Ischemic Stroke Case Study

Ischemic StrokeCase Study

January 2014

1. Basis of selection of case

In the previous years, a Food and Nutrition Research Institute 1998 study, about

21 percent of adults aging from 20 years old and above have hypertension, (the single

most important risk factor for stroke and it causes about 50 per cent of ischemic strokes

and also increases the risk of hemorrhagic stroke) while a Philippine Health Statistics

1993 figure showed 28 deaths per 100 000 population caused by stroke.

Nowadays, still, stroke makes its way on top. Worldwide, stroke is the second-

leading cause of death after heart disease and is also a big contributor to disability. Due to

the increasing number of stroke cases annually and the expanding cases in the younger

generation, the government of the Philippines should emphasize primary and secondary

prevention strategies.

As we talk about prevention strategies, there is a great role for nurses/student

nurses, as well as for the rest of the medical team, comes in. Reading a case study and

coming up with a diagnosis is a good way for nursing students to test the knowledge

they've acquired in the classroom in a more realistic, clinical way. Writing case studies is

also a useful learning tool; it forces students to reflect on the entire course of treatment

for a patient, ranging from obtaining important information to diagnosis to treating the

medical condition. Increasing the knowledge regarding the disease process of stroke, the

proper assessment of the patient, correct intervention, effective health teaching, etc will

contribute a lot in improving prevention strategies.

2. Clarity of Objectives

General Objectives

After 2 hours of case presentation, the students will be able to obtain the

knowledge to enhance skills and to develop the attitude towards caring of the patient with

cases regarding ischemic stroke.

Specific Objectives

Specifically, this aims to

KNOWLEDGE

1. Explain the pathophysiology of ischemic stroke.

2. Identify the main cause of the disease.

3. Name the signs and symptoms of the disease manifested by the client.

SKILLS

1. Carry out independent and dependent intervention being done to the client

appropriately and with care.

2. Perform comprehensive nursing interventions based on the client’s priority needs.

3. Demonstrate proper approach used in clients with ischemic stroke.

ATTITUDES

1. Establish rapport to the client and folks.

2. Encourage the folks to cooperate to the intervention being performed.

3. Avoid promising words that might worsen the client’s condition.

3.1 ASESSMENT

A. PATIENT’S PROFILE

NAME: R. C.

AGE: 64 years old

SEX: Male

DATE OF BIRTH: June 28, 1949

ADDRESS: Barotac Viejo, Iloilo

OCCUPATION: National Referee, Retired Teacher

RELIGION: Roman Catholic

NATIONALITY: Filipino

ACTIVITY: Moderate Backrest

CC: Stiffening of extremities

DATE OF ADMISSION: December 12, 2013

DIAGNOSIS: T/C Brain Mets v/s restroke prob. Bleed,

S/P CVD with no residuals (2013) HCVD R/O Metastatic cause DM 2- NIR

S/P Thyroidectomy for thyroid CA Stage 1

PHYSICIAN: Dr. A

B. NURSING HISTORY

I. Reason for Seeking Care

Stiffening of extremities

II. Present Health History

Patient R.C. is 64 years old, male and married. He is a retired teacher and a national

referee.

8 months prior to admission, patient experienced episode of syncope. He was then

admitted at St. Paul’s Hospital for 1 month and managed as CVP, no residual noted.

1 month prior to admission, undocumented fever was noted. He was admitted at Don

Ramon Tugbang Medical Center and diagnosed to have Urinary Tract Infection.

On the day of admission, patient experienced generalized weakness and stiffening of

extremities. A complaint of dizziness was noted. He was responsive and slurring of speech is

noted. He was brought to Don Ramon Tugbang Medical Center and then referred at Iloilo

Mission Hospital.

III. Past Health History

It was known that he is hypertensive and have Diabetes Mellitus. He has many previous

hospitalizations. He was diagnosed to have thyroid cancer stage 1 back in 1986. He had

undergone radiation therapy and left thyroidectomy in the same year at Philippine General

Hospital. No known allergies.

Last December 2012, He underwent Cranial CT scan and CT scan with contrast. January 7,

2014, he again underwent cranial CT scan.

IV. Current Medication

For now, he has current medication such as Amlodopine 10mg/tab OD, Simvastatin 40 mg/tab

OD, Losartan 50 mg/tab 1 tab OD for his hypertension and Metformin 500 mg 1 tab OD for his

Diabetes Mellitus.

