Cvd Case Study

I. INTRODUCTION Cerebrovascular disease is a group of brain dysfunctions related to disease Cerebrovascular of the blood vessels supplying the brain. Hypertension is the most important cause; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Sustained hypertension hypertension permanently permanentl y changes the architectur architecture e of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure. A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocke blocked d by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. The most common symptom of a stroke is sudden weakness or numbness of the face, arm or leg, most often on one side of the body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; coordinat ion; severe headache with no known cause; fainting or unconsciousness. The effects of a strok stroke e depend on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden death. The 1990 Global Burden of Disease (GBD) study provided the first global estimate on the burden of 135 diseases, and cerebrovascular diseases ranked as the second leading cause of death after ischemic heart disease. During the past decade the quantity of especially routine routine mortality data has increased, and is now covering approximately one-third of the world’s population. The increase in data availability provides the possibility for updating the estimated global burden of stroke. Data on causes of death from the 1990s have shown that cerebrovascular diseases remain a leading cause of death. In 2001 it was estimated that cerebrovascular diseases (stroke) accounted for 5.5 million deaths world wide, equivalent to 9.6 % of all deaths Two-thirds of these deaths occurred in people living in developing countries and 40% of the subjects were aged less than 70 years. Additionally, cerebrovascular Additionally, cerebrovascular disease is the leading cause of disability in adults and each year millions of stroke survivors has to adapt to a life with restrictions restricti ons in activities a ctivities of daily living as a consequence of cerebrovascular cerebrovascular disease. Many surviving stroke patients will often depend on other people’s continuous support to survive.

II. OBJECTIVES GENERAL OBJECTIVES

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1.

To be able to discuss the effect, signs and symptoms of the disease, Cerebrovascular Disease.

2.

How to diagnose, prevent and the treatment should the nurse give for the patient full recovery recovery..

SPECIFIC OBJECTIVES 1.

To T o be able to dis discuss cuss patients patients backg backgrou round nd ( life lifestyl style, e, hist history ory of the past illness, family health history) to show how may this effect on the occurrence of this disease.

2. To be able to discuss the the anatomy and and the physiology physiology of the heart, heart, for you to be able to understand where the infection takes place. 3.

To be able to discuss the pathophysiology of cardiovascular diseases and also to know and understand the etiology of the disease.

4. To be able to discuss discuss the patient patient activities activities of daily living. living. To To know if there’s a factor that triggers the disease 5. To be able able to discuss, discuss, nursing nursing care plan for our our patient. 6. To be able to dis discus cuss, s, the medicat medication ion / dru drugs gs that the patient patient taken taken and the diagnostic test that being perform for the patient. 7. Las Lastly tly,, to be abl able e to discuss discuss our discha discharg rge e pla plan n for fully fully recove recovery ry of our patient.

III. PATIENT’S PROFILE

IV.. PHYSICAL IV PHY SICAL ASSESSMENT GENERAL SURVEY Mr. X was lying semi-fowler’s on bed, conscious, coherent, afebrile with monitoring devices.











ime 07/18/0 9

7am1pm

e 36.8

210/1 00

58

t

20

B. HEAD Pink papillary conjunctiva, no nuchal rigidity and no carotid bruit. C. NEUROL NEUROLOGIC OGIC ST STATUS -Oriented to time, person and place. CRANIAL NERVES ASSESSMENT CN I- can smell CN II- (2-3) ERTL CN III, IV, VI- EDM, intact CN V- (+) corneal reflex CN VII- no facial asymmetry CN IX- (+) gag reflex CN XI- can shrug shoulder CN XII- tongue at midline

D. PULM PULMONA ONARY RY SYST SYSTEM EM -Respiratory rate was 58 cpm -SCE, no vesicular breath sounds. -AP, Apical beat at the 6 th ICS anterior axillary line normal sounds.

