03 DEE_Ward5_Med Paper

Intracerebral Hemorrhage: A Case Report

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I. Introduction

According to the World Health Organization, fifteen million people worldwide suffer

a stroke every year. Approximately six million of them die while five million are

permanently disabled. It is the fifth leading cause of death in people aged 15-59 years

old. Next to dementia, it is the second leading cause of disability as manifested by loss

of vision and/or speech, paralysis, and confusion.

Developing countries have the highest incidence of stroke compared to other counties.

Even though the incidence is said to be declining, the actual number of strokes recorded

is increasing because of the ageing population.

Stroke happens when there is bleeding into the brain when an artery bursts

(hemorrhagic) or when the blood supply to the brain is blocked (ischemic). This creates

permanent brain damage in many people. Hemorrhage stroke accounts for about 20%

of strokes. Further classifying this would give intracerebral hemorrhage and

subarachnoid hemorrhage.

Stroke is a public health problem, a growing global health problem, which needs to be

addressed. A lot of young people are already being affected. Lifestyle practices such as

smoking and drinking could cause hypertension and in turn, hypertension could cause

a stroke to occur. It contributes to more than 12.7 million strokes worldwide, making

it the leading risk factor and cause. Lack of physical activity, obesity, high cholesterol,

smoking, poor diet, stress and depression, cardiac disorders, diabetes, and high alcohol


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intake are the other major lifestyle risk factors that need to be controlled. As of late,

thirty-three million people are now living with the effects of stroke.

II. Patient Database

A. Client Profile

The patient is a 44-year old male college graduate who was admitted to the

Philippine General Hospital (PGH) primarily due to cerebrovascular (CVD) bleed

last February 21, 2015. He is currently a supervisor at PL Technology which is

based in Laguna. He lives with his wife and two children, a 21-year old daughter

and a 15-year old son, at Cabuyao, Laguna. He is Roman Catholic. He was born on

July 3, 1970. His healthcare expenses were first under the PhilHeath program and

is now being shouldered by the patient’s wife (and sometimes other relatives) due

to the lack of resources from the extended period of time they were in the hospital.

B. Nursing Health History

Data on client’s Nursing Health History (NHH) was taken at the bedside last May

4, 2015 at Ward 5 of UP-PGH. Rapport was established with the primary caregiver,

the daughter, and consent for the NHH (and physical examination later on) was

obtained after the explanation of the purpose of the interview’s purpose and

confidentiality.

The information were provided by the patient’s daughter since he was unable to

communicate effectively–verbal and non-verbal communication was not possible.


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The student nurse was standing a foot away from the informant. Privacy was

ensured as the volume and tone of voice used by both parties were low enough.

Chief Complaint

The patient was admitted to the Central ICU (CenICU) of PGH last February 21,

2015 primarily due to his cerebrovascular bleed that occurred last February 19,

2015. However, chief complaint was decreased sensorium.

History of Present Illness

The client was a known hypertensive since his 30’s. In addition to this is his work

is scheduled during the night shift. According to his daughter (whose knowledge

on the HPI is limited), the patient was feeling really stressed since his 30s. This is

a known risk factor for CVD bleed. It is also important to note that the client is a

non-smoker (but review of chart overflow revealed that the client had a smoking

history of 10 pack years), but is an occasional alcohol drinker.

Before admission [to local hospital] last February 19, 2015, the client went to the

market to buy food. He directly went there after coming home from his night shift.

When he arrived at home, he was able to eat, bathe, and take a nap in preparation

for work that night. When his youngest tried to wake him up for work, there was

no response. After calling other family members to alert them of the first-time

situation, the client was then rushed to the local hospital and stayed there for three

days (February 19-21, 2015) then was transferred to UP-PGH last February 21,


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2015. He was first admitted to the CenICU, then transferred to the pay rooms, then

finally to Ward 5.

The client’s daughter also said that during the first few days of hospitalization, the

right side of the patient’s body was rigid. Last April 2, he was given a tracheostomy

tube.

Significant Past Medical History

According to his daughter, the client experienced a small motorcycle accident (date

unknown) on his way home from his night shift. It was raining that time. She was

not sure if he either fractured an arm or dislocated a shoulder. Nevertheless, the

doctors in from their local hospital managed the injury.

Furthermore, during his 30s, the client was diagnosed with hypertension. The

informant was not sure of the exact year when the diagnosis was made.

Family History of Illness

According to the daughter, her entire father’s side has been diagnosed with

hypertension. However, none of them had stroke (hemorrhagic or ischemic). The

daughter and her mother, the patient’s wife, both have goiters and are currently

having it managed (thought the priority is the patient’s health)

Functional Health Patterns


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Gordon’s Functional Health Patterns were utilized in taking the NHH to elicit more

data on the client’s health patterns. The daughter provided all the information that

she could despite not knowing all the details of her father’s health.

Health Perception and Health Management

As previously mentioned, the patient lived a relatively healthy life. He is a non-

smoker and an occasional alcohol drinker. However, his daughter reported that the

patient has been experiencing high stress levels even before. Whenever a family

member gets sick, they consult a doctor. They do not have a hard time following

doctor’s orders nor do they hesitate to go to one when needed. The family does not

seek help from faith/traditional healers (e.g. albularyo, hilot, etc.). The client was

mostly sedentary prior to present illness.

Nutrition and Metabolic Pattern

The patient is currently on milk feeding (MF of approximately two-thirds of the

paper cup provided) for breakfast and osterized feeding (OF 312 mL) for other

meals. He has a nasogastric tube (NGT size 6, intact and in place) which is used for

the MF and OF. Gag and swallowing reflexes are still present. After every feeding,

the client is given around 50-100 mL of water. Prior to the event of stroke, the client

(as reported by the daughter), used to eat a cup of rice and mostly fish and

vegetables. He occasionally eats meat (pork, beef, or chicken). There are no known

food, medicine, and environmental allergies.


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Elimination Pattern

Presently, the client defecates about two to three times daily into an adult diaper.

His stool is yellowish in color and soft. He urinates into the diaper as well. In a day,

the client consumes about three to five adult diapers.

Activity-Exercise Pattern

Prior to the stroke event, the client had no established exercise pattern. His daily

routine consisted mostly of coming home from work in the early morning, doing

some small chores, eating, bathing, and then finally waking up at night to prepare

for his night shift work. Presently, he does not have range of motion exercises in

the ward. His watcher does not even follow the minimum requirement of turning

the patient every two hours, which explains why the client has a bed sore at his

sacral area. The client is hemiplegic on his right side, while his left side remains to

be strong enough to resist movement or procedures being done on him. However,

it is also important to note that the client has non-purposeful movements using his

left extremities, with a preferential gaze to the left as well.

Sleep-Rest Pattern

Prior to admission, the client sleeps for approximately six hours during the day as

he works the night shift. In the ward, the client’s sleep pattern is intermittent. He is

sometimes observed to be sleeping in the morning and afternoon for short periods

of time. He sleeps the longest at night, but wakes when he has to expectorate


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secretions from his tracheostomy tube. The quality of his sleep could not be

assessed as he is in no state to describe it.

Cognitive-Perceptual Pattern

The client is a college graduate. The client is not fit to be assessed/interviewed

regarding his Cognitive-Perceptual Patter.

Self-perception and Self-control Pattern

The client is not fit to assessed/interviewed regarding his Self-perception and Self-

control Patterns.

Role-Relationship Pattern

Prior to admission, both the client and his wife are the family’s breadwinners as

they are both working. However, now that the client has assumed the “sick role”,

the responsibility of being the breadwinner falls on his wife. The primary caregiver

during most of the hospitalization was the wife. However, it became the daughter’s

role when the student nurse started her duty at Ward 5 since the wife had to resume

work.

Sexuality-Reproductive Pattern

The client is not fit to assessed/interviewed regarding his Sexuality-Reproductive

Pattern.


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Coping-Stress Tolerance Pattern

The client is not fit to assessed/interviewed regarding his Coping-Stress Tolerance

Pattern.

Value-Belief Pattern

The patient and his family are Roman Catholics. No other data were given by the

informant regarding the patient’s other personal beliefs.

Course in the Ward

From their local hospital, the client was transferred to PGH last February 21, 2015 as a private

patient. He was placed at CenICU where he was primarily managed by the Neurology

Department. He was hooked to a mechanical ventilator (MV) as well. According to the chart

review, he was also referred to PGH’s Pulmonologists, Neurosciences Surgeons, Internists,

Nephrologists, Otorhinolaryngologists, Infectious Disease Section, and Rehabilitation doctors

among others to attend to his other needs. His chief complaint as of this period was decreased

sensorium. He was ordered mannitol, piperacillin-tazobactam, azithromycin, telmisartan,

amlodipine, citicoline, omeprazole, lactulose, and Paracetamol. Last March 2, he was

maintained on face mask (FM). Weaning was done by decreasing the oxygen supply to 4 lpm

if the O2 saturation was 98% and above. According to the charts, the client tolerated it well.

On March 5, it was noted that the client could follow simple commands, but have certain

limitation such as protruding the tongue out when asked. Thus, he was allowed to transfer to

a regular room, but was not able to right away. On March 7, the client could not anymore

follow simple commands.


