I.

INTRODUCTION Cerebrovascular disease is a group of brain dysfunctions related

to disease of the blood vessels supplying the brain. Hypertension is the most i
mportant cause; it damages the blood vessel lining, endothelium, exposing the un
derlying collagen where platelets aggregate to initiate a repairing process whic
h is not always complete and perfect. Sustained hypertension permanently changes
the architecture of the blood vessels making them narrow, stiff, deformed, unev
en 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 vesse
l bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrien
ts, causing damage to the brain tissue. The most common symptom of a stroke is s
udden weakness or numbness of the face, arm or leg, most often on one side of th
e 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 o
r 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 d
eath. The 1990 Global Burden of Disease (GBD) study provided the first global es
timate on the burden of 135 diseases, and cerebrovascular diseases ranked as the
second leading cause of death after ischemic heart disease. During the past dec
ade the quantity of especially routine mortality data has increased, and is now
covering approximately one-third of the world’s population. The increase in data
availability provides the possibility for updating the estimated global burden
of stroke. Data on causes of death from the 1990s have shown that cerebrovascula
r diseases remain a leading cause of death. In 2001 it was estimated that cerebr
ovascular diseases (stroke) accounted for 5.5 million deaths world wide, equival
ent 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. Ad
ditionally, cerebrovascular disease is the leading cause of disability in adults
and each year millions of stroke survivors has to adapt to a life with restrict
ions in activities of daily living as a consequence of cerebrovascular disease.
Many surviving stroke patients will often depend on other people’s continuous su
pport to survive.
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
the patient full recovery. SPECIFIC OBJECTIVES
1. To be able to discuss patients background ( lifestyle, history of the
past illness, family health history) to show how may this effect on the occurren
ce of this disease. 2. To be able to discuss the anatomy and the physiology of t
he heart, for you to be able to understand where the infection takes place.
3. To be able to discuss the pathophysiology of cardiovascular diseases
and also to know and understand the etiology of the disease. 4. To be able to di
scuss the patient activities of daily living. To know if there’s a factor that t
riggers 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 di
scuss our discharge plan for fully recovery of our patient.
III. PATIENT’S PROFILE
IV. PHYSICAL ASSESSMENT GENERAL SURVEY Mr. X was lying semi-fowler’s on bed, con
scious, coherent, afebrile with monitoring devices. A. VITAL SIGNS Date Shift T
Temp BP RR PR Intak Outpu
ime 07/18/0 9 7am1pm 36.8 210/1 00 58 20
e
t
B. HEAD Pink papillary conjunctiva, no nuchal rigidity and no carotid bruit. C.
NEUROLOGIC STATUS -Oriented to time, person and place. CRANIAL NERVES ASSESSMENT
CN CN CN CN CN CN CN CN I- can smell II- (2-3) ERTL III, IV, VI- EDM, intact V-
(+) corneal reflex VII- no facial asymmetry IX- (+) gag reflex XI- can shrug sh
oulder XII- tongue at midline
D. PULMONARY SYSTEM -Respiratory rate was 58 cpm -SCE, no vesicular breath sound
s. -AP, Apical beat at the 6th ICS anterior axillary line normal sounds. E. GAST
ROINTESTINAL SYSTEM Flabby, NaBS, no abdominal bruit, (-) edema,(-) cyanosis. F.
MUSCULOSKELETAL SYSTEM The patient manifested good posture and moved voluntaril
y; he had symmetrical musculature on both sides of the body. Weakness was noted.
G. GENITO- URINARY SYSTEM Patient voided 60 – 350 cc per shift as weighed and y
ellow in color.
