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Ischemic Stroke

Case Study January 2014

1. Basis of selection of case In the previous years, a Food and Nutrition Research Institute 1998 study, about 21 percent of adults aging from 20 years old and above have hypertension, (the single most important risk factor for stroke and it causes about 50 per cent of ischemic strokes and also increases the risk of hemorrhagic stroke) while a Philippine Health Statistics 1993 figure showed 28 deaths per 100 000 population caused by stroke. Nowadays, still, stroke makes its way on top. Worldwide, stroke is the secondleading cause of death after heart disease and is also a big contributor to disability. Due to the increasing number of stroke cases annually and the expanding cases in the younger generation, the government of the Philippines should emphasize primary and secondary prevention strategies. As we talk about prevention strategies, there is a great role for nurses/student nurses, as well as for the rest of the medical team, comes in. Reading a case study and coming up with a diagnosis is a good way for nursing students to test the knowledge they've acquired in the classroom in a more realistic, clinical way. Writing case studies is also a useful learning tool; it forces students to reflect on the entire course of treatment for a patient, ranging from obtaining important information to diagnosis to treating the medical condition. Increasing the knowledge regarding the disease process of stroke, the proper assessment of the patient, correct intervention, effective health teaching, etc will contribute a lot in improving prevention strategies.

2. Clarity of Objectives General Objectives After 2 hours of case presentation, the students will be able to obtain the knowledge to enhance skills and to develop the attitude towards caring of the patient with cases regarding ischemic stroke. Specific Objectives Specifically, this aims to KNOWLEDGE 1. Explain the pathophysiology of ischemic stroke. 2. Identify the main cause of the disease. 3. Name the signs and symptoms of the disease manifested by the client. SKILLS 1. Carry out independent and dependent intervention being done to the client appropriately and with care. 2. Perform comprehensive nursing interventions based on the clients priority needs. 3. Demonstrate proper approach used in clients with ischemic stroke. ATTITUDES 1. Establish rapport to the client and folks. 2. Encourage the folks to cooperate to the intervention being performed. 3. Avoid promising words that might worsen the clients condition.

3.1 ASESSMENT A. PATIENTS PROFILE NAME: R. C. AGE: 64 years old SEX: Male DATE OF BIRTH: June 28, 1949 ADDRESS: Barotac Viejo, Iloilo OCCUPATION: National Referee, Retired Teacher RELIGION: Roman Catholic NATIONALITY: Filipino ACTIVITY: Moderate Backrest CC: Stiffening of extremities DATE OF ADMISSION: December 12, 2013 DIAGNOSIS: T/C Brain Mets v/s restroke prob. Bleed, S/P CVD with no residuals (2013) HCVD R/O Metastatic cause DM 2- NIR S/P Thyroidectomy for thyroid CA Stage 1 PHYSICIAN: Dr. A

B. NURSING HISTORY

I. Reason for Seeking Care Stiffening of extremities

II. Present Health History Patient R.C. is 64 years old, male and married. He is a retired teacher and a national referee. 8 months prior to admission, patient experienced episode of syncope. He was then admitted at St. Pauls Hospital for 1 month and managed as CVP, no residual noted. 1 month prior to admission, undocumented fever was noted. He was admitted at Don Ramon Tugbang Medical Center and diagnosed to have Urinary Tract Infection. On the day of admission, patient experienced generalized weakness and stiffening of extremities. A complaint of dizziness was noted. He was responsive and slurring of speech is noted. He was brought to Don Ramon Tugbang Medical Center and then referred at Iloilo Mission Hospital.

III. Past Health History It was known that he is hypertensive and have Diabetes Mellitus. He has many previous hospitalizations. He was diagnosed to have thyroid cancer stage 1 back in 1986. He had undergone radiation therapy and left thyroidectomy in the same year at Philippine General Hospital. No known allergies. Last December 2012, He underwent Cranial CT scan and CT scan with contrast. January 7, 2014, he again underwent cranial CT scan. IV. Current Medication For now, he has current medication such as Amlodopine 10mg/tab OD, Simvastatin 40 mg/tab OD, Losartan 50 mg/tab 1 tab OD for his hypertension and Metformin 500 mg 1 tab OD for his Diabetes Mellitus. V. Lifestyle He is non-smoker and non-alcoholic drinker. He is also an athletic person. As verbalized by the wife, most of the time he ate carrots instead of rice. VI. Family History As verbalized by the wife, he has familial history of Hypertension and Diabetes Mellitus.

