Ischemic Stroke
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 secondleading cause of death after heart h eart disease and is also a big b ig 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
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
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
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
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
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
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
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.
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
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IMMUNOLOGY
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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 c ystic focus noted at the j unction 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 a re unremarkable. No mass/enlarged cervical lymph nodes appreciated.
Remarks:
Left thyroid nodule and cyst.
S/P Right thyroidectomy.
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 wit h surrounding edema in the right inferior frontal and right frontal periventricular areas.
There are small hypodensities on both c apsuloganghenic 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
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.
CV: Hypertension SKIN: Rash and dry skin GI: Diarrhea, abdominal pain and nausea RESPIRATORY: Cough OTHER: Back pain, fever and gout Nursing 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:Metformin Classification: Antidiabetic Agents Drugs:( Adult and pediatric 10 – 16 y.o ) = 500 mg bid/ 250 mg bid Route: Oral
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 b ruising. Other anti-diabetic drugs : Gliclazide, Sitagliptin
Generic name: Baclofen Classification: Muscle relaxant Route: Oral Dosage: 5 mg PO tid for 3 days Therapeutic Actions: Inhibits both monosynaptic and polysynaptic spinal reflexes; CNS depressant Indications: 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
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
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 Therapeutic actions:
Acts mainly as the limbic system and reticular formation; may act in spinal c ord and at supraspinal sites to produce skeletal muscle relaxation
Indications:
Nursing considerations:
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 Therapeutic actions :
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:
Nursing Considerations:
Do not expose solution to low temp crystallization may occur Make sure infusion set contains a filter if giving concentrated man nitol 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 Therapeutic actions:
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
Advise patient that this drug cannot be taken during pregnancy
Patient teachings:
Take drug in the evening Patient may experience these side effects: Nausea, heada che, 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.
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
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
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 consciou s 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,
Due to thrombosis, or embolism, some neurons die because of lack of oxygen and nutrients
Hemorrhagic
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
Cues
Subjective:
Nursing Diagnosis
Outcome Criteria
Nursing Intervention
Rationale
Evaluation
Discharge Planning
Ineffective
Short Term:
Independent:
“ Budlayan siya
Cerebral
After 8 hours of
1. Determine factors
maghulag kag
Tissue
effective nursing
related to individual
maluya na ang
Perfusion
intervention the
tuo nga parti
related to
patient will be able
sang iya lawas.
cerebral
to:
Nabudlayan sya
edema as
maghambal daw
evidenced by
stable vital
neurological status
of consciousness
partially able to:
at the right timing
indi
altered level of
signs.
frequently and
(LOC) and useful in
1. Demonstrate
of intake and
maintindihan.”
consciousness,
2. Prevent /
compare with
determining location,
stable vital
right dosage.
as verbalized by
stiffening of
minimize
baseline.
extent, and
signs.
Explain to
the folk.
extremities,
complications.
progression/resolution
2. Prevent /
3. Daily needs are
of CNS damage. May
minimize
adverse effects of
met either by
also reveal presence of
complications.
the drugs.
3. Daily needs are
slurred speech
1. Demonstrate
Objective:
PARTIALLY
M – Instruct the
Influences choice of
MET
folks and the
interventions.
Short Term:
patient to take
situation /decreased
After 8 hours of
drugs as ordered.
cerebral perfusion.
effective nursing
Emphasize the
intervention the
importance of
2. Monitor/document
Assesses trends in level patient was
taking the drugs
patient/folks the
T – 36.5
himself or
TIA, which may warn
P - 88
others.
of impending
met either by
E –
R - 22
thrombotic CVA.
himself or
Provide/maintain
BP – 180/100
others.
stress free
GCS – 11
Stiffening of
extremities
Slurred
speech
4. Be free from injury and fall 3. Monitor vital signs.
Monitor Alterations
Long Term: After 2 weeks of effective nursing
injury and fall 4. Provide safety
to:
environment for the client to lessen discomfort.
Prevent falls and injury
measures
intervention the patient will be able
4. Free from
5. Evaluate pupils,
noting size, shape,
Long Term:
T – Instruct
Pupil reactions are
After 2 weeks of
patient to perform
regulated by the
effective nursing
exercise treatment
usual/improved
reactivity.
nerve and are useful in
patient was
therapist. Advice
level of
determining whether
partially able to:
folks to assist
consciousness,
the brainstem is intact.
1. Maintain
patient.
cognition, and
Pupil size/equality is
usual/improved
motor/sensory
determined by balance
level of
H – Instruct folks
function.
between
consciousness,
to place patient
parasympathetic and
cognition, and
on moderate
cerebral
sympathetic enervation.
motor/sensory
backrest.
function and
Response to light
function.
Encourage active
decrease
reflects combined
neurological
function of the optic
2.Increased
deficits.
(II) and oculomotor
cerebral
extremities and
(III) cranial nerves
function and
perform passive
decrease
ROM for affected
Changes in cognition
neurological
extremities.
functions, including
and speech content are
deficits.
speech, if patient is
an indicator of
O – Explain to the
alert.
location/degree of
patient and folks
cerebral involvement
the importance of
and may indicate
keeping follow-
deterioration/increased
up appointments
ICP.
with health care
2. Increased
6. Assess higher
ROM for unaffected
providers and to Reduces arterial
report any
slightly elevated
pressure by promoting
untoward signs
and in neutral
venous drainage and
and symptoms.
position.
may improve cerebral
7. Position with head
circulation/perfusion
D – Instruct the patient/folks to
Continual
follow the diet
provide quiet
stimulation/activity can
intended for the
environment;
increase ICP. Absolute
patient. Healthy
restrict
rest and quiet may be
and rich in
visitors/activities as
needed to prevent
vitamins and
indicated. Provide
rebleeding in the case
minerals.
rest periods
of hemorrhage.
Collaborate with
8. Maintain bedrest;
the dietician.
between care activities, limit duration of
S – Encourage
procedures.
folks to provide physical, emotional,
Dependent: Reduces hypoxemia,
financial, and
at 2 Lpm as
which can cause
spiritual support
ordered.
cerebral vasodilation
to the patient.
1. Administer oxygen
and increase pressure/edema formation. 2. Administer the following as ordered: -Baclofen1tab BID
For skeletal muscle
and ValproicAcid
spasticity of spinal
-Mannitol
&cerebral origin
25cc IV q8H
To increase urine flow in patients w/ acute renal failure, reduce raised intracranial pressure & treat cerebral edema.
-Levetriacetam
500mg 1tab OD
Adjunctive therapy in the treatment of partial seizures w/ or w/o secondary generalization.
-Losartan
To manage HTN
To treat
50mg/tab 1tab OD -Citicoline 500mg 1tab BID
cerebrovascular disorders including ischemic stroke, Parkinsonism & head injury.
-Amlodipine 20mg
1tab OD -Simvastatin 40mg/tab 1tab OD
To manage HTN & angina pectoris.
To treatment hyperlipidemia; prophylaxis in hypercholesterolemic patients w/ ischemic heart disease.
