CEREBROVASCULAR DISEASE

CASE PRESENTATION OF BSN III-4 IIIGROUP 16 @ ARMED FORCES OF THE PHILIPPINES MEDICAL HOSPITAL

Introduction


Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most important cause. Cerebrovascular disease includes all disorders in which an area of the brain is temporarily or permanently affected by bleeding or lack of blood flow. Cerebrovascular diseases included stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms and vascular malformations. Restrictions in blood flow may occur from vessel narrowing (stenosis), clot formation (thrombosis), blockage (embolism), or blood vessel rupture (hemorrhage). Lack of sufficient blood flow (ischemia) affects brain tissue and may cause a stroke.

 Cerebrovascular

Disease Statistics

Stroke is the third leading cause of death in the United States. Of the more than 700,000 people affected every year, about 500,000 of these are first attacks, and 200,000 are recurrent. About 25 percent of people who recover from their first stroke will have another stroke within five years. Stroke is a leading cause of serious long-term longdisability. Each year, an estimated 30,000 people in the United States experience a ruptured cerebral aneurysm and as many as 6 percent may have an unruptured aneurysm.

Objectives


At the end of the presentation, nursing students will be able to.. - learn about the topic or the disease - know how this disease affect people - understand the disease - know the signs and symptoms and as well as the causes of the disease.

Nursing History
A. Biographical Data :
Name: Normita Esplana Age: 56 years old Sex: Female Nationality: Filipino Religion: Roman Catholic Address: # 53 Bogna Legaspi City, Albay Birth Day: August 8, 1954 Birth Place: Ilocos Norte Date of Admission: July 28, 2011 Chief Complaint: Body Weakness Diagnosis: Cerebro Vascular Disease Fronto Parietal Area Bilateral with hemorrhagic Conversion Parietal Area

B. Reasons for Seeking Health Care :

The patient has experiencing body weakness 2 weeks ago, when we was interviewed her.

C. History of Past Illness

Upon Interview to the patient, she said that in her childhood times she never experienced any major illness. She also said that she only experienced those common illness like fever, colds, cough and flu. The patient cannot tell about her immunization because she has forgotten if she is fully immunized or not. The patient has no allergy to any foods, medicines and environment. The patient also told that she had never been hospitalized and never had a major accidents.

C.

History of Present Illness

Patient N.E was admitted in V.Luna General Hospital (Female Medical Ward) last July 28. Prior to admission, the patient stated that the onset of her illness was occur 2 weeks ago before she was admitted. Patient N.E started complaining of left sided body weakness associated difficulty in ambulation. There was no associated of difficulty of breathing, Diabetes Mellitus, Headache and Level of consciousness.

D. Family History

There is a history of illnesses in there family.

 Hypertension  Diabetes  Asthma

Mellitus

Anatomy & Physiology

PATHOPATHO-PHYSIOLOGY
modifiable non modifiable Increase triglycerides: 242.48mg/dL Decrease HDL:29.73mg/dL Carotid stenosis Decrease cardiac output Compensatory aldosterone ADHcathecolamine compensatory release ADHcathecolamine Adequate or increase blood volume increase SVR

Increase preload, stroke volume and heart rate Systemic and pulmonary edema requirements

increase myocardial oxygen

EDEMA fraction

decrease cardiac output, decrease ejection

Increase BP

decrease tissue perfusion

Impaired cellular metabolism

Gordons Functional Health



Health perception- health management: perceptionThe patient understands her condition she is taking medications prescribed by her physician & follows all the advice in order to improve her health Nutrition metabolic : She is advised to eat low fat low sodium foods & she takes consideration of it. Although sometimes she cannot eat, she feels so dizzy & nauseated. Before she used to eat fatty foods but now it was changed. Elimination: She frequently urinate during daytime & defecate every other day, she dont have any problem in urinating or defecating even before hospitalization.

ActivityActivity-exercise: The patient stays on bed all day long she ambulates only when shes urinating. She experienced shortness of breath when she is walking & leg cramps. According to her son even before hospitalization the patient stays on bed oftentimes. Sleep & rest: The patient sometimes suffering from difficulty of sleeping due to her leg cramps & headache even before she was hospitalized CognitiveCognitive-perceptual : The patient sometimes was disoriented she cannot verbalized what she feels & sometimes cannot recognize some of her family member also due to her age. Most of the times she feels restless & dizzy at bed she also experiences some sort of pain in her leg, shortness of breath. Headache & nausea.

Role relationship:

According to her son her mom is a plain housewife living with them before she was still strong she can cook food for them & clean their house but when she gets old & her condition worsen she can no longer do the things she used to do before.


Sexuality reproductive:
Of course because of her age & condition she can no longer engage in any sexual activities.

