I. 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; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure. A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. The most common symptom of a stroke is sudden weakness or numbness of the face, arm or leg, most often on one side of the body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconsciousness. The effects of a stroke depend on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden death. The 1990 Global Burden of Disease (GBD) study provided the first global estimate on the burden of 135 diseases, and cerebrovascular diseases ranked as the second leading cause of death after ischemic heart disease. During the past decade the quantity of especially routine mortality data has increased, and is now covering approximately one-third of the worlds population. The increase in data availability provides the possibility for updating the estimated global burden of stroke. Data on causes of death from the 1990s have shown that cerebrovascular diseases remain a leading cause of death. In 2001 it was estimated that cerebrovascular diseases (stroke) accounted for 5.5 million deaths world wide, equivalent to 9.6 % of all deaths Two-thirds of these deaths occurred in people living in developing countries and 40% of the subjects were aged less than 70 years. Additionally, cerebrovascular disease is the leading cause of disability in adults and each year millions of stroke survivors has to adapt to a life with restrictions in activities of daily living as a consequence of cerebrovascular disease. Many surviving stroke patients will often depend on other peoples continuous support to survive.

II. OBJECTIVES GENERAL OBJECTIVES 1. To be able to discuss the effect, signs and symptoms of the disease, Cerebrovascular Disease. 2. How to diagnose, prevent and the treatment should the nurse give for the patient full recovery. SPECIFIC OBJECTIVES

1. To be able to discuss patients background ( lifestyle, history of the past illness, family health history) to show how may this effect on the occurrence of this disease. 2. To be able to discuss the anatomy and the physiology of the heart, for you to be able to understand where the infection takes place. 3. To be able to discuss the pathophysiology of cardiovascular diseases and also to know and understand the etiology of the disease. 4. To be able to discuss the patient activities of daily living. To know if theres a factor that triggers the disease 5. To be able to discuss, nursing care plan for our patient. 6. To be able to discuss, the medication / drugs that the patient taken and the diagnostic test that being perform for the patient. 7. Lastly, to be able to discuss our discharge plan for fully recovery of our patient.

III. PATIENTS PROFILE NAME: AGE: GENDER: ADDRESS: T.V 47 YEARS OLD FEMALE FEMALE MONCADA TARLAC

CHIEF COMPLAINT: Numbness to the left side of the body Body weakness Nape pain

IV. PHYSICAL ASSESSMENT GENERAL SURVEY Mrs. T.V was lying semi-fowlers on bed, conscious, coherent, afebrile with monitoring devices. A. VITAL SIGNS Date Shift Time Temp BP RR PR Intake Output

07/18/13

3pm-11pm

36.8

210/100

58

20

B. HEAD Pink papillary conjunctiva, no nuchal rigidity and no carotid bruit. C. NEUROLOGIC STATUS -Oriented to time, person and place. CRANIAL NERVES ASSESSMENT CN I- can smell CN II- (2-3) ERTL CN III, IV, VI- EDM, intact CN V- (+) corneal reflex CN VII- no facial asymmetry CN IX- (+) gag reflex CN XI- can shrug shoulder CN XII- tongue at midline D. PULMONARY SYSTEM -Respiratory rate was 58 cpm -SCE, no vesicular breath sounds. th -AP, Apical beat at the 6 ICS anterior axillary line normal sounds. E. GASTROINTESTINAL SYSTEM Flabby, NaBS, no abdominal bruit, (-) edema,(-) cyanosis. F. MUSCULOSKELETAL SYSTEM The patient manifested good posture and moved voluntarily; he had symmetrical musculature on both sides of the body. Weakness was noted. G. GENITO- URINARY SYSTEM Patient voided 60 350 cc per shift as weighed and yellow in color.

V. LABORATORY AND DIAGNOSTIC EXAMINATION Complete Blood Count COMPONENT RESULTS NORMAL VALUES 120 140 g/L 150 3.50x10g/l SIGNIFICANCE

Hemoglobin Platelet

136 302

Normal may indicate altered clotting factor abnormal abnormal normal abnormal abnormal abnormal abnormal

Hematocrit WBC RBC Neutrophil Lymphocyte Monocyte MPV

0.437 3.6 5.5 12.8 1.52 1.43 5.93

0.38 0.48 g/l 4.5 10x10g/l 4.5 5.5x10g/l 0.40 0.60 g/l 0.20 0.40 g/l 0.02 0.08 7.5-11.5 fL.