C. PHYSICAL ASESSMENT VITAL SIGNS R.C.s temperature is 36.5 C, pulse rate is 88 beats per minute, respiratory rate is 20 breaths per minute, and blood pressure is 180/100 mmHg. GENERAL APPEARANCE R.C. is a 64 year old male, a national referee and a retired teacher. Bedridden since the day of admission. Ectomorph, well developed and appears to be at stated age. Well cleaned and wears appropriate clothes. Difficulty or discomfort making laryngeal speech sounds or varying volume, quality, or pitch of speech. Comprehends directions. Appears to be in distress. SKIN Brown in color, dry, and wrinkled due to old age.Peeling, scaly and flaky skin on heels of the feet. Skin color differences among body areas and between sun-exposed and non-sun-exposed areas. Darker skin around elbows and knees. Warm in temperature. Turgor resilience. Bilateral symmetry. Hair present on scalp, lower face, nares, chest, legs, and pubic areas. NAILS Nails beds pink with varying opacity. Short, squoval, smooth, flat, with edges smooth and round, Longitudinal ridging and beading. Hard and firm with uniform thickness. Well-groomed and uniform without deformities. Good capillary refill.

HEAD AND FACE Hair is short, black with minimal gray hairs, and distributed evenly. Hair strands are thin, fine and silky. Head is midline. Skull normocephalic, symmetric and without deformities. Scalp is intact and without lesions or mass noted. Temporal pulses palpable. No bruits. Presence of beard on upper lip and chin. Presence of black heads on the nose. Presence of dimple at the right side of the face. EYES Eyebrows are smooth, black in color and distributed evenly and in line with each other. With mole noted on the left inner end of the brow.Superior eyelid covering a portion of iris when open. Eyelashes are black, evenly distributed, present on both lids and turned outward. Conjunctivae pink, sclera anecteric. Irides black. Pupils equal, round, and reactive to light and accommodation. EARS Auricles in alignment, same color as facial skin.Firm and mobile, readily coiling from position; non-tender.Absence of discharges.

NOSE Nose in midline, no discharges or polyps, mucosa pink and moist, septum midline, patent bilaterally. Conforms to face to color.Nares oval and symmetrically positioned. No sinus tenderness to palpation. With O2 at 2Lpm via nasal cannula.

MOUTH AND OROPHARYNX Lips symmetric vertically and horizontally at rest and moving.Dry, bluish purple, distinct border between lips and facial skin. Teeth are stained yellow and absence of left lateral incisor. Gingiva pink and moist. Tongue is midline, dull red in color and moist. No tremors and fasciculation. Hard palate and soft palate are pinkish in color. Pharynx clear without erythema. Uvula rises evenly. NECK Neck is straight and symmetrical. Trachea midline. Jugular vein distention noted. Carotid pulse palpable.Cricoid cartilages smooth and moves during swallowing. Left thyroid palpable, firm, and smooth; presence of slightly hypoechoic nodule.Absence of right thyroid lobe. THORAX AND CHEST Minimal increase in the anteroposterior diameter of chest.Thoracic expansion symmetric. No adventitious breath sounds. Regular respiratory rate. Chest retraction noted. Apical pulse on 5th intercostals space. The areola and nipples are dark brown in color and no discharges noted. ABDOMEN Soft, flat and symmetrical. Uniform in color, no pigmentation and rashes noted. No abdominal scars and masses. Active bowel sounds audible in four quadrants.