Coping stress: When the patient have problems she verbalized it in her children & husband mostly problems regarding her condition. The patient cannot effectively cope up with stress by her own, basically she needs her family support

Physical Assessment
Area Assessed Skin Color Technique Inspection Normal Findings Light brown, tanned skin (vary according to race) Lighter colored palms, soles, lips and nail beds Skin normally dry Actual Findings brown Evaluation Normal

Lips, nail beds, soles and palms Moisture

Inspection

Pallor nail beds

Normal

Inspection/ Palpation Palpation Palpation

Dry

Normal

Temperature Texture

Normally warm Smooth, soft and flexible palms and soles (thicker) Skin snaps back immediately

Warm to touch Smooth

Normal Normal

Turgor

Palpation

Goes back immediately

Normal

Skin appendages a. Nails Nail beds Nail base Capillary refill

Inspection Inspection Inspection Inspection/ Palpation

Transparent, smooth and convex Pinkish Firm White color of nail bed under pressure should return to pink within 2-3 seconds Evenly distributed Black Smooth Parallel to each other PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible

Pinkish, Convex Pinkish Firm White color of nail beds under pressure returned to pink within 2-3 seconds 2Evenly distributed Grayish Uneven Parallel to each other PERRLAPERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible

Normal Normal Normal Normal

b. Hair Distribution Color Texture c. Eyes Eyes Visual Acuity

Inspection Inspection Inspection/ Palpation Inspection Inspection (penlight)

Normal Normal because of old age Normal Normal Normal

Eyebrows

Inspection

Normal

Eyelashes Conjunctiva Sclera Cornea Pupils Iris

Inspection Inspection Inspection Inspection Inspection Inspection

Normal Normal Normal Normal Normal Normal

Ears Ear canal opening Hearing Acuity

Inspection

Free of lesions, discharge of inflammation Canal walls pink Client normally hears words when whispered

Free of lesions, discharge of inflammation Canal walls pink Client sometimes doesnt hear words when whispered, sometimes you have to speak louder Smooth, symmetric with same color as the face Close to midline, thicker anteriorly than posteriorly Oval, symmetric and without discharge Dry and pale Dry Slightly pink color, Dry and not tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red pt. has bite plane Hard palate- dome-shaped Soft Palate- light pink

Normal Normal Abnormal , d/t old age

Inspection

Nose Shape, size and skin color Nasal septum Nares Mouth and Pharynx Lips Buccal mucosa Gums

Inspection

Smooth, symmetric with same color as the face Close to midline, thicker anteriorly than posteriorly Oval, symmetric and without discharge Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny Hard palate- dome-shaped Soft Palate- light pink

Normal

Inspection Inspection Inspection Inspection Inspection

Normal Normal Normal d/t the mouth is always open Normal

Tongue

Inspection

Normal

Teeth Hard and soft palate

Inspection Inspection

To prevent dislocation of teeth Normal

Neck Symmetry of neck muscles, alignment of trachea Neck Rom Thorax and Lungs Abdomen

Inspection

Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Clear breath sounds Skin same color with the rest of the body

Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Clear breath sounds Skin same color with the rest of the body

Normal

Inspection Auscultation Inspection

Normal Normal Normal

Normal Bowel sounds Neurology system Level of consciousness Behavior and appearance Auscultation Inspection Clicks or gurgling sounds occur irregularly Fully conscious, respond to questions quickly Makes eye contact with examiner, hyperactive expresses feelings with response to the situation Clicks or gurgling sounds occur irregularly Lethargic , do not respond to questions quickly Sometimes doesn't makes eye contact with examiner, not hyperactive in expressing feelings with response to the situation Abnormal

Inspection

Abnormal

Diagnostic/ Laboratory Examinations

Lipid profile
Type Normal Findings Actual findings
121

Elevated

Decreased

Triglycerides

<150 mg/ml

hyperlipoprotenemia

hyperthyroidism

Myoglobulin

5-70 mg/ml

64

Angina, other muscle injury Type 11 hypercholesterolemia

Rheumatoid arthritis Severe hepatocellular disease Familial hypolipotremia hypolypoprotenem ia

Cholesterol

<200mg/dl

188

HDL

3535-80 mg/dl

92

Chronic liver disease

LDL

<130 mg/dl

127

hyperlipidemia

Blood Test
Type
RBC

Normal Findings
4.1-5.1 million/mm 4.1-

Actual findings
4.7

Elevated
Chronic lung disease

Decreased
Abnormal loss of erythrocyte

Hemoglobin Hematocrit WBC Neutrophils Lymphocyte Monocyte Eosinophils Basophils Platelet Count

12-16g/dl 1236% -46% 4,500-11,000/mm 4,50011.611.6-14.0 55%-70% 55%20% - 40% 28% 1-4 % 0 2% 150,000- 350,000/mm 150,000150150-350

