Introduction

Strokes can be either ischemic or hemorrhagic. In an ischemic stroke, the blood supply to part of the brain is cut off because atherosclerosis or a blood clot has blocked a blood vessel. Blood clots can travel to the brain from another artery (artery-to-artery embolization) or they can come from the heart (cardioemblic stroke). Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 3040% of all ischemic strokes. Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Ischemic strokes can be caused by a blockage anywhere along the arteries feeding the brain. The blockages can occur for a variety of reasons, including:

the buildup of fatty material (atheroma) along the walls of an artery, which reduces blood flow; breaking off of atheroma from the artery wall. The material can flow with the blood and become stuck in a smaller artery, causing a blockage; blood clots that break loose from the heart or one of its valves, known as an embolus. The clot can travel up the arteries to the brain and lodge there, causing an embolic stroke or cerebral embolism. This type of stroke is most common in people who have recently had heart surgery and in people who have defective heart valves or abnormal heart rhythms (especially atrial fibrillation);

 inflammation or an infection that narrows blood vessels that lead to the brain; drugs, such as cocaine and amphetamines, which can also narrow the blood vessels.

A sudden drop in blood pressure. Although a sudden drop in blood pressure usually causes a person to faint, it can lead to a stroke if it is severe and prolonged. This can occur when someone loses a lot of blood from an injury or during surgery, has a heart attack or has an abnormal heart rate or rhythm. (Cedars-Sinai, 2014) According to World Health Organization estimates, 5.5 million people died of stroke in 2002, and roughly 20% of these deaths occurred in South Asia. Stroke was the second most frequent cause of death worldwide in 2008, accounting for 6.2 million deaths (~11% of the total). Approximately 17 million people had a stroke in 2010 and 33million people have previously had a stroke and were still alive. Between 1990 and 2010 the number of strokes decrease by approximately 10% in the developed world and increased by 10% in the developing world. Overall two thirds of strokes occurred in those over 65 years old. Every year, more than 795,000 people in the United States have a stroke. (World Health Organization). In the Philippines, it is the most common with 70% of cases. Hemorrhagic stroke accounts for 30% of cases in the country. It is when the blood vessel bursts. (Dr. San Jose, 2010) In Tagum City, 30% most common cases. Our group choose to study this case to gather and improve our knowledge regarding on stroke particularly the ischemic stroke. Nowadays, this is the most

common case we usually encountered even during our duties in the hospital. Furthermore, on our community service we met a patient suffering from ischemic stroke. We aim to help our patient by giving factual information which could help him live better and to prevent further complications. This could also help us, presenters to familiarize this condition and give good nursing interventions if we encountered the same patient next time around.

GENERAL OBJECTIVES This is a case study that aims to educate a patient and to be able to demonstrate relative nursing management regarding Cerebrovascular Accident. SPECIFIC OBJECTIVES gather the biographical data of the client; to identify the chief complaint of the client; gather the history of present illness, past medical history, family history and socio-economic history of the client; trace the developmental task according to Erickson, Freud and Piaget; perform physical assessment to the client using the methodical head-to-toe format; review the anatomy and physiology of the involved organs and systems; trace the pathophysiology of the disease/illness; formulate nursing care plans; identify the medications that the client is taking; present conclusions about the clients condition; present recommendations about the clients condition; and present evaluation regarding this case study.

ASSESSMENT A. Biographical Data

Name: Age: Address: Birthdate: Birthplace: Religion: Ethnicity: Marital Status: Occupation: Source of Interview:

Mr. L 61 years old Purok Sunshine, Visayan Village, Tagum City February 17, 1952 Compostela Valley Province Roman Catholic Bisaya Married Self-employed Client

B. Chief Complaint Mr. L was complaining of headache, dizziness, blurry vision and body pain. C. History of Present Illness While on the work, Mr. L has been experiencing body pain, headache and blurry vision followed by dizziness. Mr. L was brought to the hospital

accompanied by his wife and was admitted there for three days last 2008. Other than that, Patient L was diagnosed of Diabetes Mellitus last 2005 when he had his check-up and Anxin and Gibenclamide.

D. History of Past Illness Mr. L had experienced childhood symptoms such as fever, cough and colds. He has no allergies to foods or in dust as what she stated. About her immunizations, he stated that he was not sure about it if he had completed it. Mr. L usually takes over-the-counter drugs when having those symptoms as selfmedication.

E. Personal, Family and Socio-economic History Personal History Mr. L was born in Comval Province on February 17, 1952. He was 61 years old, a Filipino citizen, married and has 5 children. He lives with his family and currently residing at Purok Dahlia, Visayan Village, Tagum City. He was admitted at the hospital last 2008 with a chief complaint of headache, dizziness, body pain and blurry vision. He was discharged three days after admission. Family History Mr. Ls grandparents on both sides were already died. Mr. Ls father h ad died due to hypertensive while his mother is alive and well. Also, one of his

relatives on fathers side had her cerebrovascular accident that was bedridden for almost 5 years and other than these, there were no reported illnesses within his family and relatives. Mr. L was the third child in their family with 2 sisters and 2 brothers but their youngest died; the rest of them were all alive and well. Socio-economic History Mr. L is only a high school graduate and never proceeds to college. He had his small business which is a General Merchandise. Mr. Ls family source of income was his small small business which gains an estimated of Php. 400.00 per day and the income of his child who is working abroad. He and his family were baptized as Roman Catholics. They regularly attend Sunday masses and novenas together. With minor symptoms such as fever, cough and colds, selfmedication is applied. Although they seek the advice of their physician, they also believe in albularyo and manhihilot. F. Nutritional History Mr. L usually eats meals three times a day since they can sustain and provide their needs. According to Mr. L, they usually have their stack of food such as fish and pork and only sometimes eat vegetables. According to Mr. L, he smokes and drinks alcoholic beverages during occasion or events that even until now Mr. L still drinks and smokes but rarely and stated that he couldnt stop taking it. The source of their water is through station. delivery from dumoy water