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On March 8, the client was transferred to a private room at the fifth floor. On this day, he was

noted to have desaturated, was producing yellowish secretions, and was then intubated again.

He also had a hypotensive episode. After intubation, the patient had spontaneous eye

movement and spontaneous movement of the left extremities. His repeat cranial CT scan at

this time showed resolving hematoma. On March 9, the patient was febrile. His meropenem

was shifted to cefepime and levofloxacin. On March 10, the patient was afebrile and can

follow commands. He had apneic episodes (on CPAP). His mannitol and dexamethasone

doses were lowered. On March 11, the client self-extubated. Reintubation was done and the

patient was found to be communicative after. On March 12, the patient was hypotensive, had

clear breath sounds, but was positive for A. baumannii (culture). Norepinephrine (NE) and

ampicillin/sulbactam were started. On March 13, the client was already on double inotropes,

inconsistently following commands, and positive for bilateral crackles. Mannitol was

discontinued.

The patient started becoming stuporous and febrile (≤38 °C) on March 14. However, he was

not hypotensive anymore and his inotropes were discontinued. These continued until the next

day. He had four seizure episodes last March 15. On March 16, there was very minimal eye

opening, decerebrate positioning upon infliction of pain, and the client was still febrile, but no

hypotension. Mannitol was restarted. On March 17, he was again transferred to CenICU. The

patient developed hypotension. NE drip, amikacin, and sultamicillin were started. There was

a decrease in sensorium noted few days prior to latest transfer to CenICU. Septic,

metabolic/ischemic (from stroke) encephalopathy is being considered as well. His medications


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consists of mannitol, telmisartan, amlodipine, omeprazole, lactulose, piperacillin-tazobactam,

and Paracetamol (since he was having some febrile episodes). His GCS was E2VTM2.

On March 23, the patient was for blood transfusion of two units of packed RBC. On March

25, he was for transfer to the charity ward (Ward 5). On March 28, the client was able to

undergo blood transfusion of two units of packed RBC.

As of March 27, the client’s medical diagnosis is “Acute intracerebral hemorrhage, left basal

ganglia, 37 cc, probably from hypertension. Stroke in the young. Acute respiratory failure

from hospital-acquired pneumonia (pseudomonas, A. baumannii) resolving. Acute renal

infection (ARI) on top of possible chronic renal injury from hypertensive kidney disease.

In the ward, the client is still intubated. His medications are enoxaparin, meropenem,

leviteracetam, metolazone, furosemide, telmisartan, amlodipine, carvedilol, lactulose,

fluconazole, doxofylline, salbutamol-ipratropium, N-acteylcysteine, and chlorhexidine oral

care. He has also been using anti-embolic stockings and egg crate mattress.

On April 1, he was diagnosed with complicated UTI and was ordered meropenem for the

treatment. On April 3, he was given a tracheostomy tube. The following day, after the initial

wound dressing was done by the physician, it has been ordered that the family be taught how

to perform tracheostomy care. At this point, the patient’s wife was the only one present so she

was the only one who learned how to do it. On April 5, the patient started using a tracheostomy

mask that is hooked to oxygen support at 10l liters per minute. Nebulization with salbutamol-


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ipratropium with the use of a tracheostomy mask, chest pulmophysiotherapy after nebulization

and every turning, and suctioning were also ordered. It was also noted that the infection was

slowly being treated with meropenem. On April 6, oxygen support was reduced to 4 liters per

minute. On April 7, the client took his last dose of meropenem and had shifted to levofloxacin

500 mg/tab, 1 tab daily for three days as the final treatment.

As early as April 8, the client was possible for going home as long as no more new infections

or complications arise. Home care instructions were ordered to be given. On April 11, the

patient received the “may go home” order. However, he became hypotensive that day and his

discharged was deferred until he stabilize. On April 12, he was for possible discharge again

as long as he was cleared of hypotension and has settled all medical costs with the hospital.

The family is unable to pay the hospital bill which is why they have stayed in PGH for another

month. This was also the same time the student nurse arrived at the ward to care for the patient.

The client was mostly stabilized and the healthcare team’s management, especially the nurses’

plan of care, consisted of home care. Under the student nurse’s care, the client’s airway and

home care instructions for the new caregiver were prioritized. The plan of care is discussed in

detail in Part VII of this paper.

III. Patient Assessment

A. Physical Examination

The physical examination (PE) was performed the morning of May 4, 2015. It was

done at the bedside as the patient could not be moved anywhere else. The student


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nurse explained the primary goal of the PE and provided reassurance that the

finding will be confidential. The daughter of the patient was there to give consent

and watched the whole procedure.

The PE was done in a systematic way and in a way that would not compromise the

patient’s privacy. The student nurse was also careful not to increase intracerebral

pressure (ICP) when examining the patient. The PE proceeded in a cephalocaudal

manner, examining first the anterior and lateral parts then the posterior parts since

the patient is bedridden and is in supine position most of the time.

The student nurse paid closer attention to the neurologic PE. Other data that are of

concern are of oxygenation, fluid and electrolytes, musculoskeletal functions, and

metabolism.

Data from the PE are found below.

General Survey

The patient looks according to age. The patient was noted to have right-sided

hemiplegia. He had a nasogastric tube which was kept clamped, but patent. The

client could not communicate verbally and non-verbally efficiently. His

tracheostomy tube (to room air) also prevents any sort of sound to be produced as

well. He has spontaneous eye movement and could open his eyes to tapping and

loud voices calling his name. Unpurposeful movements are observed on his left


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side. There are instances, however, when pain or discomfort is present, he is able

to localize the pain (with his left hand) as his way of saying that he is in pain.

Overall, the patient is generally clean, especially when the student nurse receives

him in the morning since he is able to have his bed bath.

Vital Signs

During the initial assessment, the patient’s vital signs were normal except for his

respiratory rate which was 26 breaths per minute, effortless, regular in rate and in

rhythm, without the use of accessory muscles. He was afebrile with a temperature

of 36.5 °C, blood pressure was 100/80 mmHg, and a pulse rate of 90 beats per

minute. His temperature was taken at the axillary region. His blood pressure taken

at the right brachial artery while lying down. His pulse was taken from the right

radial pulse which was regular in rate and rhythm as well. His pupils were reactive

to light at 3 mm on both sides. However, reaction to light was sluggish.

Neurologic Assessment

During the initial assessment, the patient was able to spontaneously open his eyes,

but was unable to follow simple commands. He is unable to communicate

effectively as well. However, there are occasions wherein he would give hand

squeezes when commanded, though this is inconsistently done. He localized the

pain when the sternal rub was done. However, when the client’s skin on the right

arms was pinched, there was no localization of pain. Thus, a Glasgow Coma Scale

score of E4VTM5. Visual threat is present. Preferential gaze to the left is observed.


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Gag and swallowing reflexes are present. Babinski reflex is present at the right foot,

but absent at the left foot. He was negative for brachioradialis, biceps, patellar and

Achilles reflexes at the right side, but are present on the left.

Skin

The patient has brown-colored skin and was found to be negative for pallor,

flushing, jaundice, cyanosis, and erythema. The patient has dry cool skin. Dry skin

is more apparent on the lower extremities, especially at both feet. The client was

sweating a lot since the room was humid. Pressure ulcer at the sacral region was

noted. The ulcer was grade II. Skin turgor on the dorsal aspect of the patient’s hand

was good. No pedal edema, petecchiae, ecchymosis, and rashes were observed.

Head

The head is normocephalic. He asymmetrical facial features. When the client

yawns, for example, symmetrical features are noted. He had coarse, dry hair. Scalp

was clean and free of lice. There were no palpable masses, nodules, or depressions.

Eyes

The patient has symmetrical eyelids and was negative for swelling, ptosis, and

periorbital edema. Eyebrows are symmetrically aligned and eye lashes are evenly

distributed. Conjunctiva of both eyes are pinkish and without lesions. Scleras of

both eyes were anicteric. Both corneas were clear. Both pupils are reactive to light,

though sluggish, at 3 mm. The client has a preferential gaze to the left.


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Ears

The patient has normoset and symmetrical ears. Gross hearing and/or hearing

abnormalities, if there were any, were not extensively tested for the client could not

respond or communicate effectively. Rinne and Weber tests were not performed.

External pinnae of both ears recoiled immediately when folded. No impacted

cerumen, discharge, or foul smell were observed in the external canals of both ears.

Nose

The patient’s septum is in midline. No perforations and alar flaring was observed.

His nasal mucosa was pinkish and there was no discharge. He had a nasogastric

tube inserted at the left nares for feeding and was checked for placement and

patency.

Mouth

The patient’s lips did not exhibit pallor, cyanosis, or lesions. However, the lips were

dry and peeling. The insides of the mouth can only be assessed when the client

yawns. His mouth could not be forced open in any way. His tongue is in midline

and without areas of atrophy or lesions. However, his tongue is covered in a thick

white film. No dental caries were noted in the brief assessment. He does not use

dentures. His oral mucosa and gums were pinkish and do not exhibit bleeding.

Pharynx

The patient’s pharynx was not assessed since he could not open his mouth upon


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command. The uvula, tonsils, among others were not assessed.

