NCM 105
A Grand Case Presentation
Cereberovascular Disease, Infarct, Left Middle Cerebral Artery Submitted by:
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.R Borja General Hospital- Medical Ward for providing a venue for clinical practice and sharing their knowled knowledge ge regardi regarding ng our case; and especia especially lly to our clinicfa clinicfall instruct instructor or Sir Jimmy Boston, RN: who taught us a lot of things and inculcated in our minds the ideal boost for nursing excellence; excellence; and most to our Almighty God who would let all things happen for a cause—a cause that will make us realize the true value of Nursing practice.
TABLE OF CONTENTS
I.
Introduction
II.
General Objectives
III.
Specific Objectives
IV.
Definition of of Te Terms
V.
Patient’s Profile
VI.
Nursing As Assessment
VII.
Anat Anato omy and and Physio siology
VIII. II.
Path athophysi ysiolog logy
IX.
Doctor’s Order
X.
Lab Laborat orato ory Resu Result lts s and and Diag Diagno nost stic ic Test Tests s
XI.
Drug Study
XII.
Nursing Care Plans
XIII.
Discharge Pl Plan
XIV.
Prognosis
XV.
Evaluation
XVI.
References
INTRODUCTION Cerebrovascular disease is a group of brain dysfunctions related to disease of blood blood vessels vessels supplyi supplying ng the brain. brain. Hyperte Hypertensio nsion n is the most most importan importantt cause cause that 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. perfect. Sustaine Sustained d hyperten hypertension sion permanen permanently tly changes changes the architec architecture ture of the blood blood vessels making them narrow, stiff, deformed and uneven which are more vulnerable to fluctuations of blood pressure. A fall in blood pressure during sleep can lead to marked reduction in blood flow in the narrowed blood vessels causing ischemic stroke in the morn morning ing where whereas as a sudde sudden n rise rise in blood blood press pressur ure e can can cause cause tearin tearing g of the blood blood vessels causing intracranial hemorrhage during excitation at daytime. Primarily people who who are elder lderly ly,, diab iabetic etic,, smoker, or have isch schemi emic heart disea sease, have cerebrovascular disease. All diseases related to artery dysfunction can be classified under a disease as known as Macrovascular disease. This is a simplistic study by which arteries are blocked by fatty deposits or by a blood clot. The results of cerebrovascular disease can include a stroke, or even sometimes a hemorrhagic stroke. Ischemia or other blood vessel dysfunctions can affect one during a cerebrovascular accident. CVD is the most disabling of all neurologic diseases. Approximately 50% of survivors have a residual neurologic deficit and greater than 25% require chronic care. Cardiovascular disease mortality in the Philippines was studied from the existing vital stati statist stics ics for 2000 2000-20 -2008 08.. Death Death rates rates from from cerebr cerebrova ovascu scular lar diseas diseases es increa increase sed d enormously both in men and women. This increase in mortality was seen in all age groups. The age-standardized mortality rate in men rose from 33.3 in 2000 to 78.0 in 2005, and that of women from 15.4 to 34.5. The male to female ratios in the agestandardized death rates increased during this 9-year period. 9-year period. Age-standardized mortality increased increased clearly in the male population but decreased in the female population of the Philippines. This excess mortality in males is mostly due to the increased cardiovascular disease death rate. This is a clear example of how chronic non-communicab non-communicable le diseases are becoming major health problems in countries where they previously have not been prevalent. Immediate preventive measures are needed in order to control cardiovascular diseases in countries , such as ours, where disease rates are rapidly increasing. We chose this case as the main subject of this presentation because we were greatly alarmed with the sudden increase of the number of people having the said disease. We want to find out what makes it such a horrifying disease. We also wanted to come up with a thorough study so as to hasten and develop our critical thinking by util utiliz izin ing g the the diff differ eren entt nurs nursin ing g theo theori ries es and and prin princi cipl ples es that that we lear learne ned d from from our our discussion. It is then through this case presentation that we will be able to apply the things we were taught to.
GENERAL OBJECTIVES At the end of the 1-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; identify the proper care to be provided; enhance our positive attitude and improve our confidence and self-esteem.
SPECIFIC OBJECTIVES At the end of our 2-hour case presentation, under the different areas of learning we will be able to: SKILLS •
•
•
Properly explain the case of the patient Obtain Obtain and maintain the interest of the audience in paying attention to the report Manage time efficiently and present the case within the allotted time frame
KNOWLEDGE •
Relay accurate, consistent and reliable data in the report
•
Gain knowledge on the case of the patient
•
Compare the theoretical scheme of the illness to the actual case
ATTITUDE •
Promote cooperation between group member when presenting the case and answering queries from the panel
•
Instill integrity and discipline all throughout the presentation
DEFINITION OF TERMS Anaerobic metabolism - The creation of energy through the combustion of carbohydrates in the absence of oxygen. Atheroma - an accumulation and swelling (-oma) in artery walls that is made up of cells (mostly macrophage cells), or cell debris, that contain lipids (cholesterol and fatty acids), calcium and a variable amount of fibrous connective tissue. Blood pressure - the pressure of the blood against the inner walls of the blood vessels, varying in different parts of the body during different phases of contraction of the heart and under different conditions of health, exertion, etc. Cerebrovascular disease - is a group of brain dysfunctions related to disease of blood vessels supplying the brain. Hypertension is the most important cause that 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. Deep tendon reflexes - A myotatic or deep reflex in which the muscle stretch receptors are stimulated by percussing the tendon of a muscle. Dysphagia – difficulty in swallowing Embolus - a mass, such as an air bubble, a detached blood clot, or a foreign body, that travels through the bloodstream and lodges so as to obstruct or occlude a blood vessel. Gag reflex – a normal neural reflex elicited by touching the soft palate or posterior pharynx; the responses are symmetric evaluation of the palate, retraction of the tongue, and contraction of the pharyngeal muscle. Hemorrhagic stroke - involves bleeding within the brain, damaging nearby brain tissue. Hypertension - elevation of the blood pressure, esp. the diastolic pressure. Hypoxia – inadequate oxygen tension at the cellular level, characterized by tachycardia, hypertension, peripheral vascular constriction, dizziness, and mental confusion. Infarction - the act of stuffing or filling; an overloading and obstruction of any organ or vessel of the body. Ischemia - local deficiency of blood supply produced by vasoconstriction or local obstacles to the arterial flow. Metabolic acidosis - a pH imbalance in which the body has accumulated too much acid and does not have enough bicarbonate to effectively neutralize the effects of the acid.