V. LABORATORY AND DIAGNOSTIC EXAMINATION Laboratory Findings Laboratory Exam Jul
y 15, 2009 1. GRAM STAIN Specimen: Sputum Gram ( - ) cocci singly: • Gram ( + )
cocci Short chain: • Gram ( + ) cocci in large chain: • Pus cells: • Epithelial
cells: 2. URINALYSIS Macroscopic • Color: • Transparency: Microscopic • RBC: • P
us cells: • Bacteria: • Epithelial cells: • Mucus threads: • Amonphous unates: 3
. HbAlC: 4. Glucose: 5. LIPID PROFILE • Cholesterol: • Triglycerides: • HDL chol
esterol: • LDL cholesterol: • Na: • K: • Ca: • Cl: • SGPT: • Result Normal Range
Few
Few
Few 2-4/010 +1
Light yellow SL. Turbid
4-6/HPF 0-2/HPF Few
Few 6. HEMATOLOGY • PT: • Control: Few Few
• INR: 7. CHEMICAL ANALYSIS • S.G: • pH: • nitri: • protein: • glucose: • ketone
: • urobilinogen: • bilirubin: • blood: • leukocyte:
12.2% 7.36mmol/L 7.2– 6.2 4.22 – 6.11
5.10mmol/L 0.70 1.24 3.54
137 4.3 1.36 98 41U/L Male: up to 40U/L Female: up to 31U/L 15.31 12 – 15sec 14.
1 1.35
1.010
6.5 (-) (-)
(-) (-)
(-) (-) +1 (-)
July 16, 2009 5:30 am 1. Capillary Blood Glucose: 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 -m
ild cortical atrophy is demonstrated -rest of the findings are unbreakable.
80 – 120mg/dl
July 17, 2009
• • •
Na: K: Ca:
137 4.3
138-146 3.6-5.0
•
Cl: 1.33 100 1.15-1.29 96-110
VI. ANATOMY AND PHYSIOLOGY The Brain Three cavities, called the primary brain ve
sicles, form during the early embryonic development of the brain. These are the
forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rho
mbencephalon).
•
•
The telencephalon generates the cerebrum (which contains the cerebral cortex, wh
ite matter, and basal ganglia). The diencephalon generates the thalamus, hypotha
lamus, and pineal gland.
• • •
The mesencephalon generates the midbrain portion of the brain stem. The metencep
halon generates the pons portion of the brain stem and the cerebellum. The myele
ncephalon generates the medulla oblongata portion of the brain stem
Figure The four divisions of the adult 1 brain.
•
The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve
fibers, the corpus callosum. The largest and most visible part of the brain, th
e cerebrum, appears as folded ridges and grooves, called convolutions. The follo
wing terms are used to describe the convolutions:
• •
•
A gyrus (plural, gyri) is an elevated ridge among the convolutions. A sulcus (pl
ural, sulci) is a shallow groove among the convolutions. A fissure is a deep gro
ove among the convolutions.
The deeper fissures divide the cerebrum into five lobes (most named after border
ing skull bones)—the frontal lobe, the parietal love, the temporal lobe, the occ
ipital lobe, and the insula. All but the insula are visible from the outside sur
face of the brain. A cross section of the cerebrum shows three distinct layers o
f nervous tissue: • The cerebral cortex is a thin outer layer of gray matter. Su
ch activities as speech, evaluation of stimuli, conscious thinking, and control
of skeletal muscles occur here. These activities are grouped into motor areas, s
ensory areas, and association areas.
•
The cerebral white matter underlies the cerebral cortex. It contains mostly myel
inated axons that connect cerebral hemispheres (association fibers), connect gyr
i within hemispheres (commissural fibers), or connect the cerebrum to the spinal
cord (projection fibers). The corpus callosum is a major assemblage of associat
ion fibers that forms a nerve tract that connects the two cerebral hemispheres.
•
Basal ganglia (basal nuclei) are several pockets of gray matter located deep ins
ide the cerebral white matter. The major regions in the basal ganglia—the caudat
e nuclei, the putamen, and the globus pallidus—are involved in relaying and modi
fying nerve impulses passing from the cerebral cortex to the spinal cord. Arm sw
inging while walking, for example, is controlled here.
The diencephalon connects the cerebrum to the brain stem. It consists of the fol
lowing major regions:
•
The thalamus is a relay station for sensory nerve impulses traveling from the sp
inal cord to the cerebrum. Some nerve impulses are sorted and grouped here befor
e being transmitted to the cerebrum. Certain sensations, such as pain, pressure,
and temperature, are evaluated here also.