Neck

The patient is negative for neck enlargement or neck vein engorgement (NVE)

ruling out congestive heart failure. His thyroid and lymph nodes were non-palpable

and not enlarged. His neck does not have any masses or lesions. He was unable to

move his neck to the right, but can move it to the left. When the student nurse tried

to position his neck to face the right, resistance was met. It is also noted that the

client has a tracheostomy tube (size 6) to room air, with the cuff deflated. Through

the tracheostomy tube, the client expectorates thick white mucus secretions. These

are further loosened up when nebulization of salbutamol-ipratropium is given. The

client could expectorate secretions well.

Chest and Lungs

The patient’s breathing pattern was regular and effortless, without the use of

accessory muscles and with a respiratory rate (RR) of 26 breaths per minute. His

inspiration-expiration ratio was 1:2. He has an anteroposterior-lateral ratio of 1:2.

His chest is symmetric, with symmetric expansion, and without visible lesions or

abnormalities/deformities. Breath sounds were clear over all lung fields. Wheezes,

ronchi, rales or pleural friction rubs were absent.

Heart

The patient was noted to have normal cardiac function. Precordial area of the


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patient was flat. Heaves and thrills were not present. Point of maximal impulse

(PMI) was located at the 5th intercostal space (ICS) left midclavicular line (LMCL).

S1 was louder than S2 at the apex while S2 was louder than S1 at the base of the

heart. No murmurs or other abnormal heart sounds were present.

Breast and Axillae

The patient’s breasts are equal in size and are symmetrical. Both breasts were

negative for tenderness, masses, dimpling, and redness/erythema. Both nipples

were negative for discharge and inversion.

Abdomen

The abdomen was flat, symmetrical in shape, and even in color. Upon percussion,

it was found to be tympanitic. No herniations or superficial veins were seen.

Umbilicus is sunken and in midline. Few dirt was observed in the umbilicus. No

visible pulsations or movements were seen. Bowel sounds were normoactive at 8-

11 bowel sounds per quadrant per minute. Bruits were not heard. Abdomen was

soft with no superficial and or deep masses palpated.

Genito-Urinary

There were no lesions, redness, swelling, discharge, masses and nodules seen or

felt from the patient’s genitals—penis, testes, and scrotal sac. Scrotum was

descended.


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Back and Extremities

The patient’s back was symmetrical in shape and even in color. Peripheral pulses

were symmetrical and regular. However, the pulses on the left side were more

prominent than the pulses on the right side of the body. Capillary refill is less than

1 second. Swelling and redness are not present in the joints. Muscle grading for

both the right and left sides were unequal. The extremities on his left side are graded

5 out of 5, while the extremities on his right side were graded 1 out of 5.

B. Laboratory Tests and Diagnostic Examinations

Hematology, Complete Blood Count (CBC)

The CBC is a test of the blood that provides information about the hematologic

status of the patient. The different components of the blood each tell something

about the patient’s current health status. It aids health professionals in

understanding the illnesses of the client and their progression. CBC is routinely

done on patients with suspected inflammatory or infectious process, to monitor

response to physical/emotional stress and malnutrition, to monitor effects of acute

or chronic blood loss, and to monitor disorders associated with decreased RBC

counts.

In the case of the patient who was septic, CBC is one of the tests used to help

confirm and/or monitor the progression of the infection. Furthermore, it also helps

in assessing his kidney injury.


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During the student nurse’s stay in the ward, the latest CBC results of the patient

was from a month ago. Results reveal that last April 4, 2015, high white blood cell

count was noted. This indicated infection. Furthermore, neutrophil levels are also

elevated. This suggests that there is an acute infection. On the other hand, the client

had low red blood cell levels which could explain the acute renal infection and

chronic kidney injury from his hypertensive kidney disease since the kidneys are

involved in erythropoietin production as well. Lastly, the client also had low

lymphocyte count that suggested sepsis as well, though it is important to note that

lymphocyte count is not a primary indicator for diagnosing sepsis.

Clinical Pathology – WIP Immunology (Procalcitonin)

Procalcitonin is specifically ordered to confirm sepsis in a patient. Since it is a test

that is primarily used to check if the patient is septic, it is also a diagnostic test. The

patient was tested last March 24, 2015. His results were 0.79 ng/mL while the

normal range is less than 0.5 ng/mL. Simply put, the patient was septic.

Coagulation Studies

This test is ordered to monitor the extrinsic pathway of clotting (PT) and the

intrinsic pathway of the clotting cascade (PTT). Increased percentages of the

activity mean hypercoaguable states and vice-versa.

Specifically, the Prothrombin Time (PT) measures the phase III of the clotting

process and is indicative of a phase III problem should there be any deviations from


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normal. PT may be a false reading because of some clotting defects. Prothrombin

is factor II of the coagulation factors and is produced in the liver. For it to be

produced, vitamin K is needed.

On the other hand, the Activated Partial Prothrombin Time (PTT) is used to detect

phase II defects in the clotting system. It’s usually ordered for monitoring heparin

therapy. PTT test is more sensitive than the PT test.

Last April 2, 2015, the patient was in a hypercoaguable state and thus a bit more

prone to bleeding. Both intrinsic and extrinsic pathways take a longer time than

controls. The nurse must therefore watch out for bleeding, particularly signs of

cerebral hemorrhage. A recurrence might occur.

Serum – Electrolytes (Sodium)

This test helps monitor and predict whether the patient is at risk for developing

seizures, cerebral edema, slipping into a coma, experiencing apnea, and/or death at

any given moment, especially when there is a sudden drop over the succeeding days

or in severe cases (<120 mmol/L). It also monitors for other neurological vitals such

as headaches, nausea, vomiting, anorexia, being restlessness and confusion or

lethargic and apathetic.

Last April 13, 19, and 28, 2015, the client was observed to have slightly below

normal level of sodium (Na)–134 mmol/L, 135 mmol/L, and 132 mmol/L


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respectively. PGH’s normal range is from 136 mmol/L to 144 mmol/L. The client

may have low Na levels, but the levels are not as low as to warrant a severe

condition. However, strict NVS monitoring was needed and proper management

should be carried out by the nurse/student nurse as this could worsen if left

unmanaged.

Arterial Blood Gas (ABG)

Acidosis and Alkalosis both represent different causes and effects on the body. The

change in blood gas may come from the metabolic processes of the body or the

respiratory system. Such changes may be masked by concurrent compensation or

left unchecked or overlooked in patients with increasing medical needs and

concerns.

ABG is ordered to measure the partial pressures of oxygen (PaO2), carbon dioxide

(PaCO2), and the pH of an arterial blood sample. Oxygen content (O2CT), oxygen

saturation (SaO2), and bicarbonate (HCO3-) are measured as well. It is done to

evaluate the patient’s gas exchange at the level of the lungs, assess the ventilator

control system, determine the acid-base levels in the blood, and for monitoring

respiratory therapy.

The trend in the results from April 1, 5, and 8, 2015 showed that the client had

uncompensated metabolic alkalosis. The nurse needs to monitor vital signs,

laboratory results, and level of consciousness frequently. Watching out for signs of


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decreasing level of consciousness is a priority. Recording the intake and output

accurately is also needed to monitor renal function. The health care team needs to

prepare for possible seizures and in administering appropriate precautions.

Urinalysis

This test is done to discover or help in diagnosing renal and other diseases.

Urinalysis evaluates the kidney functions—excreting, reabsorption, and

maintaining fluid and electrolyte balance. It can reveal diseases that have gone

unnoticed because they do not produce striking signs or symptoms.

This test is also ordered to provide baseline data of a patient’s status, especially

upon admission, before surgeries, and the like.

Last April 7, 2015, the patient’s AKI is apparent since heme is present. Normally,

it is not excreted. UTI is also apparent since bacterial count is high. Urine is also

acidic, probably due to respiratory diseases (possibly from ARF from HAP).

Blood Typing and Cross-Matching

Blood typing is a test used to identify a person’s blood type. It is most commonly

used for blood transfusions. There are four types of blood types, each of the four

contains two more types because of the Rhesus factor. While blood-typing is the

primary basis for ABO compatibility between donor and recipient, properly cross-


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matched blood is needed before administering the blood. Hypersensitivity reactions

from mismatched blood could be fatal.

Last February 21, 2015, it has been found out that the patient’s blood type is also

known as the universal donor, O+. Therefore, only blood-type O+ properly cross-

matched, will be viable for transfusion.

The team must ensure results did match and blood bag at hand is compatible with

patient’s blood type and cross matched blood before infusing. Watch out for signs

& symptoms of rejection of transfused blood. On March 23, 2015, the client the

cross-matching results came in and the patient’s blood and the blood from the blood

bag are compatible.

Microbiology Preliminary Report – Gram Stain and Culture Tests

Gram Stain and Culture go hand-in-hand. Gram staining is used to identify the

characteristics (e.g. cocci, bacilli, etc.; whether in pairs or not, etc.) of the bacteria

from the specimen. Culture, on the other hand, will identify exactly what the

infecting agent is (e.g. S. aureus, E. coli, etc.).

On March 31, 2015 and April 6, 2015, Culture tests were done and both results

showed no growth after two days of incubation. Last April 1, 2015, actual finding

of the gram staining showed no signs of infection as well.


