Requirements in NCM 106 A

Submitted to: Submitted by: Shana Alexandra Perez Bonn Eljay Paas Generoe Saavedra Sarah Estoconing Amerlina Amilasan Farhaida Susulan Rofaida Omar

I.

Introduction

A.Background of the Study

1.Disease Condition CEREBROVASCULAR ACCIDENT A cerebrovascular accident is the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or a rupture of a blood vessel. It is also called brain attack this results in the death of the brain cells. Depending on the area of the brain involved and the extent of brain cell death, the specific body function such as speech, movement or memory may be affected. 2 Main Types of CVA: An ischemic stroke is caused by a blockage, and a hemorrhagic stroke is caused by a breakage in a blood vessel. In both cases, part of the brain is deprived of blood and oxygen, causing the brains cells to die. 1. Ischemic Stroke An ischemic stroke occurs when a blood clot blocks a blood vessel, preventing blood and oxygen from getting to a part of the brain. There are two ways that this can happen. When a clot forms somewhere else in your body and gets lodged in a brain blood vessel, it is called an embolic stroke. When the clot forms in the brain blood vessel, it is called a thrombotic stroke. 2. Hemorrhagic Stroke A hemorrhagic stroke occurs when a blood vessel ruptures, or hemorrhages, which then prevents blood from getting to part of the brain. The hemorrhage may occur in a blood vessel in the brain, or in the membrane that surrounds the brain.

2.Anatomy,Physiology and Pathophysiology.

The Nervous System is responsible for coordinating all of the body's activities. It controls not only the maintenance of normal functions but also the body's ability to cope with emergency situations. I. FUNCTIONS The nervous system has three general functions: a sensory function, an interpretative function and a motor function. A. Sensory nerves gather information from inside the body and the outside environment. The nerves then carry the information to central nervous system (CNS). B. 2. Sensory information brought to the CNS is processed and interpreted. C. 3. Motor nerves convey information from the CNS to the muscles and the glands of the body. II. STRUCTURE CNS - (spinal cord and brain) Regulation and integration of body functions. PNS control of skeletal muscles. ANATOMY OF THE BRAIN Meninges Dura - dense collagenous tissue. - Outer covering of connective tissue Arachnoid Pia Inner contiguous with the brain (external surface of brain). Middle -loose connective tissue strands and blood vessels.

Cerebro-spinal Fluid (CSF) o Surrounds brain and spinal cord o Protects the brain o Allows exchange of substances between the blood and the brain.

CNS: ANATOMY Brain Cerebrum - 2 hemispheres connected by the corpus collosum Cerebellum Brainstem -Midbrain , Pons ,Medulla oblongata Cerebrum 4 lobes and their functions: 1. 2. 3. 4. Frontal Parietal Occipital Temporal Motor, behavior, emotion, higher intellectual functioning Sensory Visual center Hearing & olfaction

Cerebellum FUNCTIONS: 1. Major regulator of motor activities 2. Maintenance of balance 3. Regulates muscle tone 4. Coordination of voluntary movement 5. Limb/eye coordination Spinal cord - The spinal cord is about 45 cms long, extending from the medulla down to the second lumbar vertebrae. It acts as a message pathway between the brain and the rest of the body. Nerves conveying impulses from the brain, otherwise known as efferent or motor nerves, travel through the spinal cord down to the various organs of the body. When the impulses reach the appropriate level they leave the cord to travel to the' target organ. Brainstem Integration of complex motor patterns Control of breathing, heart rate, BP, arousal and consciousness

PNS: ANATOMY (Spinal nerves and Peripheral nerves) Spinal nerves Anterior root = axons of LMNs

Posterior root = spinal ganglia and cytoplasmic extensions

Sensory and motor neuron circuit Reflex movements.

B. Objectives.

Care is coordinated from the first point of contact, whether through the emergency department, as their nurse on duty inpatient or outpatient services or the rehabilitation ward. Our , objective is to help them to improve the quality of life Objectives :

The primary goals of rehabilitation are to prevent complications, minimize impairments, and maximize function. Secondary prevention is fundamental to preventing stroke recurrence, as well as coronary vascular events and coronary heart diseasemediated death. Early assessment and intervention are critical to optimize rehabilitation. Standardized evaluations and valid assessment tools are essential to development of a comprehensive treatment plan. Evidence-based interventions should be based on functional goals. Every patient should have access to an experienced multidisciplinary rehabilitation team to ensure optimal outcome. The patient and the patients family members and/or caregivers are essential members of the rehabilitation team. Patient and family education improves informed decision-making, social adjustment, and maintenance of rehabilitation gains. The multidisciplinary team should utilize community resources for community reintegration. Ongoing medical management of risk factors and co morbidities is essential to ensure survival.

