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NCM 105

A Grand Case Presentation

CereberovascularCereberovascular Disease, Infarct,Disease, Infarct,

Left MiddleLeft Middle Cerebral ArteryCerebral Artery

Submitted by:

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ACKNOWLEDGMENT

Our group would like to express our sincere gratitude to the persons who were

behind the success of this case presentation. First, we would like to thank our parents

who recognized our needs in financing the project; who have been supportive in terms

of their experience in the formulation of case studies; to the staff of J. !orja "eneral

#ospital$ %edical &ard for providing a venue for clinical practice and sharing their

knowledge regarding our case; and especiall' to our clinicfal instructor (ir Jimm'

!oston, )* who taught us a lot of things and inculcated in our minds the ideal boost for

nursing excellence; and most to our +lmight' "od who would let all things happen for a

cause a cause that will make us realize the true value of )ursing practice.

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TABLE OF CONTENTS

I. Introduction

II. General Objecti e!

III. S"eci#ic Objecti e!

I$. De#inition o# Ter%!

$. &atient'! &ro#ile

$I. Nur!in( A!!e!!%ent

$II. Anato%) and &*)!iolo()

$III. &at*o"*)!iolo()

I+. Doctor'! Order

+. Laborator) ,e!ult! and Dia(no!tic Te!t!

+I. Dru( Stud)

+II. Nur!in( Care &lan!

+III. Di!c*ar(e &lan

+I$. &ro(no!i!

+$. E aluation

+$I. ,e#erence!

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INT,OD-CTION

-erebrovascular disease is a group of brain d'sfunctions related to disease ofblood vessels suppl'ing the brain. #'pertension is the most important cause thatdamages the blood vessel lining endothelium exposing the underl'ing collagen whereplatelets aggregate to initiate a repairing process which is not alwa's complete and

perfect. (ustained h'pertension permanentl' changes the architecture of the bloodvessels making them narrow, stiff, deformed and uneven which are more vulnerable tofluctuations of blood pressure. + fall in blood pressure during sleep can lead to markedreduction in blood flow in the narrowed blood vessels causing ischemic stroke in themorning whereas a sudden rise in blood pressure can cause tearing of the bloodvessels causing intracranial hemorrhage during excitation at da'time. rimaril' peoplewho are elderl', diabetic, smoker, or have ischemic heart disease, havecerebrovascular disease. +ll diseases related to arter' d'sfunction can be classifiedunder a disease as known as %acrovascular disease. /his is a simplistic stud' b' whicharteries are blocked b' fatt' deposits or b' a blood clot. /he results of cerebrovasculardisease can include a stroke, or even sometimes a hemorrhagic stroke. 0schemia or

other blood vessel d'sfunctions can affect one during a cerebrovascular accident.

-12 is the most disabling of all neurologic diseases. +pproximatel' 345 ofsurvivors have a residual neurologic deficit and greater than 635 re7uire chronic care.-ardiovascular disease mortalit' in the hilippines was studied from the existing vitalstatistics for 6444$6448. 2eath rates from cerebrovascular diseases increasedenormousl' both in men and women. /his increase in mortalit' was seen in all agegroups. /he age$standardized mortalit' rate in men rose from 99.9 in 6444 to :8.4 in6443, and that of women from 3.< to 9

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GENE,AL OB ECTI$ES

+t the end of the $hour case presentation, we will be able to develop our nursing

skills in presenting our subject matter; gain new knowledge and understanding about

our clients> case; identif' the proper care to be provided; enhance our positive attitude

and improve our confidence and self$esteem.

S&ECIFIC OB ECTI$ES

+t the end of our 6$hour case presentation, under the different areas of learning

we will be able to*

(?0@@(

roperl' explain the case of the patient

AObtain and maintain the interest of the audience in pa'ing attention to the report

%anage time efficientl' and present the case within the allotted time frame

?)O&@B2"B

ela' accurate, consistent and reliable data in the report

"ain knowledge on the case of the patient

-ompare the theoretical scheme of the illness to the actual case

+//0/C2B

romote cooperation between group member when presenting the case and

answering 7ueries from the panel

0nstill integrit' and discipline all throughout the presentation

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Stro2e $ blockage or hemorrhage of a blood vessel leading to the brain, causinginade7uate ox'gen suppl' and, depending on the extent and location of theabnormalit', such s'mptoms as weakness, paral'sis of parts of the bod', speechdifficulties, and, if severe, loss of consciousness or death.

T*ro%bu! $ a fibrinous clot that forms in and obstructs a blood vessel, or that forms inone of the chambers of the heart

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&ATIENT'S &,OFILEGENE,AL INFO,MATION3

&atient'! na%e3 %r. (trokemanAddre!!3 /alisa'an, %isamis OrientalBirt*da)3 June

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STAGES OF DE$ELO&MENT

&ith regards to the data drawn together through the assessment, the patient is

classified under Brik Brickson>s Bgo integrit' vs. 2espair on his s'chosocial /heor'.

+s articulated, this theor' proposes eight developmental phases spanning infanc'through older adulthood. 0n each stage the person confronts, and hopefull' masters,

new challenges. Bach stage builds on the successful completion of earlier stages. /he

challenges of stages not successfull' completed ma' be expected to reappear as

problems in the future .

/his stage tasks to developmentall' review one>s life and derive meaning from

both positive and negative events, while achieving a positive sense of self. +s the

person reaches maturit' D33 'ears old deathE or become senior citizens, productivit'

slows down, and explores life as a retired person. 2uring this time, the individual

contemplate accomplishments and are able to develop integrit', if he sees himself living

a successful life. On one hand, seeing his life as unproductive, he then feels of guilt

about the past, dissatisfaction of life followed b' the development of despair leading to

depression and hopelessness.