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Reason/s for Choosing the Case

The student nurse was given this case to handle and suffice to say it has been one of the most

interesting cases, if not the most interesting case, handle thus far. The case provided the

opportunity for the student nurse to perform a lot of procedures daily while she was still caring

for the patient in the ward. Furthermore, the case encouraged critical thinking since the client

has been in PGH for two months now and most of the medical diagnoses were connected at

one point in time. These problems required both medical and nursing interventions as soon as

possible. The challenge here for the student nurse is understanding the case fully in order for

her to provide holistic care the patient needed.

IV. Theoretical Background

The patient was diagnosed with Acute Intracerebral Hemorrhage, left basal ganglia,

~37 cc, with IVE likely hypertension; Stroke in the young; Acute Respiratory Failure,

resolved, from hospital-acquired pneumonia; and Acute Kidney Injury from sepsis and

mannitol on top of chronic renal insufficiency from hypertensive kidney disease. Each

diagnosis will be discussed separately. Next, an analysis of the patient’s case as a whole

will be discussed after in the next section of this paper.

A. Intracerebral Hemorrhage

Definition

Intracerebral hemorrhage (ICH) is the focal bleeding from a blood vessel in the

brain parenchyma. (Merck Manual, 2013) ICH may occur anywhere within the

brain or surrounding meningeal spaces. This type of stroke occurs 8-13% of the


25

time where it can result in death or major disabilities than the other type of stroke,

ischemic stroke.

In the patient’s case, the hemorrhage happened at the left basal ganglia where

speech and movement are controlled. Memory and thought processes may also be

affected. ICH in the basal ganglia is usually due to hypertension.

Etiology and Risk Factors

As previously stated, hypertension is the most common cause of ICH. In some

cases, usually in young people who experience ICH, the cause could be abnormally

formed blood vessels. Other causes of hemorrhagic stroke include head

injury/trauma, ruptured cerebral aneurysm, arteriovenous (AV) malformation,

bleeding tumors, illicit drug use (e.g. cocaine), and bleeding disorders (e.g.

hemophilia, sickle cell anemia).

Hypertensive patients are at a higher risk for developing stroke. Those who smoke,

have an excessive intake of alcohol, are heavily stressed, and are drug abusers put

themselves at risk for stroke. These same lifestyle practices are risks for

hypertension which is, as discussed, the major underlying cause of ICH.

Pathophysiology

Chronic and poorly managed hypertension-related hemorrhages occur typically in

the deep areas of the brain such as the basal ganglia and thalamus because vessels


26

in these areas are located close to the high pressure of the circle of Willis.

(Chakrabarty & Shivane, 2008) Because of hypertension, there is hyperplasia of the

media artery walls due to the proliferation of reactive smooth muscle cells. Soon,

these smooth muscle cells die. Collagen fiber form in its place making the vessels’

walls brittle and prone to another occurrence of bleeding.

It was previously believed that ICH was a simple and rapid bleeding into the brain.

Rapid because it was thought to stop as a result of clotting. However, studies have

shown that hemorrhages continue to grow over several hours after the onset of

symptoms. The expansion of a hematoma results from rupture of an artery or

arteriole that continued to expand most likely due to continuous bleeding from the

primary source. Hypertension may add to the expansion of the hematoma. In

addition to this, inflammation cause by thrombin formation and other products of

coagulation further complicates the injury and swelling that were already present

after the initial occurrence of the ICH. The hematoma produces edema and neuronal

damage. Edema happens with 24-96 hours and is resolved within weeks. The

neuronal damage may be seen as neuronal death in the affected part of the brain

and predominantly necrotic. Recent evidence show apoptosis.

Clinical Manifestations

It is important to note that clinical manifestations vary according to the size,

location, and rate of the expansion of the bleed. Symptoms may progress over hours

or minutes.


27

Clinical manifestations may begin with a headache, nausea, vomiting, and changes

in levels of consciousness. Hypertension is present in majority of the patients

(90%). In the patient, the affected part was the basal ganglia; thus, changes in

movement (involuntary or slowed); increased muscles tone; aniscoria; muscles

spasms and rigidity; problems with words; tremors; uncontrollable, repeated

movements, speech, or cries (tics); contralateral hemiparesis; contralateral sensory

loss; contralateral conjugate gaze paresis; aphasia; neglect; apraxia; and difficulty

in walking are some of the manifestations observed.

Laboratory Tests and Diagnostic Examinations

Blood tests such as CBC with platelets are ordered to monitor for infection and

assess hematocrit and platelet count to identify hemorrhagic risk and complications;

and coagulation studies (PT and PTT) to identify a coagulopathy; serum chemistries

including electrolytes and osmolarity to assess for metabolic derangements such as

hyponatremia, and to monitor osmolarity for guidance of osmotic diuresis.

(Liebeskind, et al, 2014)

CT scans and MRIs are ordered to visualize the extent of the hemorrhage and other

damaging effects of the stroke.

Treatment Modalities

Treatment is focused on minimizing further injury and to stabilize the patient. Early


28

treatment is essential as it can decrease hematoma enlargement and may lead to

better prognoses. Some medical interventions include: intubating the patient with

decreased LOC and poor airway protection; lowering the BP to a mean arterial

pressure (MAP) to less than 130 mmHg while at the same time avoiding

hypotension; rapidly stabilizing vital signs while simultaneously acquiring CT

scan; intubate and hyperventilate if intracranial pressure (ICP) is increased and

administer mannitol if further control is needed; maintain euvolemia by using

normotonic solutions rather than hypotonic fluids to maintain brain perfusion

without exacerbating brain edema; avoid hyperthermia; correct any identifiable

coagulopathy with fresh frozen plasma, vitamin K, protamine, or platelet

transfusions; start on anticonvulsants for seizure activity (leviteracetam is said to

be more effective than phenytoin as seizure prophylaxis without the suppression of

cognitive abilities in ICH patients); and facilitate transfer to ICU or as needed.

(Liebeskind, et al, 2014)

B. Hospital-acquired Pneumonia

Definition

Hospital-acquired pneumonia (HAP) is an infection of the lungs that occurs after

48 hours or more after admission, but not present during admission. Simply put, it

is the infection that causes lungs, particularly the alveoli, to be filled with fluid. It

is associated with high mortality and morbidity. Furthermore, HAP increases the

hospital stay


29


Patients acquire pneumonia in the hospital easily because their defenses are already

weakened by their illness or diseases. This occurs especially when a patient is

intubated (ventilator-associated pneumonia or VAP) as well. In other instances,

health care workers are the ones who spread pneumonia to their patients from

another patient (healthcare-associated pneumonia or HCAP).

Bacteria have been the most common pathogen of HAP or pneumonia in general.

Viral and fungal pneumonia are the other causes. Common bacterial pathogens are

gram-negative bacteria (GNB) such as Pseudomonas aeruginosa, Acinnetobacter

baumannii, Klebsiella pneumonia, and Escherichia coli. Gram-positive bacterial

(GPB) pathogens include Staphylococcus aureus.

Pathophysiology

Pneumonia happens when an invading pathogens (bacteria, virus, or even fungi)

enter the lungs through inhalation. These pathogens travel the respiratory tract and

settle at the alveoli. Protein-rich fluid seeps into the alveoli making it less functional

for ventilation and perfusion at the lung level. As this progresses, mucus production

increases. Mucus plugs forms and this hampers the gas exchange. An increased

number of white blood cells are produced and then rush to the site of infection.

WBC (neutrophils), bacteria, and more fluid get trapped in the alveoli; thus,

impairing oxygenation.


30

After WBC (neutrophils) fight off the infection in the lungs, cytokines are also

produced which would trigger the body’s other immune responses; hence, the fever

and chills.

If poorly managed, the patient would experience respiratory failure since he would

not be able to breathe properly due to the obstruction in his airways. Furthermore,

sepsis or septic shock may occur when the bacteria finds its way into the blood

stream.


Fever, chills, and myalgias are the most common signs and symptoms. Headaches,

nausea, vomiting, abdominal pain, diarrhea, cough, malaise, shortness of breath,

dizziness, arthralgia, back or chest pain, and/or sweats are the other clinical

manifestations.


A lower respiratory tract culture should be collected from all patients before

antimicrobial therapy is started; however, the collection should not delay the

initiation of empirical therapy in critically ill patients.

Culture samples can be collected via non-invasive endotracheal aspirate (ETA) or

invasive protected specimen brush (PSB), or bronchoalveolar lavage (BAL) in

intubated patients. Non-intubated patients must submit expectorated mucus


31

samples. This makes the results not as reliable because the collection method is not

done in a sterile manner compared to when collecting from intubated patients.

Thoracentesis is performed when pleural effusions are worsening. This is to rule

out a complicating empyema or parapneumonic effusion.

Gram staining and culture tests are done to determine the specific pathogen

infecting the patient.

Blood cultures are also done to determine if the client is already having

extrapulmonary infection that originated from the pneumonia infection.

A novel approach is also being used in the diagnosis of pneumonia (or sepsis is

other cases). The test for procalcitonin (PCT) levels has been used for its high

specificity for bacterial infections compared to more traditional methods such as

the tests for C-reactive protein, erythrocyte sedimentation rate, and leukocytes.


