Ischemic

Stroke
Case Study
January 2014
1. Basis of selection of case

In the previous years, a Food and Nutrition Research Institute 1998 study, about

21 percent of adults aging from 20 years old and above have hypertension, (the single

most important risk factor for stroke and it causes about 50 per cent of ischemic strokes

and also increases the risk of hemorrhagic stroke) while a Philippine Health Statistics

1993 figure showed 28 deaths per 100 000 population caused by stroke.

Nowadays, still, stroke makes its way on top. Worldwide, stroke is the second-

leading cause of death after heart disease and is also a big contributor to disability. Due to

the increasing number of stroke cases annually and the expanding cases in the younger

generation, the government of the Philippines should emphasize primary and secondary

prevention strategies.

As we talk about prevention strategies, there is a great role for nurses/student

nurses, as well as for the rest of the medical team, comes in. Reading a case study and

coming up with a diagnosis is a good way for nursing students to test the knowledge

they've acquired in the classroom in a more realistic, clinical way. Writing case studies is

also a useful learning tool; it forces students to reflect on the entire course of treatment

for a patient, ranging from obtaining important information to diagnosis to treating the

medical condition. Increasing the knowledge regarding the disease process of stroke, the

proper assessment of the patient, correct intervention, effective health teaching, etc will

contribute a lot in improving prevention strategies.

 2. Clarity of Objectives

General Objectives

After 2 hours of case presentation, the students will be able to obtain the

knowledge to enhance skills and to develop the attitude towards caring of the patient with

cases regarding ischemic stroke.

Specific Objectives

Specifically, this aims to

KNOWLEDGE

1. Explain the pathophysiology of ischemic stroke.

2. Identify the main cause of the disease.

3. Name the signs and symptoms of the disease manifested by the client.

SKILLS

1. Carry out independent and dependent intervention being done to the client

appropriately and with care.

2. Perform comprehensive nursing interventions based on the client’s priority needs.

3. Demonstrate proper approach used in clients with ischemic stroke.

ATTITUDES

1. Establish rapport to the client and folks.

2. Encourage the folks to cooperate to the intervention being performed.

3. Avoid promising words that might worsen the client’s condition.

3.1 ASESSMENT

A. PATIENT’S PROFILE

NAME: R. C.

AGE: 64 years old

SEX: Male

DATE OF BIRTH: June 28, 1949

ADDRESS: Barotac Viejo, Iloilo

OCCUPATION: National Referee, Retired Teacher

RELIGION: Roman Catholic

NATIONALITY: Filipino

ACTIVITY: Moderate Backrest

CC: Stiffening of extremities

DATE OF ADMISSION: December 12, 2013

DIAGNOSIS: T/C Brain Mets v/s restroke prob. Bleed,

S/P CVD with no residuals (2013) HCVD R/O Metastatic cause DM 2- NIR

S/P Thyroidectomy for thyroid CA Stage 1

PHYSICIAN: Dr. A
B. NURSING HISTORY

I. Reason for Seeking Care

Stiffening of extremities

II. Present Health History

Patient R.C. is 64 years old, male and married. He is a retired teacher and a national

referee.

8 months prior to admission, patient experienced episode of syncope. He was then

admitted at St. Paul’s Hospital for 1 month and managed as CVP, no residual noted.

1 month prior to admission, undocumented fever was noted. He was admitted at Don

Ramon Tugbang Medical Center and diagnosed to have Urinary Tract Infection.

On the day of admission, patient experienced generalized weakness and stiffening of

extremities. A complaint of dizziness was noted. He was responsive and slurring of speech is

noted. He was brought to Don Ramon Tugbang Medical Center and then referred at Iloilo

Mission Hospital.
III. Past Health History

It was known that he is hypertensive and have Diabetes Mellitus. He has many previous

hospitalizations. He was diagnosed to have thyroid cancer stage 1 back in 1986. He had

undergone radiation therapy and left thyroidectomy in the same year at Philippine General

Hospital. No known allergies.

Last December 2012, He underwent Cranial CT scan and CT scan with contrast. January 7,

2014, he again underwent cranial CT scan.