Urinalysis RESULTS

Color

Light Yellow

Transparency

Slightly Turbid

Specific Gravity

1.010

Sugar

(-)

Albumin

(-)

Pus cell

01

RBC

02

Mucus threads

Few

Epith cell

Moderate

Bacteria

Rare

Acid

6.5

Laboratory Tests for Heart Failure

Routine lab blood tests are important in the evaluation of people with heart failure. These tests can help identify causes of heart failure; whether other organs, such as the kidneys and liver, have been affected by the heart failure; or whether medicines, such as diuretics, have affected the normal electrolyte levels, such as sodium or potassium levels. The following lab tests may be done in people with signs or symptoms of heart failure. Complete Blood Count (CBC) A reduced red blood cell count (anemia) may mean that heart failure is caused or aggravated by a decrease in the oxygen-carrying capacity of the blood. A very low blood count may be a sign that anemia is a contributing factor that is making your heart failure worse. Even if this is not the case, a low blood count can make your heart work harder and can be dangerous if you have severe heart failure. Knowing the white blood cell count can be helpful, because an elevated white count often indicates that you have an infection, which places additional stress on your heart. Serum Creatinine This test measures the level of a substance in the blood called creatinine. Thecreatine level can help determine how well the kidneys are working. Creatinine is excreted in the urine. High levels of creatinine may indicate that a kidney problem is responsible for fluid buildup in the body, not heart failure. Blood Urea Nitrogen (BUN) A blood urea nitrogen (BUN) test measures the amount of nitrogen in the blood that comes from urea. A BUN test helps estimate how well the kidneys are functioning. Severe heart failure can decrease kidney function. Several common heart failure medicines-particularly diuretics and angiotensin-converting enzyme (ACE) inhibitors-can also decrease kidney function.

Brain Natriuretic Peptide (BNP) A brain natriuretic peptide (BNP) test measures the amount of the BNP hormone in your blood. BNP is made by your heart and tells how well your heart is working. Normally, only a low amount of BNP is found in your blood. However, if your heart has to work harder over a long period of time, such as from heart failure, the heart releases more BNP and the blood level of BNP will get higher. The BNP level may drop when treatment for heart failure is working. Serum Albumin Albumin is a protein in the body. Decreased levels of this protein may indicate that fluid buildup in the body is caused by an intestinal disorder (hypoalbuminemia), a liver problem, or kidney disease. Thyroid Hormone Tests and Thyroid-Stimulating Hormone Test Thyroid hormone measurements may be needed if you have a rapid, irregular heartbeat (atrial fibrillation), have evidence of thyroid disease, or are older than 65. Abnormal findings may be a sign that heart failure is caused or made worse by an underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism). Urinalysis Protein or red blood cells in the urine may indicate a kidney disorder. Blood Glucose A fasting blood glucose test measures the amount of glucose in your blood after you have not eaten for at least 8 hours. Glucose is a natural sugar in the body that is used for energy. High levels of glucose in the blood may indicate diabetes. Lipid Panel A lipid panel is a blood test that measures lipids-fats and fatty substances used as a source of energy in your body. Lipids include cholesterol, triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Liver Function Tests Liver function tests include a variety of tests that measure certain enzymes and other substances produced by the liver. If the levels of these substances are high, it may mean damage or disease in the liver. Heart failure may also cause fluid buildup in the liver, which also may cause elevated liver function test results. For more information, see the topics Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST). Electrolytes People with heart failure need to maintain the concentration of electrolytes in the blood (particularly sodium, potassium, and magnesium). This is especially true for people who take diuretics, which can lower sodium, magnesium, or potassium levels in the blood if the dose is too high. Other medicines such as ACE inhibitors, by contrast, can cause high potassium levels. Your electrolytes should be checked regularly, particularly if your symptoms are changing or if your medicines are being adjusted. Prothrombin Time (PT) and Partial Thromboplastin Time (PTT) A PT or PTT test are blood tests that measure how long it takes blood to clot. These tests can be used to check for bleeding problems. PT is also used to check how medicine to prevent blood clots is working. A PT test may also be called an INR test.