!ased on the assessment conducted, we have come up with the idea that the

patient has developed integrit' through verbalization of self$acceptance worth and

importance as a husband and as a father. #e has been able to share wisdom and

guidance to his onl' daughter to become a responsible adult. "ladl' accepts his

daughter and wife>s mates and friends and is ver' much proud with the fact that his has

able to send his daughter to college who is now about to have a degree in )ursing.
http://en.wikipedia.org/wiki/Developmental_stage_theorieshttp://en.wikipedia.org/wiki/Problemshttp://en.wikipedia.org/wiki/Futurehttp://en.wikipedia.org/wiki/Developmental_stage_theorieshttp://en.wikipedia.org/wiki/Problemshttp://en.wikipedia.org/wiki/Future

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N-,SING ASSESSMENT

Nur!in( 1i!tor)Nor%al &attern! o#

Functionin((Before Admission)

Clinical In!"ectionOb!er ation Durin(

A!!e!!%ent Da)(September 21,

2009)

Clinical In!"ectionOb!er ation on Fir!t

Da) o# Dut)(September 22,

2009)

On/(oin( A""rai!alOb!er ation on

Second Da) o# Dut)(September 24,

2009)

Ot*er! Source!5Laborator) E0a%

,e!ult!

ACTI$IT45,EST etired 3 'ears ago as

a jeepne' driver (pends time reading,

watching television, andworking in the 'ard

#as no regular exerciseroutine

1isits friends or visitedb' friends once in awhile

#ad sufficient energ'for all desired andre7uired activities

(leeps about 4*44 %each evening and risesabout G*94 +%; feelwell$rested

)o sleeping difficulties

#as limited rangeof motion on theright side of thebod'

+lwa's lies on bed +ctual hours slept*

about = hours #as decreased

energ' level

erforms passiverange of motion onthe affectedextremities

@ies in semi$Fowlers position,and readsnewspaper torelieve boredom

+ctual hours slept*about 8 hours

erforms passiverange of motion onthe affectedextremities

@ies in semi$Fowlers position,and listens tomusic through hismusic pla'er torelieve boredom

+ctual hours slept*about 4 hours

)o signs of skinbreakdown overbon' prominences

+bsence ofcontractures andfoot drop.

CI,C-LATION ?nown h'pertensive # * 84 bpm # * = bpm # * G= bpm Blood chemistry

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since %a' 644= )o complaints of chest

pain, irregularheartbeats, andpalpitations, exceptwhen blood pressure isver' high

2oesn>t smoke

2rinks alcoholicbeverages occasionall'for the last 93 'ears

#as famil' histor' ofh'pertension, stroke,and heart disease

#as brown skin toneand some diffused darkbrown patches ofpigmentation on bothupper and lowerextremities

DaverageE, withregular rh'thm

)ormal pulse withcapillar' refill timeof sec

! * 93I84 mm#gDleft arm, l'ingE

(kin warm and dr';

no edema noted;with good skinturgor; with normalskin tone

/* 9G.G

DaverageE,palpitationsreported

)ormal pulse withcapillar' refill timeof sec

! * G4I 44mm#g Dleft arm,

l'ingE (kin warm andmoist; no edemanoted; with goodskin turgor; withnormal skin tone

/* 9:.t able todefecate for thewhole da'

/otal urine outputfor 6< hours* , 34m@

ellow, aromaticurine

no complaints inurinating

2efecated once toa formed brownstool

/otal urine outputfor 6< hours* ,

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upper and lowerdentures

appetite ink palpebral

conjunctiva,anicteric sclerae,dr' lips, moisttongue; no edema

6 44ml -onsumed

whole of sharewith good appetite

ink palpebralconjunctiva,anicteric sclerae,moist lips, moist

tongue; no edema

appetite ink palpebral

conjunctiva,anicteric sclerae,moist lips, moisttongue; no edema

)o recent weightgain or loss

14GIENE #ad no limitations to

self$care /akes a bath once a

da', and uses shampooN antibacterial soap

!rushes dentures $6times a da'

1isits dentist once a'ear

e7uiresassistance fromanother person ande7uipment toperform bathing,toileting, anddressing

#as dr' bod', andunkemptappearance

#air is dr', nailsare dirt'

e7uiresassistance fromanother person ande7uipment toperform bathing,toileting, anddressing

&as able to use ofhis left unaffectedhand in cleaning

some parts of hisbod' with cleanwet cloth andcombing his hair

#air and nails areclean

e7uiresassistance fromanother personand e7uipment toperform bathing,toileting, anddressing

&as able toperform self$careactivities within his

level of own abilit' #air and nails areclean

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NE-,OSENSO,4 )o histor' of brain

injur' or trauma (lightl' stooped )o diagnosed hearing

problem, although wifebelieves %r. (trokeman

ma' have slight hearingloss &orn e'eglasses

DbifocalsE for 64 'earsDfarsightedE

)o previous perceptualproblems noted

@O-* consciousand alert

Oriented to person,place, butdisoriented to time

#as appropriate

affect and mood #as intact taste

sensation upil sizeIreaction*

9I9 isocoric,e7uall' reactive

#as facialas'mmetr',drooping righte'elid

@eft$sidedweakness

)o problem withswallowing

(lurred speech %uscle strength in

extremities*o ight upper* I3o @eft upper*3I3o ight lower*9I3o @eft lower*3I3


Oriented to place,person, butdisoriented to time

#as appropriate

affect and mood #as intact taste

sensation upil

sizeIreaction* 9I9isocoric, e7uall'reactive


@eft$sidedweakness

)o problem with

swallowing (lurred speech %uscle strength in



Oriented to place,person, and time

#as appropriateaffect and mood

#as intact tastesensation upil

sizeIreaction* 9I9isocoric, e7uall'reactive


@eft$sidedweakness

)o problem withswallowing

(lurred speech %uscle strength in


Neurologic Assessment (9-20-09)CN I3 )ot testedCN II 6 III3 9I9 isocoric,e7uall' reactive to lightCN III7I$7$I3 Fullextraocular movementsCN $3 D E -orneal reflexCN $II3 D E facialas'mmetr'CN $III3 intact hearingand e7uilibriumCN I+ 6 +3 D E "ag reflexCN +I3 D E (houlder lagCN +II3 D E tonguedeviation

Mu!cle !tren(t* ine0tre%itie!3

,i(*t u""er3 I3 Le#t u""er3 3I3 ,i(*t lo8er3 9I3 Le#t lo8er3 3I3Le(end39$full O% against gravit'and resistance: $full O% against gravit'onl'; $ a weak musclecontraction when muscleis palpated, but nomovement

Dee" Tendon ,e#le0e!