FAMILY GENOGRAM Paternal Side Narciso Elisa Maternal Side Simo

Wennie

Nitoy

Noli

Luz

Lucy

Joy

Bolina

Bong

Totong

Don

Ramon

Nida

Mr. L

Mario

Rissa

LEGEND Male Hypertension Alive and well Deceased Female Stroke

DEVELOPMENTAL TASK

ERIK ERIKSONs PSYCHOSOCIAL THEORY

Stage/ Age Actual findings Interpretations Justification

Trust vs Mistrust

As what his mother At this stage, patient L During this stage the told him, Patient L had develop a sense infant is uncertain

(Infancy- birth to 18 likes months)

sucking

his of trust to his parents about the world in to his which they live. To resolve these feelings uncertainty the

thumb. He keeps on especially crying when he feels mother. pain, hungry

and Based on the actual of

doesn't get what he findings,

patient infant looks towards their primary

wants. Besides of his achieved this stage. personality shown, he still cared by his

caregiver for stability and consistency of

parents and provided the things he needed.

care.Children develop a sense of trust when caregivers reliability, provide care and

affection. A lack of this will lead to

mistrust. During this stage the When he was almost child should develop 2 y/o, his mother told

him

that

he

was Based on the actual virtue of hope. patient L During this stage the child needs sense to of

trained to walk with findings, Autonomy vs Shame assistance and Doubt (of

his achieved this stage. develop

mother). At this age, he was the one who personal control over

(Early

Childhood choose

of

what physical skills and a sense of

18months to 3 y/o)

clothes he wants to wear. He was fond of independence. playing According toy to cars. Success leads to the his feeling of autonomy, mother, he let patient failure L to play around. feeling of shame and doubt. During this stage the child should develop virtue of will. results in

At the age of 3 years old he likes to play with their neighbors like playing outdoor activities such as hide Based on the actual and seek, and findings, patient L

"dakpanay", as what achieved this stage. Initiative vs Guilt her mother said. He enjoys ( Preschool 3-5 y/o) his neighbors. playing with In this stage, the child needs to begin

childhood

asserting control and

10

power .

over

the

environment. Success to this stage leads to a sense of purpose. Children too who exert power

much

experience disapproval, resulting in sense of guilt. If parents are but in

encouraging, consistent

discipline, children will learn At this stage, Patient without L was encouraged by certain things are not his parents and allowed, but at the teachers to study hard same time will not feel as well as to shame participate in joining Based on the actual their imagination and activities school. Industry vs Inferiority ( School age 6-12 y/o) According during days, his his to him, Virtue of purpose. primary always in their findings, the patient engaging achieved this stage. believe role plays. in makewhen using guilt, that to accept

11

interact

with

his

During teachers

this

stage, an

classmates.

play

increased role in the childs development. If children encouraged reinforced for are and their

initiative, they begin to feel industrious and feel confident in their ability to achieve

goals. If this initiative is not encouraged, if it is restricted or by

parents

teacher,

then the child begins to feel inferior, his own

doubting In this stage, Patient L was confused about the things in he his

abilities and therefore may not reach his potential. Child needs to cope

perceived

environment such as with new social and smoking and drinking. Based on the actual academic At the age of 15, findings patient L Success leads to a demands.

12

Identity confusion

vs

Role Patient L tried to take achieved

this sense of competence, while failure results to feelings of inferiority. Virtue of

those things for him adolescence stage. not be ignorant

( Adolescence 20y/o)

12- though he knows that it is not right doing as competence. a teenager. He was scolded by his mother about his doing and understands side. their During this stage,

development depends on what is done to a person. At this point, development depends now primarily

upon what a person does. An adolescent must struggle to

discover and find his Patient committed relationship with the opposite sex. At the age of 28, he got married and they live together marriage. after their L had or her own identity, while negotiating and struggling with social interactions fitting in, and and

developing a sense of morality and right

from wrong. Based on the actual Those unsuccessful

13

findings,

patient

L with this stage tend to experience confusion upheaval. Adolescents begin to develop affiliation devotion to a strong and ideals, role and

Patient L was married achieved this young Intimacy vs Isolation for almost 30 years Adulthood.

( Young adulthood 18- and they have already 30y/o) 5 children. He seems happy with his family and they are

supporting each other in times of difficulties in life especially when Based on the actual

causes, and friends.

he was suffering from findings, the patient During stroke. Generativity Stagnation (30 y/o to 65 y/o) vs. achieved this stage.

this

stage,

young adult need to form inmate loving

relationship with other people. leads to Success strong while tin and

relationship failure results

loneliness isolation.

In this stage, adults need to create or

nurture things that will outlast them, often by having a children or

14

creating

positive

change that benefits with other people. to

Success

leads

feeling of usefulness and accomplishment, while failure results in shallow involvement

in the world.

JEAN PIAGETs COGNITIVE THEORY

Stage/ Age Sensory-Motor

Actual Findings

Interpretation

Justification In this stage, infants progressively construct knowledge

As what his mother Based on the actual patient L

Stage: Birth through told him, he was a findings, 2 y/o

breastfeed child. He achieved the sensoryalways sucks his motor stage.

and understanding of the world by

thumb. He cries when he was hungry or in pain. He always

coordinating experiences (such as

15

grasps

the

objects

vision and hearing) with interactions objects grasping, (such physical with as

nearer to him. He was weaned turned 2. when he

sucking,

and stepping). Infants gain knowledge of the world from these

physical actions they perform within it. They progress reflexive, from instinctual

action at birth to the beginning of symbolic thought toward the

end of the stage.