IV. Current Medication

For now, he has current medication such as Amlodopine 10mg/tab OD, Simvastatin 40 mg/tab

OD, Losartan 50 mg/tab 1 tab OD for his hypertension and Metformin 500 mg 1 tab OD for his

Diabetes Mellitus.

V. Lifestyle

He is non-smoker and non-alcoholic drinker. He is also an athletic person. As verbalized

by the wife, most of the time he ate carrots instead of rice.

VI. Family History

As verbalized by the wife, he has familial history of Hypertension and Diabetes Mellitus.
C. PHYSICAL ASESSMENT

VITAL SIGNS

R.C.’s temperature is 36.5 °C, pulse rate is 88 beats per minute, respiratory rate is 20

breaths per minute, and blood pressure is 180/100 mmHg.

GENERAL APPEARANCE

R.C. is a 64 year old male, a national referee and a retired teacher. Bedridden since the

day of admission. Ectomorph, well developed and appears to be at stated age. Well cleaned and

wears appropriate clothes. Difficulty or discomfort making laryngeal speech sounds or varying

volume, quality, or pitch of speech. Comprehends directions. Appears to be in distress.

SKIN

Brown in color, dry, and wrinkled due to old age.Peeling, scaly and flaky skin on heels of the

feet. Skin color differences among body areas and between sun-exposed and non-sun-exposed

areas. Darker skin around elbows and knees. Warm in temperature. Turgor resilience. Bilateral

symmetry. Hair present on scalp, lower face, nares, chest, legs, and pubic areas.

NAILS

Nails beds pink with varying opacity. Short, squoval, smooth, flat, with edges smooth and round,

Longitudinal ridging and beading. Hard and firm with uniform thickness. Well-groomed and

uniform without deformities. Good capillary refill.

HEAD AND FACE

Hair is short, black with minimal gray hairs, and distributed evenly. Hair strands are thin,

fine and silky. Head is midline. Skull normocephalic, symmetric and without deformities. Scalp

is intact and without lesions or mass noted. Temporal pulses palpable. No bruits. Presence of

beard on upper lip and chin. Presence of black heads on the nose. Presence of dimple at the right

side of the face.

EYES

Eyebrows are smooth, black in color and distributed evenly and in line with each other.

With mole noted on the left inner end of the brow.Superior eyelid covering a portion of iris when

open. Eyelashes are black, evenly distributed, present on both lids and turned outward.

Conjunctivae pink, sclera anecteric. Irides black. Pupils equal, round, and reactive to light and

accommodation.

EARS

Auricles in alignment, same color as facial skin.Firm and mobile, readily coiling from

position; non-tender.Absence of discharges.

NOSE

Nose in midline, no discharges or polyps, mucosa pink and moist, septum midline, patent

bilaterally. Conforms to face to color.Nares oval and symmetrically positioned. No sinus

tenderness to palpation. With O2 at 2Lpm via nasal cannula.

MOUTH AND OROPHARYNX

Lips symmetric vertically and horizontally at rest and moving.Dry, bluish purple, distinct

border between lips and facial skin. Teeth are stained yellow and absence of left lateral incisor.

Gingiva pink and moist. Tongue is midline, dull red in color and moist. No tremors and

fasciculation. Hard palate and soft palate are pinkish in color. Pharynx clear without erythema.

Uvula rises evenly.

NECK

Neck is straight and symmetrical. Trachea midline. Jugular vein distention noted. Carotid

pulse palpable.Cricoid cartilages smooth and moves during swallowing. Left thyroid palpable,

firm, and smooth; presence of slightly hypoechoic nodule.Absence of right thyroid lobe.

THORAX AND CHEST

Minimal increase in the anteroposterior diameter of chest.Thoracic expansion symmetric.

No adventitious breath sounds. Regular respiratory rate. Chest retraction noted. Apical pulse on

5th intercostals space. The areola and nipples are dark brown in color and no discharges noted.

ABDOMEN

Soft, flat and symmetrical. Uniform in color, no pigmentation and rashes noted. No

abdominal scars and masses. Active bowel sounds audible in four quadrants.
UPPER EXTREMITIES

Arms fair in color and symmetrical. No tenderness upon palpation of muscle and joints.