V. Lifestyle

He is non-smoker and non-alcoholic drinker. He is also an athletic person. As verbalized

by the wife, most of the time he ate carrots instead of rice.

VI. Family History

As verbalized by the wife, he has familial history of Hypertension and Diabetes Mellitus.

C. PHYSICAL ASESSMENT

VITAL SIGNS

R.C.’s temperature is 36.5 °C, pulse rate is 88 beats per minute, respiratory rate is 20

breaths per minute, and blood pressure is 180/100 mmHg.

GENERAL APPEARANCE

R.C. is a 64 year old male, a national referee and a retired teacher. Bedridden since the

day of admission. Ectomorph, well developed and appears to be at stated age. Well cleaned and

wears appropriate clothes. Difficulty or discomfort making laryngeal speech sounds or varying

volume, quality, or pitch of speech. Comprehends directions. Appears to be in distress.

SKIN

Brown in color, dry, and wrinkled due to old age.Peeling, scaly and flaky skin on heels of the

feet. Skin color differences among body areas and between sun-exposed and non-sun-exposed

areas. Darker skin around elbows and knees. Warm in temperature. Turgor resilience. Bilateral

symmetry. Hair present on scalp, lower face, nares, chest, legs, and pubic areas.

NAILS

Nails beds pink with varying opacity. Short, squoval, smooth, flat, with edges smooth and round,

Longitudinal ridging and beading. Hard and firm with uniform thickness. Well-groomed and

uniform without deformities. Good capillary refill.

HEAD AND FACE

Hair is short, black with minimal gray hairs, and distributed evenly. Hair strands are thin,

fine and silky. Head is midline. Skull normocephalic, symmetric and without deformities. Scalp

is intact and without lesions or mass noted. Temporal pulses palpable. No bruits. Presence of

beard on upper lip and chin. Presence of black heads on the nose. Presence of dimple at the right

side of the face.

EYES

Eyebrows are smooth, black in color and distributed evenly and in line with each other.

With mole noted on the left inner end of the brow.Superior eyelid covering a portion of iris when

open. Eyelashes are black, evenly distributed, present on both lids and turned outward.

Conjunctivae pink, sclera anecteric. Irides black. Pupils equal, round, and reactive to light and

accommodation.

EARS

Auricles in alignment, same color as facial skin.Firm and mobile, readily coiling from

position; non-tender.Absence of discharges.

NOSE

Nose in midline, no discharges or polyps, mucosa pink and moist, septum midline, patent

bilaterally. Conforms to face to color.Nares oval and symmetrically positioned. No sinus

tenderness to palpation. With O2 at 2Lpm via nasal cannula.

MOUTH AND OROPHARYNX

Lips symmetric vertically and horizontally at rest and moving.Dry, bluish purple, distinct

border between lips and facial skin. Teeth are stained yellow and absence of left lateral incisor.

Gingiva pink and moist. Tongue is midline, dull red in color and moist. No tremors and

fasciculation. Hard palate and soft palate are pinkish in color. Pharynx clear without erythema.

Uvula rises evenly.

NECK

Neck is straight and symmetrical. Trachea midline. Jugular vein distention noted. Carotid

pulse palpable.Cricoid cartilages smooth and moves during swallowing. Left thyroid palpable,

firm, and smooth; presence of slightly hypoechoic nodule.Absence of right thyroid lobe.

THORAX AND CHEST

Minimal increase in the anteroposterior diameter of chest.Thoracic expansion symmetric.

No adventitious breath sounds. Regular respiratory rate. Chest retraction noted. Apical pulse on

5th intercostals space. The areola and nipples are dark brown in color and no discharges noted.

ABDOMEN

Soft, flat and symmetrical. Uniform in color, no pigmentation and rashes noted. No

abdominal scars and masses. Active bowel sounds audible in four quadrants.

UPPER EXTREMITIES

Arms fair in color and symmetrical. No tenderness upon palpation of muscle and joints.

Unable to passively perform full range of motion at right affected hand; stiffness noted. Palms

are pale and warm. Radial and brachial pulses palpable.With PNSS 1L x 80cc/H infusing well at

left cephalic vein.

LOWER EXTREMITIES

Legs are fair in color and symmetrical. Muscles are firm and skin is slightly dry. Soles

are pale and warm to touch. Unable to passively perform full range of motion at right affected

leg. Popliteal and dorsalis pedis pulses palpable.