12 39 12.4 8 32 6 3 1 167

polycythemia Polycythemia, burns Leukocytosis infection Stress, Acute Infection

Viral infection,Tuberculosis , Leukemia

Blood loss, anemia Blood loss, anemia Leukepenia, Auto Immune disease Viral Disease Autoimmune disease Drug theraphy prednisone Corticosteroid theraphy Acute allergic reaction Thrombocytopenic purpura

Chronic Inflammatory disorders Allergic Reactions, asthma Leukemia Malignant Tumors

Drug Study
GENERIC NAME / BRAND NAME
Generic Name:

ACTION INDICATION / DOSAGE

CONTRAI NDICATIO N Hypersensiti vity to losartan, pregnancy [category C (first trimester), category D (second and third trimesters)], lactation

SIDE EFFECTS

NURSING RESPONSIBILITI ES
yMonitor BP at drug trough (prior to a scheduled dose). yInadequate response may be improved by splitting the daily dose into twice-daily dose yLab tests: Monitor CBC, electrolytes, liver & kidney function with long-term therapy.

Hypertension

Losartan Potassium
Brand Name:

Dosage: Adult: PO 2550 mg in 12 divided doses (max: 100 mg/d); start with 25 mg/d if volume depleted (i.e., on diuretics)

Cozaar
Classification:

cardiovascular agent; angiotensin ii receptor antagonist; antihypertensi ve

Angiotensin II receptor (type AT1) antagonist acts as a potent vasoconstric tor and primary vasoactive hormone of the renin angiotensin aldosterone system.

yCNS: Dizziness, insomnia, headache yGI: Diarrhea, dyspepsia. yMusculoskeletal: Muscle cramps, myalgia, back or leg pain. yRespiratory: Nasal congestion, cough, upper respiratory infection, sinusitis.

GENERIC NAME / BRAND NAME

Generic Name:

ACTION INDICATION / DOSAGE

CONTRAI NDICATI ON

SIDE EFFECTS

NURSING RESPONSIBILITI ES

Simvastatin
Brand Name:

Zocor.
Classification:

CV agent, antilipemic, HMG-COA reductase inhibitor (statin)

yAdjunct to diet in the treatment of elevated total cholestrol and LDL cholesterol with primary hypercholesterolemia (types IIa and IIb) in those unresponsive to dietary restriction of saturated fat and cholesterol and other nonpharmacologic measures yTo reduce the risk of coronary disease, mortality, and CV events, including stroke, TIA, MI and reduction in need for bypass surgery and angionplasty in patients with coronary heart disease and hypercholesterolemia yhypertriglyceridemia yTreatment of type III hyperlipoproteinemia yTreatment of adolescents 10-17 yr with heterozygous familial hypercholesterolemia Dosage: 40mg/tab 1 tab OD at hs (p.o.)

Inhibits HMG-CoA reductase, the enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs, and either an increase or no change in serum HDLs.

Contraindicat ed with allergy to simvastatin, fungal byproducts, pregnancy, lactation.

CNS: Headache, asthenia, sleep disturbances GI: Flatulence, diarrhea, abdominal pain, cramps, constipation, nausea, dyspepsia, heartburn, liver failure Respiratory: Sinusitis, pharyngitis Other: Rhabdomyolysis, acute renal failure, arthralgia, myalgia

yAssess nutrition: fat, protein, carbohydrates yMonitor bowel pattern daily yMonitor triglycerides, cholesterol baseline throughout treatment yPrecautions to Past liver disease, alcoholism, severe acute infections, trauma, severe metabolic disorders, electrolyte imbalances, elderly, renal disease

GENERIC NAME / BRAND NAME

ACTION INDICATION / DOSAGE

CONTRAINDICAT ION

SIDE EFFECTS

NURSING RESPONSIBILITIES

Generic Name: Dexamethasone Brand Name: Cortastat, Dalalone, Decadrol, Decaject, Deronil, Dexacorten, Dexameth, Dexasone, Dexone, Hexadrol, Primethasone, Solurex Classification: Longacting corticosteroid

yManagement of cerebral edema yDiagnostic agent in adrenal disorders yRelieves inflammation yAllergic disorders yAsthma yArthritis Dosage: Cerebral Edema: yPO (Adults): 2 mg q 8-12 hours yIM, IV (adults): 10 mg initially IV, 4 mg q 6 hr, may be decreased to 2 mg q 8-12 hr, then change PO. Adrenocortical Insufficiency/Antiinflammatory yPO (Adults): 0.5-9 mg daily in single or divided doses yPO (children): 23.3 mcg/kg in 3 divided doses. yIV (Adults): 0.5-24 gm/day yIM (Adults): 8-16 mg q 1-3 wk

Dexamethasone suppresses inflammation and the normal immune response. It prevents the release of substances in the body that causes inflammation.