VI. ANATOMY AND PHYSIOLOGY The Brain

Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). The telencephalon generates the cerebrum (which contains the cerebral cor tex, white matter, and basal ganglia). The diencephalon generates the thalamus, hypothalamus, and pineal gland. The mesencephalon generates the midbrain portion of the brain stem. The metencephalon generates the pons portion of the brain stem and the cerebellum. The myelencephalon generates the medulla oblongata portion of the brain stem

Figure 1 The four divisions of the adult brain.

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions: A gyrus (plural, gyri) is an elevated ridge among the convolutions. A sulcus (plural, sulci) is a shallow groove among the convolutions. A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones) the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain. A cross section of the cerebrum shows three distinct layers of nervous tissue: The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas. The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres. Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the basal ganglia the caudate nuclei, the putamen, and the globus pallidus are involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here. The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions: The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here before being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also. The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles). The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion, behavior, hunger,

thirst, body temperature, and the biological clock. It also produces two hormones (ADH and oxytocin) and various releasing hormones that control hormone production in the anterior pituitary gland. The following structures are either included or associated with the hypothalamus. The mammillary bodies relay sensations of smell. The infundibulum connects the pituitary gland to the hypothalamus. The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye cross over to the cerebral hemisphere on the opposite side of the brain. The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of gray matter. The brain stem consists of the following four regions, all of which provide connections between various pa rts of the brain and between the brain and the spinal cord Figure 2 Prominent structures of the brain stem.

The midbrain is the uppermost part of the brain stem. The pons is the bulging region in the middle of the brain stem. The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum.

The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain regions of the spi nal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one component of the reticular formation, is responsible for maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles. The cerebellum consists of a central region, the vermis, and two winglike

lobes, the cerebellar hemispheres. Like that of the cerebrum, the surface of t he cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by comparing actual skeletal movements to the movement that was intended.

The limbic system is a network of neurons that extends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to behaviors, experiences, and memories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and encircles the inside border of the cerebrum. The following components are included: The hippocampus (located in the cerebral hemisphere) The denate gyrus (located in cerebral hemisphere) The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate nucleus of the basal ganglia) The mammillary bodies (in the hypothalamus) The anterior thalamic nuclei (in the thalamus) The fornix (a bundle of fiber tracts that links components of the limbic system)

VII. PATHOPHYSIOLOGY

Modifiable factors: Smoking Ingesting fatty foods hypertension Embolus that dislodge

vasospasm

Increase oxygen demand

Decrease oxygen supply in the blood

Inadequate blood perfusion

Cell injury and death

Motor, sensory, cranial nerves disrupted Cerebrovascular disease

Dizziness, stiffening of extremeties, and non projectile vomiting

Cerebrovascular disease or brain attack happened due to modifiable factors possessed by the patient such as smoking, ingesting fatty foods, and hypertension that leads to vasospasm and an embolus that dislodged from an area of origin to the brain that results to increase oxygen demand and decrease oxygen supply in the blood. Because of inadequate blood perfusion it leads to brain cells injury and death, at this point neurons are no longer able to maintain aerobic respiration that caused to produce neurological dysfunction.

NURSING CONSIDERATIONS 1. Maintain a patent airway to promote adequate oxygenation 2. Administer oxygen therapy with possible intubation and mechanical ventilation to ensure adequate tissue perfusion 3. Maintain bed rest to minimize metabolic requirements 4. Provide I.V. fluids to support blood pressure and maintain volume 5. Administer dexamethasone to reduce cerebral edema 6. Administer anticoagulants and antiplatelet drugs for thrombotic conditions after hemorrhage has been ruled out 7. Administer sedatives, such as Phenobarbital, to decrease metabolic requirements 8. Assess the patients neurologic status; observe for CVA progression and level of consciousness (LOC) change as evidenced by decreasing numerical score on the GLASGOW COMA SCALE. 9. Correct cardiovascular abnormalities, such as atrial fibrillation, that may be contributing factors 10. Consider surgical procedures to correct circulatory impairment, prevent repeated hemorrhage, or relieve cerebral pressure 11. Begin bedside range-of-motion exercise to preserve mobility and prevent deformities 12. Teach the patient to identify risk factors and necessary life-style modifications, such as diet, stress reduction, and smoking cessation 13. Direct the family to community groups that provide support or rehabilitation