GENITO-ANAL AND GENITO-URINARY

Pubic hairs are present. No skin lesions, penile discharges and swelling noted. Urinated to

a moderate amount of yellowish colored urine.Defecated to a soft brown stool.

D. DIAGNOSTIC TEST

LABORATORY TEST RESULT NORMAL VALUES SIGNIFICANCE

URINALYSIS

Color Pale straw

Transparency Slightly Hazy

Reaction 7.0

Specific Gravity 1.015 1.010 – 1.025 NORMAL

Sugar 1+

Albumin Neg ( - )

Pus cells 3.6 hpf

Red Blood cells 0.3 hpf

Amorphous urates FEW

Squamous Cells FEW

Bacteria Occasional

Mucus Threads FEW

Yeast Cells NONE

HEMATOLOGY

Hemoglobin 103 g/L 140 – 180 Anemia, bleeding, blood dyscrasia

Hematocrit 0.31 vol.fr. 0.42- 0.52 Anemia

Red blood cell count 3.77 x 10^ 12/L 4.7 – 6.1 Anemia, bleeding, bone marrow

failure, malnutrition

White blood cell count 14.98 x 10 ^9/ L 5.2 -12.4 Infection, Anemia, adrenal or thyroid

gland issues, immune system disorder,

inflammation, tissue

damage, severe stress

Segmenter 90% 50 – 70 infection, inflammation

Stab 0 2-5

Juvenile 0 0 - 1 Normal

Basinophil 0 0.0 – 1.5 Normal

Eosinophil 0 0 – 7 Normal

Lymphocyte 9% 19 – 48 not significant

Monocyte 1% 3.4 – 9 not significant

Platelet Count 341 x 10^9/ L 130 – 400 Normal

MCV 83 fl 80 – 94 Normal

MCH 27 pq 27 – 31 Normal

MCHC 33g/dL 33 – 37 Normal

RDW 11.7% 11.5 – 14.5 Normal

ESR 37 mm/ Hr 0 – 10 inflammation

IMMUNOLOGY

CRP 48 mg/L <6- inflammation

T3 95nmol/L 0.95 – 250 Normal

T4 91.43 nmol/L 60 – 120 Normal

TSH 0.88 u/ v/mL 0.25 – 5.0 Normal

Euthyroid : 0.25 – 5.0u/V/ml

Hypothyroid : greater than

7.0u/V/ml

Hyperthyroid: less than

0.15u/V/ml

APTT 24.4 sec 24.0 – 35.0 Normal

% Activity 99% 70-100 Normal

Patient 13.1 sec 11.6- 16.0 Normal

INR 1.00 -

CHEMISTRY

Fasting blood sugar 9.58 mmol/L 4.10 – 5.90 heart attack, stroke

Cholesterol 3.44 mmol/L 1.30 – 5.2 Normal

Triglycerides .94 mmol/L 0.17 – 1.70 Normal

HDL 0.84 mmol/L .90 – 1.55 atherosclerosis, CVD

LDL 2.17 mmol/L 0.0 – 3.9 Normal

Uric Acid 178 mmol/L 160-430 Normal

Calcium 2.05 mmol/L 2.12- 2.25 Hypocalcemia

ULTRASOUND

Thyroid Ultrasound:

The right thyroid lobe is surgically absent. The left thyroid measures 3.73 x 1.63 x 1.29 cm ( LxWxAP ). The isthmus is not

thickened and measures 0.21mm in thickness. There is a slightly hyporechoic nodule noted in the inferior aspect of the left

thyroid lobe measuring 0.81 x 0.71 x 0.53 cm ( LxWxAP ). There is a cystic focus noted at the junction of the isthmus and left

thyroid lobe measuring 0.46 x 0.46 x 0.26 cm ( LxWxAP ). A cystic focus is also noted in the mid portion of the thyroid lobe

measuring 0.24 x 0.11 cm ( WxAP ).

The surrounding soft tissues and vascular structures are unremarkable.

No mass/enlarged cervical lymph nodes appreciated.

Remarks:

Left thyroid nodule and cyst.

S/P Right thyroidectomy.