Stroke - blockage or hemorrhage of a blood vessel leading to the brain, causing inadequate oxygen supply and, depending on the extent and location of the abnormality, such symptoms as weakness, paralysis of parts of the body, speech difficulties, and, if severe, loss of consciousness or death. Thrombus - a fibrinous clot that forms in and obstructs a blood vessel, or that forms in one of the chambers of the heart
PATIENT’S PROFILE GENERAL INFORMATION: Patient’s name: Mr. Strokeman Address: Talisayan, Misamis Oriental Birthday: June 4, 1949 Age: 60 years old Sex: Male Educational background: High school graduate Nationality: Filipino Religion: Roman Catholic Marital status: Married Usual occupation: Jeepney driver Present occupation: Retired Source of history: Wife Reliability of historian: Good reliability Chief Complaints: Admitted due to right sided weakness and slurred speech Date Admitted: September 20, 2009, 6:30 PM Diagnosis: Cerebrovascular disease, infarct, at left mid-cerebral artery; hypertensive cardiovascular disease Physician: Dr. Mananguete
HISTORY OF PRSENT ILLNESS: 12 hours prior to admission, patient rose from his bed when suddenly he fell on the floor. He was observed to have right sided weakness with slurred speech, and was immediately brought to Talisayan District Hospital. Other significant findings include BP = 160/100 mmHg and positive deviation of nasolabial folds to the right. Patient was given captopril 25 mg 1 tablet single dose and citicholine drops 1mL PO. For further management, he was then referred to Northern Mindanao Medical Center, hence admission. Vital signs upon admission: BP=150/90 mmHg, T=36.5 C, P=60 bpm, R=20 cpm. No vomiting, no headache, no change in sensorium noted.
STAGES OF DEVELOPMENT With regards to the data drawn together through the assessment, the patient is classified under Erik Erickson’s Ego integrity vs. Despair on his Psychosocial Theory. As articulated, this theory proposes eight developmental phases spanning infancy through older adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future.
This stage tasks to developmentally review one’s life and derive meaning from both positive and negative events, while achieving a positive sense of self. As the person reaches maturity (55 years old – death) or become senior citizens, productivity slows down, and explores life as a retired person. During this time, the individual contemplate accomplishments and are able to develop integrity, 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 by the development of despair leading to depression and hopelessness.
Based on the assessment conducted, we have come up with the idea that the patient has developed integrity through verbalization of self-acceptance worth and importance as a husband and as a father. He has been able to share wisdom and guidance to his only daughter to become a responsible adult. Gladly accepts his daughter and wife’s mates and friends and is very much proud with the fact that his has able to send his daughter to college who is now about to have a degree in Nursing.
NURSING ASSESSMENT Nursing History Normal Patterns of Functioning (Before Admission)
•
ACTIVITY/REST Retired 5 years ago as a jeepney driver Spends time reading, watching television, and working in the yard Has no regular exercise routine Visits friends or visited by friends once in a while Had sufficient energy for all desired and required activities Sleeps about 10:00 PM each evening and rises about 6:30 AM; feel well-rested No sleeping difficulties
•
CIRCULATION Known hypertensive
•
•
•
•
•
•
Clinical Inspection Observation During Assessment Day (September 21, 2009)
•
• •
•
Has limited range of motion on the right side of the body Always lies on bed Actual hours slept: about 9 hours Has decreased energy level
Clinical Inspection Observation on First Day of Duty (September 22, 2009)
•
•
•
Performs passive range of motion on the affected extremities Lies in semiFowlers position, and reads newspaper to relieve boredom Actual hours slept: about 8 hours
On-going Appraisal Observation on Second Day of Duty (September 24, 2009)
•
•
•
•
•
•
HR: 80 bpm
•
HR: 91 bpm
•
Others Sources/ Laboratory Exam Results
Performs passive range of motion on the affected extremities Lies in semiFowlers position, and listens to music through his music player to relieve boredom Actual hours slept: about 10 hours No signs of skin breakdown over bony prominences Absence of contractures and foot drop.
HR: 69 bpm
Blood chemistry
•
• •
•
•
•
•
•
since May 2009 No complaints of chest pain, irregular heartbeats, and palpitations, except when blood pressure is very high Doesn’t smoke Drinks alcoholic beverages occasionally for the last 35 years Has family history of hypertension, stroke, and heart disease Has brown skin tone and some diffused dark brown patches of pigmentation on both upper and lower extremities
EGO INTEGRITY A passive member of the Roman Catholic Church Has positive selfconcept; one reason is that he was able to provide his family a good life They have a stable marriage although they
•
•
•
•
(average), with regular rhythm Normal pulse with capillary refill time of 1 sec BP: 135/80 mmHg (left arm, lying) Skin warm and dry; no edema noted; with good skin turgor; with normal skin tone T: 36.6
•
•
•
•
•
•
•
Initially feels depressed and helpless because of his diagnosis He hopes to get well soon, and his family is supportive. Prays to God
•
(average), palpitations reported Normal pulse with capillary refill time of 1 sec BP: 160/100 mmHg (left arm, lying) Skin warm and moist; no edema noted; with good skin turgor; with normal skin tone T: 37.4
Feeling of depression and helplessness was somewhat relieved because of the moral support given by his friends and healthcare providers
•
•
•
•
•
(average), with regular rhythm Normal pulse with capillary refill time of 1 sec BP: 140/90 mmHg (left arm, lying) Skin warm and dry; no edema noted; with good skin turgor; with normal skin tone T: 37.1
Reports of gradual acceptance of his condition
Abnormal findings: 9/21/09 Glucose: 161.1 (increased) 9/23/09 Glucose: 155.3 (increased)
•
•
•
•
•
•
•
•
•
have had some problems over the years Has adjusted well to retirement and had expresses satisfaction with this stage of life
ELIMINATION Usually no complaints in urinating and defecating Normal bowel pattern is 1, soft formed stool everyday or every other day Urinates 4-6 times a day, light yellow in color Doesn’t use laxative or suppositories
FOOD/FLUID A good eater; eats 3x a day; enjoys all types of food and a particular big pork eater Loves to eat noodles and bread Weight is 62 kg and height is 5’6” Has some mastication problems due to his
Wasn’t able to defecate for the whole day Total urine output for 24 hours: 1,150 mL Yellow, aromatic urine no complaints in urinating
•
Defecated once to a formed brown stool Total urine output for 24 hours: 1,450 mL Yellow, aromatic urine no complaints in urinating and defecating
•
•
•
•
•
•
•
•
•
•
Has IVF of PNSS 1L regulated @ 30gtts/min @ right arm Actual food taken: soup and rice Total fluid intake in 24 hrs: 2050ml Consumed ¾ of share with fair
•
•
•
•
Has IVF of PNSS 1L regulated @ 30gtts/min @ right arm Actual food taken: soup and rice Total fluid intake in 24hrs:
Defecated once to a formed brown stool Total urine output for 24 hours: 1,360 mL Yellow, aromatic urine no complaints in urinating and defecating
•
•
•
•
•
•
•
•
Has IVF of PNSS 1L regulated @ 20gtts/min @ right arm Actual food taken: soup and rice Total fluid intake in 24hrs: 2200ml Consumed whole of share with good
Special diet (since 9-20-09) Low fat, low salt, soft diet
upper and lower dentures
•
•
•
•
HYGIENE Had no limitations to self-care Takes a bath once a day, and uses shampoo & antibacterial soap Brushes dentures 1-2 times a day Visits dentist once a year
•
•
•
•
appetite Pink palpebral conjunctiva, anicteric sclerae, dry lips, moist tongue; no edema
Requires assistance from another person and equipment to perform bathing, toileting, and dressing Has dry body, and unkempt appearance Hair is dry, nails are dirty
•
•
•
•
•
2100ml Consumed whole of share with good appetite Pink palpebral conjunctiva, anicteric sclerae, moist lips, moist tongue; no edema
Requires assistance from another person and equipment to perform bathing, toileting, and dressing Was able to use of his left unaffected hand in cleaning some parts of his body with clean wet cloth and combing his hair Hair and nails are clean
