PAMANTASAN NG CABUYAO

Katapatan Village Banay-Banay Cabuyao, Laguna

Submitted by:

Brofar, Paola Rica M.

Buenafe, Mary Antonette D.
Garcia, Emmanuel
Gomez, Angel Lyn D.

Submitted to:
Breezy Capinpin, RN, MAN

September 22, 2009

CASE ABSTRACT
 A 47 years old, female patient was admitted at Panlalawigang Pagamutan ng Laguna with
a chief complaint of loss of consciousness. Patient was accompanied by her relatives per
stretcher with IVF of PNSS 1L to run @ 20gtts/min. she is unconscious upon admission to
intensive care unit with right sided body weakness.

LEARNING OBJECTIVES

 To fully understand the disease process and its implications to nursing care.

 To identify the signs and symptoms and treatments of Cerebrovascular Accident, Diabetes
Mellitus and Parkinson Disease.

 To know and understand the nursing interventions and managements that is appropriate
for the patient with Cerebrovascular Accident, Diabetes Mellitus and Parkinson Disease.

CASE DEFINITION
Cerebrovascular Accident

 CVA is caused by disruption of the blood supply to the brain, causing neurologic deficit.
 The middle cerebral artery (MCA) is most commonly affected in CVA.
 The second most frequently affected side is the internal carotid artery.
 The most common cause of CVA is thrombosis, and then followed by embolism, then
cerebral hemorrhage.
 CVA due to thrombosis and embolism may occur during sleep or rest period.
 CVA due to hemorrhage is associated with activities and occurs during waking hours. It is
characterized by extensive, permanent loss of function. There is rapid onset of Hemiplegia
and rapid progression into coma. It is usually fatal.
 Transient Ischemic Attacks (TIA) refers to transient cerebral ischemia with temporary
episodes of neurologic dysfunction.
 The clinical manifestations of CVA are as follows:
• Increased ICP
• Perceptual defects
• Aphasia
• Hemianopsia (loss of half of the visual field)
• Hemiplegia
 The collaborative management for CVA are s follows:
• Emergency Care: Care of the client with increased intracranial pressure.
• Promote Communication
 Care of the client with Aphasia
o Say one word at a time.
o Identify one object at a time.
o Give simple commands
o Anticipate needs
o Allow client to verbalize, no matter how long it takes him.
o Reinforce success in speech.
o Assist the client in speech therapy.
• Care of the client with hemianopsia.
 Approach the client from the unaffected side of the visual field.
 Place frequently used articles on the unaffected side of the visual field.
 Teach the client scanning technique. Turn the head from side to be able to
see the entire visual field.
• Supportive Care:
 Promote nutrition (Enteral Feedings, TPN).
 Promote activity (turn frequently, passive ROM exercises).
 Promote elimination (monitor I and O, urinary and bowel program).
 Provide emotional support.
 Assist in the rehabilitation of the client.

Diabetes Mellitus Type II

 It is a Non-Insulin Dependent Diabetes Mellitus (NIDDM), maturity onset, ketosis-resistant
DM.
 Onset is after age of 30 years.
 With relative lack of insulin or resistance to the action of insulin; usually insulin is sufficient
to stabilize fat and protein metabolism but not deal with carbohydrate metabolism.
 The client is obese.
 The client is prone to hyperglycemic, hyperosmolar, non-ketotic coma (HHNC). This is
extreme hyperglycemia without acidosis. It may result in dehydration and vascular
collapse.
 The collaborative management for NIDDM include:
• Diet
• Activity and exercise
• Oral Hypoglycemic Agents (OHA) or injectables Hypoglycemic Agents (IHA). If
hypoglycemia is uncontrolled.
• Insulin. In case of stress, surgery, infections, and pregnancy. These conditions
trigger stress responses and stimulate secretion of epinephrine, norepinephrine and
glucocorticoids. These hormones cause hyperglycemia.
 A deficiency in insulin result to hyperglycemia.
 The clinical manifestations of DM are as follows:
• Polyuria, polydypsia, polyphagia (3Ps)
• Weight loss
• Blurred vision
• Slow wound healing
• Weakness and paresthesia
• Signs of inadequate circulation to the feet
• Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral)
 Complications includes:
• CAD
• Cardiomyopathy
• Hypertension
• CVA
• Retinopathy
• Nephropathy
• Neuropathy
Parkinson’s disease