E. GAST GASTROIN ROINTEST TESTINAL INAL SYST SYSTEM EM Flabby, NaBS, no abdominal bruit, (-) edema,(-) cyanosis. F. MUSC MUSCUL ULOSK OSKELET ELETAL AL SYSTEM SYSTEM Th The pat atiien entt ma man nife fes ste ted d go good od po pos stu turre and mov oved ed voluntarily; he had symmetrical musculature on both sides of the body. Weakness was noted.

G. GENI GENITOTO- URINAR URINARY Y SYSTEM SYSTEM











V. LABORATORY AND DIAGNOSTIC DI AGNOSTIC EXAMINATION Laboratory Findings Laboratory Exam July 15, 2009

Result

1. GRAM GRAM ST STAI AIN N Specimen: Sputum Gram ( - ) cocci singly: Gram ( + ) cocci Short chain: Gram ( + ) cocci in large chain: Pus cells: Epithelial cells: 2. UR URIN INAL ALYS YSIS IS Macroscopic Color: Transparency: Microscopic •

•

•

Few

• •

Few

•

Few

•

RBC: Pus cells: Bacteria: Epithelial cells: Mucus threads: Amonphous unates: 3. HbAlC: 4. Glucose: 5. LI LIPI PID D PRO PROFI FILE LE Cholesterol: Triglycerides: HDL cholesterol cholesterol:: LDL cholesterol: Na: K: Ca: Cl: SGPT: •

2-4/010 +1

• • • •

•

Light yellow SL. Turbid

• • • • • •

4-6/HPF 0-2/HPF

•

• •

Few

Normal Range











INR: 7. CHE CHEMIC MICAL AL ANA ANAL LYSI YSIS S S.G: pH: nitri: protein: glucose: ketone: urobilinogen: bilirubin: blood: leukocyte: •

•

12.2% 7.36mmol/L

•

7.2– 6.2 4.22 – 6.11

• • •

5.10mmol/L

• • • • •

0.70 1.24 3.54

137 4.3 1.36 98 41U/L Male: up to 40U/L Female: up to 31U/L 15.31 12 – 15sec 14.1 1.35

1.010

6.5











(-) (-)

(-) (-) +1 (-)

July 16, 2009 5:30 am 1. Capi Capill llar ary y Bl Bloo ood d Glucose: 2. He Head ad CT sc scan an::

142 -shows a low attenuation focus on the left occipital lobe Consistent with a recent infarction -ventricles are not dilated -midline structure are in place -mild cortical atrophy is demonstrated -rest of the findings are unbreakable.

July 17, 2009

80 – 120mg/dl













•

Cl: 1.33

1.15-1.29

100

96-110

VI. ANATOMY AND PHYSIOLOGY The Brain Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). •

The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia).

•

The diencephalon generates the thalamus, hypothalamus, and pineal gland.

•

The mesencephalon generates the midbrain portion of the brain stem.

•

The metencephalon generates the pons portion of the brain stem and the cerebellum.

•

The myelencephalon generates the medulla oblongata portion of the brain stem





















•

A gyrus (plural, gyri) is an elevated ridge among the convolutions.

•

A sulcus (plural, sulci) is a shallow groove among the convolutions.

•

A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)—the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain. A cross section of the cerebrum shows three distinct layers of nervous tissue: •

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas.

•

The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve











The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions: •

The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here before being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also.

•

The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles).

•

The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion, behavior, hunger, thirst, body temperature, and the biological clock. It also produces two hormones (ADH and oxytocin) and various releasing hormones that control hormone production in the anterior pituitary gland.

The following structures are either included or associated with the hypothalamus. •

The mammillary bodies relay sensations of smell.

•

The infundibulum connects the pituitary gland to the hypothalamus.











•

The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum.