UPPER EXTREMITIES Arms fair in color and symmetrical. No tenderness upon palpation of muscle and joints. Unable to passively perform full range of motion at right affected hand; stiffness noted. Palms are pale and warm. Radial and brachial pulses palpable.With PNSS 1L x 80cc/H infusing well at left cephalic vein. LOWER EXTREMITIES Legs are fair in color and symmetrical. Muscles are firm and skin is slightly dry. Soles are pale and warm to touch. Unable to passively perform full range of motion at right affected leg. Popliteal and dorsalis pedis pulses palpable. GENITO-ANAL AND GENITO-URINARY Pubic hairs are present. No skin lesions, penile discharges and swelling noted. Urinated to a moderate amount of yellowish colored urine.Defecated to a soft brown stool.

D. DIAGNOSTIC TEST LABORATORY TEST URINALYSIS


RESULT

NORMAL VALUES

SIGNIFICANCE

Color Transparency Reaction Specific Gravity Sugar Albumin Pus cells Red Blood cells Amorphous urates Squamous Cells Bacteria Mucus Threads Yeast Cells

Pale straw Slightly Hazy 7.0 1.015 1+ Neg ( - ) 3.6 hpf 0.3 hpf FEW FEW Occasional FEW NONE 1.010 1.025 NORMAL

HEMATOLOGY

Hemoglobin

103 g/L

140 180

Anemia, bleeding, blood dyscrasia

Hematocrit Red blood cell count

0.31 vol.fr. 3.77 x 10^ 12/L

0.42- 0.52 4.7 6.1

Anemia Anemia, bleeding, bone marrow failure, malnutrition

White blood cell count

14.98 x 10 ^9/ L

5.2 -12.4

Infection, Anemia, adrenal or thyroid gland issues, immune system disorder, inflammation, tissue damage, severe stress

Segmenter Stab Juvenile

90% 0 0

50 70 2-5 0-1

infection, inflammation

Normal

Basinophil Eosinophil Lymphocyte Monocyte Platelet Count MCV MCH MCHC RDW ESR IMMUNOLOGY

0 0 9% 1% 341 x 10^9/ L 83 fl 27 pq 33g/dL 11.7% 37 mm/ Hr

0.0 1.5 07 19 48 3.4 9 130 400 80 94 27 31 33 37 11.5 14.5 0 10

Normal Normal not significant not significant Normal Normal Normal Normal Normal inflammation

CRP T3 T4 TSH

48 mg/L 95nmol/L 91.43 nmol/L 0.88 u/ v/mL Euthyroid : 0.25 5.0u/V/ml Hypothyroid : greater than 7.0u/V/ml Hyperthyroid: less than 0.15u/V/ml

<60.95 250 60 120 0.25 5.0

inflammation Normal Normal Normal

APTT % Activity Patient INR CHEMISTRY

24.4 sec 99% 13.1 sec 1.00

24.0 35.0 70-100 11.6- 16.0 -

Normal Normal Normal

Fasting blood sugar Cholesterol Triglycerides

9.58 mmol/L 3.44 mmol/L .94 mmol/L

4.10 5.90 1.30 5.2 0.17 1.70

heart attack, stroke Normal Normal

HDL LDL Uric Acid Calcium

0.84 mmol/L 2.17 mmol/L 178 mmol/L 2.05 mmol/L

.90 1.55 0.0 3.9 160-430 2.12- 2.25

atherosclerosis, CVD Normal Normal Hypocalcemia

ULTRASOUND

Thyroid Ultrasound:

The right thyroid lobe is surgically absent. The left thyroid measures 3.73 x 1.63 x 1.29 cm ( LxWxAP ). The isthmus is not thickened and measures 0.21mm in thickness. There is a slightly hyporechoic nodule noted in the inferior aspect of the left thyroid lobe measuring 0.81 x 0.71 x 0.53 cm ( LxWxAP ). There is a cystic focus noted at the junction of the isthmus and left thyroid lobe measuring 0.46 x 0.46 x 0.26 cm ( LxWxAP ). A cystic focus is also noted in the mid portion of the thyroid lobe measuring 0.24 x 0.11 cm ( WxAP ). The surrounding soft tissues and vascular structures are unremarkable. No mass/enlarged cervical lymph nodes appreciated.

Remarks:

Left thyroid nodule and cyst. S/P Right thyroidectomy.