CHEST X-RAY

Chest PA:

Clear lung field with no grossly evident active koch’s infiltrates

Trachea midline

Intact costophrenic sinuses

Smooth diaghragmatic leaves

Cardiac silhouette nor enlarged transversely

Curvilinear calcific density noted at the aortic knob

Rest of the visualized soft and osseous tissues appear

Unremarkable

Impression:

Atherosclerosis: Aorta

CT SCAN

Plain and contrast enhanced axial tomographic sections of the head reveal inhomogeneously enhancing hypodensity with gyral enhancement at the right

frontoparietal areas. Also note of enhancing isodense nodules lesions with surrounding edema in the right inferior frontal and right frontal periventricular

areas.

There are small hypodensities on both capsuloganghenic and bifrontoparietal periventricular areas.

The ventricles are enlarged.

The midline structures are displaced to the left.

The cerebral sulci are effaced.

No abnormal extra-axial fluid collection demonstrated.

No posterior fossa , brain stem and sellar region do not appear unusual.

The petromastoids, included orbits and parancoal sinuses and the bony calvarium are unremarkable.

Remarks:

Right frontoparietalhypodensity with gyral enhancement.

Right inferior frontal and right frontal periventricular enhancing lesions with surrounding edema.

Lacunar infarcts, bilateral capsuloganglionicbifrontoparietal periventricular areas.

Leftward subfalcine herniation.

Obstructive hydrocephalus.

Drug Therapy

Generic name:Valporic AcidClassification: Anti ConvulsantDosage:( Adult and children > 10 y.o )

= 10- 15 mg/kg/day PO Route: OralTherapeutic Actions:

Mechanism of action not understood; Anti epileptic activity may be related to the metabolism of inhibitory neurotransmitter, GABA.

Indications: Solo and adjunctive therapy in simple ( petit mal ) and complex absence seizure Acute treatment of manic episode associated with bipolar disorder Prophylaxis of migraine headache

Contraindication and Cautions: Contraindicated with hypersensitivity to valporic acid, hepatic disease or significant

hepatic impairment Use cautiously with children younger than 18 months; children younger than 2 y.o

Adverse Effects: CNS: Sedation, emotional upset, depression, psychosis, aggression, behavioral

deterioration, suicibility. SKIN: Hair loss, rash GI: Nausea, vomiting, indigestion, diarrhea, abdominal cramps, constipation.

GU: Irregular menses, amenorrhea HEMATOLOGIC: Altered bleeding, bruising.

Nursing considerations:

Products containing alcohol should be avoided. Give drug with food if GI upset occurs. Be aware that the patient maybe increased risk for suicidal ideation monitor accordingly.

Patient Teaching: Take this drug exactly as prescribed. Do not chew tablet or capsule before swallowing them. Do not discontinue this drug abruptly or change dosage. Avoid alcohol and sleep inducing drugs.

Generic name:Losartan PotassiumClassification:Angioten II AntagonistDosage:( Adult and children 6 yrs and older )

= Starting dose of 50 mg PO daily Route: OralTherapeutic Actions:

Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland.

Indications: Treatment of hypertension, done or combination with other hypertensive. Treatment of diabetic nephropathy. Reduction of risk of CVA in patients.

Contraindications and Cautions: Contraindicated in previous hypersensitivity. Pregnancy or lactation Reduce dosage with hepatic or renal impairment.

Adverse Effects: CNS: Headache, dizziness and insomnia CV: Hypertension SKIN: Rash and dry skin GI: Diarrhea, abdominal pain and nausea RESPIRATORY: Cough

OTHER: Back pain, fever and goutNursing Considerations:

Assessment Hypersensitivity to Losartan Pregnant Lactation

Patient Teaching: Take drug without regard to meals May experience these side effects:

- Dizziness- Headache- Nausea and vomiting

Report fever, chills and pregnant

Generic name:MetforminClassification:Antidiabetic AgentsDrugs:( Adult and pediatric 10 – 16 y.o )

= 500 mg bid/ 250 mg bid Route: OralTherapeutic Reaction:

Increase peripheral utilization of glucose and decrease hepatic glucose production.Indications:

Adjunct to diet to lower blood glucose with type 2 DMContraindication and Cautions:

With allergy to metformin, heart failure, diabetes complicated by fever, severe trauma and severe infection.

Use cautiously with the elderlyAdverse Effects:

ENDOCRINE: Hypoglycemia GI: Anorexia, nausea and vomiting HYPERSENSITIVITY: Allergic skin reaction

Nursing Considerations: Allergy to metformin Pregnancy Lactation

Patient Teaching: Monitor blood for glucose and ketones as prescribed. Do not use this drug during preganancy. Avoid using alcohol while taking this drug. Report fever, sore throat, unusual bleeading and bruising.