C.Significance The significance of this study is to imply general knowledge about cerebrovascular accident or stroke.It will also help us know the pathophysiology of the disease condition.It can help us, as a student nurse in which it is our task to educate the patient via health teaching.We can easily explain it to stroke patients and for them to fully understand their condition.Thus,it will also benefit the patient when they learn from the study, they can assess the signs and symptoms,the treatments and the independent interventions,that they can apply for themselves.Stroke patients can also help themselves in their rehabilitative process.It will help them to initiate self care and promote independence.This study will aso help people to prevent the occurrence of stroke by having this as a reference.

II.

THE NURSING PROCESS

A. Assessment Phase

Name: Patient M Age: 70 years old Clinical history:

Before the patient was admitted, her daughter found her on the floor, awake, confused and slightly short of breath. 3days prior from the accident,her daughter observed that her mother had an episode of sudden-onset of numbness, tingling in the right limb with slight confusion and slurred speech.it lasted for about 5 minutes. patient M has a past history of hypertension for 10 years but not compliant with her medications.She never smoked, drinks occasionally and is in normal weight.

General Assesment: >blood pressure is 180/110mmHg >pain felt in her left arm >experiences severe headache >there are slight carotid bruits >hemiparesis on the left side of the body >has left visual/spatial neglect

Laboratory exam: computer Tomography(CT) - shows that the brain indicates a thrombus in a branch of the right internal carotid artery with approximately 50% occlusion due to atherosclerosis. There is an area of infarction in the right anterior hemisphere. There is no evidence of a subarachnoid hemorrhage.

Problem identification: 1. Impaired verbal communication > slurred speech 2. Risk for injury >numbness and tingling in the right limb 3. Noncompliance to treatment regiment >noncompliant with antiheypertensive medicine 4. Ineffective cerebral tissue perfusion >Ct scan result 5. Impaired physical mobility >numbness and tingling in the right limb

Prioritization: 1st * Ineffective tissue perfusion 2nd *Risk for injury 3rd *Impaired physical mobility 4th *Impaired verbal communication 5th *Noncompliance to treatment regimen

III.Nursing responsibilities of the treatment modalities for the condition Monitoring and managing potential complication Assess vital signs and oxygenation status for adequate blood flow to the brain and tissues. Improve respiratory gas exchange with supplemental oxygen, suctioning, and chest physiotherapy. Maintain adequate cardiac output by medication and fluid administration.

Improving mobility and preventing deformities Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies. Apply a posterior splint at night to prevent flexion of affected extremity. Elevate affected arm to prevent edema and fibrosis. Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day. Establishing an exercise program Provide full range of motion four or five times a day to maintain joint mobility, regain motor control, and prevent contracture development, prevent further deterioration of the neuromuscular system, enhance circulation and exercise to prevent venous stasis. If tightness occurs in any area, perform range of motion exercises more frequently. Supervise and support patient during exercises; plan frequent short periods of exercise, not longer periods; encourage patient to exercise unaffected side at intervals throughout the day.

Preparing for Ambulation Start an active rehabilitation program when consciousness returns. Teach patient to maintain balance in a sitting position then to balance while standing Begin walking as soon as standing balance is achieved. Keep training periods for ambulation brief and frequent.

 Preventing Shoulder Pain Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder. Use proper patient movement and positioning. Range-of-motion exercises are beneficial, but avoid over-strenuous arm movement. Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as indicated. Enhancing self care Encourage patient to assist in personal hygiene, select suitable self care activities that can be carried out with one hand. Help patient to set realistic goals. Improve morale by making sure patient is fully dressed during ambulatory activities. Assist with dressing activities. Provide emotional support and encouragement to prevent fatigue and discouragement. Managing Sensory-Perceptual Difficulties Approach patient with a decreased field of vision on the side where visual perception is intact; place all visual stimuli on this side. Teach patient to turn and look in the direction of the defective visual field to compensate for the loss; make eye contact with patient, and draw attention to the affected side. Remind patient with hemianopsia of the other side of the body, place extremities so that patient can see them. Managing Dysphagia Have patient sit upright, preferably in chair, when eating and drinking; advance diet as tolerated. Prepare for gastrointestinal feedings through a tube if indicated; elevate head of bed during feedings, administer feeding slowly, and ensure that cuff of tracheostomy is inflated (if applicable); monitor and report excessive retained or residual feeding. Attaining bowel and bladder control Perform intermittent sterile catheterization during period of loss of sphincter control. Analyze voiding pattern and offer urinal or bedpan on this schedule.