The

child

in

pre-

operational stage is not yet able to think As what his mother Based on the actual logically. Pre-operational (2-7 years) told him, when he findings, wants something he achieved patient the L acquisition prelanguage the child is can definitely get it. operational stage. able to represent the His mother also notice world trough mental of With the

16

that his playing and talking without And any he

images and symbols, but in stage, these symbols depend on his own perception

playmates.

always ask question in the things and

and his intuition. The preoperational child is completely egocentric.

happening him.

surround

This

stage

begins when the child is able to perform mental During According to him, he children was starting to make Based on the actual reason logically, and Concrete Operations some excuses to his findings (7-12 years) the patient organize parent. He was able achieved this stage. coherently. However, to solve simple they can only think mathematical about actual physical problem. objects, and cannot handle abstract thoughts begin to operations. this stage,

reasoning. This stage is also characterized by a loss of

17

egocentric thinking.

The

formal

operational stage is characterized by the ability to formulate and test

hypotheses systematically

them to arrive at an answer to a problem. According to him, The individual during this time he Formal Operations 11 years to adulthood can

solve Based on the actual in the formal stage is patient L also able to and think to

mathematical problem findings,

even it is difficult. And achieved this formal abstractly he also develop the operational stage. sense of arguing.

understand the form or structure of a

mathematical According to Mr. L, as a father he always looks up to his Another characteristic of the individual ability to is their reason problem.

children especially in times of problems and decision making. His opinion is very

contrary to fact.

important in the family

18

and most of the time it was followed.

SIGMUD FREUDs PSYCHOSEXUAL THEORY

Stage/ Age Oral Stage (Birth to 18 months)

Actual Findings

Interpretation

Justification

During this stage, he Based on the actual During this stage, the was breastfeed and findings the patient child is focused on often feed through achieved this stage. oral pleasures

bottle. As what his mother said that

(sucking). Too much or too little can an oral

when his hungry, he will sucks his thumb. He was weaned

gratification result fixation. in

when he turned 2.

At this stage, Patient Anal Stage (18 months to 3 y/o ) L was trained by his Not achieved mother way of the proper The anus is the

primary

erogenous

elimination

zone and pleasure is derived controlling and from bladder bowel

and had control his bodily needs.

19

movement.

The

major conflict issue during this stage is toilet training. A

fixation at this stage can result in a

personality that is too rigid or one that is too disordered. Patient L had these Phallic Stage (3-6 years old) feelings of wanting to In possess the mother Based on the actual center of desire is the and the desire to findings, patient L genital. replace the father, as achieved this stage. development occurs verbalized by his at this stage due to mother. But later on the he realized that his Electra mother have no penis Freud believed that a like him. boy would have complex. Oedipus and Gender this stage, the

natural love for his mother up until this stage, but as the

pleasure focus at this stage is the genital region, it was

20

inevitable

that

this

love would become sexual.

Whilst these sexual feelings were in the unconscious, a

young boy would see his father as a rival standing in his way, and would therefore feel feelings of and his

aggression hatred father. Patient L mingles towards

with his friends as he enters the school. He Latency Stage (6 years old is interested in

Children at this stage will form healthy

same-sex friendships

to playing basketball or Based on the actual at school, and will other activities that findings, the patient start to focus on involves in sports and achieved the latency he enjoys stage. their school life and sport. Fixation is not possible at this stage,

puberty)

participating in their school activities.

21

as

there

is

no

pleasure focus. According to him, he got a relationship Through the lessons with opposite sex learned Genital Stage Puberty to adulthood when he was in high previous school. Based on the actual adolescents Pt. L was married to findings, patient L their sexual urges to his wife for more than achieved the genital the 30years already and stage. peers he was happy living primary focus is the with his family. He genitals. was a good husband and caring a warm father. and He with the opposite sex direct stages, during the

balanced his time for his work and family.

22

23

Physical Assessment General Survey Patient L is a 61 years old male. The patient is conscious, oriented and is responsive during examination.

Vital Signs are taken last January 14, 2014, 10:00 am and as follows: Temperature: 37.2 OC RR: 21 cpm PR: 82 bpm BP: 180/100 mmHg

Interpretation The vital signs of the patient are recorded as normal since it is within normal range except for the blood pressure taken; it is above the normal range. Review of the System Physical Assessment is a part of a health assessment representing a synthesis of the information obtained in a physical examination. It involves the detailed examination of the body from head to toe using the techniques of

observation/inspection, palpation, percussion and auscultation. Upon assessment, instruments and equipment are also used such as

sphygmomanometer, stethoscope, thermometer, tuning fork, and penlight. We made every effort to make sure that the client is comfortable and is responsive during the conversation.

24

Assessment

Normal Findings

Actual Findings

Interpretation

Neurologic Status

Inspection

Alert and Conscious

Patient is able to think The and awake. He

level

of of

is consciousness

oriented to time, place patient is oriented and and date; He's able to he is also responsive. follow instructions and is cooperative during the assessment.

No Speech Defects

Have contact

eye

to

eye He

has

a but

good in a

during

the language Hes slow

examination.

pace

during

using clear words but conversation. in slows pace and understands what we are saying. Integumentary System Skin - Generally intact with The patient's skin was Based on its actual

25

Inspection

smooth texture

observed

laceration findings, the patients

- evenly colored skin with pus on his calf, skin as part of the tone without unusual abrasion on his right integumentary system discoloration - no rashes arm, edema on both was feet, even hematoma found seen Palpation - Temp: 36.5 37 OC Skin moist on his findings. It's Pus in the wound or indicates observed and

abnormal

extremities.

and temperature is 37.2 laceration

O

pinches easily - No edema

C.

infection. Also edema is a decrease in skin mobility caused by an accumulation of fluid in the intracellular

space. (Dr. Barbarito, 2007) Hair Inspection - Generally Brown or The patients hair is Based on its actual Black evenly black with gray, findings the patients

distributed evenly distributed, no hair as a part of the signs of damage, also integumentary system

over the scalp

- No signs of damage non dry and semi- is in normal status. - not excessively dry oily, no dandruff and Gray or oily no parasites lived in typically hair color occurs 26

