic, with
ongoing IVF infusing well at #12 PNSS1L x 12 with 20-21
gtts/min at the right metacarpal vein. Patient has an endomorphic
type of body built and weighs 80 kilograms. Height was not taken.
Hygiene and cleanliness are maintained. He is fully assisted
during hospitalization. There is the presence of endotracheal tube
in his mouth connecting to the mechanical ventilator, presence of
pulse oximeter on the fore finger connected to a cardiac
monitoring device, with a Jackson-Pratt drainage on the right
temporo-parietal side of the head with a 10cc amount of blood.
Also, there is a presence of edema on the both upper and lower
extremities, presence of hernia on the mid right upper quadrant of
the abdomen and obvious drooling of saliva due to the inserted
nasogastric tube in his mouth.
Vital Signs:
T 37.1C
P 94 bpm