CHEST X-RAY

Chest PA: Clear lung field with no grossly evident active kochs infiltrates Trachea midline Intact costophrenic sinuses Smooth diaghragmatic leaves Cardiac silhouette nor enlarged transversely Curvilinear calcific density noted at the aortic knob Rest of the visualized soft and osseous tissues appear Unremarkable

Impression: Atherosclerosis: Aorta

CT SCAN

Plain and contrast enhanced axial tomographic sections of the head reveal inhomogeneously enhancing hypodensity with gyral enhancement at the right frontoparietal areas. Also note of enhancing isodense nodules lesions with surrounding edema in the right inferior frontal and right frontal periventricular areas.

There are small hypodensities on both capsuloganghenic and bifrontoparietal periventricular areas. The ventricles are enlarged. The midline structures are displaced to the left. The cerebral sulci are effaced. No abnormal extra-axial fluid collection demonstrated. No posterior fossa , brain stem and sellar region do not appear unusual. The petromastoids, included orbits and parancoal sinuses and the bony calvarium are unremarkable.

Remarks: Right frontoparietalhypodensity with gyral enhancement. Right inferior frontal and right frontal periventricular enhancing lesions with surrounding edema. Lacunar infarcts, bilateral capsuloganglionicbifrontoparietal periventricular areas. Leftward subfalcine herniation. Obstructive hydrocephalus.

Drug Therapy Generic name:Valporic Acid Classification: Anti Convulsant Dosage:( Adult and children > 10 y.o ) = 10- 15 mg/kg/day PO Route: Oral Therapeutic Actions: Mechanism of action not understood; Anti epileptic activity may be related to the metabolism of inhibitory neurotransmitter, GABA. Indications: Solo and adjunctive therapy in simple ( petit mal ) and complex absence seizure Acute treatment of manic episode associated with bipolar disorder Prophylaxis of migraine headache Contraindication and Cautions: Contraindicated with hypersensitivity to valporic acid, hepatic disease or significant hepatic impairment Use cautiously with children younger than 18 months; children younger than 2 y.o Adverse Effects:

CNS: Sedation, emotional upset, depression, psychosis, aggression, behavioral deterioration, suicibility. SKIN: Hair loss, rash GI: Nausea, vomiting, indigestion, diarrhea, abdominal cramps, constipation. GU: Irregular menses, amenorrhea HEMATOLOGIC: Altered bleeding, bruising.

Nursing considerations: Products containing alcohol should be avoided. Give drug with food if GI upset occurs. Be aware that the patient maybe increased risk for suicidal ideation monitor accordingly. Patient Teaching: Take this drug exactly as prescribed. Do not chew tablet or capsule before swallowing them. Do not discontinue this drug abruptly or change dosage. Avoid alcohol and sleep inducing drugs.

Generic name:Losartan Potassium Classification:Angioten II Antagonist Dosage:( Adult and children 6 yrs and older ) = Starting dose of 50 mg PO daily Route: Oral Therapeutic Actions: Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland. Indications: Treatment of hypertension, done or combination with other hypertensive. Treatment of diabetic nephropathy. Reduction of risk of CVA in patients. Contraindications and Cautions: Contraindicated in previous hypersensitivity. Pregnancy or lactation Reduce dosage with hepatic or renal impairment. Adverse Effects: CNS: Headache, dizziness and insomnia

CV: Hypertension SKIN: Rash and dry skin GI: Diarrhea, abdominal pain and nausea RESPIRATORY: Cough OTHER: Back pain, fever and gout Nursing Considerations: Assessment Hypersensitivity to Losartan Pregnant Lactation Patient Teaching: Take drug without regard to meals May experience these side effects: - Dizziness - Headache - Nausea and vomiting Report fever, chills and pregnant

Generic name:Metformin Classification:Antidiabetic Agents Drugs:( Adult and pediatric 10 16 y.o ) = 500 mg bid/ 250 mg bid Route: Oral Therapeutic Reaction: Increase peripheral utilization of glucose and decrease hepatic glucose production. Indications: Adjunct to diet to lower blood glucose with type 2 DM Contraindication and Cautions: With allergy to metformin, heart failure, diabetes complicated by fever, severe trauma and severe infection. Use cautiously with the elderly Adverse Effects: ENDOCRINE: Hypoglycemia GI: Anorexia, nausea and vomiting HYPERSENSITIVITY: Allergic skin reaction Nursing Considerations: Allergy to metformin Pregnancy Lactation