 It is a degenerative disease that affects the extrapyramidal system (EPS). This cause
decreased dopamine production.
 The cause of Parkinson’s disease is as follows: unknown, viral infections, drugs,
disequilibrium between dopamine and acetylcholine, encephalitis, arteriosclerosis and
carbon monoxide poisoning. The initial sign is tremors.
 Resting tremors (non-intention tremors). Shakings are more severe when the client is not
performing physical activities.
 Rigidity occurs due to decreased dopamine production. Dopamine is a neurotransmitter
that promotes muscle relaxation.
 Cogwheel rigidity and absence of arm swing when walking.
 Bradykinesia - Is slow muscle movement, not associated with muscle weakness.
 Akinesia - Is absence of muscle movement, not associated with muscle weakness.
 The other signs and symptoms of Parkinson’s Disease are as follows:
• Flattened affect (mask-like facial expression)
• Stooped posture
• Moist, oily skin
• Emotional instability
• Fatigue
• Soft, monotonous voice
• Shaky, small handwriting
 The collaborative management of Parkinson’s Disease are as follows:
• Thickened liquid diet to soft diet for Dysphagia.
• Firm bed to prevent contractures.
• Aspiration precaution. Keep client in upright position when feeding.
• Increase fluid intake and fiber in the diet to prevent constipation.
• Pharmacotherapy
o Anticholinergics – reduce rigidity and some of the tremors in Parkinson’s
disease.
- Artane (Trihexyphenidyl)
- Cogentin (Benztropine)
- Akineton (Biperiden)
- Norflex (Orphenadine)
o Dopaminergics – improves muscle flexibility.
- Levodopa
- Carbidopa with Levodopa (Sinemet). Carbidopa reduces destruction of
levodopa at the periphery. A single dose per day is administered.
- Dopamine cannot cross blood brain barrier.
- Levodopa, a precursor of dopamine can cross the blood brain barrier.
ANATOMY AND PHYSIOLOGY

The forebrain is responsible for a variety of functions including receiving and processing
sensory information, thinking, perceiving, producing and understanding language, and
controlling motor function. There are two major divisions of forebrain: the diencephalon and the
telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus
which are responsible for such functions as motor control, relaying sensory information, and
controlling autonomic functions. The telencephalon contains the largest part of the brain, the
cerebral cortex. Most of the actual information processing in the brain takes place in the cerebral
cortex.
The midbrain and the hindbrain together make up the brainstem. The midbrain is the
portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is
involved in auditory and visual responses as well as motor function.
The hindbrain extends from the spinal cord and is composed of the metencephalon and
myelencephalon. The metencephalon contains structures such as the pons and cerebellum. This
region assists in maintaining balance and equilibrium, movement coordination, and the
conduction of sensory information. The myelencephalon is composed of the medulla oblongata
which is responsible for controlling such autonomic functions as breathing, heart rate, and
digestion.