•
•
•
•
•
appetite Pink palpebral conjunctiva, anicteric sclerae, moist lips, moist tongue; no edema No recent weight gain or loss
Requires assistance from another person and equipment to perform bathing, toileting, and dressing Was able to perform self-care activities within his level of own ability Hair and nails are clean
•
• •
•
•
NEUROSENSORY No history of brain injury or trauma Slightly stooped No diagnosed hearing problem, although wife believes Mr. Strokeman may have slight hearing loss Worn eyeglasses (bifocals) for 20 years (farsighted) No previous perceptual problems noted
•
•
•
•
•
•
•
•
LOC: conscious and alert Oriented to person, place, but disoriented to time Has appropriate affect and mood Has intact taste sensation Pupil size/reaction: 3/3 isocoric, equally reactive Has facial asymmetry, drooping right eyelid Left-sided weakness No problem with swallowing Slurred speech Muscle strength in extremities: o Right upper:1/5 o Left upper:5/5 o Right lower:3/5 o Left lower:5/5
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
LOC: conscious and alert Oriented to place, person, and time Has appropriate affect and mood Has intact taste sensation Pupil size/reaction: 3/3 isocoric, equally reactive Has facial asymmetry, drooping right eyelid Left-sided weakness No problem with swallowing Slurred speech Muscle strength in extremities: o Right upper:1/5 o Left upper:5/5 o Right lower:3/5 o Left lower:5/5
•
•
• •
LOC: conscious and alert Oriented to place, person, but disoriented to time Has appropriate affect and mood Has intact taste sensation Pupil size/reaction: 3/3 isocoric, equally reactive Has facial asymmetry, drooping right eyelid Left-sided weakness No problem with swallowing Slurred speech Muscle strength in extremities: o Right upper:1/5 o Left upper:5/5 o Right lower:3/5 o Left lower:5/5
•
• •
Neurologic Assessment (9-20-09) CN I: Not tested CN II & III: 3/3 isocoric, equally reactive to light CN III,IV,VI: Full extraocular movements CN V: (+) Corneal reflex CN VII: (+) facial asymmetry CN VIII: intact hearing and equilibrium CN IX & X: (+) Gag reflex CN XI: (+) Shoulder lag CN XII: (+) tongue deviation Muscle strength in extremities: •
Right upper:1/5
•
Left upper:5/5
•
Right lower:3/5
Left lower:5/5 Legend: 5-full ROM against gravity and resistance 3-full ROM against gravity only 1- a weak muscle contraction when muscle is palpated, but no movement
•
Deep Tendon Reflexes
Legend: +(Diminished)
CT Scan Result (9-22-09) Subacute hemorrhage centered in the left lentiform nucleus with minimal surrounding edema (2mm) rightward subfalcine herniation and partial effacement the left lateral ventricle •
• •
PAIN/DISCOMFORT Usually doesn’t experience pain in any part of his body except when he has a significantly high blood pressure RESPIRATION Doesn’t smoke No history of COPD;
•
•
•
No complaints of pain Complaints of body weakness
Not in respiratory distress; thorax
•
•
•
No complaints of pain Complaints of body weakness and palpitations
Not in respiratory distress; thorax
•
•
•
No complaints of pain Complaints of body weakness
Not in respiratory distress; thorax
Chest X-Ray (9/20/90) -mild cardiomegaly, left ventricular form -atheromatous aorta
•
•
tuberculosis; and other lung diseases No family history of lung diseases Did not complain of dyspnea at rest or on exertion
•
•
•
•
•
•
• •
• •
•
SAFETY No known food & drug allergies Immunization history: cannot be recalled if complete When he was 37 years old, he had a vehicular accident had bruises but no permanent damage developed, No surgical procedure No past major illness SEXUALITY Has one daughter only Finds sex life satisfactorily, but sexual activity lessens due to increasing age No history of STD’s or reproductive tract
symmetric with equal expansion RR=19 cpm (average); regular pattern No cough; clear breath sounds Head of bed elevated at semifowler’s position with 1 pillow
Has bedside rails His wife watches over him
•
•
•
symmetric with equal expansion RR= 20 cpm, bounding pattern No cough; clear breath sounds Head of bed elevated at semifowler’s position with 1 pillow
•
•
•
•
Feels quite uncomfortable with the subject matter
Has bedside rails His wife watches over him No unusualities noted that will promote injury
•
•
•
symmetric with equal expansion RR= 16cpm, normal pattern No cough; clear breath sounds Head of bed elevated at semifowler’s position with 1 pillow
•
•
•
Has bedside rails His wife watches over him No unusualities noted that will promote injury
•
•
• •
problems SOCIAL INTERACTIONS Role within the family structure: head of the family, housekeeper Lives with his wife and daughter, together with their maid, in a house thy have owned for 30 years Has several friends Speech is clear and understandable if dentures are worn
•
•
Although he converses, his speech is unclear due to slurring of speech and absence of dentures Has impaired articulation of words, incomprehensible words from the patient, inability to use facial or body expressions
•
•
•
Although he converses, his speech is unclear Few friends were able to visit, and he feels happy Communicates by nodding, hand gestures, and using short sentences
•
•
His speech is quite understandable although slurred because he wears his dentures Few relatives were able to visit
TEACHING/LEARNING •
•
•
•
Dominant language: Filipinos (Cebuano) High school graduate; literate Seeks doctor’s consultation when having health problems Takes prescribed amlodipine as a maintenance antihypertensive drug, but doesn’t have a strict medication
•
Follows treatment regimen
•
•
Follows treatment regimen Listens carefully to health teachings imparted
•
•
Follows treatment regimen Reported that he is willing to have a healthy lifestyle
•
compliance Nonprescription drugs: paracetamol, bigesic, neozep as needed; doesn’t use street drugs
ANATOMY AND PHYSIOLOGY OF THE BRAIN There is nothing in the universe to compare with the human brain. This mysterious three-pound squishy tissue controls all necessary functions of our physical body, receives information from the outside world and makes it understandable, and goes beyond that which is understandable to embody the essence of our mind and soul. Intelligence, creativity, emotion, love, memories are but a few of the many things the brain does. The weight of the brain changes from birth through adulthood. At birth, the average brain weighs about one pound, and grows to about two pounds during childhood. The average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three pounds. The brain receives information through our five senses: sight, smell, touch, taste, and hearing - often many at one time. It puts together the messages in a way that has meaning for us, and can store that information in our memory. Our brain controls our thoughts, memory and speech, the movements of our arms and legs and the function of many organs within our body. It also determines how we respond to stressful situations (i.e., writing of an exam, loss of a job, illness) by regulating our heart and breathing rate. Nervous system
(CNS) is composed of the brain and spinal cord PERIPHERAL NERVOUS SYSTEM (PNS) is composed of spinal nerves that branch from the spinal cord and cranial nerves that branch from the brain. The PNS includes the autonomic nervous system, which controls our vital internal functions such as respiration, digestion, heart rate, and secretion of hormones. CENTRAL NERVOUS SYSTEM
Brain The brain is composed of the cerebrum, cerebellum, and brainstem
The brain is composed of three parts: the brainstem, cerebellum, and cerebrum. The cerebrum is divided into four lobes: frontal, parietal, temporal, and occipital. A. Brainstem - includes the midbrain, pons, and medulla. It acts as a relay center
connecting the cerebrum and cerebellum to the spinal cord. It performs many automatic functions such as breathing, heart rate, body temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing. Ten of the twelve cranial nerves originate in the brainstem. The brainstem is the lower extension of the brain, located in front of the cerebellum and connected to the spinal cord. It consists of three structures: the midbrain, pons and medulla oblongata. It serves as a relay station, passing messages back and forth between various parts of the body and the cerebral cortex. Many simple or primitive functions that are essential for survival are located here. 1. 2. 3.