Unable to passively perform full range of motion at right affected hand; stiffness noted. Palms

are pale and warm. Radial and brachial pulses palpable.With PNSS 1L x 80cc/H infusing well at

left cephalic vein.

LOWER EXTREMITIES

Legs are fair in color and symmetrical. Muscles are firm and skin is slightly dry. Soles

are pale and warm to touch. Unable to passively perform full range of motion at right affected

leg. Popliteal and dorsalis pedis pulses palpable.

GENITO-ANAL AND GENITO-URINARY

Pubic hairs are present. No skin lesions, penile discharges and swelling noted. Urinated to

a moderate amount of yellowish colored urine.Defecated to a soft brown stool.

D. DIAGNOSTIC TEST
LABORATORY TEST RESULT NORMAL VALUES SIGNIFICANCE

URINALYSIS

 Color Pale straw

 Transparency Slightly Hazy

 Reaction 7.0

 Specific Gravity 1.015 1.010 – 1.025 NORMAL

 Sugar 1+

 Albumin Neg ( - )

 Pus cells 3.6 hpf

 Red Blood cells 0.3 hpf

 Amorphous urates FEW

 Squamous Cells FEW

 Bacteria Occasional

 Mucus Threads FEW

 Yeast Cells NONE

HEMATOLOGY

 Hemoglobin 103 g/L 140 – 180 Anemia, bleeding, blood

dyscrasia
 Hematocrit 0.31 vol.fr. 0.42- 0.52 Anemia

 Red blood cell count 3.77 x 10^ 12/L 4.7 – 6.1 Anemia, bleeding, bone marrow
failure, malnutrition

 White blood cell count 14.98 x 10 ^9/ L 5.2 -12.4 Infection, Anemia, adrenal or
thyroid gland issues, immune
system disorder, inflammation,
tissue
damage, severe stress
 Segmenter 90% 50 – 70 infection, inflammation