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Le(end3D2iminishedE

! Scan "esult (9-22-09)(ubacutehemorrhage centeredin the left lentiformnucleus with minimalsurrounding edemaD6mmE rightwardsubfalcine herniationand partialeffacement the leftlateral ventricle

&AIN5DISCOMFO,T Csuall' doesn>texperience pain in an'part of his bod' exceptwhen he has asignificantl' high bloodpressure

)o complaints ofpain

-omplaints of bod'weakness


-omplaints of bod'weakness andpalpitations


-omplaints ofbod' weakness

hest #-"ay(9/20/90)-mild cardiomegal',left ventricular form$atheromatous aorta

,ES&I,ATION 2oesn>t smoke )o histor' of -O 2;

)ot in respirator'distress; thorax



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tuberculosis; and otherlung diseases

)o famil' histor' of lungdiseases

2id not complain ofd'spnea at rest or onexertion

s'mmetric withe7ual expansion

H = cpmDaverageE; regularpattern

)o cough; clearbreath sounds

#ead of bed

elevated at semi$fowler>s positionwith pillow


H 64 cpm,bounding pattern


#ead of bedelevated at semi$

fowler>s positionwith pillow


H Gcpm,normal pattern


#ead of bedelevated at semi$

fowler>s positionwith pillow

SAFET4 )o known food N drug

allergies 0mmunization histor'*

cannot be recalled ifcomplete

&hen he was 9: 'earsold, he had a vehicularaccident had bruisesbut no permanentdamage developed,

)o surgical procedure )o past major illness

#as bedside rails#is wife watches overhim

#as bedsiderails

#is wifewatches overhim

)ounusualitiesnoted that willpromote injur'

#as bedsiderails

#is wifewatches overhim

)ounusualitiesnoted that willpromote injur'

SE+-ALIT4 #as one daughter onl' Finds sex life

satisfactoril', but sexualactivit' lessens due toincreasing age

)o histor' of (/2>s orreproductive tract

Feels 7uiteuncomfortablewith the subjectmatter

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problemsSOCIAL

INTE,ACTIONS ole within the famil'

structure* head of thefamil', housekeeper

@ives with his wife anddaughter, together with

their maid, in a houseth' have owned for 94'ears

#as several friends (peech is clear and

understandable ifdentures are worn

+lthough heconverses, hisspeech is uncleardue to slurring ofspeech and

absence ofdentures #as impaired

articulation ofwords,incomprehensiblewords from thepatient, inabilit' touse facial or bod'expressions

+lthough heconverses, hisspeech is unclear

Few friends wereable to visit, and

he feels happ' -ommunicates b'nodding, handgestures, andusing shortsentences

#is speech is7uiteunderstandablealthough slurredbecause he

wears hisdentures Few relatives

were able to visit

TEAC1ING5LEA,NING 2ominant language*

Filipinos D-ebuanoE #igh school

graduate; literate (eeks doctor>s

consultation whenhaving healthproblems

/akes prescribedamlodipine as amaintenanceantih'pertensivedrug, but doesn>thave a strictmedication

Follows treatmentregimen

Follows treatmentregimen

@istens carefull' to

health teachingsimparted

Followstreatmentregimen

eported that heis willing to havea health'lifest'le

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compliance )onprescription

drugs* paracetamol,bigesic, neozep asneeded; doesn>t usestreet drugs

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ANATOM4 AND &14SIOLOG4 OF T1E B,AIN/here is nothing in the universe to compare with the human brain. /his

m'sterious three$pound s7uish' tissue controls all necessar' functions of our ph'sicalbod', receives information from the outside world and makes it understandable, andgoes be'ond that which is understandable to embod' the essence of our mind and soul.0ntelligence, creativit', emotion, love, memories are but a few of the man' things thebrain does. /he weight of the brain changes from birth through adulthood. +t birth, theaverage brain weighs about one pound, and grows to about two pounds duringchildhood. /he average weight of an adult female brain is about 6.: pounds, while thebrain of an adult male weighs about three pounds.

/he brain receives information through our five senses* sight, smell, touch, taste,and hearing $ often man' at one time. 0t puts together the messages in a wa' that hasmeaning for us, and can store that information in our memor'. Our brain controls ourthoughts, memor' and speech, the movements of our arms and legs and the function ofman' organs within our bod'. 0t also determines how we respond to stressful situationsDi.e., writing of an exam, loss of a job, illnessE b' regulating our heart and breathingrate.

Ner ou! !)!te%

CENT,AL NE,$O-S S4STEM D-)(E is composed of the brain and spinal cord&E,I&1E,AL NE,$O-S S4STEM D )(E is composed of spinal nerves that branch fromthe spinal cord and cranial nerves that branch from the brain. /he )( includesthe autonomic nervous s'stem, which controls our vital internal functions such asrespiration, digestion, heart rate, and secretion of hormones.

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Brain

/he brain is composed of the cerebrum, cerebellum, and brainstem

/he brain is composed of three parts* the brainstem, cerebellum, and cerebrum./he cerebrum is divided into four lobes* frontal, parietal, temporal, and occipital.

A. Brain!te% $ includes the midbrain, pons, and medulla. 0t acts as a rela' centerconnecting the cerebrum and cerebellum to the spinal cord. 0t performs man'automatic functions such as breathing, heart rate, bod' temperature, wake and

sleep c'cles, digestion, sneezing, coughing, vomiting, and swallowing. /en of thetwelve cranial nerves originate in the brainstem. /he brainstem is the lowerextension of the brain, located in front of the cerebellum and connected to thespinal cord. 0t consists of three structures* the %idbrain , "on! and %edullaoblon(ata . 0t serves as a rela' station, passing messages back and forthbetween various parts of the bod' and the cerebral cortex. %an' simple orprimitive functions that are essential for survival are located here.