Midbrain - is an important center for ocular motion Pons - is involved with coordinating eye and facial movements, facial sensation, hearing and balance. Medulla oblongata - controls breathing, blood pressure, heart rhythms and swallowing. Messages from the cortex to the spinal cord and nerves that branch from the spinal cord are sent through the pons and the brainstem. Destruction of these regions of the brain will cause "brain death." Without these key functions, humans cannot survive.
The reticular activating system is found in the midbrain, pons, medulla and part of the thalamus. It controls levels of wakefulness, enables people to pay attention to their environments, and is involved in sleep patterns. Originating in the brainstem are 10 of
the 12 cranial nerves that control hearing, eye movement, facial sensations, taste, swallowing and movements of the face, neck, shoulder and tongue muscles. The cranial nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves originate from the pons: nerves 5 through 8. B. Cerebrum - the largest part of the brain and is composed of right and left
hemispheres. It is separated from the cerebrum by the tentorium (fold of dura). The cerebrum, which forms the major portion of the brain, is divided into two major parts: the right and left cerebral hemispheres . The cerebrum is a term often used to describe the entire brain. A fissure or groove that separates the two hemispheres is called the great longitudinal fissure. The two sides of the brain are joined at the bottom by the corpus callosum. The corpus callosum connects the two halves of the brain and delivers messages from one half of the brain to the other. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex
C. Cerebellum - located under the cerebrum. Its function is to coordinate muscle
movements, maintain posture, and balance. The cerebellum fine tunes motor activity or movement, e.g. the fine movements of fingers as they perform surgery or paint a picture. It helps one maintain posture, sense of balance or equilibrium, by controlling the tone of muscles and the position of limbs. The cerebellum is important in one's ability to perform rapid and repetitive actions such as playing a video game. It performs higher functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement.
The cerebral cortex appears grayish brown in color and is called the "gray matter ." The surface of the brain appears wrinkled. The cerebral cortex has sulci (small grooves), fissures (larger grooves) and bulges between the grooves called gyri. Beneath the cerebral cortex or surface of the brain, connecting fibers between neurons form a white-colored area called the "white matter."
The cerebral hemispheres have several distinct fissures. By locating these landmarks on the surface of the brain, it can effectively be divided into pairs of "lobes." Lobes are simply broad regions of the brain. The cerebrum or brain can be divided into pairs of frontal, temporal, parietal and occipital lobes. Each hemisphere has a frontal, temporal, parietal and occipital lobe. Each lobe may be divided, once again, into areas that serve very specific functions. The lobes of the brain do not function alone – they function through very complex relationships with one another.
Lobes of the brain Frontal lobe • • • • •
Personality, behavior, emotions Judgment, planning, problem solving Speech: speaking and writing (Broca’s area) Body movement (motor strip) Intelligence, concentration, self awareness
Parietal lobe • • • •
Interprets language, words Sense of touch, pain, temperature (sensory strip) Interprets signals from vision, hearing, motor, sensory and memory Spatial and visual perception
Occipital lobe •
Interprets vision (color, light, movement)
Temporal lobe • • • •
Understanding language (Wernicke’s area) Memory Hearing Sequencing and organization
Messages within the brain are delivered in many ways. The signals are transported along routes called pathways. Any destruction of brain tissue by a tumor can disrupt the communication between different parts of the brain. The result will be a loss of function such as speech, the ability to read, or the ability to follow simple spoken commands. Messages can travel from one bulge on the brain to another (gyri to gyri), from one lobe to another, from one side of the brain to the other, from one lobe of the brain to structures that are found deep in the brain, e.g. thalamus, or from the deep structures of the brain to another region in the central nervous system.
Deep structures
Hypothalamus - The hypothalamus is located in the floor of the third ventricle and is the master control of the autonomic system. It plays a role in controlling behaviors such as hunger, thirst, sleep, and sexual response. It also regulates body temperature, blood pressure, emotions, and secretion of hormones. Thalamus - The thalamus serves as a relay station for almost all information that comes and goes to the cortex. It plays a role in pain sensation, attention, alertness and memory. Basal ganglia - The basal ganglia include the caudate, putamen and globus pallidus. These nuclei work with the cerebellum to coordinate fine motions, such as fingertip movements. Limbic system - The limbic system is the center of our emotions, learning, and memory. Included in this system are the cingulate gyri, hypothalamus, amygdala (emotional reactions) and hippocampus (memory).
Cranial nerves The brain communicates with the body through the spinal cord and twelve pairs of cranial nerves ten of the twelve pairs of cranial nerves that control hearing, eye movement, facial sensations, taste, swallowing and movement of the face, neck, shoulder and tongue muscles originate in the brainstem. The cranial nerves for smell and vision originate in the cerebrum. Number I II III IV V VI VII VIII IX X XI XII
Name Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal
Function Smell sight moves eye, pupil moves eye face sensation moves eye moves face, salivate hearing, balance taste, swallow heart rate, digestion moves head moves tongue
Blood supply
Blood is carried to the brain by two paired arteries, the internal carotid arteries and the vertebral arteries. The internal carotid arteries supply most of the cerebrum. The vertebral arteries supply the cerebellum, brainstem, and the underside of the cerebrum. After passing through the skull, the two vertebral arteries join together to form a single basilar artery. The basilar artery and the internal carotid arteries “communicate” with each other at the base of the brain called the Circle of Willis. The communication between the internal carotid and vertebral-basilar systems is an important safety feature of the brain. If one of the major vessels becomes blocked, it is possible for collateral blood flow to come across the Circle of Willis and prevent brain damage. The Circle of Willis
The Circle of Willis or the Circulus Arteriosus is an arterial polygon where the blood carried by the two internal carotid arteries and the basilar system comes together and then is redistributed by the anterior , middle, and posterior cerebral arteries. The posterior cerebral artery is connected to the internal carotid artery by the posterior communicating artery . Internal Carotid System The internal carotid artery divides into two main branches called the middle cerebral artery and the anterior cerebral artery . The middle cerebral artery supplies blood to the frontoparietal somatosensory cortex . The anterior cerebral artery supplies blood to the frontal lobes and medial aspects of the parietal and occipital lobes. Before this divide, the internal carotid artery gives rise to the anterior communicating artery and the posterior communicating artery . Vertebral Artery The two vertebral arteries run along the medulla and fuse at the pontomedullary junction to form the midline basilar artery, also called the vertebro-basilar artery . Before forming the basilar artery , each vertebral artery gives rise to the posterior spinal artery , the anterior spinal artery , the posterior inferior cerebellar artery (PICA) and branches to the medulla. Basilar Artery At the ponto-midbrain junction, the basilar artery divides into the two posterior cerebral arteries. Before this divide, it gives rise to numerous paramedian, short and long circumferential penetrators and two other branches known as the anterior inferior cerebellar artery and the superior cerebellar artery .
