Case Study
by
Ms. Qing Xie
Objective
♀ To review the anatomy and physiology of
brain
♂ To describe the pathophysiology of CVA
♀ To show the complications & clinical
manifestations of CVA
♂ To describe the medical treatment of CVA
♀ To discuss nursing management after
intracranial surgery
♂ To identify the nursing diagnosis &
interventions of CVA
Anatomy & Physiology of Brain
Brainstem - The lower extension of the brain where it
connects to the spinal cord. Neurological functions located in
the brainstem include those necessary for survival (breathing,
digestion, heart rate, blood pressure) and for arousal (being
awake and alert). Most of the cranial nerves come from the
brainstem. The brainstem is the pathway for all fiber tracts
passing up and down from peripheral nerves and spinal cord
to the highest parts of the brain.
• First Symptoms
Once the aneurysm starts growing, then
symptoms will begin. These will include
problems seeing, problems speaking,
problems with coordination, dizziness,
severe mood swings, inability to
concentrate and inability to handle the
smallest decision or task.
Warning Symptoms
• persistent headache
• vomiting without diarrhea
• double vision
• irritability
• tiredness
• fits
• bulging of the fontanel, if this is
still open
Nursing Management
Guidelines for Care of the Person after
intracranial surgery:
Preoperative Care
1. Baseline data of neurological and physiologic status should be
recorded
2. Patient and family should be encouraged to verbalize fears
3. Treatments and procedures are explained fully, even if unsure whether
patient understands
4. If head is shaved, it is usually done in the operating room
5. Antiseptic shampoo may be ordered night before surgery and may be
repeated in morning
6. If hair is shaved, it is saved and given to patient or family
7. Prepare family for appearance of patient after surgery
a. Head dressing
b. Edema and ecchymosis of face common
c. Temporary decreased mental status (possible)
Postoperative Care
1. Monitoring
• Assess neurological status frequently for any decrease in mental
status
• Observe for symptoms of subdural hematoma, one of the possible
side effects of the surgery
• Monitor for symptoms of over-drainage, as evidenced by headache,
especially when patient is sitting upright or standing
• Assess degree and characteristics of drainage
-Amount of drainage and bleeding should be minimal
-Reinforce dressing as needed
-Often incision areas are left open to air after several days
4. Promoting mobility
a. Turning position either side is permitted
c. Patient is encouraged to ambulate as much as possible to encourage
adaptation to decreased ICP
Client’s History
Client: Mrs. A Age: 62-years old
Sex: Female Room/Bed: 706-A
Admission Date: March, 14, 2009
Medical Diagnosis:
–Recurrent ruptured left anterior communicating artery aneurysm
–Obstructive hydrocephalus
–Deep vein thrombosis
–Hypertension
Post operation:
–Intravenous cholangiography filter (25/01/09) –Ventriculo-peritoneal
shunt implantation (03/02/09) –Tracheostomy(17/02/09)
–Cerebral angiogram with GDC embolization (07/03/09)
–Right frontal ventriculostomy with continuous cerebrospinal fluid
drainage and removal of VP shunt (07/03/09)
Chief Complaints: Both arms & legs weakness
Present Illness: December, 30, 2008: Hypertension, stroke, ruptured
aneurysm, deep vein thrombosis, and hydrocephalus
Past Illness:
– Hypertension
Nursing Diagnosis & Interventions
(1) ND: Ineffective breathing pattern related to altered level of consciousness &
respiratory muscle weakness.
Nursing intervention and reasons:
• Assess reparatory status, such as, rate, pattern, lung sounds, and depth of breath
to detect early signs of respiratory compromise
• Assess change in mental status (↑consciousness, dyspnea, restlessness, ↑pulse
rate) can be early signs of cerebral hypoxia
• Provide O2 on tracheotomy tube with collar mask 3L/min. as ordered to meet the
need of O2 in body
• Arrange semi-Fowler’s position to promote lungs excursion and chest expansion
• Provide airway suctioning as needed to maintain airway clearance
• Observer characteristic of secretion from airway such as color, odor, and amount
to early detect infection of airway
• Encourage fluid intake and perform percussion to loosed secretions
• Administer Beradual NGq 12 hour to treat COPD w/ reversible bronchospasm
(monitor ADR of drug: dizziness, headache, nervousness, palpitations,
tachycardia)
• Administer Fluimucil 60mg 1x2 ☉pc to treat resp. tract affection w/ abundant
mucus secretions (monitor ADR of drug: bronchospasm, GI upset, headache)
(2) ND: Risk for disuse syndrome related to (3) ND: Self care deficit related to impaired
physical immobility physical mobility and alteration in cognitive
process