Canossa College of Nursing San Pablo City

CASE PRESENTATION
Ischemic Stroke

Prepared by: Group 1 BSN 2-A Abrigo, Angelou Denice Ariate, Fatima Love Baldovino, Ireneo Jr. Claveria, Rizelle Myra Desamero, Mary Ellaine Gallardo, Paul John Dominique Lundang, Siena Marie Manito, Sun Shine Micarsos, Tricia Kaye Ollanda, Laurice

Introduction Cerebrovascular accident is the term that refers to any functional abnormality of the Central Nervous System that occurs when the normal blood supply to the brain is disrupted, as by a blood clot or a ruptured blood vessel, and vital brain tissue dies. Cerebrovascular accident is commonly called Stroke. Major Types of Stroke Ischemic Hemorrhagic In an ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. The following are the symptoms of Cerebrovascular accident: Headache Dizziness and confusion Visual disturbance Slurred speech or loss of speech Difficulty of swallowing Risk factors: Age High blood pressure Atherosclerosis Heart disease Diabetes mellitus Smoking Epidemology: Vascular Disease which includes C.V.A. is the second leading cause of death in the Philippines with a total of 51,680 according to DOH 2004. Along with this are 37,092 who survived with it.

OBJECTIVES This case presentation has the main goal of explaining the causes of cerebro vascular accident and its different possible complications. It also emphasizes the proper nursing interventions that are applicable for this type of medical condition. RATIONALE FOR CHOOSING THE CASE This case was chosen by the group for the following reasons: To better understand the whole concept of cerebro vascular accident and to identify the possible complications that may arise and affect the patient To be able to enhance the groups knowledge regarding the proper nursing interventions needed in this particular medical condition SIGNIFICANCE OF THE STUDY This study will greatly aid the students in broadening their knowledge regarding this particular medical condition and will promote the proper nursing interventions that are needed in this particular case. SCOPE AND LIMITATION The study contains the following; a brief discussion of the condition and its causes, possible complications and proper treatment, a pathophysiology to better understand the connection of the condition to the persons over-all health, a nursing care plan that would present a nursing analysis and diagnosis about the condition, including a plan and intervention to assist in an enhance recovery.

PATIENTS PROFILE Name: Patient X Gender: Female Age: 88 years old Birthday: June 1923 Address: Dolores, Quezon Status: widowed Religion: Catholic Chief Complain: body weakness with slurred speech Admitting Diagnosis: left side body weakness with slurred speech Past History Immunization: complete childhood immunization Allergies: No known allergies Family History of Illness: no family history of diabetes Present Illness: Alzheimers Disease (diagnosed 3 years ago)

PHYSICAL ASSESSMENT Skin Warm and dry to touch Poor skin turgor No swelling, pitting or edema Hair Gray colored hair With normal amount and distribution of hair No head lice Scalp Smooth No lesions Nail Pinkish nail beds Thick nails Face Proportion facial features Neck Cant rotate within the range of motions Cant follow instructions Eyes

PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) Symmetrical Brown eyes in color Wearing eye glasses

Ears Equal size and similar appearance No lesions and discoloration Client is unable to hear whispered words

 Mouth Lips no lesions, slightly pink With complete set of dentures Gums pink Tongue moist, symmetrical appearance, midline fissures present Nose Color same as face Proportion appearance Patent nares Chest Synchronized chest movements With clear breathe sounds Abdominal No rashes or lesions on Sunken and centrally located umbilicus Flabby Positive bowel sounds (3) in all four quadrants Musculoskeletal Arm Right can flex and extend arm Left with weakness Hand Right can grip well Left with weakness Leg Right can flex and extend leg Left with weakness Neurologic Alert and awake with eyes open Expresses feelings appropriate to situation

GORDONS FUNCTIONAL HEALTH PATTERN Health Perception-Health Management Pattern Due to her body weakness, she cant perform her daily activities like cooking and gardening. Maintains her health by eating healthy foods like vegetables. Regular check-up every 2-3 months. Consults her doctor every time she is not feeling well. Nutritional-Metabolic Pattern Drinks Anlene and Caltrate for bone development. Likes to eat vegetables, fruits, and fish. Doesnt eat canned goods and foods with preservatives. Doesnt have problem in swallowing. Doesnt use any herbal medicines. Elimination Pattern With normal bowel movement (1/day). She voids without pain She doesnt use any rectal suppositories nor laxatives. She doesnt have any discomfort with her bowel movement Activity-Exercise Pattern She cooks kakanin and sell it on schools to earn money for her family. She loves to plant vegetables on their farm. She spends her time talking care of her grandchildren. Sexually-Reproduction Pattern She got pregnant 5 times. She gave birth on 3 girls and 2 boys. Sleep-Rest Pattern She sleeps almost 8-10 hours at night. She is not using any sleeping pills to fall asleep. Cognitive-Perceptual Pattern Cant communicate well because of her Alzheimers disease. Not able to recall past memories