PATHOPHYSIOLOGY RISK FACTORS: Age: 60 yrs. old Gender: male Genetics: has family history of stroke and hypertension
PRECIPITATING FACTORS: Alcohol Drinking Diet: High Fat/Cholesterol diet Hypertension Sedentary Lifestyle Lipid deposits and turbulent blood flow in intima of arterial cerebral wall Inflammatory response Ingestion of Lipids Atheroma Formation Hypertension Narrowing of arterial lumen Plaque ruptures Thrombosis Occlusion of cerebral artery
Lysed or moved thrombus from the vessel Vascular wall becomes weakened or fragile
Cerebral hemorrhage
Legend: Bold – applicable to patient - - - - signs and symptoms
Cerebral hypoperfusion Impaired distribution of oxygen and glucose
- flow of disease process
Tissue hypoxia and cellular starvation Cerebral ischemia Initiation of ischemic cascade
Anaerobic metabolism by mitochondria
Production of oxygenfree radicals and other reactive oxygen species
Generates large
Failure of production
Metabolic Acidosis
Failure of energy dependent process (ion pumping)
Damage to the blood
Release of excitatory neurotransmitter lutamate Anaerobic metabolism b mitochondria
Activates enzymes that digest cell proteins, lipids and nuclear material
Failure of mitochondria Further energy depletion
Brain sustains an irreversible damage Release of metalloprotease (zinc and calcium-dependent enzymes) Break down of collagen, hyaluronic acid and other elements of connective tissue Structural integrity loss of brain tissue and blood vessels Breakdown of the protective Blood Brain Barrier
Cerebral edema Vascular Congestion Compression of tissue Increased intracranial Pressure •
Impaired perfusion and function
•
Middle Cerebral Artery
•
Lateral hemisphere, frontal, parietal and temporal lobes, basal ganglia
•
If managed (long-term medical and nursing intervention):
With ineffective or without medical and nursing
Partial or total recovery in any of the following: Understanding and forming speech Cognitive loss Mobility of extremities and facial muscles Mental status
Continued insufficiency of blood flow
•
•
• •
•
•
•
•
Further compression of tissues Coma
Cerebral Death
Loss of neural feedback mechanisms Cessation of physiologic functions
•
Sx: Numbness or weakness of the face, arm, leg, esp. on one side of the body Confusion or change in mental status Memory deficits Trouble speaking or understanding speech (dysphasia, dysarthia, apraxia) Sensory loss Visual disturbances Drooping of eyelids Difficulty walking, dizziness Sudden severe headache
Cardiovascular System
Loss of cardiac muscle function Sx: bradycardia
GIT
GUT
Relaxation of intestines and sphincters
Relaxation of venous valves
h
Decreased cardiac output
Pulmonary System
Sx: otension
Loss of bowel control
Failure of accessory muscles for breathing
Other systems
Sx: restlessness, abnormal thermoregulation, mental confusion, increased secretions, decreased urinary output.
Loss of lung movement Neurogenic bladder
Sx: Apnea
Cardiopulmonary arrest
Systemic Failure
Death
Loss of sphincter control
DOCTOR’S ORDER DATE
TIME
Septembe r 20, 2009
6:30pm
ORDER •
Please admit at P 1F2 (Male Pay Ward)
RATIONALE •
• •
•
•
•
PWI: Cardiovascular disease, infarct, Left Mid Cerebral Artery Diet: Low fat, low salt, soft
Change IVF to PNSS 1L @30 gtts/min IVFTF PNSS 1L @ 30 gtts/min Nursing: Monitor v/s q2º and chart. Refer if BP > 160/90 mmHg or <90/60 mmHg HR > 100 bpm or < 60 bpm RR > 24 cpm or or < 12 cpm Monitor SPERM q4º and chart
•
•
•
Monitor I & O qshiftº and chart •
Monitor for change in sensorium, determination of any neurologic deficits, chest pain, SOB, and other unusualities
•
•
Diagnostics: CBC UA Chest X-Ray PA View
•
•
•
Serum Na, K, BUN, Crea 12 lead ECG •
For immediate medical attention Basis for medical and nursing Ideal for clients have cardiovascular disease and mastication problems
For continued surveillance of the condition of the patient
To provide an assessment level of consciousness of the patient To provide physician view of the abnormal and normal function of the urinary organ as well as the ambulation of the patient To monitor a decrease in the function of the brain and/or nerves and provide baseline data for additional treatment
To determine presence of inflammatory process Determines functionality of kidneys To evaluate the lungs for the presence of abnormalities and also the condition and size of the heart To determine the presence of damage in
CT Scan of the Brain, Plain •
•
Therapeutics: Citicoline 1gm IVTT now then q12º Imidapril 10mg 1tab now then OD PO Simvastatin 80mg 1tab now then OD at 8pm PO Captopril 25mg 1tab SL q6º and PRN for BP > 140 Refer accordingly Thank you! Start Aspirin 80mg tab PC lunch OD PO Senna concentrate 2tabs @ HS Omeprazole 20mg 1cap OD PO Turn patient side to side
•
Refer to Rehab Medicine
•
For follow-up CT Scan of the brain, plain
•
•
• •
Septembe r 21, 2009
6:00am
•
•
•
Septembe r 22, 2009
11:00 am
• • •
•
•
•
IVFTF with PNSS 1L @ 20gtts/min D/C aspirin Continue other medications IVFTF with PNSS 1L @ 20gtts/min Follow-up referral to Rehab Medicine Start mannitol 20% 75cc q6º Tranexamic acid 1gm IVTT q8º Decrease simvastatin to 20mg 1tab OD @ HS
•
•
•
cardiac cells To identify cardiovascular involvement To provide view and detect possible hematomas and reduce the need for more invasive procedures
Prevents muscle atrophy and bedsores Indicated for restoration of neurologic function To provide view and detect possible hematomas and reduce the need for more invasive procedures
Confirmation of hemorrhagic stroke through CT scan
LABORATORY RESULTS AND DIAGNOSTIC TESTS BLOOD CHEMISTRY Sept. 21, 2009
Interpretation
Reference values
Potassium
4
Normal
3.5-5.3 mmol/L
Sodium Creatinine Blood Urea Nitrogen Glucose
145
22.2
Normal Normal Normal
134-149 mmol/L 0.59-1.21 mg/dL 4.6-23.4 mgs %
161.1
Increased
59.9-110.1 mg/dL
Sept. 23, 2009
Interpretation
Reference values
Potassium
3.6
Normal
3.5-5.3 mmol/L
Sodium Creatinine Blood Urea Nitrogen Glucose
141.9
20.63
Normal Normal Normal
134-149 mmol/L 0.59-1.21 mg/dL 4.6-23.4 mgs %
155.3
Increased
59.9-110.1 mg/dL
1.13
0.82
CT SCAN RESULT (BRAIN, PLAIN) September 22, 2009 Impression: Subacute hemorrhage centered in the left lentiform nucleus with minimal surrounding edema (2mm) rightward subfalcine herniation and partial effacement the left lateral ventricle
CHEST X-RAY (POSTERIOR-ANTERIOR VIEW) September 20, 2009 Impression: -Suspicious right apical infiltrates; suggest apicolordotic view -Mild cardiomegaly, left ventricular form -Atheromatous aorta
DRUG STUDY Drug Name
Classifi cation
Therapeutic action
Dose/ Route/
Indication(s)
Contraindication and caution
Nursing considerations
Adverse effects
Timing
Omeprazole
proton pump inhibitor (PPI)
like other proton-pump inhibitors, blocks the enzyme in the wall of the stomach that produces acid. By blocking the enzyme, the production of acid is decreased
20 mg 1 cap OD PO
prevention of upper gastrointestinal bleeding in critically ill patients
Malignant neoplasm of stomach Adverse reaction to proton pump inhibitors
• • • • • •
•
• •
•
•
Headache Dizziness Dry cough Dry mouth Fatigue Disturbances of the gut such as dia -rrhoea,constipation, nausea, vomiting, indigestion or abdominal pain Pain in the muscles or joints Chest pain (angina). Pins and needles sensations (paraesthesia) Feeling of weakness (asthenia) Low blood pressure (hypotension)
•
•
•
Take the drug befor meals. Swallow whole capsule. Do not chew, open, or crush them. Instruct to take Omeprazole 30 minutes apart from Atacids because of possible antagonistic interactions
Tell the patient that he may experience the said side effects
DRUG STUD Y Drug Name
Classifica tion
Therapeutic action
Senna concentrate
Stimulant laxative
Precise mechanism of action not known. More recent evidence shows that stimulant laxatives alter fluid and electrolyte absorption, producing net intestinal fluid accumulation and laxation.
