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I. INTRODUCTION
Cerebrovascular disease is a group of brain dysfunctions related to disease 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 notalways complete and perfect. Sustained hypertension permanently changes the
architecture 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 blocked 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; severe
headache with no known cause; fainting or unconsciousness.
The effects of a stroke 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 thesecond leading cause of death after ischemic heart disease.
During the past decade the quantity of especially routine mortality data has
increased, and is now covering approximately one-third of theworlds 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 disease is the leading cause of disability in adults
and each year millions of stroke survivors has to adapt to a life with restrictions in
activities of daily living as a consequence of cerebrovascular disease. Many
surviving stroke patients will often depend on otherpeoples continuous support
to survive.
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II. OBJECTIVES
GENERAL OBJECTIVES
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 thepatient full recovery.
SPECIFIC OBJECTIVES
1. To be able to discuss patients background ( lifestyle, history of the pastillness, family health history) to show how may this effect on the
occurrence of this disease.
2. To be able to discuss the anatomy and the physiology of the heart, foryou to be able to understand where the infection takes place.
3. To be able to discuss the pathophysiology of cardiovascular diseasesand also to know and understand the etiology of the disease.
4. To be able to discuss the patient activities of daily living. To know iftheres a factor that triggers the disease
5. To be able to discuss, nursing care plan for our patient.6.To be able to discuss, the medication / drugs that the patient taken and
the diagnostic test that being perform for the patient.
7. Lastly, to be able to discuss our discharge plan for fully recovery of ourpatient.
III. PATIENTS PROFILE
IV. PHYSICAL ASSESSMENT
GENERAL SURVEY
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Mr. X was lying semi-fowlers on bed, conscious, coherent, afebrile with
monitoring devices.
A. VITAL SIGNSDate Shift Time Temp BP RR PR Intake Output
07/18/09 7am-
1pm
36.8 210/100 58 20
B. HEADPink papillary conjunctiva, no nuchal rigidity and no carotid bruit.
C. NEUROLOGIC 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. PULMONARY SYSTEM-Respiratory rate was 58 cpm
-SCE, no vesicular breath sounds.
-AP, Apical beat at the 6th ICS anterior axillary line normal
sounds.
E. GASTROINTESTINAL SYSTEMFlabby, NaBS, no abdominal bruit, (-) edema,(-) cyanosis.
F. MUSCULOSKELETAL SYSTEM
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The patient manifested good posture and moved
voluntarily; he had symmetrical musculature on both sides of the
body. Weakness was noted.
G. GENITO- URINARY SYSTEMPatient voided 60350 cc per shift as weighed and yellow in
color.
V. LABORATORY AND DIAGNOSTIC EXAMINATION
Laboratory Findings
Laboratory Exam Result Normal Range
July 15, 2009
1. GRAM STAINSpecimen: Sputum
Gram ( - ) coccisingly:
Gram ( + ) cocciShort chain:
Gram ( + ) cocci inlarge chain:
Pus cells: Epithelial cells:
2. URINALYSISMacroscopic
Color: Transparency:Microscopic
RBC: Pus cells: Bacteria: Epithelial cells: Mucus threads: Amonphous unates:
3. HbAlC:4. Glucose:5. LIPID PROFILE
Cholesterol: Triglycerides:
Few
Few
Few
2-4/010
+1
Light yellow
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HDL cholesterol: LDL cholesterol: Na: K: Ca:
Cl: SGPT:
6. HEMATOLOGY PT: Control: INR:
7. CHEMICAL ANALYSIS S.G: pH:
nitri: protein: glucose: ketone: urobilinogen: bilirubin: blood: leukocyte:
SL. Turbid
4-6/HPF
0-2/HPF
Few
Few
Few
Few
12.2%
7.36mmol/L
5.10mmol/L
0.70
1.24
3.54
137
4.3
1.36
98
41U/L
7.26.24.226.11
Male: up to
40U/L
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15.31
14.1
1.35
1.010
6.5
( - )
( - )
( - )
( - )
( - )
( - )
+1
( - )
Female: up to
31U/L
1215sec
July 16, 2009
5:30 am
1. Capillary BloodGlucose:
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2. Head CT scan: 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 corticalatrophy is
demonstrated
-rest of the findings
are unbreakable.