- no dandruff - no parasites Palpation fine, silky and

the hair.

naturally

as

people

getting older. (Dr. Scalp is smooth with 2003) Helmenstine,

resilient

Scalp is smooth with no lesions noted. no presence of

lesions Nails Inspection pink nail bed As with observed, the Based on its actual

glossy patients nail beds on findings, the patients his fingers are pink fingernails as a part of of and have 160 angle the integumentary

appearance, absence hemorrhage,

nail curvature. Upon system is in normal the status. But on his toe nails hard are nails it could be sign and of a disease. (Dr. Lior,

discoloration of palpation, the surrounding tissues patients convex, basically

immobile 2002)

and its capillary refill Palpation is less than 2

Normally160 seconds. But on his

degrees angle of the feet, nails are already nail attachment - nails are convex detached and

greenish in color with 27

- nails are hard and foul odor. basically immobile -capillary refill ( less than 2 seconds) Eyes Inspection -Eyebrows aligned, movement, - Eyelashes distributed Symmetrically As observed, the Based on its actual

equal patients evenly are

eyebrows findings, the patients symmetrically eyes as a part of the

aligned, have equal integumentary system

- Close symmetrically, movement and evenly is in normal status. evenly distributed, distributed. Its

slightly curved upward eyelashes can close - Eyelids symmetrically, evenly - smooth, pink, close distributed and slightly - Ability to blink symmetrically curved upward. Its

- blinks voluntarily and eyelids are smooth, Ocular bilaterally - eyes moves freely pink and can close symmetrically. eyes -medium can Its blink and

movement - size - Conjunctiva

voluntarily

- transparent with light bilaterally. It can move color, shiny, smooth freely and its size is 28

- Cornea

and no lesions

medium.

Its are

- clear, shiny, smooth conjunctivas - Pupils and transparent

transparent with light

Equal in size, round color, shiny, smooth and constrict briskly, and no lesions. Its Palpation - Texture equally light reactive to corneas shiny, are smooth clear, and

transparent. Its pupils - mobile, firm, non- are equal in size,

tender, transparent to round, can constrict light briskly and equally

reactive to light. Upon palpation, its texture is mobile, firm, nontender and

transparent to light. Ears Inspection -symmetrically aligned As observed during Based on its actual - Intact Skin No drainage inspection, or patients ears the findings, the patients are ears as a part of the

lesions Palpation

symmetrically aligned, integumentary system

both ears can skin is intact and pink, is in normal status. hear no drainage, no 29

- skin is smooth and lesions and both ears without nodules and can color pink - soft and non-tender hear. Upon the

palpation,

patients ears have no nodules palpated. It is soft and non-tender

Head Inspection -Normocephalic symmetric -no lesions - no swelling Palpation - non-tender and As observed during Based on its actual inspection, patients head the findings, the patients is head and status. is in normal

normocephalic

symmetric, no lesions

- no palpable masses and swelling noted. Upon palpation, the patients head is nontender palpable masses. Neck Inspection - skin is intact As observed during Based on its actual the findings, the patients is in normal and mass no or

-no abnormal thyroid inspection, enlargement

patients neck has no neck

30

-symmetric - no swelling noted - no lesions Palpation

abnormal enlargement, symmetric,

thyroid status. it is no and noted. no And

- no palpable mass or swelling masses -Non- tender lesions

upon palpation, it has no palpable mass or masses noted and it is non-tender.

Respiratory System Nose Inspection As observed during Based on its actual -symmetrical, smooth inspection, and fair -Mucosa color -pinkish oval patients nose the findings, the patients is nose as a part of the

symmetrical,

smooth respiratory system is

-Nasal septum -

and and fair. Its mucosa is in normal status. pinkish and its nasal septum is oval and

symmetrical nares

-Nasal discharge Palpation - Sinuses

- clear discharges

has nares.

symmetrical no nasal

- Non-tender

discharges are noted. Upon palpation, the sinuses tender. 31 are non-

Cardiovascular System Palpation - Normal radial pulse : Upon palpation, the Based on its actual 60-80 bpm patients pulse rate is findings, the patients bpm, no lift, cardiovascular system

- no lift, heaves or 82 thrills or

abnormal heaves, no thrills or is in above normal. abnormal palpitations Blood noted. pressure of

palpitation Auscultation - No murmurs -normal pattern

Upon 180/100 indicates of High

beating auscultation, there is hypertension. no and beating murmurs has

noted blood pressure can normal damage your heart, pattern. blood vessels, and other

During blood pressure kidneys,

taking the result is parts of your body. (as 180/100. cited Heart, in National and

Lung,

Blood Institute, 2004) Gastrointestinal System Mouth Inspection -Lips As observed upon Based on the actual the findings, the patients lips are mouth as a part of the

- pinkish, symmetrical, inspection, soft and moist - pinkish and moist patients

pinkish, symmetrical, gastrointestinal

- gums

- pinkish, moist and soft and moist. Its system is in normal 32

mucosa - tongue

buccal soft

gums are pinkish and status, Its is buccal having

except tooth

for

- pinkish, moist and moist. symmetrical - at the midline mucosa

decay

pinkish, and cavities.

moist and soft. Its is pinkish, and

- uvula - teeth

- no tooth decay and tongue cavities noted moist

symmetrical. Its uvula is at the midline and its teeth have tooth decay and cavities. Gastrointestina l tract Inspection normal The patient has no Based on the actual bowel tenderness felt when findings, the patients palpated gastric pain. Palpation -non-tender -no gastric pain and no GI tract as a part of the gastrointestinal

movement

system is in normal status.