Brand Name Senokot
Dose/ Route/ Timing 40 mg 2 tabs at HS (8PM) PO
Indication(s)
Constipation to prevent straining at defecating To prevent ↑ ICP
Contraindication and caution
•
•
•
Intestinal obstruction Abdominal pain, nausea, vomiting, or other symptomsof appendicitis or undiagnosed abdominal pain. Diabetes mellitus
Adverse effects CNS: Faintness • GI: Abdominal discomfort, nausea • Other: Mild cramps, griping, laxative dependence , electrolyte disturbances •
Nursing considerations
•
•
•
•
•
Ensure adequate hydration. Offer support and encouragement to deal with GI discomforts. Administer 2 hours before or 2 hours after taking other medications. Advise the patient not to use laxative products for a period longer than 1 week unless directed by a clinician. Advise patients of a potential discoloration in urine.
DRUG STUDY Drug Name
Imidapril
Brand Name:
Tinatril
Dose/ Route/Ti ming
Classifica tion
Therapeutic action
Ace inhibitor
prevents the 10 mg conversion of angiotensin I 1 tab to angiotension OD II by inhibiting ACE. Limits chronic ischemic injury
Indication(s)
Hypertension Essential hypertension Poor hypertension control
Contraindication and caution
Aortic stenosis or outflow tract obstruction; renovascular disease; ascites.
• • • •
•
Peripheral vascular diseases, generalised atherosclerosis, idiopathic or hereditary angioedema, heart failure, patients likely to be salt or water depleted.
Nursing considerations
Adverse effects
• • • • • • • • • • • • •
•
Dizziness, headache, fatigue, GI and taste disturbances, persistent dry cough skin rash, angioedema, hyperkalaemia, hyponatraemia, blood disorders, proteinuria, chest pain palpitations, tachycardia, alopecia, musclecramps, paraesthesias, mood and sleep disturbances, impotence.
•
•
•
Take the drug with food or after meals if GI upset occurs. Assess renal function before and during therapy Tell the patient that he may experience the said side effects
DRUG STUDY Drug Name
Classifi cation
Captopril
ACE inhibitor Antihype rtensive
Brand Name Capoten
Therapeutic action
Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.
Dose/ Route/ Timing
Indication(s)
25 mg hyperten1 tab sion every 6 hours and PRN for BP >140/90
Contraindic ation and caution •
•
Contraindic ated with allergy to captopril, history of angiodema Use cautiously with impaired renal function; CHF; salt or volume depletion
Adverse effects
CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt- or volume-depleted patients • Dermatologic: Rash, pruritus, scalded mouth sensation, exfoliative dermatitis, alopecia, photosensitivity • GI: Gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation • GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency • Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia • Other: Cough, malaise, dry mouth, lymphadenopathy •
Nursing considerations
•
•
•
•
Administer 1 hr before or 2 hr after meals. Monitor patient’s blood pressure and pulse rate frequently. Monitor patient closely for fall in BP secondary to reduction in fluid volume (due to excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension may occur. Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing.
DRUG STUDY Drug Name Citicoline
Classification
Nootropics Neurotonics
Brand Name Somazine
Therapeutic action Activates the biosynthesis of structural phospholipids in the neuronal membrane, increases cerebral metabolism and increases the level of various neurotransmitter s, including acetylcholine and dopamine.
Dose/ Route/ Timing 500 mg 1 cap BID PO
Indication( s) Cerebrovascular disorders
Contraindication and caution
•
•
Hypersensitiv e to drug Hypertonia of the parasympathe tic
Nursing considerations
Adverse effects
•
• • • • •
Transient headaches Stomach pain Diarrhea Hypotension Tachycardia Bradycardia
•
•
•
May be administered with or without food. (Take w/ or between meals.) Inform the patient that she may experience the said side effects It must not be administered in conjunction with medicaments containing meclofenoxate (also known as clophenoxate).
DRUG STUDY Drug Name simvast a-tin Brand Name Zocor
Classifica tion
Therapeutic action
HMG-CoA reductase inhibitor
Inhibits HMG-CoA reductase, an early (and rate-limiting) step in cholesterol biosynthesis.
Antihyperlipidemic
Dose/ Route/ Timing 20 mg 1 tab OD At HS (8PM) PO
Indication(s)
To reduce risk of CV events, including stroke, TIA
Contraindication and caution
•
Contraindicate d in patients hypersensitive to drug and in those with active liver disease or condition that causes unexplained persistent eleva-tions of transami-nase levels.
Adverse effects
• • • •
• • •
Headache Flatulence Diarrhea Abdominal pain Cramps Constipa-tion Nausea
Nursing considerations
•
•
• •
•
Ensure that patient has tried a cholesterollowering diet regimen for 3-6 months. Before beginning therapy. Obtain liver function test result at start of therapy and then periodically. Give in the evening Inform the patient that she may experience the said side effects. Report severe GI upset, changes in vision, unusual bleeding or bruising, dark urine or light-colored stools, fever, muscle pain, or soreness
DRUG STUDY Drug Name Mannitol
Classifica tion
Therapeutic action
Osmotic diuretic agent
Increase the osmotic pressure of the glomerular filtrate thereby inhibiting reabsorption of H2Oand electrolytes and causes excretion of water, sodium, potassium, chloride calium, phosphorus, magnesium, urea, and uric acid.