1. Midbrain / is an important center for ocular motion2. &on! / is involved with coordinating e'e and facial movements, facial sensation,

hearing and balance.3. Medulla oblon(ata / controls breathing, blood pressure, heart rh'thms and

swallowing. %essages from the cortex to the spinal cord and nerves that branchfrom the spinal cord are sent through the pons and the brainstem. 2estruction ofthese regions of the brain will cause Pbrain death.P &ithout these ke' functions,humans cannot survive.

/he reticular activating s'stem is found in the midbrain, pons, medulla and part ofthe thalamus. 0t controls levels of wakefulness, enables people to pa' attention to theirenvironments, and is involved in sleep patterns. Originating in the brainstem are 4 of

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the 6 cranial nerves that control hearing, e'e movement, facial sensations, taste,swallowing and movements of the face, neck, shoulder and tongue muscles. /he cranialnerves for smell and vision originate in the cerebrum. Four pairs of cranial nervesoriginate from the pons* nerves 3 through 8.

B. Cerebru% $ the largest part of the brain and is composed of right and lefthemispheres. 0t is separated from the cerebrum b' the tentorium Dfold of duraE.

/he cerebrum, which forms the major portion of the brain, is divided into twomajor parts* t*e ri(*t and le#t cerebral *e%i!"*ere! . /he cerebrum is a termoften used to describe the entire brain. + fissure or groove that separates the twohemispheres is called the (reat lon(itudinal #i!!ure . /he two sides of the brainare joined at the bottom b' the corpus callosum. /he cor"u! callo!u% connectsthe two halves of the brain and delivers messages from one half of the brain tothe other. /he surface of the cerebrum contains billions of neurons and glia thattogether form the cerebral cortex

C. Cerebellu% $ located under the cerebrum. 0ts function is to coordinate musclemovements, maintain posture, and balance. /he cerebellum fine tunes motoractivit' or movement, e.g. the fine movements of fingers as the' perform surger'or paint a picture. 0t helps one maintain posture, sense of balance or e7uilibrium,b' controlling the tone of muscles and the position of limbs. /he cerebellum isimportant in oneQs abilit' to perform rapid and repetitive actions such as pla'ing avideo game. 0t performs higher functions like interpreting touch, vision andhearing, as well as speech, reasoning, emotions, learning, and fine control ofmovement.

/he cerebral corte0 appears gra'ish brown in color and is called the

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Dee" !tructure!

1)"ot*ala%u! / /he h'pothalamus is located in the floor of the third ventricle and isthe master control of the autonomic s'stem. 0t pla's a role in controlling behaviors such

as hunger, thirst, sleep, and sexual response. 0t also regulates bod' temperature, bloodpressure, emotions, and secretion of hormones.

T*ala%u! $ /he thalamus serves as a rela' station for almost all information thatcomes and goes to the cortex. 0t pla's a role in pain sensation, attention, alertness andmemor'.

Ba!al (an(lia $ /he basal ganglia include the caudate, putamen and globus pallidus./hese nuclei work with the cerebellum to coordinate fine motions, such as fingertipmovements.

Li%bic !)!te% $ /he limbic s'stem is the center of our emotions, learning, andmemor'. 0ncluded in this s'stem are the cingulate g'ri, h'pothalamus, am'gdalaDemotional reactionsE and hippocampus Dmemor'E.

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Cranial ner e!

/he brain communicates with the bod' through the spinal cord and twelve pairsof cranial nerves ten of the twelve pairs of cranial nerves that control hearing, e'emovement, facial sensations, taste, swallowing and movement of the face, neck,shoulder and tongue muscles originate in the brainstem. /he cranial nerves for smelland vision originate in the cerebrum.

Nu%ber Na%e FunctionI Ol#actor) S%ellII O"tic !i(*tIII Oculo%otor %o e! e)e7 "u"ilI$ Troc*lear %o e! e)e$ Tri(e%inal #ace !en!ation$I Abducen! %o e! e)e$II Facial %o e! #ace7 !ali ate$III $e!tibulococ*lear *earin(7 balance

I+ Glo!!o"*ar)n(eal ta!te7 !8allo8+ $a(u! *eart rate7 di(e!tion+I Acce!!or) %o e! *ead+II 1)"o(lo!!al %o e! ton(ue

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Blood !u""l)

!lood is carried to the brain b' two paired arteries, the internal carotid arteriesand the vertebral arteries. /he internal carotid arteries suppl' most of the cerebrum.

/he vertebral arteries suppl' the cerebellum, brainstem, and the underside of thecerebrum. +fter passing through the skull, the two vertebral arteries join together to forma single basilar arter'. /he basilar arter' and the internal carotid arteries RcommunicateKwith each other at the base of the brain called the -ircle of &illis. /he communicationbetween the internal carotid and vertebral$basilar s'stems is an important safet' featureof the brain. 0f one of the major vessels becomes blocked, it is possible for collateralblood flow to come across the -ircle of &illis and prevent brain damage.

T*e Circle o# Willi!

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/he ircle o$ %illis or the irculus Arteriosus is an arterial pol'gon where theblood carried b' the two internal carotid arteries and the &asilar system comes togetherand then is redistributed b' the anterior , middle , and posterior cere&ral arteries . /he

posterior cere&ral artery is connected to the internal carotid artery b' the posteriorcommunicating artery .

Internal Carotid S)!te%

/he internal carotid artery divides into two main branches called the middlecere&ral artery and the anterior cere&ral artery . /he middle cere&ral artery suppliesblood to the $rontoparietal somatosensory corte' . /he anterior cere&ral artery suppliesblood to the $rontal lo&es and medial aspects of the parietal and occipital lo&es . !eforethis divide, the internal carotid artery gives rise to the anterior communicating artery andthe posterior communicating artery .