Auscultation

-normal bowel sounds

33

Abdomen -Flat The patient abdomen Based on the actual is flat, smooth and findings, the patients

Inspection

Palpation Auscultation

-smooth

presence of gurgling abdomen is in normal status.

-presence of gurgling sound is noted. sound noted

Musculoskeletal System Upper lower extremities Inspection and -Fair -equal appropriate body - no deformities -symmetrical for As observed during Based on the actual and the inspection. left The findings, the patient upper has hemiplegia. A

his patients

and lower extremities paralysis of one side has impaired of the of body. the

movement. It is slow Movements

to move, difficulty in face and arms are stretching the hands. specially often more severely affected than those of the leg. It is caused by disease affecting the hemisphere brain. 34 opposite of the

(Bantam, 2006)

ANATOMY AND PHYSIOLOGY

Nervous System

The human nervous system is made up of two main components: the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS is composed of the brain, the cranial nerves, and the spinal cord. The PNS is made up of the nerves that exit from the spinal cord at various levels of the spinal column as well as their tributaries. The autonomic nervous system (divided into the sympathetic and parasympathetic nervous system) is also considered to be a part of the PNS and it controls the body's many vegetative (non-voluntary) functions.

35

Central Nervous System

Brain

The human brain serves many important functions ranging from imagination, memory, speech, and limb movements to secretion hormones and control of various organs within the body. These functions are controlled by many distinct parts that serve specific and important tasks. These components and their functions are listed below.

Brain Cells: The brain is made up of two types of cells: neurons and glial cells. Neurons are responsible for all of the functions that are attributed to the brain while the glial cells are non-neuronal cells that provide support for neurons. In an adult brain, the predominant cell type is glial cells, which outnumber neurons by about 50 to 1. Neurons communicate with one another through connections called synapses.

Meninges: The bony covering around the brain is called the cranium, which combines with the facial bones to create the skull. The brain and spinal cord are covered by a tissue known as the meninges, which is made up of three layers: dura mater, arachnoid layer, and pia mater. The dura mater is a whitish and nonelastic membrane which, on its outer surface, is attached to the inside of the cranium. This layer completely covers the brain and the spinal cord and has two major folds in the brain that are called the falx and thetentorium. The falx separates the right and left halves of the brain while the

36

tentorium separates the upper and lower parts of the brain. The arachnoid layer is a thin membrane that covers the entire brain and is positioned between the dura mater and the pia mater, and for the most part does not follow the folds of the brain. The pia mater, which is attached to the surface of the entire brain, follows the folds of the brain and has many blood vessels that reach deep into the brain. The space between the arachnoid layer and the pia mater is called the subarachnoid space and it contains the cerebrospinal fluid.

Cerebrospinal Fluid (CSF): CSF is a clear fluid that surrounds the brain and spinal cord, and helps to cushion these structures from injury. This fluid is constantly made by structures deep within the brain called the choroid plexus which is housed inside spaces within the brain called ventricles, after which it circulates through channels around the spinal cord and brain where is it finally reabsorbed. If the delicate balance between production and absorption of CSF is disrupted, then backup of this fluid within the system of ventricles can cause hydrocephalus.

Ventricles: Brain ventricles are a system of four cavities, which are connected by a series of tubes and holes and direct the flow of CSF within the brain. These cavities are the lateral ventricles (right and left), which communicate with the third ventricle in the center of the brain through an opening called the interventricular foramen. This ventricle is connected to the fourth ventricle through a long tube called the Cerebral Aqueduct. CSF then exits the ventricular system through several holes in the wall of the fourth ventricle (median and lateral apertures) after which it flow around the brain and spinal cord.

37

Brainstem: The brainstem is the lower extension of the brain which connects the brain to the spinal cord, and acts mainly as a relay station between the body and the brain. It also controls various other functions, such as wakefulness, sleep patterns, and attention; and is the source for ten of the twelve cranial nerves. It is made up of three structures: the midbrain, pons and medulla oblongata. The midbrain is involved in eye motion while the pons coordinates eye and facial movements, facial sensation, hearing, and balance. The medulla oblongata controls vegetative functions such as breathing, blood pressure, and heart rate as well as swallowing.

Thalamus: The thalamus is a structure that is located above the brainstem and it serves as a relay station for nearly all messages that travel from the cerebral cortex to the rest of the body/brain and vice versa. As such, problems within the thalamus can cause significant symptoms with regard to a variety of functions, including movement, sensation, and coordination. The thalamus also functions as an important component of the pathways within the brain that control pain sensation, attention, and wakefulness.

Cerebellum: The cerebellum is located at the lower back of the brain beneath the occipital lobes and is separated from them by the tentorium. This part of the brain is responsible for maintaining balance and coordinating movements. Abnormalities in either side of the cerebellum produce symptoms on the same side of the body.

Cerebrum: The cerebrum forms the major portion of the brain, and is divided into the right and left cerebral hemispheres. These hemispheres are separated by a groove called the great longitudinal fissure and are joined at the bottom of this fissure by a structure called the corpus callosum which allows communication between the two 38

sides of the brain. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex (brain surface), also known as "gray matter." The surface of the cerebral cortex appears wrinkled with small grooves that are called sulci and bulges between the grooves that are called gyri. Beneath the cerebral cortex are connecting fibers that interconnect the neurons and form a white-colored area called the "white matter.

Lobes: Several large grooves (fissures) separate each side of the brain into four distinct regions called lobes: frontal, temporal, parietal, and occipital. Each hemisphere has one of each of these lobes, which generally control function on the opposite side of the body. The different portions of each lobe and the four different lobes communicate and function together through very complex relationships, but each one also has its own unique characteristics. The frontal lobes are responsible for voluntary movement, speech, intellectual and behavioral functions, memory, intelligence, concentration, temper and personality. The parietal lobe processes signals received from other areas of the brain (such as vision, hearing, motor, sensory and memory) and uses it to give meaning to objects. The occipital lobe is responsible for processing visual information. The temporal lobe is involved in visual memory and allows for recognition of objects and peoples' faces, as well as verbal memory which allows for remembering and understanding language.