Patient Teaching: Monitor blood for glucose and ketones as prescribed. Do not use this drug during preganancy. Avoid using alcohol while taking this drug. Report fever, sore throat, unusual bleeading and bruising. Other anti-diabetic drugs: Gliclazide, Sitagliptin

Generic name: Baclofen Classification: Muscle relaxant Dosage: 5 mg PO tid for 3 days Route: Oral Therapeutic Actions: Inhibits both monosynaptic and polysynaptic spinal reflexes; CNS depressant Indications: Alleviation of signs and symptoms of spasticity resulting from MS Spinal cord injuries and other spinal cord diseases Contraindications and Cautions: Contraindicated in previous hyper sensitivity. With skeletal muscle spasm Use cautiously with strokes, cerebral palst, parkinsons disease Lactation and pregnancy Adverse Effects: CNS: Transient drowsiness, weakness, fatigue CV: Hypotension GI: Nausea, Constipation GU: Urinary frequency, dysuria OTHER: Rash, pruritus, ankle edema Nursing Considerations: Discontinue drug if hypersensitivity reaction occur Lactation Evaluate therapeutic response Patient Teachings: Take this drug exactly as prescribed Avoid alcohol Do not take this during pregnancy

Generic Name: Amlodipine Classification:Antianginal; Antihypertensive; Calcium channel blocker Dosage: Adult and Pediatric 6-17 y.o. 2.5-5 mg daily Route: Oral Therapeutic actions: Inhibits the movement of calcium ions across the membranes of cardiac cells; inhibits transmembrane calcium flow, w/c result in depression of impulse formation in specialized cardiac pacemaker cells, slowing velocity of conduction of the cardiac impulse. Indications: Angina pectoris due to coronary artery spasm(Prinzmetals Variant angina) Essential hypertension Contraindications and cautions: Contraindicated w/ allergy to amlodipine Use cautiously w/ heart failure Pregnancy Adverse effects: CNS: Dizziness, headache, and fatigue CV: Peripheral edema

Skin; Flushing, rash GI: Nausea, abdominal discomfort Nursing Consideration: Administer drug w/out regards to meals Monitor BP carefully

Patient teachings: Take w/ meals if upset stomach occurs Report irregular heartbeat, shortness of breath, and constipation

Generic name: Diazepam 5 mg IV Classification: Antiepileptic; Anxiolytic Dosage: Usual dosage is 2-20 mg IM/IV Route: IM/IV Therapeutic actions: Acts mainly as the limbic system and reticular formation; may act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation Indications: Management of anxiety d/o Acute alcohol withdrawal Muscle relaxant Contraindications and cautions: Contraindicated w/ hypersensitivity to benzodiazepines Use cautiously w/ elderly, impaired renal function Adverse effects: CNS: Sedation, depression, fatigue, and restlessness CV: Bradycardia, CV collapse, and hypertension Skin: Rash and dermatitis GI: Constipation and diarrhea GU: Urinary retention Hematologic: Decreased Hct Other: Phlebitis and thrombosis in IV site, fever, diaphoresis, and muscular disturbances

Nursing considerations: Hypersensitivity to benzodiazepines Pregnancy and lactation Carefully monitor P, BP, respiration, during IV administration

Patient teachings: Take this drug exactly as prescribed Tell patient to report drowsiness, and weakness

Generic name: Mannitol Classification: Osmotic; Urinary irrigant Dosage: 50-200g/day Route: IV Therapeutic actions: Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsortion of water leading to a loss of water, sodium, chloride: creates an osmotic gradient in the eye between plasma and ocular fluids thereby reducing IOP. Indications: Prevention and treatment of oliguric phase of renal failure Promotion of urinary excretion of toxic substances Irrigant in transurethral prostatic resection Contraindications and cautions: Contraindicated w/ anuria due to severe renal disease Use cautiously w/ pulmonary congestion, dehydration, heart failure Lactation Pregnancy