yHypersensitivity to dexamethasone yActive untreated infection yLactation ySystemic fungal infection

yAcne yDecreased wound healing yDepression yVomiting yEasy bruising yHeadache yIncreased hair growth yInsomnia yRestlessness yStomach irritation yIrregular or absent menstruation yDizziness

yMonitor intake and output of patient. yObserve the patient for peripheral edema, steady weight gain, rales or crackles or dyspnea. Notify the physician immediately if these clinical manifestations are noted. yPeriodic growth evaluation for children should be done time to time. yFor patients with cerebral edema, assess then for level of consciousness changes and headache during the therapy. yGuaiac-test stools should be carried out. Guaiac-positive stools should be reported to the physician immediately. yAdminister with meals to minimize GI irritation. yFor patients with difficulty swallowing, tablets can be crushed and administered with fluids or food. However, capsules should be swallowed whole. yEducate the patient to take missed doses as soon as remembered, unless almost time for the next dose skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one. yInstruct patient to avoid people with known infection and contagious illnesses ascorticosteroids causes immunosuppression and may mask symptoms of infection.

GENERIC NAME Citicholine

BRAND DOSAG NAME E

Zynapse

INDICATION

MECHANISM OF ACTION

CONTRAINDICATIO ADVERSE N EFFECT citicoline may exert a stimulating action of the parasympatheti c, as well as a fleeting and discrete hypotensor effect

500mg IV q8

Cerebrovascu lar Diseases, accelerates Discontin the recovery ued on of Septemb consciousnes er 9, s and 2009 overcoming motor deficit.

Citicoline hypertonia of the activates the parasympathetic biosynthesis of structural phospholipids in the neuronal membrane, increases cerebral metabolism and increases the level of various neurotransmitte rs, including acetylcholine and dopamine. Citicoline has shown neuroprotective effects in situations of hypoxia and ischemia.

NURSING RESPONSIBILITI ES y Watch out for hypotensive effects y Somazine must not be administered along with medicaments containing

Nursing Care Plan

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S - Hindi sya makagalaw ng maayos at nahihirapan syang igalaw ang kanyang katawan kahit ang kanyang mga kamay at binti." as verbalized by pt. relative. O - Limited range of motion ( client cant fully extend her extremities ) - Limited ability and difficulty to perform gross motor skills like extending and lifting extremities. - Slowed movement. -Inability to purposefully move involved body parts. -Decreased muscle strength. -Functional level : level 2 - requires help from another person.

Impaired Physical mobility r/t neuromuscular damage involvement

Short term : After 4 hours of nursing intervention, the patient and the patient's relative will verbalize understanding situation or riskfactors and individual treatment regimen and safety measures

Montitor V/S

To note changes and for baseline comparison To be informed about the situations that may restrict movements.) The longer the patient remains immobile the greater the level of debilitation that will occur

Determine the diagnosis that contributes to immobility Encourage and facilitate early ambulation and other ADLs when possible.Assist with each initial change :dangling, sitting in chair, ambulation Perform passive or active ROM exercises to all extremities

Short tem : After 4 hours of nursing intervention the patient and the patient's relatives was able to verbalize understanding situation or risk factors and individual treatment regimen and safety measures. Goal was met. Long term : After 4 days of continuous ,effective and collaborative nursing interventions, patient was able to increase physical mobility and decrease difficulty of moving. Goal was met

Long term : After 4 days of continuous , effective and collaborative nursing interventions. client would possibly be able to increase her range of mobility and decrease difficulty of moving. Exercise promotes increased venousr eturn, prevents stiffness, and maintains muscle strength and endurance This optimizes circulation to all tissues and relieves pressure

Turn and position every 2 hours or as needed

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Provide safety measures(side rails,using pillow tosupport body part

To provide safety and reduce the risk of pressure ulcers

Massage back and bony prominences

it provides comfort to the patient and promote good circulation

Discharge Plan


Medication Patient will continue take medicine such as Losartan Potassium 50 mg OD, Simvastatin 40mg/tab 1 tab OD. Exercise Patient will verbalize need importance of exercise and demonstrate proper initiation of appropriate exercise and needs to rest in between periods of activities. Treatment Patient will know appropriate treatment like using nebulization. Hygiene The patient must take a bath daily and know the proper oral hygiene Outpatient Patient must come back after 2 weeks at the OPD Diet Low salt low fat diet Spiritual The patient should go to mass and know how to pray to God

Prepared by: BSN III-4 Group 16 IIITuazon, Gian Paul Varsovia, Paul Joram Viacrucis, Vianne Maig Vidal, Kimberly Mae Villafuerte, Janella Marie Villanueva, Cheryl Ann Villarina, Fidel Vinco, Maria Karmela Louise T. Submitted to: Mr. Arnel Ipapo Area: AFPMC -5D