The American Thoracic Society (ATS) and Infectious Disease Society of America

(IDSA) guidelines from 2005 recommend clinicians to start empiric microbial

therapy based on the perceived severity, presence of risk factors of multi-drug

resistant organisms, and onset of HAP.


32

For GNB with known risk factors for MDR pathogens, beta-lactam/beta-lactamase

inhibitor (piperacillin/taxobactam 4.5 g q6h), antipseudomonal cephalosporins

(ceftazihime or cefepime 2 g q8h), or antipseudomonal carbapenems (imipinem

500 mg q8h; meropenem 1 g q8h) PLUS antipseudomonal fluoroquinolones

(levofloxacin 750 mg daily; moxifloxacin 400 mg daily; ciprofloxacin 400 mg q8h)

or aminoglycosides (gentamicin 7 mg/Kg daily; tobramycin 7 mg/Kg daily;

amikacin 20 mg/Kg daily).

For GPB with known risk factors for MDR pathogens, linezolid (600 mg q12h) or

vancomycin (15-20 mg/Kg q12h).

For GNB with unknown risk factors for MDR pathogens, ceftriaxone (2 g daily),

ampicillin-sulbactam (3 g q6h), levofloxacin (750 mg daily); moxifloxacin (400 mg

daily), or ertapenem (1 g daily).

Antibiotic treatment must be assessed during the second or third day of treatment

so treatment may be adjusted accordingly.

C. Chronic Renal Insufficiency

Definition

Renal insufficiency is the poor function of the kidneys that may be due to reduced

blood flow to the kidneys caused by renal artery disease. Kidneys normally regulate

body fluid and blood pressure, regulate blood chemistry, and filter waste from the


33

blood. Some patients with renal insufficiency may develop severe hypertension or

kidney failure requiring dialysis.


Risk factors of renal insufficiency due to renal artery disease may be similar to the

risk factors of atherosclerosis which are old age, gender, family history, race or

ethnicity, genetic factors, hyperlipidemia, hypertension, smoking, diabetes, and

obesity.

Pathophysiology

Chronic renal insufficiency, chronic kidney disease (CKD), or renal failure (end-

stage renal disease or ESRD) is the loss of renal function as the renal tissues lose

their function. This causes problems in the fluid and electrolyte balance. Urine is

not properly concentrated as are phosphates, acids, and potassium are not properly

excreted. As renal failure advances, the kidneys’ ability to dilute urine is

compromised, a manifestation that the glomerular filtration rate (GFR) is

diminishing. As the GFR diminishes, plasma concentrations of creatinine and urea

increase quickly.

Sodium and water balance may be yet normal as it maintained by the excretion of

sodium and the body’s normal response to thirst.


34

Calcium, phosphate, parathyroid hormone (PTH), and vitamin D metabolism

abnormalities, and renal osteodystrophy could occur in the CKD progression.

Decreased production of calcitriol is the kidneys further contributes to

hypocalcemia. Hyperphosphatemia occurs as well because the kidneys do not get

to excrete phosphates. Thus, it is common that hyperparathyroidism may develop

in patients with renal failure even before abnormal calcium and phosphate

concentrations are detected.

Moderate acidosis and anemia are commonly seen as well due to the deficient

erythropoietin production of the kidneys.


Dangerously high blood pressure, anorexia, nausea, vomiting, stomatitis,

dysgeusia, nocturia, lassitude, fatigue, pruritus, decreased mental acuity, muscle

twitches and cramps, water retention, weight loss, undernutrition leading to

generalized tissue wasting, peripheral neuropathies, and seizures are some of the

symptoms that develop slowly over time.

Patients with mild renal problems, sometimes even those with mild to moderate,

are usually asymptomatic despite increased BUN and creatinine levels. For patients

with severe renal insufficiency (creatinine clearance of < 10 mL/min),

neuromuscular symptoms such as coarse muscular twitches, peripheral sensory and


35

motor neuropathies, muscle cramps, hyperreflexia, restless legs syndrome, and

seizures. In some instances, uremic frosts, urea crystals from sweat, are present.

Pericarditis and GI ulceration and bleeding are seen in advanced CKD.

Hypertension (related to hypovolemia from activation of the renin-angiotensin-

aldosterone system) is seen in more than 80% of CKD patients. Heart failure from

hypertension or coronary artery disease (CAD) edema from renal retention of

sodium may also be observed.


Renal insufficiency may be diagnosed by duplex ultrasound scanning and other

non-invasive tests such as CT angiography and MR angiography. Contrast

angiography is the definitive test for this disease.

Electrolytes, BUN, creatinine, phosphates, calcium, complete blood count, and

urinalysis are also ordered. Renal biopsy may also be ordered.


Underlying disorders must be controlled (e.g. if diabetic, control blood sugar; if

hypertensive, control blood pressure). Possible restriction of dietary protein,

phosphate, and potassium may be ordered. Intake of vitamin D supplements,

treatment of anemia and heart failure, maintenance of sodium bicarbonate levels at

> 20, dialysis for severe CKD, and adjustment of drug doses (as needed) are done


36

to manage the CKD. Water intake is also restricted when sodium is below 135

mmol/L, there is heart failure, and/or severe edema. Sodium restriction of 1.5 grams

per day is done on patients with severe edema, hypertension, and heart failure.

In other cases, kidney transplantation is also done.

D. Sepsis

Definition

Sepsis is an inflammatory state resulting from a systemic response to bacterial

infection. Very poor tissue perfusion and acute failure of multiple organs (e.g.

lungs, kidney, and liver) is highly likely to occur in patients with severe sepsis. A

wide variety of GNB and GPB are the common pathogens of sepsis. In severely

immunocompromised patients, aside from GNB and GPB, uncommon bacterial

species and fungi could be a cause for sepsis. Sepsis represents a spectrum of

diseases ranging from systemic inflammatory response syndrome (SIRS) to septic

shock. (Maggio & Carvalho, 2015)


Most cases of sepsis are due to gram-negative bacilli or gram-positive cocci

occurring in immunocompromised patients or patients with chronic and debilitating

diseases. For patients who just had surgery, postoperative infection could be an

etiology for sepsis as well.


37

Vulnerable population groups such as neonates, older persons, and pregnant women

are more prone to contracting sepsis. Sepsis is also easily acquired in patients who

have diabetes mellitus, cirrhosis of the liver, leukopenia (especially those

associated with cancer or use cytotoxic drugs), invasive devices (e.g. endotracheal

tubes, vascular or urinary catheters, drainage tubes), and those who have prior

treatment with antibiotics or corticosteroids.

Common sites of infection are the lungs, urinary biliary, and GI tracts. (Maggio &

Carvalho, 2015)

Pathophysiology

The process starts when there is a production of proinflammatory mediators due to

the presence of an inflammatory stimulus. Cytokines produced cause eutrophil-

endothelial cell adhesion that activate the clotting mechanism. Leukotreines,

lipoxygenase, histamine, bradykanin, serotonin, and IL-2 are also released. A

negative feedback system, however, is present to stop the proinflammatory

mediators. Anti-inflammatory mediators are IL-4 and IL-10.

Warm shock initially occurs by the dilation of arteries and arterioles; thus,

decreasing peripheral arterial resistance and increasing cardiac output. Vasoactive

mediators cause blood flow to bypass capillary exchange vessels; hence, decreasing

the delivery of oxygen to tissues and decreasing the removal of carbon dioxide and

other waste products.


38

In other cases, cardiac output may decrease, hypotension occurs, and other signs

and symptoms of shock appears. The decrease in perfusion causes problems in the

brain, lungs, heart, liver, and kidneys. (Maggio & Carvalho, 2015)


SIRS consists of four major symptoms including temperature above 38°C or below

36 °C, heart rate of above 90 beats per minute, respiratory rate of above 20 breaths

per minute, and a WBC count of more than 12,000 cells per micro liter or less than

4,000 cells per microliter or more 10% immature formations of WBC. In sepsis,

two or more of these criteria is present, while severe sepsis is sepsis but with organ

dysfunction. Septic shock is sepsis with refractory hypotension and impaired end

organ perfusion despite adequate fluid resuscitation.

Diaphoresis is also another manifestation. Confusion or a decrease in level of

alertness and skin becomes cool and pale with peripheral cyanosis and mottling are

also observed. (Maggio & Carvalho, 2015)


CBC with differential count, electrolytes, creatinine, and lactate are tests ordered.

Blood, urine, and other cultures collected from different sites of the body are done.

[Invasive] central venous pressure (CVP), PaO2, and central venous oxygen

saturation (ScvO2) readings are also diagnostic.


39


Oxygen support, restoration of perfusion with IV fluids (preferably isotonic

crystalloid or 0.9% saline; some add albumin during the initial fluid bolus) with

vasopressors, broad-spectrum antibiotics, source control, and sometimes

corticosteroids are used for treatment.

V. Case Analysis of the Intracerebral Hemorrhage and Other

Comorbidities

This section provides an analysis of the client’s ICH and other comorbidities such as

his acute respiratory failure from hospital-acquired pneumonia and acute kidney injury

from mannitol on top of chronic renal insufficiency from hypertensive kidney disease.