Adverse effects: CNS: Dizziness, headache , blurred vision, SEIZURES CV: Hypertension, edema, thrombophlebitis and chest pain Skin: Skin necrosis w/ infiltration GI: Nausea, dry mouth GU: Diuresis, urine retention Hematologic: Fluid and electrolyte imbalance Respiratory: Pulmonary congestion

Nursing Considerations: Do not expose solution to low temp crystallization may occur Make sure infusion set contains a filter if giving concentrated mannitol Monitor serum electrolytes periodically w/ prolonged therapy Patient teachings: Patient may experience these side effects: Increased urination, GI upset, dry mouth, headache, blurred vision- ask for assistance Report difficulty of breathing, pain at the IV site and chest pain

Generic name: Simvastatin Classification:Antihyperlipidemic Dosage: 20-40 up to 80 mg PO daily in the evening Route: Oral Therapeutic actions: Inhibits HMG-CoA reductase, the enzyme that catalyze the first step in the cholesterol synthesis pathway Indications: To reduce the risk of coronary disease Treatment of patients w/ isolated hyper triglyceridemia Treatment of type III hyperlipoproteinemia Contraindications and cautions: Contraindicated w/ allergy to simvastatin Use cautiously w/ impaired hepatic and renal function Cataracts Adverse effects: CNS: Headache, sleep disturbances GI: Flatulence, diarrhea, abdominal cramps, constipation, nausea, heartburn, LIVER FAILURE Respiratory: Sinusitis Other: ACUTE RENAL FAILURE, myalgia Nursing considerations: Allergy to simvastasin Give in evening; highest rate of cholesterol synthesis are bet midnight and 5 am

Advise patient that this drug cannot be taken during pregnancy Patient teachings: Take drug in the evening Patient may experience these side effects: Nausea, headache, muscle and joint pains, sensitivity to light Report severe GI upset, changes in vision, unusual bleeding/bruising, dark urine or light colored stool, fever, muscle pain or soreness

E. Pathophysiology Stroke or cerebrovascular accident also known as the brain attack is a vascular disorder that injures the brain function. Stroke remains one of the leading causes of mortality and morbidity. The term brain attack has become a popular substitute for stroke, with the intent of equating stroke with a heart attack in terms of the timetable associated with the development of neurologic deficits and the need for prompt emergency treatment. A brain attack is a sudden impairment of cerebral circulation in one or more blood vessels. It occurs when a blood clot blocks the blood flow in a vessel or artery or when a blood vessel breaks, interrupting blood flow to an area of the brain. Regardless of the cause, the underlying event is deprivation of oxygen and nutrients. Normally, if the arteries become blocked, autoregulatory mechanisms help maintain cerebral circulation until collateral circulation develops to deliver blood to the affected area. If the compensatory mechanism becomes overworked, or if cerebral blood flow remains impaired for more than a few minutes, oxygen deprivation leads to infarction of brain tissue. Stroke interrupts or diminishes oxygen supply and

commonly causes serious damage or necrosis in the brain tissues. When either of these things happens, brain cells begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These include functions such as speech, movement, and memory. The specific abilities lost or affected depend on the location of the stroke and its severity. There are two types of brain attacks ischemic and hemorrhagic. With ischemic strokes, a blood clot blocks or plugs a blood vessel in the brain. With hemorrhagic strokes, a blood vessel in the brain breaks or ruptures. An ischemic stroke can occur in several ways embolic, thrombotic, Transient ischemic attack, and lacunar infarcts. Embolic stroke occurs when a blood clots forms in the body (usually the heart) and travels through the blood stream to the brain. Once in the brain, the clot eventually travels to a blood vessel small enough to blocks its passage. The clot lodges there, blocking the blood vessel causing a stroke. In the thrombotic stroke, blood flow is impaired because of the blockage to one or more arteries supplying blood in the brain. Blood-clot strokes can also happen as the result of unhealthy blood vessels clogged with the build up with fatty acids and cholesterol. So your body reacts in these injuries just as it would if you were bleeding from a wound- it responds by forming clots. Transient ischemic attacks, or TIAs, are brief episodes of stroke symptoms resulting from temporary interruptions of blood flow to the brain. It can last anywhere from a few seconds up to 24 hours. Lacunar infarcts are small (1.5 to 2.0 cm) to very small (3 to 4 mm) infarcts located in the deeper noncortical parts of the brain or in the brain stem. They are found in the territory of single deep penetrating arteries supplying the internal capsule, basal ganglia, or brain stem. They result from occlusion of the smaller branches of large