 Sensory-Perceptual Pattern Blurred vision (wears eyeglasses) With slurred speech. Cant hear well. Role-Relationship Pattern She took care of her grandchildren. Good relationship with her family Her daughter provides financially Self-perception Self-concept Pattern She had a hard time communicating with her family because of her slurred speech. Her strength is her family. Coping-Stress Tolerance Pattern She just spends her time with her grandchildren to entertain herself and divert her attention if shes stressed. Value-Belief Pattern She used to go to church every week alone, but when she got sick, she just attends the mass in television.

ANATOMY AND PHYSIOLOGY

DRUG STUDY GENERIC NAME: Citicoline BRAND NAME: Zynapse CLASSIFICATION: Vasoconstrictors DOSAGE: 1g 1 tab OD; 500mg 1amp every 6hrs Pharmacodynamics: Narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, particularly the large arteries and small arterioles. The process is the opposite of vasodilatation, the widening of blood vessels. Pharmacokinetics: Once absorbed it disperse widely throughout the body, cross the blood-brain barrier and reach the central nervous system (CNS). Pharmacotherapeutics: In acute recovery phase in signs and symptoms of cerebrovascular insufficiency and in cranial traumatism Nursing Responsibility: Check for history of allergy Monitor vital signs Instruct the patient to avoid alcohol while taking this drug.

GENERIC NAME: Mannitol BRAND NAME: Osmitrol, Rescitisol CLASSIFICATION: Diuretics DOSAGE: 75cc every 12hrs

Pharmacodynamics: Elevates the osmolarity of the glomerular filtrate, there by hindering the reabsorption of water and leading to loss of water sodium, chloride, creates an osmotic gradient in the eye between plasma and ocular fluids.

Pharmacokinetics: Route and Dosage: A: IV 1.5-2.0mg/kg; 15%-25% sol infused over 30-60mins Pharmacotherapeutics: Increase urine flow of the patient, reduction of intra-cranial pressure and treatment of cerebral edema Nursing Responsibility: Do not administer unless solution is clear and container is undamaged. Should not be given conjointly with blood Monitor I & O

GENERIC NAME: Celecoxib BRAND NAME: Celebrex CLASSIFICATION: NSAIDs DOSAGE: 20mg 1cap BID; PNN for headache Pharmacodynamics: usually indicated for the treatment of acute or chronic conditions where pain and inflammation are present. Pharmacokinetics: Route (oral) Onset (slow) Peak (3hrs)

Pharmacotherapeutics: Management of acute pain Nursing Responsibility: Alert patients to the potential side effects of the drug Should be taken with food or milk to lessen the chance of gastric upset Discontinue if they have gastrointestinal symptoms (bloody stools or cramping)

GENERIC NAME: Ambroxol HCL BRAND NAME: Ambrolex CLASSIFICATION: Mucolytic DOSAGE: 75mg 1cap TID Pharmacodynamics: Breaks down the chemical structure of mucus molecules and helps loosen thick bronchial secretions Pharmacokinetics: Cleared rapidly from the plasma mainly by hepatic metabolism. Half-life: 4-5 minutes (initial); about 40 minutes (terminal) Pharmacotherapeutics: Acute exacerbations of chronic and asthmatic bronchitis, bronchial asthma and bronchiectasis. Nursing Responsibility: Monitor for signs and symptoms of aspiration of excess secretions and for bronchospasm. Report difficulty with clearing the airway or any other respiratory distress. Increase fluid intake

GENERIC NAME: Simvastatin BRAND NAME: Altovast CLASSIFICATION: Dyslipidemic Agents DOSAGE: 40mg 1 tab OD at HS Pharmacodynamics: An abnormal concentration of lipids or lipoproteins in the blood. Pharmacokinetics: Route (oral) Onset (slow)

Peak (1.3-2.4hrs) Highly protein bound

Pharmacotherapeutics: Treatment of hypercholesterolemia hyperlipoproteinemias particularly type IIA and IIB

Nursing Responsibility: Check for history of allergy. Report severe GI upset, changes in vision, unusual bleeding or bruising, dark urine or light-colored stools, fever, muscle pain, or soreness. Renal tests for patients with impaired renal function.