•
The epithalamus contains the pineal gland. The pineal gland secretes melatonin,
a hormone that helps regulate the biological clock (sleep-wake cycles).
•
The hypothalamus regulates numerous important body activities. It controls the a
utonomic nervous system and regulates emotion, behavior, hunger, thirst, body te
mperature, and the biological clock. It also produces two hormones (ADH and oxyt
ocin) and various releasing hormones that control hormone production in the ante
rior pituitary gland.
The following structures are either included or associated with the hypothalamus
.
• • •
The mammillary bodies relay sensations of smell. The infundibulum connects the p
ituitary gland to the hypothalamus. The optic chiasma passes between the hypotha
lamus and the pituitary gland. Here, portions of the optic nerve from each eye c
ross over to the cerebral hemisphere on the opposite side of the brain.
•
The midbrain is the uppermost part of the brain stem. The pons is the bulging re
gion in the middle of the brain stem.
•
•
The medulla oblongata (medulla) is the lower portion of the brain stem that merg
es with the spinal cord at the foramen magnum.
•
The reticular formation consists of small clusters of gray matter interspersed w
ithin the white matter of the brain stem and certain regions of the spinal cord,
diencephalon, and cerebellum. The reticular activation system (RAS), one compon
ent of the reticular formation, is responsible for maintaining wakefulness and a
lertness and for filtering out unimportant sensory information. Other components
of the reticular formation are responsible for maintaining muscle tone and regu
lating 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 cereb
ellum is convoluted, but the gyri, called folia, are parallel and give a pleated
appearance. The cerebellum evaluates and coordinates motor movements by compari
ng actual skeletal movements to the movement that was intended. The brain stem c
onnects 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 gr
ay matter. The brain stem consists of the following four regions, all of which p
rovide connections between various parts of the brain and between the brain and
the spinal cord Figure Prominent structures of the brain 2 stem.
•
The midbrain is the uppermost part of the brain stem. The pons is the bulging re
gion in the middle of the brain stem.
•
•
The medulla oblongata (medulla) is the lower portion of the brain stem that merg
es with the spinal cord at the foramen magnum.
•
The reticular formation consists of small clusters of gray matter interspersed w
ithin the white matter of the brain stem and certain regions of the spinal cord,
diencephalon, and cerebellum. The reticular activation system (RAS), one compon
ent of the reticular formation, is responsible for maintaining wakefulness and a
lertness and for filtering out unimportant sensory information. Other components
of the reticular formation are responsible for maintaining muscle tone and regu
lating 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 cereb
ellum is convoluted, but the gyri, called folia, are parallel and give a pleated
appearance. The cerebellum evaluates and coordinates motor movements by compari
ng actual skeletal movements to the movement that was intended. The limbic syste
m is a network of neurons that extends over a wide range of areas of the brain.
The limbic system imposes an emotional aspect to behaviors, experiences, and mem
ories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparte
d 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 e
ncircles the inside border of the cerebrum. The following components are include
d: • The hippocampus (located in the cerebral hemisphere) The denate gyrus (loca
ted in cerebral hemisphere) The amygdala (amygdaloid body) (an almond-shaped bod
y associated with the caudate nucleus of the basal ganglia)
• • •
•
The mammillary bodies (in the hypothalamus) The anterior thalamic nuclei (in the
thalamus) The fornix (a bundle of fiber tracts that links components of the lim
bic system)
•
VII. PATHOPHYSIOLOGY
Cerebrovascular disease or brain attack happened due to modifiable factors posse
ssed by the patient such as smoking, ingesting fatty foods, and hypertension tha
t 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.