Other anti-diabetic drugs: Gliclazide, Sitagliptin

Generic name: BaclofenClassification: Muscle relaxantDosage: 5 mg PO tid for 3 days Route: OralTherapeutic Actions:

Inhibits both monosynaptic and polysynaptic spinal reflexes; CNS depressantIndications:

Alleviation of signs and symptoms of spasticity resulting from MS Spinal cord injuries and other spinal cord diseases

Contraindications and Cautions: Contraindicated in previous hyper sensitivity. With skeletal muscle spasm Use cautiously with strokes, cerebral palst, parkinson’s disease Lactation and pregnancy

Adverse Effects: CNS: Transient drowsiness, weakness, fatigue CV: Hypotension GI: Nausea, Constipation GU: Urinary frequency, dysuria OTHER: Rash, pruritus, ankle edema

Nursing Considerations: Discontinue drug if hypersensitivity reaction occur Lactation Evaluate therapeutic response

Patient Teachings: Take this drug exactly as prescribed Avoid alcohol Do not take this during pregnancy

Generic Name: Amlodipine

Classification:Antianginal; Antihypertensive; Calcium channel blocker

Dosage: Adult and Pediatric 6-17 y.o. 2.5-5 mg daily

Route: Oral

Therapeutic actions:

Inhibits the movement of calcium ions across the membranes of cardiac cells; inhibits transmembrane calcium flow, w/c result in depression of impulse formation in specialized cardiac pacemaker cells, slowing velocity of conduction of the cardiac impulse.

Indications: Angina pectoris due to coronary artery spasm(Prinzmetal’s

Variant angina) Essential hypertension

Contraindications and cautions: Contraindicated w/ allergy to amlodipine Use cautiously w/ heart failure Pregnancy

Adverse effects: CNS: Dizziness, headache, and fatigue CV: Peripheral edema Skin; Flushing, rash GI: Nausea, abdominal discomfort

Nursing Consideration: Administer drug w/out regards to meals Monitor BP carefully

Patient teachings:

Take w/ meals if upset stomach occurs Report irregular heartbeat, shortness of breath, and constipation

Generic name: Diazepam 5 mg IV

Classification: Antiepileptic; Anxiolytic

Dosage: Usual dosage is 2-20 mg IM/IV

Route: IM/IV


Acts mainly as the limbic system and reticular formation; may act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation

Indications:

Management of anxiety d/o Acute alcohol withdrawal Muscle relaxant

Contraindications and cautions:

Contraindicated w/ hypersensitivity to benzodiazepines Use cautiously w/ elderly, impaired renal function

Adverse effects:

CNS: Sedation, depression, fatigue, and restlessness CV: Bradycardia, CV collapse, and hypertension Skin: Rash and dermatitis GI: Constipation and diarrhea GU: Urinary retention Hematologic: Decreased Hct Other: Phlebitis and thrombosis in IV site, fever, diaphoresis, and muscular disturbances


Hypersensitivity to benzodiazepines Pregnancy and lactation Carefully monitor P, BP, respiration, during IV administration

Patient teachings:

Take this drug exactly as prescribed Tell patient to report drowsiness, and weakness

Generic name: Mannitol

Classification: Osmotic; Urinary irrigant

Dosage: 50-200g/day

Route: IV


Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsortion of water leading to a loss of water, sodium, chloride: creates an osmotic gradient in the eye between plasma and ocular fluids thereby reducing IOP.

Indications:

Prevention and treatment of oliguric phase of renal failure Promotion of urinary excretion of toxic substances Irrigant in transurethral prostatic resection


Contraindicated w/ anuria due to severe renal disease Use cautiously w/ pulmonary congestion, dehydration, heart failure Lactation Pregnancy

Adverse effects:

CNS: Dizziness, headache , blurred vision, SEIZURES CV: Hypertension, edema, thrombophlebitis and chest pain Skin: Skin necrosis w/ infiltration GI: Nausea, dry mouth GU: Diuresis, urine retention Hematologic: Fluid and electrolyte imbalance Respiratory: Pulmonary congestion

Nursing Considerations:

Do not expose solution to low temp crystallization may occur Make sure infusion set contains a filter if giving concentrated mannitol Monitor serum electrolytes periodically w/ prolonged therapy