Generic: Omeprazole Brand: Zegerid Dosage: 40mg capsule Classification - proton pump inhibitor

Pharmacodynamic block the enzyme in the wall of the stomach that produces acid, by blocking the enzyme the production of acid is decrease and allows the stomach and esophagus to heal. Pharmacokinetics duration of omeprazole is 72 hours short life and highly protein bound taken before meals Pharmacotherapeutic effective in suppressing gastric and secretions and used to treat peptic ulcer. use for epigastic pain/dizcomfort w/ or w/o heart burn for hepatic impairments Nursing Responsibility Monitor liver enzyme Assess for any allergy to the drug

Generic: Clopidogrel Brand: Plavix Dosage: 75mg tablet Classification - Anti-platelets Pharmacodynamic inhibits platelet aggregation by blocking ADP receptors on platelets, prevents clumping of platelets Pharmacokinetic prevent platelet aggregation Pharmacotherapeutic treatment for patients at risk of ischemic events history of MI, ischemic stroke, peripheral artery disease treatment for patient w/ acute coronary syndrome Nursing Responsibility Assess for symptoms of stroke, MI during treatment Monitor liver function studies :bilirubin ,creatinine if patient is on longtermtherapy Monitor blood studies:CBC,Hgb, Hct ,protime ,cholesterol if the patient is on long-termtherapy ; thrombocytopenia and neutropenia mayoccur Generic: Carvedilol Brand: Dilatrend Dosage: 25mg Classification - Beta-Blockers Pharmacodynamic Reduces the pressure that the heart has pump against as well as controlling your heart rate Pharmacokinetic All is absorbed thru GI after oral administration Metabolized in liver excreted in urine Pharmacotherapeutic For heart failure High BP or Hypertension

Nursing Responsibility Swallow and drink water immediately after meal, same time every day Explain that do not take 2 dose if miss,, take the dose after remembering the drug Assess for any sign of dehydration Assess for any allergy to drugs especially to carvedilol Generic: Ferrous Gluconate Brand: Sangobion Dosage: 1 capsule Classification - Anti-anemics Pharmacodynamic Essential minerals found in hemoglobin, myoglobulins and enzyme enters the blood stream and is transported to the organs of the reticuloendothelial system, where it is separated out and becomes part of iron stones Pharmacotherapeutic Prevention and treatment of iron deficiency anemia Nursing responsibility Assess bowel function for constipation and diarrhea Instruct patient that stool may turn in back black color and if it is normal due to the medication Instruct patient to intake of food rich in Vit C for better absorption of the medication Instruct to increase oral fluid intake to avoid constipation Encourage patient to increase intake of green leafy vegetable Observe for seizure , tachycardia and hypotension Advice patient to report severe vomiting and taste disorder Generic: Losartan potassium Brand: Combizar Dosage: 50/12.5mg tablet Classification: Angiotensin II antagonist Pharmacodynamics Block the angiotensin II Pharmacokinetics Protein bound

Absorbed in GI Metabolized in liver and excreted thru kidney

Pharmacotherapeutics Hypertension Heart failure Nursing Responsibility Assess V/S especially the BP Monitor intake and output Monitor potassium level Assess for edema Generic: Fenofibrate Brand: Lipanthyl Classification - Anti lipidemics Pharmacodynamics Can lower blood cholesterol by 20%-25% and blood triglycerides by 40%-50% Reduction of blood cholesterol is due to the lowering of the therogenic ratio of low density fractions (VLDL and LDL). It improves the distribution of plasma cholesterol as it reduces the total cholesterol / HDL ratio increase during atherogenic hyperlipidemia Pharmacokinetics The plasma half life of elimination of fenobric acid is 20 hours. Multiple dosing show the absence of accumulation of product Pharmacotherapeutics Hypercholesterol , mixed hyperlipidemia, hypertriglyceridemia Nursing Responsibility Monitor V/S especially BP

RECOMMENDATION 1. Prevent dehydration, encourage increase fluid intake 2. Food intake should be monitored to prevent aspiration 3. Teach the importance of maintaining good oral and dental hygiene 4. Patient should be encouraged to undertake regular physical therapy 5. Introduce alternative means of communication to assist in promoting good speaking skills