 Stab 0 2-5

 Juvenile 0 0-1 Normal

 Basinophil 0 0.0 – 1.5 Normal

 Eosinophil 0 0–7 Normal

 Lymphocyte 9% 19 – 48 not significant

 Monocyte 1% 3.4 – 9 not significant

 Platelet Count 341 x 10^9/ L 130 – 400 Normal

 MCV 83 fl 80 – 94 Normal

 MCH 27 pq 27 – 31 Normal

 MCHC 33g/dL 33 – 37 Normal

 RDW 11.7% 11.5 – 14.5 Normal

 ESR 37 mm/ Hr 0 – 10 inflammation

IMMUNOLOGY

 CRP 48 mg/L <6- inflammation

 T3 95nmol/L 0.95 – 250 Normal

 T4 91.43 nmol/L 60 – 120 Normal

 TSH 0.88 u/ v/mL 0.25 – 5.0 Normal

Euthyroid : 0.25 – 5.0u/V/ml

Hypothyroid : greater than

7.0u/V/ml
Hyperthyroid: less than
0.15u/V/ml
 APTT 24.4 sec 24.0 – 35.0 Normal

 % Activity 99% 70-100 Normal

 Patient 13.1 sec 11.6- 16.0 Normal

 INR 1.00 -

CHEMISTRY

 Fasting blood sugar 9.58 mmol/L 4.10 – 5.90 heart attack, stroke

 Cholesterol 3.44 mmol/L 1.30 – 5.2 Normal

 Triglycerides .94 mmol/L 0.17 – 1.70 Normal

  HDL 0.84 mmol/L .90 – 1.55 atherosclerosis, CVD

 LDL 2.17 mmol/L 0.0 – 3.9 Normal

 Uric Acid 178 mmol/L 160-430 Normal

 Calcium 2.05 mmol/L 2.12- 2.25 Hypocalcemia

ULTRASOUND

Thyroid Ultrasound:
 The right thyroid lobe is surgically absent. The left thyroid measures 3.73 x 1.63 x 1.29 cm ( LxWxAP ). The
isthmus is not thickened and measures 0.21mm in thickness. There is a slightly hyporechoic nodule noted in the
inferior aspect of the left thyroid lobe measuring 0.81 x 0.71 x 0.53 cm ( LxWxAP ). There is a cystic focus
noted at the junction of the isthmus and left thyroid lobe measuring 0.46 x 0.46 x 0.26 cm ( LxWxAP ). A cystic
focus is also noted in the mid portion of the thyroid lobe measuring 0.24 x 0.11 cm ( WxAP ).
The surrounding soft tissues and vascular structures are unremarkable.
No mass/enlarged cervical lymph nodes appreciated.

Remarks:
 Left thyroid nodule and cyst.
 S/P Right thyroidectomy.

CHEST X-RAY

Chest PA:
 Clear lung field with no grossly evident active koch’s infiltrates
 Trachea midline
 Intact costophrenic sinuses
 Smooth diaghragmatic leaves
 Cardiac silhouette nor enlarged transversely
 Curvilinear calcific density noted at the aortic knob
 Rest of the visualized soft and osseous tissues appear
 Unremarkable

Impression:
 Atherosclerosis: Aorta

CT SCAN
  Plain and contrast enhanced axial tomographic sections of the head reveal inhomogeneously enhancing hypodensity with gyral
enhancement at the right frontoparietal areas. Also note of enhancing isodense nodules lesions with surrounding edema in the right
inferior frontal and right frontal periventricular areas.

There are small hypodensities on both capsuloganghenic and bifrontoparietal periventricular areas.
The ventricles are enlarged.
The midline structures are displaced to the left.
The cerebral sulci are effaced.
No abnormal extra-axial fluid collection demonstrated.
No posterior fossa , brain stem and sellar region do not appear unusual.
The petromastoids, included orbits and parancoal sinuses and the bony calvarium are unremarkable.

Remarks:
 Right frontoparietalhypodensity with gyral enhancement.
 Right inferior frontal and right frontal periventricular enhancing lesions with surrounding edema.
 Lacunar infarcts, bilateral capsuloganglionicbifrontoparietal periventricular areas.
 Leftward subfalcine herniation.
 Obstructive hydrocephalus.

Drug Therapy

Generic name:Valporic Acid

Classification: Anti Convulsant
Dosage:( Adult and children > 10 y.o )
= 10- 15 mg/kg/day PO Route: Oral
Therapeutic Actions:
 Mechanism of action not understood; Anti epileptic activity may be related to the
metabolism of inhibitory neurotransmitter, GABA.
Indications:
 Solo and adjunctive therapy in simple ( petit mal ) and complex absence seizure
 Acute treatment of manic episode associated with bipolar disorder
 Prophylaxis of migraine headache
Contraindication and Cautions:
 Contraindicated with hypersensitivity to valporic acid, hepatic disease or significant
hepatic impairment
 Use cautiously with children younger than 18 months; children younger than 2 y.o
Adverse Effects:
  CNS: Sedation, emotional upset, depression, psychosis, aggression, behavioral
deterioration, suicibility.
 SKIN: Hair loss, rash
 GI: Nausea, vomiting, indigestion, diarrhea, abdominal cramps, constipation.
 GU: Irregular menses, amenorrhea
 HEMATOLOGIC: Altered bleeding, bruising.

Nursing considerations:

 Products containing alcohol should be avoided.

 Give drug with food if GI upset occurs.
 Be aware that the patient maybe increased risk for suicidal ideation monitor accordingly.

Patient Teaching:
 Take this drug exactly as prescribed.
 Do not chew tablet or capsule before swallowing them.
 Do not discontinue this drug abruptly or change dosage.
 Avoid alcohol and sleep inducing drugs.