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 - routine care done
3.11
- 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 monit
or 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 ug
tts @ 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 cho
ice - endorsed 5:00pm accompanied - received patient on bed awake via stretcher
ERMEOD, transferred to bed safely - on NPO except meds with ongoing IVF of PNSSL
@ 750 cc level regulated @ 10gtts/minand SD nicardipine10mg + 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 - w
ith 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 carried
-
S/E by Dr. Somson-Crux with orders made and Out
- nexicum 40mg tab OD - refer to Dr. Soccom Rosales for Co. Mgt. Dr. Solero info
rmed - for sputum AFB 3x; GS/CS with SB
initial V/S BP:180/90mmHg @ ER;
T:36.4
C,
HR:68,
RR:28,
- with the ff. meds mannitol 75cc x 3doses started Nexicum 40mg OD; olmesartan 3
0mg tab OD; liticolin TID given 9:00pm - on CBR without BPR - seen and examined
by Dr. Martinez with orders meds and carried out - clopidogel 5 tabs stat then O
D given - for 2Decho with Doppler- to request AAC 10:25pm - shift citicoline dro
ps to IV as ordered by Dr. Solero - adequate UO - V/S q hour, medicine clerk inf
ormed - no complaints - needs attended - endorsed
11-7
- flaccid patient on bed - with IVF of PNSSL @ 650 level q 6hr - with nicardipin
e 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 sput
um GS/CS - CBG monitoring q 12 - for FBS, hemoglobin,A1C - V/S taken and recorde
d - due meds given - above IVF hooked and consumed @ same rate - (-) BM - needs
attended - endorsed
07/15/09 7.3 received patient ongoing PNSS with same regulation and rate; afebri
le - with O2 @ 2LPM connected to nasal cannula - with NGT intact - with CBG moni
toring q 12 - for sputum AFB - for 2Decho with Doppler - BP: 130/90 mmHg - endor
sed
Addendum
- start feeding AP order - for SGOT - (-)gag reflex
3-11 PNSSL diet
-
received patient on bed with ongoing IVF of with NGT to start of 1600 kcal in fe
edings, DM
- with O2 inhalation @ 2LPM via nasal cannula - with FC to urobag - with CBG mon
itoring - for 2Decho with Doppler - sputum GS/CS-TF - still for sputum AFB 4:30p
m carried out S/E by Dr. Martinez, orders were made and
- 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 7:30pm Simon - dilantin 100mg IV gi
ven slow push - s. electrolytes and SGPT result in referred to Dr. - due meds gi
ven - refer prn - no BM, afebrile - endorsed
11.7
- received patient on bed - with ongoing IVF PNSS @ level of 100cc regulated @ 2
1gtts/min
- on1600kcal feedings DM diet - sputum GS/CS-TF - CBG monitoring q 12 - for sput
um AFB - for repeat plain CTscan 1;15am - above IVF consumed and hooked same IVF
and rate - V/s taken and recorded - 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 r
eg. and rate - afebrile, BP: 100/70mmHg - with NGT intact - with O2 @ 2LPM via n
asal 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 - rep
eat CTscan plain-TF - due meds given 8;00pm - (+) restlessness- MROD endorsed to
give Diphenhydramine 1 amp- given as ordered 9;30pm to - Dr, Martinez made roun
ds with new order made 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 @ 250cc level 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 - 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 Creat
inine - seen from time to time - I&O monitored and recorded - V/S taken and reco
rded - refer prn - endorsed
11.7
- received patient lying on bed, asleep - with IVF PNSS @ 900cc - with cardiac m
onitoring 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 plai
n-TF - due meds given
- morning care done - (-)BM, afbrile - 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
XI. DISCHARGE PLANNING
M- Instructed immediate relatives to facilitate the
patient to continue
taking the drugs given to her on the right time and with the right dose to facil
itate continuity of care.
E- Encouraged immediaterelatives to facilitate regular exercise such as
brisk walking but not making herself too much tired. -Encouraged her not to carr
y heavy loads and do not force herself too much in doing household chores. Encou
raged patient to limit number of hours in playing domino.
T- encouragedpatient to have enough rest and comply to the physicians
when ever health problems occur
H-Encouraged and explained to her the benefits and advantages of proper
hygiene to promote wellness.
O- instructed patient to come back for follow up check up on the date
ordered.
D- advised patient to eat nutritional foods like fruits and vegetables. Eat a
well balanced diet. Instructed patient to limit eating foods high in fats and wi
th cholesterols. And also avoid salty foods.
S- Encouraged pt to continue her habits in going to church every day and
always seek God helps when ever problems occur. XII. DEVELOPMENTAL TASK