Dose/ Route/ Timing 20% 75 cc Every 6 hours
Indication(s)
•
•
Cerebral edema To prevent ↑Intracranial Pressure
Contraindicati on and caution Hypersensitivity ; anuria, dehydration; & active intracranial bleeding.
Adverse effects
Confusion, headache, blurred vision, rhinitis, transient volume. Expansion, chest pain, CNF, pulmonary edema tachycardia, nausea, thirst, vomiting, renal failure, urinary retention, dehydration, hyperkolena, hypernatremia, hypokalemia, hyponatremia.
Nursing considerations
Observe infusion site frequency for infiltration; extravasation may cause tissue irritation and necrosis Do not administer electrolyte-free mannitol solution with blood; if food must be administered spontaneously with mannitol; and at least 20 mEq NaCl to each liter of mannitol IV: Administer by IV infusion undiluted; if solution contains crystals warm bottle 1 hot H2o & share vigorously; do not administer solution in w/c crystals remain undissolved; cool to body temperature; use an in-line filter for 15%, 20% and 25% infusions.
•
•
•
DRUG STUDY Drug Name
Classifica tion
Therapeutic action
Tranexa mic acid
Fibrinolytic Inhibitor
Forms a reversible complex that displaces plasminoge n from fibrin resulting in inhibition of fibrinolysis; it also inhibits the proteolytic activity of plasmin
Brand name Cyklokap ron
Dose/ Route/ Timing 1 gm IVTT Every 8 hours
Indication(s)
Contraindicati on and caution
• •
Treatment of excessive bleeding resulting from systemic or local hyperfibrinoly sis
Acquired Chromatopsia
Adverse effects
• • • •
•
Subarachnoid Hemorrhage
• •
Diarrhea, Nausea, Vomiting Blurred Vision, Hypotension, Local infiltration
Nursing considerations
•
•
Tell the patient that he may experience the said side effects Report any signs of bleeding or myopathy, vision changes; GI upset usually disappears when dose is reduced
NURSING CARE PLAN #1 Cues Objective Cues:
Nursing Diagnosis
Ineffective Cerebral Tissue Slurred Perfusion speech related to Right-sided alteration weakness of noted Cerebral Disorientation arterial to time noted blood flow Loss of ability to perform purposeful movements
Outcome Identification Short Term Goal
•
•
•
•
Nursing Interventions Independent: •
At the end of 8 hours of nursing interventions, the patient will be able to maintain usual level of consciousness, cognition, and motor and sensory function.
•
•
Monitor vital signs noting hypertension and hypotension.
Monitor neurological status frequently and compare with baseline; Glasgow Coma Scale.
Assess for restlessness and irritability
Rationale
Goal met. After 8 hours of nursing Fluctuations in intervention, the pressure may occur because of patient was able to maintain cerebral pressure usual level of in the vasomotor consciousness, area of the brain cognition and motor and Assesses sensory function trends in level of as evidenced by consciousness the absence of and potential for further increased ICP deterioration of and is useful in neurologic determining status. location, extent, and progression of CNS damage. •
•
This might be a sign of hypoxia •
Promotes circulation/venou s drainage •
•
Elevate HOB and maintain head/neck in midline or neutral
Evaluation
position •
•
•
Maintain bed rest; provide quiet environment, limit visitors and activities as indicated. Provide rest periods between care activities, limit duration of procedures. Review specific dietary changes/restrictions with client emphasizing decreased sodium and fat and increased fluids and fiber.
Collaborative: Administer medications as indicated: •
Continual stimulation can increase intracranial pressure. Absolute rest and quite may be needed to prevent rebleeding in the case of hemorrhage. •
Neuroprotective agents
Imidapril – 10 mg 1tab OD •
•
•
To prevent exacerbation of symptoms and constipation
Blocks Angiotensin converting enzyme thereby reducing blood pressure and limiting ischemic injury.
NURSING CARE PLAN #2 Cues Subjective Cue: “ Maglisud sya ug lihuk ug sya ra usa“ as verbalized by the Patient’s wife. Objective Cues: Limited range of motion on the right affected extremities Loss of ability to execute purposeful motor act on both upper and lower right extremities Right -sided weakness noted Unequal hand grasp noted •
•
•
•
Nursing Diagnosis
Outcome Identification
Impaired Short Term Goal physical Mobility At the end of 8 related to hours of nursing neuromus interventions, the cular patient will be able to maintain involveme nt optimal position secondary of functions as to evidenced by underlyin absence of g contractures and pathologic foot drop. process
Nursing Interventions
Rationale
Independent: •
•
•
•
Assess functional ability or extent of impairment initially Observe affected side for color, edema or other signs of compromised circulation Begin passive range of motion exercise to right affected extremities Prop extremities in functional position: use of foot board during the period of flaccid paralysis
Identifies strengths or deficiencies and may provide information regarding recovery •
Edematous tissue is more easily traumatized and heals more slowly •
Minimizes muscle atrophy, promotes circulation and helps prevent contractures •
Prevent contractures or foot drop and facilitates •
Evaluation Goal met. After 8 hours of nursing interventions, the patient was able to maintain optimal position of function as evidenced by absence of contractures and foot drop.
and maintain neutral position of head. •
•
•
•
Reposition or turn the client to sides every two hours
Provide client with ample time to perform mobility-related tasks. Encourage adequate intake of fluids/nutritious foods. Involve client and wife in care, assisting them to learn ways of managing problems of immobility.
use when or if function returns
Prevents development of pressure ulcer, muscle strain, and superficial nerve and blood vessel damage •
Enhances selfconcept and sense of independence •
Promotes wellbeing and maximizes energy production •
Enhances commitment to plan, optimizing outcome •
NURSING CARE PLAN #3 Cues Subjective Cue: “Dili kayo me makasabot sa iya ginasulti”, as verbalized by the wife of the patient. Objective Cues: Impaired articulation of words Incomprehensible words from the patient Inability to use facial or body expressions •
•
•
Nursing Diagnosis Impaired verbal communication related to hemorrhagic changes in the brain affecting communication centers
Outcome Identification Short Term Goal
Nursing Interventions Independent: •
At the end of 4 hours of nursing interventions, the patient will be able to establish method of communication in which needs can be expressed appropriately
Rationale
•
•
Assess type/ degree of dysfunction like when the patient has trouble speaking or making self understood
Assist with necessary adaptations to accomplish ADLs. Begin with familiar, easily accomplished tasks Ask client to follow simple commands such
•
Helps determine area and degree of brain involvement and difficulty client has with any steps or all steps of communication process Enhances sense of independence •
Provides for communicatio n needs/ •
Evaluation Goal met. After 4 hours of nursing interventions, the patient was able to establish method of communication in which needs can be expressed appropriately.
as nodding for a yes and repeat simple words/ sentences and pointing to objects that he may need •
•
Provide privacy and equipment within easy reach during personal care activities. Allow sufficient time for client to accomplish tasks to fullest extent of ability. Provide alternative methods of communication such as writing boards. Provide visual clues (gestures and pictures)
desires based on individual situation/ underlying deficit.