Patient teachings:

Patient may experience these side effects: Increased urination, GI upset, dry mouth, headache, blurred vision- ask for assistance

Report difficulty of breathing, pain at the IV site and chest pain

Generic name: Simvastatin

Classification:Antihyperlipidemic

Dosage: 20-40 up to 80 mg PO daily in the evening

Route: Oral


Inhibits HMG-CoA reductase, the enzyme that catalyze the first step in the cholesterol synthesis pathway

Indications:

To reduce the risk of coronary disease Treatment of patients w/ isolated hyper triglyceridemia Treatment of type III hyperlipoproteinemia


Contraindicated w/ allergy to simvastatin Use cautiously w/ impaired hepatic and renal function Cataracts

Adverse effects:

CNS: Headache, sleep disturbances GI: Flatulence, diarrhea, abdominal cramps, constipation, nausea, heartburn, LIVER

FAILURE Respiratory: Sinusitis Other: ACUTE RENAL FAILURE, myalgia


Allergy to simvastasin Give in evening; highest rate of cholesterol synthesis are bet midnight and 5 am Advise patient that this drug cannot be taken during pregnancy

Patient teachings:

Take drug in the evening Patient may experience these side effects: Nausea, headache, muscle and joint pains,

sensitivity to light

Report severe GI upset, changes in vision, unusual bleeding/bruising, dark urine or light colored stool, fever, muscle pain or soreness

E. Pathophysiology

Stroke or cerebrovascular accident also known as the brain attack is a vascular disorder

that injures the brain function. Stroke remains one of the leading causes of mortality and

morbidity. The term brain attack has become a popular substitute for stroke, with the intent of

equating stroke with a heart attack in terms of the timetable associated with the development of

neurologic deficits and the need for prompt emergency treatment.

A brain attack is a sudden impairment of cerebral circulation in one or more blood

vessels. It occurs when a blood clot blocks the blood flow in a vessel or artery or when a blood

vessel breaks, interrupting blood flow to an area of the brain. Regardless of the cause, the

underlying event is deprivation of oxygen and nutrients. Normally, if the arteries become

blocked, autoregulatory mechanisms help maintain cerebral circulation until collateral circulation

develops to deliver blood to the affected area. If the compensatory mechanism becomes

overworked, or if cerebral blood flow remains impaired for more than a few minutes, oxygen

deprivation leads to infarction of brain tissue. Stroke interrupts or diminishes oxygen supply and

commonly causes serious damage or necrosis in the brain tissues. When either of these things

happens, brain cells begin to die.

When brain cells die during a stroke, abilities controlled by that area of the brain are lost.

These include functions such as speech, movement, and memory. The specific abilities lost or

affected depend on the location of the stroke and its severity.

There are two types of “brain attacks” – ischemic and hemorrhagic. With ischemic

strokes, a blood clot blocks or plugs a blood vessel in the brain. With hemorrhagic strokes, a

blood vessel in the brain breaks or ruptures.

An ischemic stroke can occur in several ways – embolic, thrombotic, Transient ischemic

attack, and lacunar infarcts. Embolic stroke occurs when a blood clots forms in the body (usually

the heart) and travels through the blood stream to the brain. Once in the brain, the clot eventually

travels to a blood vessel small enough to blocks its passage. The clot lodges there, blocking the

blood vessel causing a stroke. In the thrombotic stroke, blood flow is impaired because of the

blockage to one or more arteries supplying blood in the brain. Blood-clot strokes can also happen

as the result of unhealthy blood vessels clogged with the build up with fatty acids and

cholesterol. So your body reacts in these injuries just as it would if you were bleeding from a

wound- it responds by forming clots. Transient ischemic attacks, or TIAs, are brief episodes of

stroke symptoms resulting from temporary interruptions of blood flow to the brain. It can last

anywhere from a few seconds up to 24 hours. Lacunar infarcts are small (1.5 to 2.0 cm) to very

small (3 to 4 mm) infarcts located in the deeper noncortical parts of the brain or in the brain

stem. They are found in the territory of single deep penetrating arteries supplying the internal

capsule, basal ganglia, or brain stem. They result from occlusion of the smaller branches of large

cerebral arteries, commonly the middle cerebral and posterior cerebral arteries and less

commonly the anterior cerebral, vertebral, or basilar arteries. In the process of healing, lacunar

infarcts leave behind small cavities, or lacuna. Six basic causes of lacunar infarcts have been

proposed: embolism, hypertension, small-vessel occlusive disease, hematologic abnormalities,

small intracranial haemorrhages, and vasospasm. Because of their size and location, lacunar

infarcts do not usually cause profound deficits such as aphasia or apracticagnosia of the minor

hemisphere. Instead, they often produce syndromes such as pure motor hemiplegia, pure sensory

hemiplegia, and dysarthria with the clumsy hand syndrome.