80120mg/dl
July 17, 2009
Na: K: Ca: Cl:
137
4.3
1.33
100
138-146
3.6-5.0
1.15-1.29
96-110
VI. ANATOMY AND PHYSIOLOGY
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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 thecerebral cortex, white matter, and basal ganglia).
The diencephalon generates the thalamus, hypothalamus, and pinealgland.
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 thebrain stem
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Figure 1 The four divisions of the adult brain.
The cerebrum consists of two cerebral hemispheres connected by abundle of nerve fibers, the corpus callosum. The largest and most
visible part of the brain, the cerebrum, appears as folded ridges and
grooves, called convolutions. The following terms are used to describe
the convolutions:
A gyrus (plural, gyri) is an elevated ridge among theconvolutions.
A sulcus (plural, sulci) is a shallow groove among theconvolutions.
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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. Suchactivities as speech, evaluation of stimuli, conscious thinking,
and control of skeletal muscles occur here. These activities aregrouped into motor areas, sensory areas, and association
areas.
The cerebral white matter underlies the cerebral cortex. Itcontains 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 tract
that connects the two cerebral hemispheres.
Basal ganglia (basal nuclei) are several pockets of gray matterlocated deep inside the cerebral white matter. The major
regions in the basal gangliathe caudate nuclei, the putamen,
and the globus pallidusare involved in relaying and modifying
nerve impulses passing from the cerebral cortex to the spinal
cord. Arm swinging while walking, for example, is controlled
here.
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 impulsestraveling from the spinal cord to the cerebrum. Some nerve
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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 glandsecretes 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 optic chiasma passes between the hypothalamus and thepituitary gland. Here, portions of the optic nerve from each eye
cross over to the cerebral hemisphere on the opposite side of
the brain.
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 2 Prominent structures of the brain stem.
The midbrain is the uppermost part of the brain stem. The pons is the bulging region in the middle of the brain stem.
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The medulla oblongata (medulla) is the lower portion of thebrain stem that merges with the spinal cord at the foramen
magnum.
The reticular formation consists of small clusters of gray matterinterspersed 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 range ofareas of the brain. The limbic system imposes an emotional aspect to
behaviors, experiences, and memories. Emotions such as pleasure, fear,
anger, sorrow, and affection are imparted to events and experiences. The
limbic system accomplishes this by a system of fiber tracts (white matter) and
gray matter that pervades the diencephalon and encircles the inside border
of the cerebrum. The following components are included:
The hippocampus (located in the cerebral hemisphere) The denate gyrus (located in cerebral hemisphere) The amygdala (amygdaloid body) (an almond-shaped body
associated with the caudate nucleus of the basal ganglia)
The mammillary bodies (in the hypothalamus)
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Modifiable factors:
Smoking
Ingesting fatty foods
vasospasm
Embolus that
dislod e
Increase oxygen
demand
Decrease oxygen
supply in the blood
Inadequate blood perfusion
The anterior thalamic nuclei (in the thalamus) The fornix (a bundle of fiber tracts that links components of the limbic
system)
VII. PATHOPHYSIOLOGY
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Cell injury and death
Motor, sensory, cranial nerves
disrupted
Cerebrovascular
disease
Dizziness, stiffening of
extremeties, and non projectile
vomiting
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 and decrease
oxygen supply in the blood. Because of inadequate blood perfusion it leads to
brain cells injury and death, at this point neurons are no longer able to maintain
aerobic respiration that caused to produce neurological dysfunction.