Basal Ganglia
• Involved in cognition and voluntary movement
• Diseases related to damages of this area are Parkinson's and Huntington's
Brainstem
• Relays information between the peripheral nerves and spinal cord to the upper parts of the
brain
• Consists of the midbrain, medulla oblongata, and the pons
Broca's Area
• Speech production
• Understanding language
Central Sulcus (Fissure of Rolando)
• Deep grove that separates the parietal and frontal lobes
Cerebellum
• Controls movement coordination
• Maintains balance and equilibrium
Cerebral Cortex
• Outer portion (1.5mm to 5mm) of the cerebrum
• Receives and processes sensory information
• Divided into cerebral cortex lobes
Cerebral Cortex Lobes
• Frontal Lobes -involved with decision-making, problem solving, and planning
 • Occipital Lobes-involved with vision and color recognition
• Parietal Lobes - receives and processes sensory information
• Temporal Lobes - involved with emotional responses, memory, and speech
Cerebrum
• Largest portion of the brain
• Consists of folded bulges called gyri that create deep furrows
Corpus Callosum
• Thick band of fibers that connects the left and right brain hemispheres
Cranial Nerves
• Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck
and torso
Fissure of Sylvius (Lateral Sulcus)
• Deep grove that separates the parietal and temporal lobes
Limbic System Structures
• Amygdala - involved in emotional responses, hormonal secretions, and memory
• Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and
the regulation of aggressive behavior
• Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the
hypothalamus
• Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for
long-term storage and retrieves them when necessary
• Hypothalamus - directs a multitude of important functions such as body temperature,
hunger, and homeostasis
• Olfactory Cortex - receives sensory information from the olfactory bulb and is involved in
the identification of odors
• Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal cord
and the cerebrum
Medulla Oblongata
• Lower part of the brainstem that helps to control autonomic functions
Meninges
• Membranes that cover and protect the brain and spinal cord
Olfactory Bulb
• Bulb-shaped end of the olfactory lobe
• Involved in the sense of smell
Pineal Gland
• Endocrine gland involved in biological rhythms
• Secretes the hormone melatonin
Pituitary Gland
• Endocrine gland involved in homeostasis
• Regulates other endocrine glands
Pons
• Relays sensory information between the cerebrum and cerebellum
Reticular Formation
• Nerve fibers located inside the brainstem
• Regulates awareness and sleep
Substantia Nigra
• Helps to control voluntary movement and regulates mood
Tectum
• The dorsal region of the mesencephalon (mid brain)
Tegmentum
• The ventral region of the mesencephalon (mid brain).
Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid
• Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth
ventricle
• Choroid Plexus - produces cerebrospinal fluid
 • Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the
cerebellum
• Lateral Ventricle - largest of the ventricles and located in both brain hemispheres
• Third Ventricle - provides a pathway for cerebrospinal fluid to flow
Wernicke's area
• Region of the brain where spoken language is understood.

The pancreas is located retroperitoneal, posterior to the stomach in the inferior part of
the left upper quadrant. It has a head near the midline of the body and a tail that extends to
the left where it touches the spleen. It is a complex organ composed of both endocrine and
exocrine tissues that perform several functions. The endocrine parts of the pancreas consist of
pancreatic islets (islets of Langerhans). The islet cells produce the hormones insulin and
glucagon, which enter the blood. These hormones are very important in controlling blood levels
of nutrients such as glucose and amino acids.

The exocrine part of the pancreas is a compound acinar gland. The acini produce
digestive enzymes. Clusters of acini are connected by small ducts, which join to form larger
ducts, and the larger ducts join to form the pancreatic duct. The pancreatic duct joins the
common bile duct and empties into the duodenum.

Functions of Pancreas
The exocrine secretions of the pancreas include HCO3-, which neutralize the acidic chyme
that enters the small intestine from the stomach. The increased pH resulting from the secretion
of HCO3- stops pepsin digestion but provides the proper environment for the function of
pancreatic enzymes. Pancreatic enzymes are also present in the exocrine secretions and are
important for the digestion of all major classes of food. Without the enzymes produced by the
pancreas, lipids, proteins, and carbohydrates are not adequately digested.

The major proteolytic enzymes are trypsin, chymotrypsin, and carboxypaptidase.