Overview

The Neurological System is divided into two major parts: the Central Nervous System

(CNS) and the Peripheral Nervous System (PNS).

The Central Nervous System is the body’s information headquarters, ultimately

regulating nearly all body functions. It CNS includes the brain and spinal cord.

The brain processes incoming information from within the body, and outside the body by

way of the sensory nerves of sight, touch, smell, sound, and taste. In other words, the brain is

where all thinking and decision-making takes place.

The spinal cord is the main pathway for information connecting the brain and peripheral

nervous system. Electrical impulses travel through the nerves and allow the brain to

communicate with the rest of the body.

The Peripheral Nervous System is responsible for the remainder of the body. It includes

cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal

cord) and all the major sense organs.

The PNS is divided into the somatic (SNS) and autonomic nervous system (ANS).

The Somatic Nervous System (SNS) is responsible for all muscular activities that we

consider voluntary or that are within our conscious control.

The Autonomic Nervous System (ANS) is responsible for all activities that occur

automatically and involuntarily, such as breathing, muscle contractions within the digestive

system, and heartbeat.

The ANS is further divided into two- the sympathetic and parasympathetic system.

The Sympathetic System stimulates cell and organ function. It is activated by a perceived

danger or threat: by very strong emotions such as fear, anger or excitement; by intense exercise;

or when under large amounts of stress.

The Parasympathetic System inhibits cell and organ function. It slows down heart rate,

resumes digestion, and increases relaxation throughout the body.

The brain is the center of our body functioning. Once it is injured the total functioning of our

body will be affected. Physical activities are hampered and other vital organs will also be

affected as well. Once vital organs are not in their optimum functioning, it will aggravate the

seriousness of the condition of the patient.

Space – occupying blood clots put more pressure in the brain

tissues

The ruptured cerebral vessels may constrict to limit blood

loss; however, this vasospasm will result to further ischemia and necrosis of brain tissues.

The regulatory mechanisms of the brain attempt to maintain equilibrium by increasing BP

and ICP.

Due to thrombosis, or embolism, some neurons die because of lack of oxygen and

nutrients

Hemorrhagic

Infarction of the Cerebral Vessels known as Stroke

Tissue injury triggers an inflammatory response which

increases intracranial pressure.

The injury disrupts metabolism leading to changes in ionic

transport, localized acidosis, and free radical formation

Calcium, Sodium, water accumulate in the injured cell, and excitatory neuro transmitters are released

F. Prioritizing Nursing Diagnosis

1. Ineffective Cerebral Tissue Perfusion related to cerebral edema as evidenced by altered

level of consciousness, stiffening of extremities, slurred speech

2. Impaired Physical Mobility r/t neuromuscular/musculoskeletal impairment

3. Self-Care Deficit r/t impaired mobility status

4. Disturbed Sensory Perception r/t altered sensory perception

5. Impaired Verbal Communication r/t decreased circulation to the brain

Cues Nursing Diagnosis Outcome Criteria Nursing Intervention Rationale Evaluation Discharge Planning

Subjective:

“ Budlayan siya

maghulag kag

maluya na ang

tuo nga parti

sang iya lawas.

Nabudlayan sya

maghambal daw

indi

maintindihan.”

as verbalized by

the folk.

Objective:

T–36.5

P - 88

R - 22

BP – 180/100

GCS – 11

Stiffening of

extremities

Slurred

speech

Ineffective

Cerebral

Tissue

Perfusion

related to

cerebral

edema as

evidenced by

altered level of

consciousness,

stiffening of

extremities,

slurred speech

Short Term:

After 8 hours of

effective nursing

intervention the

patient will be able

to:

1. Demonstrate

stable vital

signs.

2. Prevent /

minimize

complications.

3. Daily needs are

met either by

himself or

others.