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VIII. COURSE ON THE WARD
Date/Shift Approach/Intervention
07/14/09 - Admitted a 66 y/o male with the chief complaint of
body weakness and vomiting and fetched in a
stretcher
3-11 - routine care done- S/C ERMEOD Dr. Anluete, and MROD Dr. Solero,
MIOD with made and carried out
- hooked to O2 inhalation with 2-3 LPM via nasal
cannula
- hooked to cardiac 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
- Meds: nicardipine drip(D5W 90cc+ 1 amp
nicardipine) @ 5ugtts 10 ugtts @ 3:10 pm; zantac 1
amp given @ 3:20 pm
- FC inserted connected to urobag
- mannitol 75mg x 1st dose
- UO drained- 1000cc
- fixed and brought to room of choice
- endorsed
5:00pm - received patient on bed awake via stretcher
accompanied
ERMEOD, transferred to bed safely
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- on NPO except meds
- with ongoing IVF of PNSSL @ 750 cc level regulated
@ 10gtts/minand SD nicardipine 10mg + 90ml of D5W
reg. @ 10gtts/min infusing well and hooked to infusion
pump @ 5:20pm
5:30pm - hooked to cardiac monitor and pulse oximetry
- with NGT connected to bedside bottle
- with the ff. labs: cranial CT scan-TF and CBG
@5:30pm
- urinalysis-TF as endorsed
- BUN, Creatinine, HDL, HBA1C, FBS, TL, TC, LDL, HDL,
PROTiME
6;00pm - S/E by Dr. Somson-Crux with orders made and
carried
Out
- nexicum 40mg tab OD
- refer to Dr. Soccom Rosales for Co. Mgt. Dr. Solero
informed
- for sputum AFB 3x; GS/CS with SB
- initial V/S T:36.4 C, HR:68, RR:28, BP:180/90mmHg
- with the ff. meds mannitol 75cc x 3doses started @
ER;
Nexicum 40mg OD; olmesartan 30mg tab OD;
liticolin
TID given
9:00pm - on CBR without BPR
- seen and examined by Dr. Martinez with orders
meds and carried out
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- clopidogel 5 tabs stat then OD given
- for 2Decho with Doppler- to request AAC
10:25pm - shift citicoline drops to IV as ordered by Dr. Solero
- adequate UO
- V/S q hour, medicine clerk informed
- no complaints
- needs attended
- endorsed
11-7 - flaccid patient on bed
- with IVF of PNSSL @ 650 level q 6hr
- with nicardipine hold
- on NPO except meds
- assess; BP 170/100
- O2 @ 2LPM via nasal cannula
- on CBR without BPR
- on CTscan-TF
- urinalysis, creatinine
- for sputum AFB
- for sputum GS/CS
- CBG monitoring q 12
- for FBS, hemoglobin,A1C
- V/S taken and recorded
- due meds given
- above IVF hooked and consumed @ same rate
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- (-) BM
- needs attended
- endorsed
07/15/09
7-3 - received patient ongoing PNSS with sameregulation and rate; afebrile
- with O2 @ 2LPM connected to nasal cannula
- with NGT intact
- with CBG monitoring q 12
- for sputum AFB
- for 2Decho with Doppler
- BP: 130/90 mmHg
- endorsed
Addendum - start feeding AP order
- for SGOT
- (-)gag reflex
3-11 - received patient on bed with ongoing IVF of PNSSL
- with NGT to start of 1600 kcal in feedings, DM diet
- with O2 inhalation @ 2LPM via nasal cannula
- with FC to urobag
- with CBG monitoring
- for 2Decho with Doppler
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- sputum GS/CS-TF
- still for sputum AFB
4:30pm - S/E by Dr. Martinez, orders were made and carried
out
- start dilantin suspension, to load 12ml x 6doses q 4
then
4ml q 6
- for repeat scan (plain) on Thursday to reg. AAC
5:00pm - dilantin 100mg IV given slow push
7:30pm - s. electrolytes and SGPT result in referred to Dr. Simon
- due meds given
- refer prn
- no BM, afebrile
- endorsed
11-7 - received patient on bed- with ongoing IVF PNSS @ level of 100cc regulated @21gtts/min
- on 1600kcal feedings DM diet
- sputum GS/CS-TF