Hypothalamus: The hypothalamus is a structure that communicates with the pituitary gland in order to manage hormone secretions as well as controlling functions such as eating, drinking, sexual behavior, sleep, body temperature, and emotions.

39

Pituitary Gland: The pituitary gland is a small structure that is attached to the base of the brain in an area called the sella turcica. This gland controls the secretion of several hormones which regulate growth and development, function of various organs (kidneys, breasts, and uterus), and the function of other glands (thyroid gland, gonads, and the adrenal glands).

Basal Ganglia: The basal ganglia are clusters of nerve cells around the thalamus which are heavily connected to the cells of the cerebral cortex. The basal ganglia are associated with a variety of functions, including voluntary movement, procedural learning, eye movements, and cognitive/emotional functions. The various components of the basal ganglia include caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nucleus. Diseases affecting these parts can cause a number of neurological conditions, including Parkinson's disease and Huntington's disease.

Cranial Nerves: There are 12 pairs of nerves that originate from the brain itself, as compared to spinal nerves that initiate in the spinal cord. These nerves are responsible for specific activities and are named and numbered as follows:

Cranial nerve I (Olfactory nerve): Smell Cranial nerve II (Optic nerve): Vision Cranial nerve III (Oculomotor nerve): Eye movements and opening of the eyelid Cranial nerve IV (Trochlear nerve): Eye movements Cranial nerve V (Trigeminal nerve): Facial sensation and jaw movement Cranial nerve VI (Abducens nerve): Eye movements Cranial nerve VII (Facial nerve): Eyelid closing, facial expression and taste sensation 40

Cranial nerve VIII (Vestibulocochlear nerve): Hearing and sense of balance Cranial nerve IX (Glossopharyngeal nerve): Taste sensation and swallowing Cranial nerve X (Vagus nerve): Heart rate, swallowing, and taste sensation Cranial nerve XI (Spinal accessory nerve): Control of neck and shoulder muscles Cranial nerve XII (Hypoglossal nerve): Tongue movement Pineal Gland: The pineal gland is an outgrowth from the back portion of the third ventricle, and has some role in sexual maturation, although the exact function of the pineal gland in humans is unclear.

Stroke

A stroke is a condition in which the brain cells suddenly die because of a lack of oxygen. A stroke can be caused by an obstruction in the blood flow, or the rupture of an artery that feeds the brain. The patient may suddenly lose the ability to

speak, there may be memory problems, or one side of the body can become paralyzed.

The two main types of stroke include ischemic stroke and

hemorrhagic stroke.

41

Ischemic stroke

Ischemic stroke accounts for about 87 percent of all strokes and occurs when a blood clot, or thrombus, forms that blocks blood flow to part of the brain. If a blood clot forms somewhere in the body and breaks off to become free-floating, it is called an embolus. This wandering clot may be carried through the bloodstream to the brain where it can cause ischemic stroke.

2 types of Ischemic stroke:

Thrombotic stroke

A thrombotic stroke occurs when diseased or damaged cerebral arteries become blocked by the formation of a blood clot within the brain. Clinically referred to as cerebral thrombosis or cerebral infarction, this type of event is responsible for almost 50 percent of all strokes.

Embolic stroke

An embolic stroke is also caused by a clot within an artery, but in this cases the clot (or emboli) forms somewhere other than in the brain itself. Often from the heart, these emboli will travel in the bloodstream until they become lodged and cannot travel any farther. This naturally restricts the flow of blood to the brain and results in nearimmediate physical and neurological deficits.

Hemorrhagic stroke

42

A hemorrhagic stroke occurs when a blood vessel on the brain's surface ruptures and fills the space between the brain and skull with blood (subarachnoid hemorrhage) or when a defective artery in the brain bursts and fills the surrounding tissue with blood (cerebral hemorrhage).

Both types of stroke result in a lack of blood flow to the brain and a buildup of blood that puts too much pressure on the brain.

The outcome after a stroke depends on where the stroke occurs and how much of the brain is affected. Smaller strokes may result in minor problems, such as weakness in an arm or leg. Major strokes may lead to paralysis or death. Many stroke patients are left with weakness on one side of the body, difficulty speaking, incontinence, and bladder problems.

43

SYMPTOMATOLOGY
CLINICAL MANIFESTATIONS ACTUAL FINDINGS IMPLICATIONS

1. Dizziness

Dizziness

is

common

occurrence before or after stroke. common It is with particularly brainstem

stroke. Decreased blood flow in the back of the brain, called insufficiency vertebrobasilar the blood

vessels leading to the brain from the heart may be as which

blocked

(known

atherosclerosis)

causes dizziness. (Swenson, 2008)

2. Speech problems

Problems with speech were a common early symptom of a stroke. This was usually due

44

to weakness of the muscles that are crucial for speech production on one side of the face. (Health Talk, 2014)

3. Confusion

Confusion

is

common

problem before or after a stroke. When different areas of the brain are damaged, the pathways that control

thoughts and behaviors can become confusion everyone, jumbled. is Stroke for on

different

depending

where in the brain the stroke takes place. It can range anywhere from difficulty

understanding speech to a lack of judgment safety about issues.

serious

(Jacques, 2010)

4. Blurred or double vision

Visual problems are more common in people who have suffered a stroke affecting the right side of their brain. The damage the stroke does in the brain impacts the visual

45

pathways of the eye which can result in visual field loss, blurry vision, double vision and moving images. When stroke affects the areas of the brain that processes the

information we see, it can cause 'visual neglect' (lack of awareness to one half of the body or space) as well as difficulties with judging depth and movement. In a few cases, caused visual by problems stroke can

improve on their own with time. (RNIB, 2012)

5. Sudden severe headache

The

other

major

site

of

trouble, the basilar artery, is formed at the base of the skull from the vertebral

arteries, which run up along the spine and join at the back of the head. When stroke or TIAs occur here, both

hemispheres of the brain may be affected so that symptoms

46

occur on both sides of the body such as a sudden severe 2008) headache. (Simon,

6. Sudden loss of coordination or problems with balance

Loss of coordination on one side of the body. While your limb may be strong, you may not have the coordination to do something you were

before, such as hold a spoon or button a clasp. In rare cases develop spontaneous a body part may

abnormal, movements.