These enzymes continue the protein digestion that started in the stomach, and pancreatic
amylase continues the polysaccharides digestion that began in the oral cavity. The pancreatic
enzymes also include a group of lipid-digesting enzymes called pancreatic lipases. Nucleases
are pancreatic enzymes that reduce DNA and ribonucleic acid to their component nucleotides.

The exocrine secretory activity of the pancreas is controlled by both hormonal and neural
mechanisms. Secretin initiates the release of a watery pancreatic solution that contains a large
amount of HCO3-. The primary stimulus for secretin release is the presence of acidic chime in the
duodenum. Cholecystokinin stimulates the pancreas to release enzyme-rich solution. The
primary stimulus for cholecystokinin release is the presence of fatty acids and amino acids in the
duodenum, and the enzymes secreted by the pancreas digest fatty acids and amino acids.
Parasympathetic stimulation through the vagus nerves also stimulates the secretion of
pancreatic juices rich in pancreatic enzymes. Sympathetic action potentials inhibit pancreatic
secretion.
PATHOPHYSIOLOGY

Predisposing Factors Precipitating Factors

Parkinson’s disease Diabetes Mellitus (Type II) eats too much rice Fatty foods as
favorite food

Can trigger autonomic decreased insulin production increased carbohydrate

increased fat deposits
Nervous system to stimulate breakdown
in blood vessels
Sympathetic nervous system increased blood glucose
Incr eased
production increased peripheral
Vasoconstriction blood becomes viscous of glucose
resistance

Blood Pressure increases

May cause rupture in brain capillaries

Brain tissue compression

Increased ICP brain herniation

Further tissue damage

Neurologic deficits
PART I – PATIENT ASSESSMENT DATA BASE

HEALTH HISTORY

Patient: X Inclusive Date of Confinement

Age: 47 years old Admission date and Time:

September 07, 2009/ 07:45 am
Birth date: October 17,
1961 Discharge Date and Time: N/A

Sex: Female Attending Physician: Dr. Pestaňo

Nationality: Filipino Initial Diagnosis: CVA Infarct R/O Hemorrhagic T/C

Parkinsons
Civil Status: Married
Final Diagnosis: Acute Intracerebral Hematoma 2°
Religion: Roman Catholic to CVA; DM II

Address: Lamot I Calauan, Source of History: Relatives and Chart

Laguna
Chief Complain: Loss of consciousness
PHYSICAL
ASSESSMENT
I. General Survey

II. Vital Sign

September 14, 2009
Vital Signs 10:00 am 1:00 pm
Blood Pressure 120/80 120/80
Temperature 36.2 °C 36.5 °C
Respiratory Rate 16 20
Pulse Rate 76 76

III. Integumentary
A. Skin: Palpation
-dry skin
-skin turgor returns to 2-3 seconds

B. Nails: Inspection
-pinkish color
-without clubbing
 Palpation
-capillary refill of 2-3 seconds

C. Hair and Scalp: Inspection

-black with some white hairs
-equally distributed

Palpation
-thick
-fine course

IV. HEENT
A. Head: Palpation
-without masses
B. Face:
C. Eyes: Inspection
-Both eyes, eyelids and eyebrows are symmetrical
-Pinkish conjunctiva
-Moist conjunctiva
-Tears are present in both eyes
-Reactive to light
D. Ears: Inspection
-Bean- shaped
-Bilateral & symmetrical
-With some cerumen
-No lesions

Palpation
-No masses

E. Nose: Inspection
- Nasal septum is at midline without deviation
-Pinkish nasal mucosa with few cilia
-with Nasogastric tube (intact)

F. Mouth/ throat/ mucous membranes: Inspection

-Lips: dry
-Oral mucosa: pinkish, without inflammation
-Gums: pinkish without bleeding and inflammation
-With cloudy white sputum
D. Trachea:

E. Thyroid gland:

V. Neck/ Lymph nodes

Inspection
-no scars

Palpation
-no masses
-lymph nodes are palpable

VI. Pulmonary (respiratory)

Inspection
 -normal chest
-without endotracheal tube

Palpation
-no masses
-no fractured ribs

Auscultation
-with crackles

VII. Cardiovascular
Inspection and Palpation
-Apical pulse palpable, strong and visible
-Carotid Pulse Palpable

VIII. Abdomen
Inspection
-no scars, striae and visible veins
-no herniations and inflammations

Auscultation
- bowel sounds: 2-4 BS/min (decreased)

Percussion
-dull on liver and abdomen

Palpation
-no masses

IX. Cranial Nerves

I – Olfactory = normal
II – Optic = normal
III – Oculomotor = normal
IV – Trochlear = normal
V – Trigeminal =
VI – Abducens = normal
VII – Facial =
VIII – Acoustic = normal
IX – Glossopharyngeal = normal
X – Vagus = normal
XI – Spinal Accessory =
XII – Hypoglossal =

X. Glasgow Coma Scale

Eye Openings
Spontaneous……….. 4
To command……….. 3
To pain…………………. 2
Unresponsive………. 1
Findings: 4
Best Verbal Response
Oriented……………….5
 Confused…………….. 4
Inappropriate………..3
Incomprehensible…2
Unresponsive……….1
Findings: 6
Best Motor Response
Obeys commands……..6
Localizes pain…………….5
Withdraws from pain…4
Abnormal flexion……….3
Abnormal extension….2
Unresponsive…………….1
Findings: 3
Total: 13

LABORATORY RESULT

Cranial CT Scan

Impression: Acute intracerebral hematoma in the left capsulo-ganglionic region and

left deep temporal lobe, with associated significant perilesional edema, as described, for which
possibility of tumoral bleed cannot be entirely ruled out, follow up examination with contrast is
recommended.

Chest X-ray

Examination Performed: Chest PA lying

Findings: Essentially normal chest findings

Blood Chemistry
September 10, 2009
Normal Result Interpretation
FBS 70-110 mg/dL 210.4 mg/dL Indicates that the pt. has possibility
of pancreatitis or brain tumors.
September 07, 2009
Normal Result Interpretation
BUN 8.0 – 25.0 mg/dL 15.9 mg/dL It is used to determine if the pt. has
renal disease, dehydration, urinary
tract obstruction or malnutrition.
Creatinine 0.5 – 1.7 mg/dL 0.7 mg/dL It indicates that the pt. possibly had
defective tubular absorption or
 acute hepatic atrophy.
FBS 70-110 mg/dL 189.2 mg/dL Indicates that the pt. has possibility
of pancreatitis or brain tumors.
Cholesterol Up to 200 189.0 mg/dL It indicates that the pt. is
malnourished.
Triglyceride 35-135 66.8 It is used to determine if the pt. has
s biliary obstruction, diabetes,
nephritic syndrome, endocrine
disorders.
Electrolytes:
Potassium 3.4 – 5.3 meq/L 3.0 meq/L It indicates that the pt. possibly had
GI or renal disorders.
Sodium 135 – 155 120.0 meq/L It indicates that the pt. possibly had
meq/L adrenal insufficiency.

Urinalysis
September 07, 2009
Normal Result Interpretation
Color Yellow, Clear Light Yellow It screen for the abnormalities
within the urinary system as well as
for systemic problem.
Transparency Clear Clear Used to determine if the urine of
the patient has bacteria, pus, and
presence of WBC, RBC.
Specific Gravity 1.003 -1.029 1.020 Indicator that the kidney has the
ability to reabsorb water.
Albumin Positive The glomerulus is possibly damage.
Sugar Negative Negative Used to determine if the patient
has significant hyperglycemia or
DM.
RBC 1-2 1-2 The pt. is possibly had trauma or
tumors.
Bacteria Negative Positive It indicates the presence of
infections.
Epithelial Cells Few Few Determine if the patient CHON
tubular destruct.