- CBG monitoring q 12
- for sputum AFB
- for repeat plain CTscan
1;15am - above IVF consumed and hooked same IVF and
rate
- V/s taken and recorded
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- due meds given
- I&O monitored and recorded
- no BM, afebrile
- refer prn
- needs attended
- endorsed
07/16/09
7-3 - received patient lying on bed
- with ongoing IVF PNSS with same reg. and rate
- afebrile, BP: 100/70mmHg
- with NGT intact
- with O2 @ 2LPM via nasal cannula
- for sputum AFB x 5 days
- for 2Decho
- needs attended
- endorsed
3-11 - received patient awake on bed- with ongoing IVF PNSS reg. @ same rate
- with FC connected to urobag
- with OF 1600kcal; 6 feedings
- for 2Decho
- for sputum GS/CS
- on CBR without SBR
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- repeat CTscan plain-TF
- due meds given
8;00pm - (+) restlessness- MROD endorsed to give
Diphenhydramine 1 amp- given as ordered
9;30pm - Dr, Martinez made rounds with new order made to
Carried out
- if no restless until tomorrow may TROC, if (+) restless
@ 11pm, to give rizomil 2mg tab sat
- dilantin 125mg/5ml was freq. @ q 8- carried out
- V/S monitored and recorded
- I&O monitored and recorded
- needs attended
- endorsed
07/17/09
7-3 - received on bed with ongoing PNSS IVF @ 250cclevel With same reg.
- afebrile, BP: 130/70mmHg
- repeat CTscan (plain)
10:35am - due meds given
- possible TPOC
- BP: 140/80mmHg
- endorsed
3-11 - with NGT, OF 1600kcal feedings
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- for sputum GS/CS
- for CTscan-TF
- V/S taken and recorded
07:00pm - (+) restlessness; refer to Dr. Solero
- diazepam 5mg given
- for CBG and Creatinine
- seen from time to time
- I&O monitored and recorded
- V/S taken and recorded
- refer prn
- endorsed
11-7 - received patient lying on bed, asleep- with IVF PNSS @ 900cc
- with cardiac monitoring q 12
- with NGT, OF 1600kcal and 6 feedings
- with 02 @ 2LPM via nasal cannula
- on CBR without BPR
- T:36.5C, HR:53bpm, RR:20cpm BP:130/70mmHg
- with FC connected to urobag
- still for sputum AFB
- for 2Decho
- repeat CTscan plain-TF
- due meds given
- morning care done
- (-)BM, afbrile
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- needs attended
- endorsed
07/18/09
7-3 - received patient on bed- with IVF PNSS @ 520cc level with same reg.
- afebrile, BP: 130/80mmHg
- with patent NGT
- with FC connect to urobag
- 2Decho
- sputum GS/CS
- due meds given
-endorsed
IX. NURSING CARE PLAN
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XI. DISCHARGE PLANNING
M- Instructed immediate relatives to facilitate the patient to continue takingthe drugs given to her on the right time and with the right dose to facilitate
continuity of care.E- Encouraged immediate relatives to facilitate regular exercise such as briskwalking but not making herself too much tired.
-Encouraged her not to carry heavy loads and do not force herself too much in
doing household chores. Encouraged patient to limit number of hours in playing
domino.
T- encouraged patient to have enough rest and comply to the physicianswhen ever health problems occur
H-Encouraged and explained to her the benefits and advantages of properhygiene to promote wellness.
O- instructed patient to come back for follow up check up on the dateordered.
D- advised patient to eat nutritional foods like fruits and vegetables. Eat a wellbalanced diet. Instructed patient to limit eating foods high in fats and with
cholesterols. And also avoid salty foods.
S- Encouraged pt to continue her habits in going to church every day andalways seek God helps when ever problems occur.
XII. DEVELOPMENTAL TASK