(Pressman, 2012)

7. Sudden numbness and weakness

Numbness typically occurs on one side of the body, opposite the side of the brain affected by the stroke.

(Caplan, 2007)

ETIOLOGY PREDISPOSING FACTORS

CLINICAL MANIFESTATIONS ACTUAL FINDINGS IMPLICATIONS

47

1. Vices (Alcohol, smoke)

Smoking doubles the risk for stroke when compared to a nonsmoker. It reduces the amount of oxygen in the blood, causing the heart to work harder and allowing blood clots to form more easily. increases Smoking the amount also of

build-up in the arteries, which may block the flow of blood to the brain, causing a stroke. Drinking three or more

alcoholic beverages a day may raise the risk for

spontaneous hemorrhage at

intracerebral a much

younger age than typical, researchers found. (National Stroke Association, 2003)

2. Age

For each decade of life after age 55, the chance of having a stroke more than doubles. (American Heart Association, 2006)

48

3. Diet

A poor diet is a major risk factor for a stroke. High-fat foods can lead to the build-up of fatty plaques in your

arteries and being overweight can lead to high blood

pressure 2012)

(NHS

Choices,

4. Sex

Stroke incidence rates are 1.25 times greater in men, but because women tend to live longer than men, more women than men die of stroke each year. ( American Heart Association, 2003)

5. Heredity

The chance of stroke is greater in people who have a family history of stroke.

(American Heart Association, 2004)

PRECIPITATING FACTORS
CLINICAL MANIFESTATIONS ACTUAL FINDINGS IMPLICATIONS

49

1. Hypertension

The

most

important

controllable risk factor for stroke (brain attack) high is

controlling

blood

pressure (140/90 or higher). High blood pressure can

damage blood vessels (called arteries) that supply blood to the brain. According to the CDC, reducing the systolic (or top number) blood

pressure by 12 to 13 points can decrease the risk for a stroke Hopkins by 37%. (John Health

Medical

Library, 2009)

2. Diabetes Mellitus

Diabetes is controllable, but having it increases the risk for stroke. People with

diabetes have 2 to 4 times the risk of having a stroke than someone without

diabetes. Blood pressure for people with diabetes should be 130/80 or less to reduce the risk of stroke. (John

50

Hopkins

Medical

Health

Library, 2008)

3. Heart diseases

Heart disease is the second most important risk factor for stroke, and the major cause of death among survivors of stroke. Heart disease and stroke have many of the same risk factors. Medical (John Health

Hopkins

Library, 2008)

4. Cardiac structural abnormalities

Damaged heart valves can cause chronic heart damage, which can ultimately increase the risk of developing stroke. This is known as valvular heart disease. New evidence shows that heart structure abnormalities including

patent foramen ovale and atrial septal defect risk may for

possibly embolic Hopkins

increase stroke. Medical

(John Health

Library, 2012)

51

5. Atherosclerosis

Stroke

secondary

to

atherosclerosis affects about 2 out of 1,000 people, or approximately 50% of all

those who have strokes. Atherosclerosis (hardening of the arteries) occurs when sticky, fatty substances called plaque buildup in the inner lining of the arteries. The plaque may slowly block or narrow an artery or trigger a clot (thrombus). Clots can lead to stroke. (John Hopkins Medical Health Library, 2008)

52

NURSING CARE PLAN NURSING CARE PLAN #1

DATE & ASSESSMENT SHIFT SUBJECTIVE CUES: dili na kaau NURSING DIAGNOSIS Impaired physical ko mobility Physiological r/t needs. After 2 days 1.Determine of nursing degree immobility 1.To NEEDS PLANNING INTERVENTION RATIONALE EVALUATIO N establish GOAL MET: After 2 days of nursing

of comparative baseline

intervention the client will

kahipos-hipos binhod na

kay neuromuscular akung damage

intervention 2.To note any the client is

Activity be able to 2.Observe exercise pattern physical mobility. Expected outcome: Demonstrate resumption of activities 4.Give movementwhen client isunaware 3.Support

kamot as verbalized involvement by the patient. (left armnumbness) as OBJECTIVE CUES: >left hemiplegia >Limited range of by control. evidenced motor

incongruence with able abilities tophysical mobility of asevidenced by resumption of

affected partwith 3.Reducerisk pillows pressureulcers

rest 4.To helpreducefatigue and O2demand

activities, participation in his ADLs

motion(client

cant SCIENTIFIC

Participate in periods ADLs toactivities

fully extend his left BASIS:

53

arm) >

CVA

can

be byan in

Maintain muscle control.

or 5. Encourage 5. production

and

left

caused

energy armnumbnes s.

Limited ability and occlusion

adequatefluids and right dietas necessary to the client.

difficulty to perform the blood flow. gross motor skills This canlead to and

like extending and O2 lifting of the left arm. > Unsteady gait > Slowed movement > Left arm numbness thecause failure tonourish tissues capillary andthat

6. Consult with 6. physical/ the atthe level can occupational therapist indicated.

To

develop

individual exercise/ mobility as program identify appropriate adjunctive devices. 7. Feeling of / and

causeneuromu scular damage w/c can

causeimpaired physicalmobilit y.