$ertebral Arter)/he two erte&ral arteries run along the medulla and fuse at the pontomedullary

unction to form the midline &asilar artery* also called the erte&ro-&asilar artery . !eforeforming the &asilar artery , each erte&ral artery gives rise to the posterior spinal artery ,the anterior spinal artery , the posterior in$erior cere&ellar artery D 0-+E and branches tothe medulla .

Ba!ilar Arter) +t the ponto-mid&rain unction , the &asilar artery divides into the two posterior

cere&ral arteries . !efore this divide, it gives rise to numerous paramedian, short andlong circumferential penetrators and two other branches known as the anterior in$eriorcere&ellar artery and the superior cere&ellar artery .

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&AT1O&14SIOLOG4

@ipid deposits andturbulent blood flow in

intima of arterialcerebral wall

0(? F+-/O (* +ge* G4 'rs. old"ender* male"enetics* has famil'histor' of stroke and

h'pertension

B-0 0/+/0)"F+-/O (*

+lcohol 2rinking2iet* #igh FatI-holesteroldiet

#'pertension(edentar' @ifest'le

0nflammator' response

0ngestion of @ipids

+theroma Formation

)arrowing of arteriallumen

la7ue ruptures

-erebral h'poperfusion

0mpaired distribution ofox'gen and glucose

1)"erten!ion

@egend*Bold = applicableto patient

$ $ $ $ signs ands'mptoms

$ flow ofdiseaseprocess

/hrombosis

Occlusion of cerebral arter'

@'sed or moved thrombus from the vessel

1ascular wall becomes weakened or fragile

-erebral hemorrhage

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1ascular -ongestion

-ompression of tissue

0ncreased intracranialressure

0mpaired perfusion andfunction

%iddle -erebral +rter'

(x* )umbness or

8ea2ne!! of the#ace7 ar%7 le( ,esp. on one sideof the bod'

Con#u!ion orc*an(e in%ental !tatu!

Me%or) de#icit! Trouble

!"ea2in( orunderstanding

speechDd'sphasia,d'sarthia,apraxiaE

(ensor' loss 1isual

disturbances Droo"in( o#

e)elid! 2ifficult' walking,

dizziness (udden severe

headache

0f managed Dlong$termmedical and nursing

interventionE*

artial or total recover' inan' of the following*

Cnderstanding andforming speech

-ognitive loss %obilit' of extremities

and facial muscles %ental status

@ateral hemisphere, frontal,parietal and temporal lobes,

basal ganglia

&ith ineffective or withoutmedical and nursing

-ontinued insufficienc' ofblood flow

Further compression oftissues

-oma

-erebral 2eath

@oss of neural feedbackmechanisms

-essation of ph'siologicfunctions

-erebral edema

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-ardiovascular('stem

ulmonar'('stem

Other s'stems"C/"0/

elaxation ofvenousvalves

elaxationof intestines

andsphincters

@oss of cardiacmusclefunction

(x*brad cardia

@oss ofbowelcontrol

Failure ofaccessor'

muscles forbreathing

@oss of lungmovement

(x*h otension

2ecreasedcardiac output

(x* +pnea

)eurogenicbladder

@oss ofsphincter

control

(x* restlessness,abnormal

thermoregulation

mental confusionincreasedsecretions,

decreased urinar'output.

-ardiopulmonar' arrest

('stemic Failure

2eath

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DOCTO,'S O,DE,DATE TIME O,DE, ,ATIONALE

(eptember 64, 644=

G*94pm lease admit at F6 D%ale a'&ardE

&0* -ardiovascular disease,infarct, @eft %id -erebral +rter'

2iet* @ow fat, low salt, soft

-hange 01F to )(( @ L94gttsImin 01F/F)(( @ L 94 gttsImin

)ursing*%onitor vIs 76S and chart. efer if ! T G4I=4 mm#g or U=4IG4mm#g # T 44 bpm or U G4 bpm T 6< cpm or or U 6 cpm%onitor ( B % 7

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LABO,ATO,4 ,ES-LTS AND DIAGNOSTICTESTS

BLOOD C1EMIST,4

(ept. 6 ,644= 0nterpretation eference valuesotassium 4 )ormal 9.3$3.9 mmolI@

(odium 145 )ormal 9

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D,-G ST-D4D,-G ST-D4

Dru( Na%e Cla!!i#icationT*era"eutic

action

Do!e5,oute5

Ti%in(

Indication?!@ Contraindicationand caution Ad er!e e##ect!Nur!in(

con!ideration!

O%e"ra ole protonpumpinhibitorD 0E

like otherproton$pumpinhibitors,blocks theenz'me in thewall of thestomach thatproduces acid.!' blocking theenz'me, theproduction ofacid isdecreased

64 mg

cap

O2

O

prevention of uppergastrointestinalbleeding in criticall' illpatients

%alignantneoplasm ofstomach

+dversereaction toproton pumpinhibitors

#eadache 2izziness 2r' cough 2r' mouth Fatigue 2isturbances of the

gut such as dia$rrhoea,constipation,nausea, vomiting,indigestion orabdominal pain

ain in the musclesor joints

-hest pain DanginaE. ins and needles

sensationsDparaesthesiaE

Feeling ofweakness DastheniaE

@ow blood pressureDh'potensionE

/ake the drugbefor meals.(wallow wholecapsule. 2o notchew, open, orcrush them.

0nstruct to takeOmeprazole 94minutes apartfrom +tacidsbecause ofpossibleantagonisticinteractions

/ell the patientthat he ma'experience thesaid side effects

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D,-G ST-DD,-G ST-D 4 4

Dru( Na%e Cla!!i#icationT*era"eutic

action

Do!e5,oute5Ti%in(

Indication?!@ Contraindicationand cautionAd er!ee##ect! Nur!in( con!ideration!