cerebral arteries, commonly the middle cerebral and posterior cerebral arteries and less commonly the anterior cerebral, vertebral, or basilar arteries. In the process of healing, lacunar infarcts leave behind small cavities, or lacuna. Six basic causes of lacunar infarcts have been proposed: embolism, hypertension, small-vessel occlusive disease, hematologic abnormalities, small intracranial haemorrhages, and vasospasm. Because of their size and location, lacunar infarcts do not usually cause profound deficits such as aphasia or apracticagnosia of the minor hemisphere. Instead, they often produce syndromes such as pure motor hemiplegia, pure sensory hemiplegia, and dysarthria with the clumsy hand syndrome.

Overview The Neurological System is divided into two major parts: the Central Nervous System (CNS) and the Peripheral Nervous System (PNS). The Central Nervous System is the bodys information headquarters, ultimately regulating nearly all body functions. It CNS includes the brain and spinal cord. The brain processes incoming information from within the body, and outside the body by way of the sensory nerves of sight, touch, smell, sound, and taste. In other words, the brain is where all thinking and decision-making takes place. The spinal cord is the main pathway for information connecting the brain and peripheral nervous system. Electrical impulses travel through the nerves and allow the brain to communicate with the rest of the body.

The Peripheral Nervous System is responsible for the remainder of the body. It includes cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal cord) and all the major sense organs. The PNS is divided into the somatic (SNS) and autonomic nervous system (ANS). The Somatic Nervous System (SNS) is responsible for all muscular activities that we consider voluntary or that are within our conscious control. The Autonomic Nervous System (ANS) is responsible for all activities that occur automatically and involuntarily, such as breathing, muscle contractions within the digestive system, and heartbeat. The ANS is further divided into two- the sympathetic and parasympathetic system. The Sympathetic System stimulates cell and organ function. It is activated by a perceived danger or threat: by very strong emotions such as fear, anger or excitement; by intense exercise; or when under large amounts of stress. The Parasympathetic System inhibits cell and organ function. It slows down heart rate, resumes digestion, and increases relaxation throughout the body. The brain is the center of our body functioning. Once it is injured the total functioning of our body will be affected. Physical activities are hampered and other vital organs will also be affected as well. Once vital organs are not in their optimum functioning, it will aggravate the seriousness of the condition of the patient.

Due to thrombosis, or embolism, some neurons die because of lack of oxygen and nutrients

Hemorrhagic

Infarction of the Cerebral Vessels known as Stroke

Tissue injury triggers an inflammatory response which increases intracranial pressure.

Space occupying blood clots put more pressure in the brain tissues

The injury disrupts metabolism leading to changes in ionic transport, localized acidosis, and free radical formation

The regulatory mechanisms of the brain attempt to maintain equilibrium by increasing BP and ICP.

Calcium, Sodium, water accumulate in the injured

The ruptured cerebral

F. Prioritizing Nursing Diagnosis 1. Ineffective Cerebral Tissue Perfusion related to cerebral edema as evidenced by altered level of consciousness, stiffening of extremities, slurred speech 2. Impaired Physical Mobility r/t neuromuscular/musculoskeletal impairment 3. Self-Care Deficit r/t impaired mobility status 4. Disturbed Sensory Perception r/t altered sensory perception 5. Impaired Verbal Communication r/t decreased circulation to the brain

Cues

Nursing Diagnosis

Outcome Criteria

Nursing Intervention

Rationale

Evaluation

Discharge Planning

Subjective: Budlayan siya maghulag kag maluya na ang tuo nga parti sang iya lawas. Nabudlayan sya maghambal daw indi maintindihan. as verbalized by the folk.