Before the stroke event occurred, the client was already hypertensive and under a lot

of stress. This is compounded by the fact that the client had a smoking history of ten

pack years according to the charts. Over time, these risk factors contributed to the

occurrence of his intracerebral hemorrhage last February 19, 2015. Respiration, among

the many other complications seen in post-stroke patients, is severely affected. The

client was then intubated for mechanical ventilation. Ventilator-associated pneumonia

(VAP) is a highly likely infection that can occur in patients who are ventilated over a

period of time. Furthermore, since the client is mostly stuporous and weak, his other

protective mechanisms such as the ability to cough, are not being utilized to help the

body fight off infection. Thus, in time, the patient contracted pneumonia (an infection


40

of A. baumannii). The problems in respiration brought about by his stroke and

exacerbated by pneumonia resulted in desaturation and soon, acute respiratory failure.

Thus, continuous ventilator support, antibiotic therapy, close monitoring, and strict

observance of VAP bundles of care are some of the important management carried out

by the healthcare team.

Furthermore, the infection most likely spread that sepsis was diagnosed in the patient

as well. Complicated UTI was then diagnosed, but was also resolved. The client is

already severely immunocompromised with CRI. His chronic hypertension greatly

contributed to the CRI as well. As mentioned in the previous section, CRI produces

neuromuscular problems on top of other manifestations such as muscle wasting and

undernutrition among others. His ins and outs in the CenICU further attested to the

fragility of his overall condition. With his kidneys’ poor function, his body could not

fight off a systemic infection. Thus, aggressive antibiotic therapy is again needed,

maintaining the balance of fluids, intake of vitamin D supplements, and the like are

some of the treatment modalities done.

VI. Medical Management

A. Laboratory Tests and Diagnostic Examinations

Please refer to page appendices for the list and results of laboratory tests and

diagnostic examinations done.


41

B. Pharmacologic Management

Enoxaparin (0.6 cc, OD, SQ, 8 am)

This drug is for the prevention of deep vein thrombosis (DVT) after hip, knee, or

abdominal surgery, treatment of DVT and pulmonary embolism, and management

of acute coronary syndrome. It is a low molecular weight heparin with anti-

thrombotic properties. Its anti-thrombotic properties are due to its anti-factor Xa

and anti-thrombin (anti-factor IIa) in the coagulation activities. Enoxaparin is an

effective anticoagulation agent and it used for prophylactic treatment as an

antithrombotic agent.

It is contraindicated in patients with active major bleeding, gastrointestinal (GI)

bleeding, hemophilia, heparin hypersensitivity, thrombocytopenia, and other

bleeding disorders. Some adverse effects include allergic reactions (rash,

urticarial), fever, peripheral edema, arthralgia, abnormal liver function tests, pain

and inflammation at the injection site, hemorrhage, thrombocytopenia, anemia,

ecchymoses, dyspnea, and pruritus.

When giving this drug, strict monitoring of CBC (especially the platelet count if <

100,000/mm3), coagulation studies, and urine and stool tests for the presence of

occult blood must be done (if there is any). Also monitor for any signs and

symptoms of bleeding.


42

Leviteracetam (100 mg/mL, 5 mL, q12h, 8 am and 8 pm or 500 mg/tab, 1 tab, q12h,

8 am and 8 pm)

This drug inhibits complex partial seizures and prevents epileptic and seizure

activity. It is also an adjunctive therapy for partial onset seizures in adults. It is a

broad spectrum anti-epileptics agent, which does not involved GABA inhibition.

It’s contraindicated in patients who are hypersensitive to leviteracetam.

Some adverse effects include asthenia, headache, pain, depression, paradoxical

increase in seizures, cough, pharyngitis, rhinitis, sinusitis, and diplopia.

Monitor CBC (especially hemoglobin and hematocrit levels). Educate the patient’s

family that the drug is not to be discontinued promptly. Tapering the drug off is

important.

Calcitriol (0.25mg/tab, 1 tab, OD, 8 am)

This is for the management of hypocalcemia. It’s a synthetic form of an active

metabolite of ergocalciferol (vitamin D2). In the liver, cholecalciferol (vitamin D3)

and ergocalciferol (vitamin D2) are enzymatically metabolized to calcifediol, an

activated form of vitamin D3. Calcifediol is biodegraded in the kidney to calcitriol,

the most potent form of vitamin D3. Patients with nonfunctioning kidneys are

unable to synthesize sufficient calcitriol and therefore must receive it

pharmacologically.


43

By promoting intestinal absorption and renal retention of calcium, calcitriol

elevates serum calcium levels, decreases elevated blood levels of phosphate and

parathyroid hormone, and decreases subperiosteal bone resorption and

mineralization defects in some patients. Since this patient is bedridden for

approximately two months since admission, calcium is not absorbed anymore since

bone and muscle use are very limited. Thus, the body has no need for calcium. More

importantly, his kidney damage impaired the production of calcitriol in the kidneys;

thus, producing problems in vitamin D metabolism. Therefore, administration of

calcitriol would help manage this.

Some adverse effects include muscle or bone pain, palpitations, nausea, vomiting,

dry mouth, headaches, weakness, and increased urination.

When giving this drug, one must always watch out for signs of hypercalcemia and

notify the physician if there are any. Also ensure that the patient has an adequate

fluid intake. However, since he has kidney problems, special orders from the

physician must be taken into consideration.

Calcium Carbonate (500 mg/tab, 1 tab, TID, 8 am, 1pm, 6 pm)

This is used for the relief of transient symptoms of hyperacidity as in acid

indigestion, heartburn, peptic esophagitis, and hiatal hernia. It is also used as a

calcium supplement when calcium intake may be inadequate and in treatment of

mild calcium deficiency states and for the control of hyperphosphatemia in chronic


44

renal failure (calcium acetate). It is also for the treatment of hyperphosphatemia in

patients with chronic renal failure and to lower BP in selected patients with

hypertension.

It is contraindicated in hypercalcemic states, in patients with hypercalciuria,

calcium loss due to immobilization, severe renal diseases, renal calculi,

gastrointestinal hemorrhage or obstruction, dehydration, alkalosis, ventricular

fibrillation, and cardiac diseases. Adverse effects include constipation or laxative

effect, acid rebound, nausea, vomiting, flatulence, hypercalcemia with alkalosis,

hypercalciuria, polyuria, and renal calculi.

When giving this drug, note the number and consistency of the stools, determine

serum and urine calcium (if available), and observe for signs and symptoms of

hypercalcemia especially in patients who have impaired renal functions. This

should not be taken in conjunction with foods high in vitamin D and foods high in

oxalates.

Carvedilol (6.25 mg/tab, 1 tab, BID, 8 am and 6 pm)

This drug was ordered for the management of the client’s essential hypertension.

Carvedilol works through the adrenergic receptor blocking agent that combines

selective alpha activity and nonselective beta-adrenergic blocking actions. Both

activities contribute to blood pressure reduction, peripheral vasodilatation and,


45

therefore, decreased peripheral resistance results from alpha1-blocking activity of

carvedilol. It is 3–5 times more potent than labetalol in lowering blood pressure.

It is contraindicated in patients with class IV decompensated cardiac failure,

bronchial asthma or related bronchospastic conditions (e.g. chronic bronchitis and

emphysema, or COPD), and cardiogenic shock or severe bradycardia. Adverse

effects include increased sweating, chest pain, arthralgia, bradycardia, hypotension,

hypertension, syncope, AV block, angina, nausea, vomiting, diarrhea, abdominal

pain, sinusitis, bronchitis, thrombocytopenia, hyperglycemia, weight increase,

gout, dizziness, headache, and paresthesia.

The student nurse must monitor blood pressure of the patient and for signs and

symptoms of the adverse effects previously stated.

Salbutamol-Ipratropium (q4h, 8 am, 12 nn, 4 pm, 8 pm, 12 am, 4 am, or PRN)

Salbutamol-Ipratropium is used for the relief of secretions. With the tracheostomy

tube present, it is hard for the patient to expectorate mucus secretions when it

thickens. Salbutamol-Ipratropium through nebulization loosens these secretions so

they may be expelled easily.

It works through the synthetic sympathomimetic amine and moderately selective

beta2-adrenergic agonist which have comparatively long action. It acts more

prominently on beta2 receptors (particularly smooth muscles of bronchi, uterus, and


46

vascular supply to skeletal muscles) than on beta1 (heart) receptors. It inhibits

histamine release by mast cells then produces bronchodilation, regardless of

administration route, by relaxing smooth muscles of bronchial tree.

Adverse effects include hypersensitivity reaction to the drug, tremors, anxiety,

nervousness, restlessness, convulsions, weakness, headaches, hallucinations,

palpitations, hypertension, hypotension, bradycardia, reflex tachycardia, dilated

pupils, nausea, vomiting, and muscle cramps.

When administering this medication, watch out for signs and symptoms of

dizziness, tremors and tachycardia. Avoid contact with the eyes as well.

C. Surgical Intervention

There were no surgical interventions performed on the client.

VII. Nursing Care Plan

A. Problem Identification and Prioritization

The following nursing diagnoses are prioritized according to the student nurse’s

judgment on the ranking of each problem’s urgency.