7. note emotional frustration / behavioral powerlessness to may

responses

impede

54

problem immobility.

of attainment goals.

of

NURSING CARE PLAN #2

DATE & SHIFT SUBJECTIV E CUES: ASSESSMENT NURSING DIAGNOSIS Self-Care Deficit Physiol R/t o-gical needs. After 2 hrs. of 1. Assess for type 1. nursing intervention and severity Provides data GOAL MET: NEEDS PLANNING INTERVENTION RATIONALE EVALUATION

of regarding mobility and After 2 hrs. of ability to perform nursing with in intervention

dili na lagi musculoskel kayo ko maka etalim ayos sa sarili pairment kay maglisod secondaryto naku as CVA

immobility

the pt. will be impairment, muscle activities Activity exercis e able to Demonstrate techniques/ lifestyle changes flaccidity, and spasticity limitations

without the pt. is able to Demonstrate techniques/ lifestyle to

coordination, injury or frustrations.

ability to walk, sit, and move. to 2.Passive ROM to limbs

verbalized by the pt. SCIENTIFIC BASIS: Motor deficit

pattern

meet self-care all needs.

and 2.promotes circulation, changes tone,

progress to assistive muscle

joint meet self-care

55

OBJECTIVE CUES: >left hemiplegic >with clothes >with unsatisfying appearance

are themost obvious effect stroke. of

and

then

active flexibility,preventscontr

needs.

ROM in all joints actures and weakness four times a day 3.use devices appropriate assistive 3. Provides safe

soiled Symptoms arecaused by destructiono f motor

as support for immobility for and other self-care

ambulation, clothing activities to promote with zipper closures, independence. cups on personal

>with minimal neurons sweating >uncombed hair >foul odor inthe pyramidalpa thways (nerve fibersin brain andpassing through the

hygiene articles for brushing combing teeth, hair,

clothing that is easily managed to dress and undress 4.promote participation problem 4. enhances

client commitment to plan, in optimizing outcome.

56

thespinal cord themotor tract.) of One those to

identification decision making

and 5. individual who have

5. Note willingness a sense of their own to seek assistance, self image and are motivation change. for willing to look at

symptoms couldbe inability to

themselves realistically will be

able to progress I the to improve.

performADL S.

NURSING CARE PLAN #3

57

DATE & SHIFT

ASSESSMENT

NURSING DIAGNOSIS

NEEDS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE CUES:

Unilateral neglect

Physiolor/t gical needs. to

After 2 days of nursing 1. Monitored and 1. assessed signs will 2.To note To

GOAL MET: obtain After 2 days of nursing

gina hemiparesis secondary

intervention the

vital baseline data

pasagdahan

intervention the for pt. is able to participate in the

raman naku ni CVA akung wala na kamot. verbalized the pt. As SCIENTIFIC by BASIS: An ischemicbrain attack, OBJECTIVE CUES: >slight irritability >left isdisruption the cerebralblood flow due to of there of

Activity pt. exercise pattern

participate in 2.Assessed the performance of range patients general

anyabnormality

of physicalconditio n 3.To

performanc enhance e of range & of motion

motion exercises the extremities. .

on 3. Performed AM well-being care

providecomfort 4.To

exercises the

help on

reduce risk of extremities. another 4. attack

obstruction

Instructedpt. & prevent rise

58

hemiplegia >muscle

abloodvessel. This can causea

to alow fat, low in BP saltdiet with SAP 5. To determine muscle 5. Performed functioning on

strength test of wide variety of rightarm:0/5; rightleg:o/5; left neurologic deficits on

muscle strength the extremities test 6. To increase strength mobility 6. Instructedpt. and

arm:5/5; depending

left leg:5/5 >needs assistance performing ADLs >decrease

the location of the lesion with in which vessels

are obstructed. A stroke upper is an motor lesion in

on aPROM on 7. To promote the extremities 7. Promoted 8. To prevent injury left comfort relaxation and

attentionto the neuron affectedside and

results

adequate rest

loss of voluntary control motor movements.Bec over

8. Assisted pt. 9. To promote with self-care andstimulatecir

59

ause the upper motor neurons

activities 9. Maintain body alignment functional

culation

decussate (cross),a disturbance of

in 10.To stimulate and increase pt.s awareness on the side affected

position 10.Shift pt.s attention towards theaffected side

voluntary motor control on one side of the body may reflect

damage to the upper motor

neurons on the opposite side of the most motor dysfunction is brain. The common

hemiplegia(paral

60

ysis on one side of the body).

Pharmacological Management
DATE / SHIFT Generic Name: GLIBENCLA NAME OF DRUG DOSSAGE/ TIME/ ROUTE Dosage: 5 mg Indicated as an Patients Sulfonylureas Dizziness INDICATION CONTRAIN DICATION MOA SIDE EFFECTS NURSING RESPONSIBILI TIES >provide safety measures. >instruct pt. to

adjunct to diet sensitive to such as glyburide Asthenia to lower the one of the bind to ATP- Headache

61

MIDE Brand Name: DEBTAN

Time: PRN

blood

glucose sulfonylurea may

sensitive

Nausea Vomiting

take

on

an

in patients with s NIDDM

be potassium

empty stomach, at least 30 min. before reaction hours meals. >advice client to avoid drinking or 2 after

whose sensitive to channels on the GI pain the others pancreatic cell Diarrhea

Route:

hyperglycemia cannot satisfactorily controlled diet alone.

Clasification P.O : Antidiabetic Drawing:

be also; cross- surface, sensitivity to potassium by other sulfonamide

reducing Allergic

w/ skin rash and Hypoglycemia

conductance causing

- or thiazide- depolarization type medications may occur. the

of

soda. >monitor specially characteristics of stool. >tell pt. to report any discomfort I&O

membrane.

Depolarization

also stimulates calcium ion influx through voltage-sensitive calcium channels, raising intracellular concentrations calcium of

about the drug.

ions,

62

which induces the secretion, exocytosis, insulin. or of

63