Sennaconcentrate

Brand Na%e

(enokot

(timulantlaxative

recisemechanism of

action notknown. %orerecentevidenceshows thatstimulantlaxatives alterfluid andelectrol'teabsorption,producing netintestinal fluidaccumulationand laxation.

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D,-G ST-D4D,-G ST-D4Dru(Na%e

Cla!!i#ication T*era"eutic action

Do!e5,oute5Ti%in(

Indication?!@Contraindic

ation andcaution

Ad er!e e##ect! Nur!in( con!ideration!

Ca"to"ril

BrandNa%e

-apoten

+-Binhibitor

+ntih'pe

rtensive

!locks +-B fromconvertingangiotensin 0 to

angiotensin 00, apowerfulvasoconstrictor,leading todecreased ! ,decreasedaldosteronesecretion, a smallincrease in serumpotassium levels,and sodium andfluid loss; increasedprostaglandins'nthesis also ma'be involved in theantih'pertensiveaction.

63 mg tab

ever' G

hoursand) for

!T

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D,-G ST-D4D,-G ST-D4Dru(Na%e Cla!!i#ication

T*era"euticaction

Do!e5,oute5Ti%in(

Indication?!@

Contraindicationand caution Ad er!e e##ect!

Nur!in(con!ideration!

Citicoline

BrandNa%e

(omazine

)ootropics

)eurotonics

+ctivates thebios'nthesis ofstructural

phospholipids inthe neuronalmembrane,increasescerebralmetabolism andincreases thelevel of variousneurotransmitter s, includingacet'lcholineand dopamine.

344 mg cap!02

O

-erebrovas$cular

disorders

#'persensitive to drug

#'pertonia of

theparas'mpathetic

/ransientheadaches

(tomach pain 2iarrhea #'potension /ach'cardia !rad'cardia

%a' beadministered withor without food.

D/ake wI orbetween meals.E 0nform the patient

that she ma'experience thesaid side effects

0t must not beadministered inconjunction withmedicamentscontainingmeclofenoxateDalso known asclophenoxateE.

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Cla!!i#ication

T*era"euticaction

Do!e5,oute5Ti%in(

Indication?!@ Contraindicationand cautionAd er!ee##ect! Nur!in( con!ideration!

!i% a!ta/tin

BrandNa%e

Yocor

#%"$-o+reductase

inhibitor

+ntih'per$lipidemic

0nhibits#%"$-o+

reductase,an earl' Dandrate$limitingEstep incholesterolbios'nthesis.

64 mg tab

O2 +t #(D8 %E

O

/o reduce riskof -1 events,

includingstroke, /0+

-ontraindicated in patients

h'persensitiveto drug and inthose withactive liverdisease orcondition thatcausesunexplainedpersistenteleva$tions oftransami$naselevels.

#eadache Flatulence 2iarrhea +bdominal

pain -ramps -onstipa$tion )ausea

Bnsure that patient hastried a cholesterol$

lowering diet regimen for9$G months. !eforebeginning therap'.

Obtain liver function testresult at start of therap'and then periodicall'.

"ive in the evening 0nform the patient that

she ma' experience thesaid side effects.

eport severe "0 upset,changes in vision,unusual bleeding orbruising, dark urine orlight$colored stools, fever,muscle pain, or soreness

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Cla!!i#ication

T*era"euticaction

Do!e5,oute5Ti%in(

Indication?!@ Contraindication and caution Ad er!e e##ect! Nur!in( con!ideration!

Mannitol Osmoticdiuretic

agent

0ncrease theosmotic

pressure oftheglomerularfiltratethereb'inhibitingreabsorptionof #6Oandelectrol'tesand causesexcretion ofwater,sodium,potassium,chloridecalium,phosphorus,magnesium,urea, anduric acid.

645:3 cc

Bver' Ghours

-erebraledema

/o preventX0ntracranialressure

#'persensitivit'; anuria,

deh'dration; Nactiveintracranialbleeding.

-onfusion,headache,

blurred vision,rhinitis, transientvolume.Bxpansion, chestpain, -)F,pulmonar' edematach'cardia,nausea, thirst,vomiting, renalfailure, urinar'retention,deh'dration,h'perkolena,h'pernatremia,h'pokalemia,h'ponatremia.

Observe infusion site

fre7uenc' forinfiltration;extravasation ma'cause tissue irritationand necrosis

2o not administerelectrol'te$freemannitol solution withblood; if food must beadministeredspontaneousl' withmannitol; and at least64 mB7 )a-l to eachliter of mannitol

01* +dminister b' 01infusion undiluted; ifsolution containscr'stals warm bottle hot #6o N sharevigorousl'; do notadminister solution inwIc cr'stals remainundissolved; cool tobod' temperature; usean in$line filter for 35,645 and635 infusions.

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Cla!!i#ication

T*era"euticaction

Do!e5,oute5Ti%in(

Indication?!@ Contraindication and caution Ad er!e e##ect! Nur!in( con!ideration!

Trane0a%ic acid

Brandna%e

-'klokapron

Fibrinol'tic0nhibitor

Forms areversiblecomplex

thatdisplacesplasminogen from fibrinresulting ininhibition offibrinol'sis;it alsoinhibits theproteol'ticactivit' ofplasmin

gm01//

Bver' 8

hours

/reatment ofexcessive

bleedingresultingfroms'stemic orlocalh'perfibrinol'sis

+c7uired-hromatopsia

(ubarachnoid#emorrhage

2iarrhea, )ausea, 1omiting !lurred 1ision, #'potension, @ocal

infiltration

/ell the patient that hema' experience thesaid side effects

eport an' signs ofbleeding or m'opath',vision changes; "0upset usuall'disappears when doseis reduced

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position

%aintain bed rest;provide 7uietenvironment, limitvisitors andactivities asindicated.

rovide rest periodsbetween careactivities, limitduration ofprocedures.

eview specificdietar'changesIrestrictionswith clientemphasizingdecreased sodiumand fat andincreased fluids andfiber.