4. Be free from

injury and fall

Long Term:

After 2 weeks of

effective nursing

intervention the

patient will be able

to:

1. Maintain

Independent:

1. Determine factors

related to individual

situation /decreased

cerebral perfusion.

2. Monitor/document

neurological status

frequently and

compare with

baseline.

3. Monitor vital signs.

4. Provide safety

measures

5. Evaluate pupils,

noting size, shape,

equality, light

Influences choice of

interventions.

Assesses trends in level

of consciousness

(LOC) and useful in

determining location,

extent, and

progression/resolution

of CNS damage. May

also reveal presence of

TIA, which may warn

of impending

thrombotic CVA.

Monitor Alterations

Prevent falls and injury

Pupil reactions are

regulated by the

oculomotor (III) cranial

PARTIALLY

MET

Short Term:

After 8 hours of

effective nursing

intervention the

patient was

partially able to:

1. Demonstrate

stable vital

signs.

2. Prevent /

minimize

complications.

3. Daily needs are

met either by

himself or

others.

4. Free from

injury and fall

Long Term:

After 2 weeks of

effective nursing

intervention the

M – Instruct the

folks and the

patient to take

drugs as ordered.

Emphasize the

importance of

taking the drugs

at the right timing

of intake and

right dosage.

Explain to

patient/folks the

adverse effects of

the drugs.

E –

Provide/maintain

stress free

environment for

the client to

lessen discomfort.

T – Instruct

patient to perform

exercise treatment

given by physical

usual/improved

level of

consciousness,

cognition, and

motor/sensory

function.

2. Increased

cerebral

function and

decrease

neurological

deficits.

reactivity.

6. Assess higher

functions, including

speech, if patient is

alert.

7. Position with head

slightly elevated

and in neutral

position.

nerve and are useful in

determining whether

the brainstem is intact.

Pupil size/equality is

determined by balance

between

parasympathetic and

sympathetic enervation.

Response to light

reflects combined

function of the optic

(II) and oculomotor

(III) cranial nerves

Changes in cognition

and speech content are

an indicator of

location/degree of

cerebral involvement

and may indicate

deterioration/increased

ICP.

Reduces arterial

pressure by promoting

venous drainage and

may improve cerebral

patient was

partially able to:

1. Maintain

usual/improved

level of

consciousness,

cognition, and

motor/sensory

function.

2.Increased

cerebral

function and

decrease

neurological

deficits.

therapist. Advice

folks to assist

patient.

H – Instruct folks

to place patient

on moderate

backrest.

Encourage active

ROM for

unaffected

extremities and

perform passive

ROM for affected

extremities.

O – Explain to the

patient and folks

the importance of

keeping follow-

up appointments

with health care

providers and to

report any

untoward signs

and symptoms.

8. Maintain bedrest;

provide quiet

environment;

restrict

visitors/activities as

indicated. Provide

rest periods

between care

activities, limit

duration of

procedures.

Dependent:

1. Administer oxygen

at 2 Lpm as

ordered.

2. Administer the

following as

ordered:

-Baclofen1tab BID

and ValproicAcid

-Mannitol

circulation/perfusion

Continual

stimulation/activity can

increase ICP. Absolute

rest and quiet may be

needed to prevent

rebleeding in the case

of hemorrhage.

Reduces hypoxemia,

which can cause

cerebral vasodilation

and increase

pressure/edema

formation.

For skeletal muscle

spasticity of spinal

&cerebral origin

D – Instruct the

patient/folks to

follow the diet

intended for the

patient. Healthy

and rich in

vitamins and

minerals.

Collaborate with

the dietician.

S – Encourage

folks to provide

physical,

emotional,

financial, and

spiritual support

to the patient.

25cc IV q8H

-Levetriacetam

500mg 1tab OD

-Losartan

50mg/tab 1tab OD

-Citicoline 500mg

1tab BID

-Amlodipine 20mg

1tab OD

-Simvastatin

40mg/tab 1tab OD

To increase urine flow

in patients w/ acute

renal failure, reduce

raised intracranial

pressure & treat

cerebral edema.

Adjunctive therapy in

the treatment of partial

seizures w/ or w/o

secondary

generalization.

To manage HTN

To treat

cerebrovascular

disorders including

ischemic stroke,

Parkinsonism & head

injury.

To manage HTN &

angina pectoris.

To treatment hyperlipidemia; prophylaxis in hypercholesterolemic patients w/ ischemic heart disease.

Documents

Ischemic Stroke Case Study