PHYSIOLOGIC

1. Ineffective Airway Clearance related to the presence of thick and copious

secretions of the upper airways


47

NANDA defines Ineffective Airway Clearance as the state in which an

individual is unable to clear secretions or obstructions from the respiratory tract

to maintain airway patency.

Maintaining a patent airway is vital to life. Coughing is the main mechanism

for clearing the airway. However the cough may be ineffective in both normal

and disease states secondary to factors (such as pain from surgical

incisions/trauma, respiratory muscle fatigue, or neuromuscular weakness).

Other mechanisms that exist in the lower bronchioles and alveoli to maintain

the airway include the mucociliary system, macrophages, and the lymphatics.

Other factors (such as anesthesia and dehydration) can affect function of the

mucociliary system. Likewise, conditions that cause increased production of

secretions (pneumonia, bronchitis, chemical irritants) can overtax these

mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative

recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord

injury) problem.

In the case of the client, there is difficulty in breathing since the secretions are

obstructing the airway. The tracheostomy was given to the client since the

respiratory centers were greatly affected as well during the CVD bleed. In time,

it was decided that an artificial airway had to be constructed to relieve the

patient of respiratory distress. This was prioritized first since it involved the


48

airways. The student nurse used the A-B-C or Airway-Breathing-Circulation in

the decision-making process.

Taken into were also the reports of the watcher when she relayed that her father,

the patient, had difficulty expectorating the mucus secretions. It was also

observed, as stated earlier, that the secretions were thick and copious in amount.

A productive cough was also observed. It was important to note that the

presence of the gag and swallowing reflexes that could aid in the expectoration.

His latest ABG results though dated April 1, 5, and 8, 2015 (hardly a reliable a

cue as it is from a month prior to assessment of the student nurse), showed that

he had uncompensated metabolic acidosis with a pO2 that was 150.2 mmHg

which suggested the use of a mechanical ventilator at that time.

2. Self-care Deficit related to decreased motor functions secondary to

cerebrovascular accident bleed

NANDA defined Self-care Deficit as the state in which the individual

experiences a limitation of ability for independent physical movement.

Alteration in mobility may be a temporary or more permanent problem. Most

disease and rehabilitative states involve some degree of immobility, as seen in

strokes. Restricted movement, an effect of the neuromuscular impairment in

stroke patients, affects the performance of most activities of daily living

(ADLs).


49

As with the patient who has a damaged left basal ganglia, presenting signs and

symptoms present are inability to control movement of the right side of his body

or right-sided hemiplegia. Speech was also affected. Very limited movement

from the left side of the body is produced. Should there be any movement, it is

usually unpurposeful movements. The patient is also fully dependent in ADLs.

He is allowed bedwetting or the use of adult diapers for urinating and

defecating. The client cannot turn self, cannot stand, and cannot transfer from

bed to any other position. He is not ambulatory. Neck has a limited range of

motion, with a preference to facing the left side. Rigidity and resistance is

present when the student nurse tried to position the client’s head and neck to

face the right side. Range of motion (ROM) at both shoulders, elbows, arms,

and legs are full. ROM at the hips are limited.

Generally, damage to the basal ganglia cells may cause problems with one's

ability to control speech, movement, and posture. A person with basal ganglia

dysfunction may have difficulty starting, stopping, or sustaining movement.

Problems with memory and other thought processes are also of great concern.

In general, symptoms vary and may include:

Movement changes, such as involuntary or slowed movements

Increased muscle tone

Muscle spasms and muscle rigidity


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Memory loss

Problems finding words

Tremors

Uncontrollable, repeated movements, speech, or cries (tics)

Walking difficulty

Subsumed in this Nursing Diagnosis is the problem, Readiness for Enhanced

Home Management. This nursing problem focuses not on the patient, but on

the primary caregivers. Because the patient has an evident self-care deficit, the

significant others must fill in this gap in the self-care by being the ones who

provide care. This must be inculcated into the family members since the patient

has been for discharge for approximately a month as of writing this paper. The

family members should be able to continue the care given at the hospital, at

home. Nursing management of this patient in the ward is mostly for home care

when the student nurse started her rotation last May 4, 2015.

PSYCHOSOCIAL

3. Interrupted Family Processes related to change in family roles and structure

associated with progressive disability

Interrupted family processes occurs in this family due to the shift in family

roles. The father (his wife also works), the primary breadwinner of the family,

has been hospitalized for two months straight. The wife has taken leave off

work to care for the patient at the hospital, but had to go back after a month


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since she had to earn to pay the hospital bills. If unpaid, the patient does not get

clearance to go home. Both husband and wife used to work, but since the patient

assumed the sick role, his wife immediately assumed the caregiver role for a

month, until she had to return to work, now as the primary breadwinner of the

family.

Now, the eldest child of the couple, their daughter, took the place of her mother

as the primary caregiver. This has become their arrangement, that a primary

caregiver should always be present at the bedside daily, since the patient needs

very close supervision and assistance since he is very dependent on ADLs.

B. Nursing Interventions and Rationales

PHYSIOLOGIC

1. Ineffective Airway Clearance related to the presence of thick and copious

secretions of the upper airways

NOC: Respiratory Status (0415)

With this Nursing Outcomes Classification (NOC), the main goal for this patient

under this nursing problem is for him to be relieved of thick and copious secretions

as evidenced by being able to expectorate the mucus secretions effectively. With

this, vital signs within normal ranges will also be achieved.

NIC: Airway Management (3140)

Guided by this Nursing Interventions Classification (NIC), the student nurse first


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monitored for the neurologic vital signs before and after every procedure. This will

serve as baseline data that will guide in performing other succeeding nursing

interventions and performance of other independent nursing functions.

Administration of Salbutamol-Ipratropium via nebulization was also done to thin

the secretions. Thick secretions are difficult to expectorate and can cause mucus

plugs and might lead to atelectasis. After nebulizing the patient, suctioning the

secretions from the tracheostomy tube and orally were done to help the patient since

expectorating also takes a lot of effort on his part. Next is performing tracheostomy

care once daily after nebulization with salbutamol-ipratropium and suctioning,

since it will be easier to clean the tube when the secretions are removed.

Furthermore, when the clean tube is placed back, it would not be easily covered in

secretions again. Suctioning and tracheostomy care are done to relieve the client of

any obstruction brought about by thick and copious secretions that are difficult to

expectorate; thus, facilitating proper ventilation.

Aside from the whole process of nebulization to tracheostomy care, the student

nurse also increases his hydration in between meals and after feeding. This is done

so that secretions could be fluid enough for easier expulsion, preventing stasis of

secretions, which could provide a medium of organism growth.

Placing the client 30° head of bed elevation or on moderate to high back rest every

once in a while helps mobilize secretions. Sitting upright shifts abdominal organs

away from the lungs, as opposed to lying flat on the back; thus, enabling greater


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lung expansion and better expectoration of secretions. This is also done to observe

aspiration precautions.

2. Self-care Deficit related to decreased motor functions secondary to

cerebrovascular accident bleed

Subsuming Diagnosis:

Readiness for Enhanced Home Management

NOC: Self-care: Activities of Daily Living; Self-care: Bathing; Self-care: Hygiene;

Self-care: Oral Hygiene; Tissue Integrity: Skin; Joint Movement: Elbow, Fingers,

Hip, Knee, Neck, Shoulder, and Wrist

The primary goal is for the client’s self-care needs to be addressed by his significant

others, especially upon discharge, as evidenced by the family being able to perform

his ADLs for him, perform ROM exercises for him, prevent new pressure ulcers

from developing, and placing the client in neutral position to prevent contractures

and/or poor circulation.

NIC: Skin Surveillance; Pressure Management; Teaching: Prescribed Activity:

Exercise; Exercise Promotion: Strength Training

The student nurse performed the ADLs for the patient while simultaneously

teaching and demonstrating to the significant others what to do when they will be

the ones fully in-charge of the ADLs at home.


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First, providing daily mouth care using chlorhexidine mouth wash done. Bed baths,

diaper changes, and grooming were also done. Maintaining good hygiene,

especially during the illness state, is essential in preventing further complications

such as infections and other tissue injuries. Administering oral feeding was also

demonstrated. It is important for the client to maintain his nutrition inside and

outside the hospital. Nutrition remains an important part of the client’s recovery

and health maintenance. Though he cannot open his mouth on command (open

mouth only during yawning), an alternative route, NGT, is used. Teaching the

daughter how to administer feeding correctly is important to avoid aspiration or

other complications.

As for exercise, the student nurse also explained to the watcher the importance of

still being able to exercise even if the patient is confined to the bed. Aside from

preventing disuse and promoting circulation, this makes the watcher an active

partner in caring for the patient. Warming up and cooling down were also advised

before and after exercise respectively to allow muscles to get ready gradually for

more work. Next is the actual performance of the passive ROM exercises. Regular

[ROM] exercises can help maintain integrity of joint function. (Addams & Clough,

1998). It also improves circulation and strengthens muscle groups needed for

ambulation, increases muscle mass/tone, and improves cardiac and respiratory

functioning.