Collaborati e3

+dminister medicationsas indicated*

)europrotectiveagents

0midapril 4 mgtab O2

-ontinualstimulation canincreaseintracranialpressure.

+bsolute rest and

7uite ma' beneeded topreventrebleeding in thecase ofhemorrhage.

/o preventexacerbation ofs'mptoms andconstipation

!locks +ngiotensinconvertingenz'me thereb'reducing bloodpressure andlimiting ischemicinjur'.

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N-,SING CA,E &LAN

Cue! Nur!in(Dia(no!i!Outco%e

Identi#icationNur!in(

Inter ention! ,ationale E aluation

Subjecti e Cue3

R %aglisud s'a uglihuk ug s'a ra usaRas verbalized b' theatient>s wife.

Objecti e Cue!3 @imited range

of motion onthe rightaffectedextremities

@oss of abilit'to executepurposefulmotor act onboth upperand lowerrightextremities

ight $sidedweaknessnoted

Cne7ual handgrasp noted

I%"aired"*)!icalMobilit)

related toneuro%u!

cularin ol e%e

nt!econdar)

tounderl)in

("at*olo(ic

"roce!!

S*ort Ter% Goal

+t the end of 8hours of nursinginterventions, the

patient will beable to maintainoptimal positionof functions asevidenced b'

absence ofcontractures and

foot drop.

0ndependent*

+ssessfunctional abilit'or extent ofimpairmentinitiall'

Observe affectedside for color,edema or othersigns ofcompromisedcirculation

!egin passiverange of motionexercise to rightaffectedextremities

rop extremitiesin functionalposition* use offoot board duringthe period offlaccid paral'sis

0dentifiesstrengths ordeficiencies andma' provideinformationregarding recover'

Bdematoustissue is moreeasil' traumatizedand heals moreslowl'

%inimizesmuscle atroph',promotescirculation andhelps preventcontractures

reventcontractures or footdrop and facilitates

"oal met. +fter 8 hours of

nursinginterventions,

the patient wasable to maintainoptimal position

of function asevidenced b'

absence ofcontractures and

foot drop.

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and maintainneutral positionof head.

eposition orturn the client tosides ever' twohours

rovide clientwith ample timeto performmobilit'$relatedtasks.

Bncourageade7uate intakeoffluidsInutritiousfoods.

0nvolve clientand wife in care,assisting them tolearn wa's ofmanagingproblems ofimmobilit'.

use when or iffunction returns

revents

development ofpressure ulcer,muscle strain, andsuperficial nerveand blood vesseldamage

Bnhances self$concept and senseof independence

romotes well$being andmaximizes energ'production

Bnhancescommitment toplan, optimizingoutcome

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N-,SING CA,E &LAN :

Cue! Nur!in( Dia(no!i! Outco%eIdenti#icationNur!in(


Subjecti e Cue3

2ili ka'o me makasabotsa i'a ginasultiK, asverbalized b' the wife ofthe patient.

Objecti e Cue!3 0mpaired articulation of

words 0ncomprehensible

words from the patient 0nabilit' to use facial or

bod' expressions

I%"aired erbalco%%unication

related to*e%orr*a(ic c*an(e!in t*e brain a##ectin(

co%%unicationcenter!

S*ort Ter%Goal

+t the endof < hours ofnursinginterventions,the patient willbe able toestablishmethod ofcommunicationin which needscan beexpressedappropriatel'

0ndependent*

+ssess t'peIdegree ofd'sfunction likewhen the patienthas troublespeaking ormaking selfunderstood

+ssist withnecessar'adaptations toaccomplish

+2@s. !eginwith familiar,easil'accomplishedtasks

+sk client tofollow simplecommands such

#elpsdetermine areaand degree ofbraininvolvementand difficult'client has withan' steps or allsteps ofcommunicationprocess

Bnhancessense ofindependence

rovides forcommunication needsI

"oal met. +fter < hours of


the patient wasable to establish

method ofcommunicationin which needs

can beexpressed

appropriatel'.

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as nodding for a'es and repeatsimple wordsIsentences andpointing toobjects that hema' need

rovide privac'and e7uipmentwithin eas'reach duringpersonal careactivities. +llowsufficient timefor client toaccomplishtasks to fullestextent of abilit'.

rovidealternativemethods ofcommunicationsuch as writingboards. rovidevisual cluesDgestures andpicturesE

desires basedon individualsituationIunderl'ingdeficit.

#elpful indecreasingfrustrationwhendependent onothers andunable tocommunicatedesires

educesconfusionIanxiet' athaving toprocess andrespond tolarge amountof informationat one time,advancingcomplexit' ofcommunication stimulates

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+nticipate andprovide forclient>s needs.

/alk directl' tothe client,speaking slowl'and distinctl'.Cse onl' 'es orno 7uestions inasking the clientthenprogressing incomplex7uestions

Bncourage wifeor visitors topersist in effortsto communicatewith client

-ollaborative*

-onsult with orrefer to speech

memor' andenhanceswordassociation

-lient is notnecessaril'hearing

impairedand raisingvoice ma'irritate theclient

/hisreducesclient>sisolation,promoteestablishmentof effectivecommunication

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therapist +ssessesindividualverbalcapabilitiesand sensor',motor andcognitivefunctioning to

identif'therap' needs

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N-,SING CA,E &LAN Cue! Nur!in( Dia(no!i! Outco%e Identi#ication Nur!in( Inter ention! ,ationale E aluation

Subjecti eCue3

R ?inahanglanpa s'atabangankung maligoRas verbalizedb' theatient>s wife.

Objecti eCue!3

0nabilit' towashbod'; dr'bod'

0nabilit' toputonItake offnecessar'items ofclothing

0nabilit' toget totoilet andcarr' outpropertoileth'giene

Sel#/Care De#icitre(ardin(

bat*in(5*)(iene7dre!!in(5(roo%in(

and toiletin(related to

neuro%u!culari%"air%ent and

8ea2ne!!