Ineffective Cerebral Tissue Perfusion related to cerebral edema as evidenced by altered level of consciousness, stiffening of extremities, slurred speech

Short Term: After 8 hours of effective nursing intervention the patient will be able to: 1. Demonstrate stable vital signs. 2. Prevent / minimize complications. 3. Daily needs are met either by himself or others. 4. Be free from injury and fall

Independent: 1. Determine factors related to individual situation /decreased cerebral perfusion. Assesses trends in level of consciousness (LOC) and useful in determining location, extent, and progression/resolution of CNS damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA. 3. Monitor vital signs. Monitor Alterations Prevent falls and injury Influences choice of interventions.

PARTIALLY MET Short Term: After 8 hours of effective nursing intervention the

M Instruct the folks and the patient to take drugs as ordered. Emphasize the importance of taking the drugs at the right timing of intake and right dosage. Explain to patient/folks the adverse effects of the drugs. E Provide/maintain stress free environment for the client to lessen discomfort. T Instruct patient to perform exercise treatment given by physical

2. Monitor/document neurological status frequently and compare with baseline.

patient was partially able to: 1. Demonstrate stable vital signs. 2. Prevent / minimize complications. 3. Daily needs are met either by himself or others. 4. Free from injury and fall

Objective: T36.5 P - 88 R - 22 BP 180/100 GCS 11 Stiffening of extremities Slurred speech

Long Term: After 2 weeks of effective nursing intervention the patient will be able to: 1. Maintain 5. Evaluate pupils, noting size, shape, equality, light Pupil reactions are regulated by the oculomotor (III) cranial 4. Provide safety measures

Long Term: After 2 weeks of effective nursing intervention the

usual/improved level of consciousness, cognition, and motor/sensory function. 2. Increased cerebral function and decrease neurological deficits.

reactivity.

nerve and are useful in determining whether the brainstem is intact. Pupil size/equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves Changes in cognition and speech content are an indicator of location/degree of cerebral involvement and may indicate deterioration/increased ICP.

patient was partially able to: 1. Maintain usual/improved level of consciousness, cognition, and motor/sensory function.

therapist. Advice folks to assist patient. H Instruct folks to place patient on moderate backrest. Encourage active ROM for

2.Increased cerebral function and decrease

unaffected extremities and perform passive ROM for affected extremities. O Explain to the patient and folks the importance of keeping followup appointments with health care providers and to

6. Assess higher functions, including speech, if patient is alert.

neurological deficits.

7. Position with head slightly elevated and in neutral position.

Reduces arterial pressure by promoting venous drainage and may improve cerebral

report any untoward signs and symptoms.

circulation/perfusion Continual stimulation/activity can increase ICP. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.

D Instruct the patient/folks to

8. Maintain bedrest; provide quiet environment; restrict visitors/activities as indicated. Provide rest periods between care activities, limit duration of procedures.

follow the diet intended for the patient. Healthy and rich in vitamins and minerals. Collaborate with the dietician. S Encourage folks to provide physical,

Dependent: 1. Administer oxygen at 2 Lpm as ordered. Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/edema formation. 2. Administer the following as ordered: -Baclofen1tab BID and ValproicAcid -Mannitol For skeletal muscle spasticity of spinal &cerebral origin

emotional, financial, and spiritual support to the patient.

25cc IV q8H

To increase urine flow in patients w/ acute renal failure, reduce raised intracranial pressure & treat cerebral edema.

-Levetriacetam 500mg 1tab OD

Adjunctive therapy in the treatment of partial seizures w/ or w/o secondary generalization.

-Losartan 50mg/tab 1tab OD -Citicoline 500mg 1tab BID

To manage HTN To treat cerebrovascular disorders including ischemic stroke, Parkinsonism & head injury.

-Amlodipine 20mg 1tab OD -Simvastatin 40mg/tab 1tab OD

To manage HTN & angina pectoris. To treatment hyperlipidemia; prophylaxis in hypercholesterolemic patients w/ ischemic heart disease.