Provide high fiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated. Establish a regular time after breakfast for toileting.

Improving thought process Reinforce structured training program using cognitive-perceptual retraining, visual imagery, reality orientation, and cuing procedures to compensate of losses. Support patient; observe performance and progress, give positive feedback, convey an attitude of confidence and hopefulness, provide other interventions as used for improving cognitive function after a head injury. Achieving communication Reinforce individually tailored program. Be consistent in schedule, routines, and repetitions. Talk to aphasic patients when providing care activities to provide social contact. Maintain patients attention when talking with patient, sleep slowly, and give one instruction at a time; allow patient time to process. Maintaining skin integrity Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts. Keep skin clean and dry, gently massage healthy dry skin, and maintain adequate nutrition. Improving family coping through health teaching Provide counseling and support to family. Involve others in patient care; teach stress management techniques and maintenance of personal health for family coping. Give family information about the expected outcome of the stroke, and counsel them to avoid doing things for patient that she can do. Develop attainable goals for patient at home by involving that total health care team, patient, and family. Encourage everyone to approach patient with supportive and optimistic attitude, focusing on abilities that remain; explain to family that emotional lability usually improves with time.

3. Evaluation phase of the nursing process Achieves improved mobility

Has no complaints of pain

Achieves self care

Turns head to see people or object

Demonstrates improved swallowing ability

Achieves normal bowel and bladder elimination

Demonstrates improved communication

Family member demonstrates a positive attitude and coping mechanisms

Antihypertensives are a class of drugs that are used to treat hypertension (high blood pressure) Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke and myocardial infarction. There are many classes of antihypertensives, which lower blood pressure by different means; among the most important and most widely used are the thiazide diuretics, the ACE inhibitors, the calcium channel blockers, the beta blockers, and the angiotensin II receptor antagonists or ARBsDiuretics help the kidneys eliminate excess salt and water from the body's tissues and blood.

Loop diuretics: bumetanide ethacrynic acid furosemide torsemide Thiazide diuretics: epitizide hydrochlorothiazide and chlorothiazide bendroflumethiazide Thiazide-like diuretics: indapamide chlorthalidone metolazone Potassium-sparing diuretics: amiloride triamterene spironolactone

Adrenergic receptor antagonists Beta blockers atenolol metoprolol nadolol nebivolol oxprenolol pindolol propranolol timolol Although beta blockers lower blood pressure, they do not have a positive benefit on endpoints as some other antihypertensives.[12] In particular, beta-blockers are no longer recommended as firstline treatment due to relative adverse risk of stroke and new-onset diabetes when compared to other medications,[3] while certain specific beta-blockers such as atenolol appear to be less useful in overall treatment of hypertension than several other agents.

Calcium channel blockers Calcium channel blockers block the entry of calcium into muscle cells in artery walls.

dihydropyridines: amlodipine Cilnidipine felodipine isradipine lercanidipine nicardipine nifedipine nimodipine nitrendipine non-dihydropyridines: diltiazem verapamil

Vasodilators Vasodilators act directly on the smooth muscle of arteries to relax their walls so blood can move more easily through them; they are only used in hypertensive emergencies or when other drugs have failed, and even so are rarely given alone. Sodium nitroprusside, a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as malignant hypertension or aortic dissection). Hydralazine and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies.They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in gestational hypertension. ACE inhibitors[edit] Captopril, the prototypical ACE inhibitor ACE inhibitors inhibit the activity of Angiotensin-converting enzyme (ACE), an enzyme responsible for the conversion of angiotensin I intoangiotensin II, a potent vasoconstrictor.

captopril enalapril fosinopril lisinopril perindopril quinapril ramipril

III.Synthesis and Conclusion

We therefore conclude that the case study about cerebrovascular accident or stroke is very helpful to our part as a student because it give us additional knowledge and trained us to be able to decide our own in handling the situation given to us..As a 4th year student, our critical thinking skills was challenged in making this case study, we were able to brainstorm to come up with ideas with the given situation.In this manner, when we will face an actual situation similar to this we will know how to respond properly using the applicable nursing interventions.It is really beneficial for us because aside from letting our minds work, we were able to exercise our leadership and management skills in which will contribute a big part in our future nursing career.