S*ort Ter% Goal

+t the end of 8 hours ofnursing interventions, thepatient will be able toperform self$care activitieswithin level of patient>s ownabilit'

0ndependent*

+ssess abilities andlevel of deficit D4$s related tobathing, dressingand toileting.

+ssist withnecessar'adaptations toaccomplish +2@s.!egin with familiar,easil'accomplishedtasks.

%aintain asupportive, firmattitude.

+void doing thingsfor client that clientcan do for self,providingassistance asnecessar'

+ims inparticipatingor planningfor meetingindividualneeds

Bncourages client andbuilds onsuccesses

/heconsistenc'

of caregiverprovidesassurance tothe client

/his clientma' becomefearful, it isimportant forthe client todo as much


nursinginterventions, thepatient was ableto perform self$care activities

within his level ofown abilit' as

evidenced b' theuse of his left

unaffected handin cleaning someparts of his bod'

with clean wetcloth and

combing his hair.

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rovide forcommunicationamong those who

are involved incaring forIassistingthe client.

rovide privac' ande7uipment withineas' reach duringpersonal careactivities. +llowsufficient time forclient toaccomplish tasksto fullest extent ofabilit'.

eview safet'concerns. %odif'activitiesIenviron$ment.

as possible tomaintain selfesteem

Bnhancessense ofindependence

Bnhancescoordinationand continuit'of care

educesrisk of injur'and promotessuccessfulfunctioning.

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N-,SING CA,E &LAN 9

Cue! Nur!in( Dia(no!i! Outco%eIdenti#icationNur!in(


No !ubjecti e andobjecti e cue!.

,i!2 #actor!3

h'sicalimmobilit' *right$sidedweakness

+lteredmetabolic state

,i!2 #or i%"aired !2ininte(rit) related to

alteredneuro%u!cular

#unction

S*ort Ter%Goal

+t the end of 8hours of nursing

interventions,the patient will

be able todemonstrate

behaviours andtechni7ues toprevent skinbreakdown.

0ndependent*

0nspect all skinareas, notingcapillar'blanchingI refill,redness, swelling.

-hange position inbed on a regularschedule Dever' 6hoursE.

Bncouragecontinuation ofregular exerciseprogram, passiverange of motionexercises on theright extremitiesand active rangeof motionexercises on the

(kin isespeciall' proneto breakdownbecause ofchanges inperipheralcirculation,inabilit' to sensepressure

Bnhancescoordination andcontinuit' ofcare

(timulatescirculation,enhancingcellular nutritionIox'genation toimprove tissuehealth



the patient wasable to

demonstratebehaviours andtechni7ues toprevent skin

breakdown asevidenced b'

absence ofsigns of skinbreakdownover bon'

prominences.

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DISC1A,GE &LAN-"on di!c*ar(e7 t*e "atient 8ill

&,OGNOSIS

Medication (trictl' adhere to medication regimen speciall' the prescribedhome medications, to wit;

+mlodipine 3mg tab L lunch then #(0midapril 4mg 6.3mg tab O2 L breakfast(enna -oncentrate 6 tabs L #( x weekOmeprazole 64mg tab dail' x week(imvastatin 64mg tab L #(

E0erci!e #ave fre7uent short periods of exercise.

T (afel' engage in active and passive range of motion exerciseson the affected extremit' assisted b' rehabilitative personnel asprescribed.

Treat%ent -onsult with speech therapist to improve abilit' to communicate.

%ake sure that follow$up care is adhered to religiousl'.1ealt*Teac*in(

"iven positive reinforcement and emotional support from hisfamil'.!e informed about the expected outcome of stroke, and hisfamil' should be counselled to avoid doing things for him that hecan do.

T #ave at least one famil' member who will be taught how totake blood pressure to enable the famil' to monitor the patient>sblood pressure at home.

Ob!er able!i(n! and!)%"to%!

!e able to report, with the help of his famil', exacerbation ofpresent signs and s'mptoms and seek prompt medical attentionwhen deterioration of neurological status is apparent such asloss of consciousness, worsening of posture, severe headache,irritabilit' and restlessness.

Diet !e advised to take osteorized food as prescribed with aspirationprecaution if nasogastric tube is still in place upon discharge!e reminded to thicken osteorized feeding if gag reflex graduall'regains or if there is still residual d'sphagia.

T +dhere to a low$sodium, low$fat diet such as avoidance ofcanned and processed foods, milk and dair' products, andsaturated fats from pork and poultr'.

S"iritual $+dvise patient not to be discouraged and to have strong faith in"od.

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E$AL-ATION /hrough this case presentation, the group was able to have a thoroughunderstanding of the case of a G4 'ear old patient with cerebrovascular disease. &ecould sa' that our general and specific objectives for the case stud' were met.

&e were able to gather a detailed profile of the patient, including theassessment of the patient>s condition throughout our hospital dut', identif' the anatom'and ph'siolog' of the brain which is the organ involved in -12; discuss thepathoph'siolog' of -12 in relation to the patient>s clinical manifestations, providerationale to the ph'sician>s orders, interpret the results of laborator' test and diagnosticprocedures, make a stud' of the drugs prescribed to the patient, design five actualpriorit' nursing care plans, formulate effective discharge plan for the patient, andh'pothesize a realistic prognosis based on patients> response to medical and nursinginterventions.

/hrough this case presentation, we were able to develop our nursing skills,knowledge and attitude utilizing the nursing process appropriatel' which will surel' helpus to become better e7uipped as future nurses read' to take on the challenges of ourprofession in the real world in whatever setting.

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,EFE,ENCES

Boo2!

%edical (urgical )ursing, vol. and 6 b' (meltzer

)ursing -are lans : th Bd. !' 2eonges

Internet re!ource!

-liffs)otes.com. /he !rain. 63 +pr 644=Uhttp*IIwww.cliffsnotes.comI&ile'-2+I-liffs eview/opicItopic+rticle0d$66496,article0d$6 =

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