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It has been observed that the client has not been following the turning schedule of

the ward. Therefore, the student nurse emphasized the importance and benefits of

turning the patient every two hours. It was explained to the watcher that turning

relieves the pressure a body part experiences during periods of [prolonged] bed

confinement. Furthermore, this helps in proper circulation as the blood is allowed

to flow to the parts previously receiving pressure for a longer time period. Basically,

doing so prevents bed sores. She was also taught to observe affected side for color,

edema, or other signs of compromised circulation. Edematous tissue is more easily

traumatized and heals more slowly. The watcher was also told to elevate lower

extremities to functional position to prevent contractures and footdrop and

facilitates use when function returns.

Maintaining neutral positions was also emphasized. As for maintaining the head’s

neutral position, spastic paralysis may lead to deviation of head to one side. Flaccid

paralysis may interfere with ability to support head. Placing a pillow under the

axilla to abduct the arm was also discussed. This prevents adduction of shoulder

and flexion of elbow. Other instructions include elevating the arms and hands to

promote venous return and help prevent edema formation, placing had-rolls in the

palm with fingers and thumb opposed to decrease the stimulation of finger flexion,

maintaining finger and thumb in a functional position, maintaining the legs in

neutral positions with a trochanter roll to prevent external hip rotation, and placing

the knee in extended position.


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PSYCHOSOCIAL

3. Interrupted Family Processes related to change in family roles and structure

associated with progressive disability

NOC: Family Coping; Family Environment: Internal; Family Normalization

The goal is to maintain functional system of mutual support for one another. This

will be achieved through encouraging the family members to frequently verbalize

feelings to the health care professionals, the student nurse, and to one another in the

family; verbalizing ways to adapt to required roles and lifestyle changes;

demonstrating active participation in decision making and client’s care, and

demonstrating positive interactions with one another.

NIC: Family Involvement Promotion; Coping Enhancement; Family Integrity

Promotion

The student nurse approached the family with warmth, respect, and support. Doing

so shows that she is sincere and understanding. She also kept the family members

abreast of changes in ill member’s condition (as deemed appropriate). This allows

the family to feel included in the care for the client. Encouragement of verbalization

of guilt, anger, blame, and hostility and subsequent recognition of own feelings in

family members was also done. This type of verbalization allows the family

members to release stress from the experiences of taking care of all ill family

member. The importance of continuous, open dialogue between family members to

facilitate ongoing problem solving was also stressed. Through this, the family will

be able to work together harmoniously in providing care for their ill member. The


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student nurse also involved the family in planning for future and mutual goal setting

and promoted commitment to goals/continuation of plan. This is important

especially in patients who are about to go home. Nursing care would then be

provided by the family members and it is important that the family members and

nurse have consulted each other regarding the appropriateness of the home care

interventions that will be carried out by the family.

VIII. Evaluation

The objectives for the plan of care of the patient were sufficiently met. Sufficiently

because there were minor, yet important, objectives that were not met. For example,

though the patient remained stable throughout the student nurse’s stay, looking into the

specifics of the vital signs at the end of the procedure would show that the respiratory

rate remained elevated despite the patient’s pulse rate, temperature, and blood pressure

being within their normal ranges.

As for his GCS score, it still remained E4VTM5. Spontaneous eye movement was

observed and could still open his eyes to tapping and loud voices calling his name.

Unpurposeful movements are observed on his left side. When pain or discomfort is

present, he is able to localize the pain (with his left hand) as his way of saying that he

is in pain. His right-sided hemiplegia has not improved. Reflexes remained the same as

was first assessed.


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Pupillary reaction to light, however, differed. During the prescribed clinical rotation,

the pupils were equally sluggish in reacting to light. When the student nurse came back

post-rotation, the pupils were anisocoric, though the differences were not too wide-

3mm at the right pupil and 2 mm at the left pupil.

Tracheostomy care is being done daily by the patient’s daughter though with the help

of the nurse-on-duty (NOD) or her mother who arrives at night and is more acquainted

with the procedure. This includes the administration of salbutamol-ipratropium via

nebulization and the performance of suctioning after. The daughter also is now

confident administering MF and OF via the NGT.

The client always maintained cleanliness and proper grooming. The patient maintained

his skin integrity, though turning every two hours is still not being strictly followed.

Nevertheless, the client presented with normal color, no edema, or other signs of

compromised circulation on both sides of the body. He is mostly placed in functional

positions when not turned on his sides. ROM exercises are being done by the daughter,

though not completely done every day.

The daughter, who was mostly the family member the student nurse was able to

converse with, was able to verbalize feelings regarding the situation their family is in.

She confided feeling relieved that the student nurse was there to teach her how to care

for her father more efficiently. She is now more equipped to with ways on how to adapt

to the situation and is now more hopeful. She talks to her father by saying, “Malapit na


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tayo umuwi,” in a hopeful manner. At the end of the student nurse’s clinical rotation,

the daughter verbalized her promise to follow the home care instructions taught to her.

IX. The Learning Experience

Modifications in the Plan of Care

The student nurse did not modify the care plan as it was designed to help and prepare

the family members for discharge of the patient. Home care and coping became the

focus together with the maintenance of the airway. Both were equally addressed since

the student nurse saw the need to teach the patient’s daughter since she was new to the

caregiver role.

Sources of Frustration and Satisfaction

The student nurse was overall satisfied with the experience. Working with a

cooperative and hopeful family member was inspiring. She was able to utilize the

cooperation and hopefulness of the patient’s daughter in imparting her knowledge of

the procedures that will be done when the client goes home.

A source of frustration however is the vital signs, specifically the respiratory rate, not

dropping to within normal ranges. Another source of frustration is the seemingly

ceasing of improvement of the client. The student nurse, however, understands that

there are different rates of recovery per patient. The student nurse would have only

liked to see improvement in the GCS, for example since an improvement in the LOC


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would have made the family happy despite their huge hospital bill and not being to go

home yet (since the unsettled balance in the bill is preventing this from happening).

Some medications were also not being given regularly since the family is running out

of funds to buy these medications.

Despite this setback, what struck the student nurse the most is that the family members

she gets to interact with are coping well and have happy dispositions. As previously

stated, their hopefulness is inspiring.

Learning Experience

This is one of the interesting cases the student nurse has handled, if not the most

interesting. Though the plan of care is focused on the home care management, looking

back at the charts provided a lot of learning as well. The patient’s course in the wards

and medical diagnoses sparked an interest in wanting to further understand the case

beyond just the home care management. The collaboration and management of the

healthcare team from CenICU to the private rooms, to CenICU again, then finally to

Ward 5 was awe-inspiring, especially considering that the patient was a “toxic” case

and has been staying for approximately two months already.

Furthermore, this rotation showed the different neurologic deviations not normally seen

in the other wards she had rotated in.


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Suggestions to Improve Nursing Care

There is not much improvement needed to be done since the care given by the team

was well-coordinated and organized.

X. Conclusions and Recommendations

Cases like this need good team effort. Neurologic disorders require a person to think

on his toes because at one time, the patient could be stable, but in the next moment, he

is suddenly experiencing seizures or becoming hypotensive. These patients are

unpredictable which is why a good clinical eye is needed to detect in its early stages

the complications arising during the student nurse’s time with the patient.

The patient is only one out of the millions who experience stroke yearly. The amount

of patients with stroke is overwhelming. It is every person’s duty to his or her self to

eliminate modifiable risk factors such as smoking, excessive alcohol drinking, and

other factor contributing to stroke’s underlying causes like hypertension. Though

difficult, everyone should also learn to take some time off to recover from the stress in

life. Stress is a huge contributing factor to the development of stroke.

The costs of healthcare is very expensive especially when the illness has struck the

primary breadwinner of a family. Despite being a developing country, the Philippines

still has a lot to improve in terms of the delivery of health care. PGH is the national

hospital of the country and it is heartbreaking to see patients staying in the hospital for

an extra month because they could not be sent home due to unpaid hospital bills.


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Some would say that it is the patient’s fault for not taking care of himself while some

would say the government has not been financing our healthcare needs adequately.

Though both arguments may be true, as health professionals, we must do our duty to

promote the healthy lifestyle among our patients. Furthermore, as health professionals

of the premier university hospital, it is also our duty to remind or to push our

government in providing adequate budget for the needs of our patients.

Being the family of a stroke patient is difficult. They must always be reminded to give

proper routine home care so that when they are independently doing it, we are assured

that they’re doing it correctly. As health professionals, we must not lack in reminders

to our patients. For example, we must remind the family of our stroke patients to attend

all sessions of their rehab to regain optimal control and functions despite having

residuals from the stroke event. Continuously providing emotional support to the

patient and his family are an important part of care. Though emotional support is not

enough to solve the problem, it can facilitate in solving the problem quickly. The

patient is fortunate to have close family ties that his family are not giving up on him

despite the huge difficulties they are facing and will face.

At first, the student nurse was anxious that she won’t be able to do much for the patient

since he was already for discharge. However, it was timely that the daughter of the

patient was the new primary caregiver. In the end, the experience gave me more

confidence since it was evident in the watcher the learning she got and the gratitude


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she showed. To us nurses, teaching a family member procedures she would do at home

may be a little thing, but to them, it was something bigger. The student nurse realized

once again that it is in the little things we do that make a huge difference in our patient’s

lives.

Documents

03 DEE_Ward5_Med Paper