Helpful in decreasing frustration when dependent on others and unable to communicate desires •
Reduces confusion/ anxiety at having to process and respond to large amount of information at one time, advancing complexity of communicatio n stimulates •
memory and enhances word association •
•
•
Anticipate and provide for client’s needs. Talk directly to the client, speaking slowly and distinctly. Use only yes or no questions in asking the client then progressing in complex questions Encourage wife or visitors to persist in efforts to communicate with client
Collaborative:
•
Consult with or refer to speech
Client is not necessarily hearing •
impaired and raising voice may irritate the client •
This reduces client’s isolation, promote establishment of effective communicatio n •
therapist
Assesses individual verbal capabilities and sensory, motor and cognitive functioning to identify therapy needs •
NURSING CARE PLAN #4 Cues Subjective Cue: “ Kinahanglan pa sya tabangan kung maligo“ as verbalized by the Patient’s wife.
Nursing Diagnosis Self-Care Deficit regarding bathing/hygiene, dressing/grooming and toileting related to neuromuscular impairment and weakness
Outcome Identification Short Term Goal At the end of 8 hours of nursing interventions, the patient will be able to perform self-care activities within level of patient’s own ability
Nursing Interventions Independent: •
•
Objective Cues: Inability to wash body; dry body Inability to put on/take off necessary items of clothing Inability to get to toilet and carry out proper toilet hygiene
Rationale
•
•
•
Assess abilities and level of deficit (0-4 scale) 3-performing ADL’s related to bathing, dressing and toileting. Assist with necessary adaptations to accomplish ADLs. Begin with familiar, easily accomplished tasks. Maintain a supportive, firm attitude.
•
•
Avoid doing things for client that client can do for self, providing assistance as necessary
Aims in participating or planning for meeting individual needs •
Encourage s client and builds on successes •
The consistency of caregiver provides assurance to the client •
This client may become fearful, it is important for the client to do as much •
Evaluation Goal met. After 8 hours of nursing interventions, the patient was able to perform selfcare activities within his level of own ability as evidenced by the use of his left unaffected hand in cleaning some parts of his body with clean wet cloth and combing his hair.
as possible to maintain self esteem Enhances sense of independence • •
Provide for communication among those who are involved in caring for/assisting the client.
Enhances coordination and continuity of care •
•
Provide privacy and equipment within easy reach during personal care activities. Allow sufficient time for client to accomplish tasks to fullest extent of ability.
Reduces risk of injury and promotes successful functioning. •
•
Review safety concerns. Modify activities/environment.
NURSING CARE PLAN #5 Cues No subjective and objective cues. Risk factors: •
•
Physical immobility : right-sided weakness
Altered metabolic state
Nursing Diagnosis Risk for impaired skin integrity related to altered neuromuscular function
Outcome Identification Short Term Goal
Nursing Interventions Independent: •
At the end of 8 hours of nursing interventions, the patient will be able to demonstrate behaviours and techniques to prevent skin breakdown.
Rationale
•
•
Inspect all skin areas, noting capillary blanching/ refill, redness, swelling.
Change position in bed on a regular schedule (every 2 hours). Encourage continuation of regular exercise program, passive range of motion exercises on the right extremities and active range of motion exercises on the
Skin is especially prone to breakdown because of changes in peripheral circulation, inability to sense pressure •
Enhances coordination and continuity of care •
Stimulates circulation, enhancing cellular nutrition/ oxygenation to improve tissue health •
Evaluation Goal met. After 8 hours of nursing interventions, the patient was able to demonstrate behaviours and techniques to prevent skin breakdown as evidenced by absence of signs of skin breakdown over bony prominences.
left extremities •
•
•
•
•
Elevate lower extremities periodically if tolerated Reposition frequently, whether in bed or in sitting position. Place in prone position periodically. Emphasize importance of adequate nutritional fluid intake Wash and dry skin, especially in high-moisture areas such as perineum. Take care to avoid wetting lining of brace Massage bony prominences gently and avoid friction when moving client
Enhances venous return, reduces edema formation •
Improves skin circulation and reduces pressure time on bony prominences •
To maintain general good health and skin turgor •
Clean, dry skin is less prone to excoriation/ breakdown •
To keep the integrity of the skin at optimal level •
DISCHARGE PLAN Upon discharge, the patient will; Medication
Exercise
Treatment
Strictly adhere to medication regimen specially the prescribed home medications, to wit; Amlodipine 5mg tab @ lunch then HS Imidapril 10mg + 12.5mg tab OD @ breakfast Senna Concentrate 2 tabs @ HS x 1 week Omeprazole 20mg tab daily x 1 week Simvastatin 20mg tab @ HS Have frequent short periods of exercise.
> Safely engage in active and passive range of motion exercises on the affected extremity assisted by rehabilitative personnel as prescribed.
Consult with speech therapist to improve ability to communicate.
Health Teaching
Make sure that follow-up care is adhered to religiously. Given positive reinforcement and emotional support from his family. Be informed about the expected outcome of stroke, and his family should be counselled to avoid doing things for him that he can do.
Observable signs and symptoms
Diet
Spiritual
> Have at least one family member who will be taught how to take blood pressure to enable the family to monitor the patient’s blood pressure at home.
Be able to report, with the help of his family, exacerbation of present signs and symptoms and seek prompt medical attention when deterioration of neurological status is apparent such as loss of consciousness, worsening of posture, severe headache, irritability and restlessness. Be advised to take osteorized food as prescribed with aspiration precaution if nasogastric tube is still in place upon discharge Be reminded to thicken osteorized feeding if gag reflex gradually regains or if there is still residual dysphagia.
> Adhere to a low-sodium, low-fat diet such as avoidance of canned and processed foods, milk and dairy products, and saturated fats from pork and poultry.
-Advise patient not to be discouraged and to have strong faith in God.
PROGNOSIS
Based on the criteria given below, the patient has a GOOD prognosis. Mr. Strokeman’s condition was properly managed and her body responded well with the interventions and medications given to him. GOOD FAIR
POOR
•
•
Response of the patient regarding the presence of pain after its managements.
Physiologic response of the body to the medications.
•
•
•
•
Healing process of the affected organs.
Performance of the daily living of the patient during hospitalization (eating, toileting, daily dressing). Compliance of patient to medication regimen.
Consumption of the patient with nutritious and therapeutic diet.
•
•
Patient’s behavior regarding the health teachings given by the health caregivers and physician.
Ability of the patient to understand and demonstrate the health teachings being given.
EVALUATION Through this case presentation, the group was able to have a thorough understanding of the case of a 60 year old patient with cerebrovascular disease. We could say that our general and specific objectives for the case study were met. We were able to gather a detailed profile of the patient, including the assessment of the patient’s condition throughout our hospital duty, identify the anatomy and physiology of the brain which is the organ involved in CVD; discuss the pathophysiology of CVD in relation to the patient’s clinical manifestations, provide rationale to the physician’s orders, interpret the results of laboratory test and diagnostic procedures, make a study of the drugs prescribed to the patient, design five actual priority nursing care plans, formulate effective discharge plan for the patient, and hypothesize a realistic prognosis based on patients’ response to medical and nursing interventions. Through this case presentation, we were able to develop our nursing skills, knowledge and attitude utilizing the nursing process appropriately which will surely help us to become better equipped as future nurses ready to take on the challenges of our profession in the real world in whatever setting.