•

The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one component of the reticular formation, is responsible for maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by comparing actual skeletal movements to the movement that was intended. The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of gray matter. The brain stem consists of the following four regions, all of which provide connections between various parts of the brain and between the brain and the spinal cord Figure













•

The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one component of the reticular formation, is responsible for maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by comparing actual skeletal movements to the movement that was intended. The limbic system is a network of neurons that extends over a wide











VII. PATHOPHYSIOLOGY











Cerebrovascular disease or brain attack happened due to modifiable factors possessed by the patient such as smoking, ingesting fatty foods, and hypertension that leads to vasospasm and an embolus that dislodged from an area of origin to the brain that results to increase oxygen demand demand and decrease oxygen supply in the blood. Because of inadequate blood perfusion











- S/C ERMEOD ERMEOD Dr Dr.. Anl Anluet uete, e, and MRO MROD D Dr Dr.. Sol Soler ero, o, MIOD with made and carried out - hook hooked ed to to O2 inha inhalatio lation n with with 2-3 2-3 LPM LPM via nasa nasall cannula - hooked to cardiac cardiac monitor monitor BP 260/100 mmHg HR 60 bpm 3:00pm

- venicolysis started hooked IVF of PNSSL x KVO - Lab: CBG: 156mg/dl; CBC: TF; Serum electrolytes: TF; CT Scan: (plain head) done: TF - Me Meds ds:: nic icar ardi dip pin ine e drip( p(D D5W 90 90cc cc+ + 1 am amp p nicar ni cardip dipine ine)) @ 5ugtts 5ug tts ↑ 10 ug ugtts tts @ 3:10 3:10 pm; zantac 1 amp given @ 3:20 pm - FC inserted inserted connected to urobag urobag - mannitol 75mg x 1st dose - UO drained- 1000cc fixed and brought to room room of choice











6;00pm 6;00pm carried

-

S/E by Dr Dr.. Soms Somson-Cr on-Crux ux with ord orders ers made and Out

- nexicum 40mg tab OD - refer to Dr. Dr. Soccom Rosales for Co. Mgt. Dr. Dr. Solero informed - for sputum sputum AFB 3x; GS/CS with SB

initial V/S BP:180/90mmHg

T:36.4

C,

HR:68,

RR:28,

- with the ff ff. meds mannitol mannitol 75cc x 3doses 3doses started @ ER; Nexicum Nexic um 40m 40mg g OD; olm olmesa esarta rtan n 30m 30mg g tab OD; liticolin TID given 9:00pm

- on CBR without BPR













- on NPO except except meds - assess; BP 170/100 - O2 @ 2LPM via nasal cannula cannula - on CBR without without BPR - on CT CTscan scan-TF -TF - urinalysis, creatinine - for sputum AFB - for sputum GS/CS - CBG monitoring q 12











Addendum

- start feeding AP order order - for SGOT - (-)gag reflex

3-11 PNSSL

-

received patient on bed with ongoing IVF of with NGT NGT to start start of 1600 kcal kcal in feedin feedings, gs, DM

diet - with O2 inhalation @ 2LPM via nasal cannula cannula











- on1600kcal feedings DM diet - sputum GS/CS-TF - CBG monitoring q 12 - for sputum AFB - for repeat repeat plain CTscan 1;15am

- above IVF consumed and hooked same IVF and rate - V/s taken and recorded











- with ongoing IVF PNSS reg. @ same rate - with FC connecte connected d to urobag - with OF 1600kcal; 1600kcal; 6 feedings - for 2Decho - for sputum GS/CS - on CBR without without SBR - repeat CTscan CTscan plain-TF plain-TF - due meds given 8;00pm

- (+ (+) restlessness- MROD endorsed to give











- possible TPOC - BP: 140/80mmHg - endorsed

3-11

- with NGT, OF 1600kcal feedings - for sputum GS/CS - for CT CTscan scan-TF -TF - V/S taken and recorded

07:00pm

- (+) restlessness; refer to Dr Solero













- morning care done - (-)BM, afbrile - needs attended











M- Instructed immediate immediate relatives to facilitate facilitate the

patient to continue

taking the drugs given to her on the right time and with the right dose to facilitate continuity of care.

Cvd Case Study

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