Generic name:Losartan Potassium

Classification:Angioten II Antagonist
Dosage:( Adult and children 6 yrs and older )
= Starting dose of 50 mg PO daily Route: Oral
Therapeutic Actions:
 Selectively blocks the binding of angiotensin II to specific tissue receptors found in the
vascular smooth muscle and adrenal gland.
Indications:
 Treatment of hypertension, done or combination with other hypertensive.
 Treatment of diabetic nephropathy.
 Reduction of risk of CVA in patients.
Contraindications and Cautions:
 Contraindicated in previous hypersensitivity.
 Pregnancy or lactation
 Reduce dosage with hepatic or renal impairment.
Adverse Effects:
 CNS: Headache, dizziness and insomnia
  CV: Hypertension
 SKIN: Rash and dry skin
 GI: Diarrhea, abdominal pain and nausea
 RESPIRATORY: Cough
 OTHER: Back pain, fever and gout
Nursing Considerations:
Assessment
 Hypersensitivity to Losartan
 Pregnant
 Lactation

Patient Teaching:
 Take drug without regard to meals
 May experience these side effects:
- Dizziness
- Headache
- Nausea and vomiting
 Report fever, chills and pregnant

Generic name:Metformin
Classification:Antidiabetic Agents
Drugs:( Adult and pediatric 10 – 16 y.o )
= 500 mg bid/ 250 mg bid Route: Oral
Therapeutic Reaction:
 Increase peripheral utilization of glucose and decrease hepatic glucose production.
Indications:
 Adjunct to diet to lower blood glucose with type 2 DM
Contraindication and Cautions:
 With allergy to metformin, heart failure, diabetes complicated by fever, severe trauma
and severe infection.
 Use cautiously with the elderly
Adverse Effects:
 ENDOCRINE: Hypoglycemia
 GI: Anorexia, nausea and vomiting
 HYPERSENSITIVITY: Allergic skin reaction
Nursing Considerations:
 Allergy to metformin
 Pregnancy
 Lactation
Patient Teaching:
 Monitor blood for glucose and ketones as prescribed.
 Do not use this drug during preganancy.
 Avoid using alcohol while taking this drug.
 Report fever, sore throat, unusual bleeading and bruising.
Other anti-diabetic drugs: Gliclazide, Sitagliptin

Generic name: Baclofen

Classification: Muscle relaxant
Dosage: 5 mg PO tid for 3 days Route: Oral
Therapeutic Actions:
 Inhibits both monosynaptic and polysynaptic spinal reflexes; CNS depressant
Indications:
 Alleviation of signs and symptoms of spasticity resulting from MS
 Spinal cord injuries and other spinal cord diseases
Contraindications and Cautions:
 Contraindicated in previous hyper sensitivity.
 With skeletal muscle spasm
 Use cautiously with strokes, cerebral palst, parkinson’s disease
 Lactation and pregnancy
Adverse Effects:
 CNS: Transient drowsiness, weakness, fatigue
 CV: Hypotension
 GI: Nausea, Constipation
 GU: Urinary frequency, dysuria
 OTHER: Rash, pruritus, ankle edema

Nursing Considerations:
 Discontinue drug if hypersensitivity reaction occur
 Lactation
 Evaluate therapeutic response
Patient Teachings:
 Take this drug exactly as prescribed
 Avoid alcohol
 Do not take this during pregnancy
Generic Name: Amlodipine

Classification:Antianginal; Antihypertensive; Calcium channel blocker

Dosage: Adult and Pediatric 6-17 y.o.

2.5-5 mg daily

Route: Oral

Therapeutic actions:

 Inhibits the movement of calcium ions across the membranes of cardiac cells; inhibits
transmembrane calcium flow, w/c result in depression of impulse formation in
specialized cardiac pacemaker cells, slowing velocity of conduction of the cardiac
impulse.

Indications:
 Angina pectoris due to coronary artery spasm(Prinzmetal’s
Variant angina)
 Essential hypertension

Contraindications and cautions:

 Contraindicated w/ allergy to amlodipine
 Use cautiously w/ heart failure
 Pregnancy

Adverse effects:
 CNS: Dizziness, headache, and fatigue
 CV: Peripheral edema
  Skin; Flushing, rash
 GI: Nausea, abdominal discomfort

Nursing Consideration:
 Administer drug w/out regards to meals
 Monitor BP carefully

Patient teachings:
 Take w/ meals if upset stomach occurs
 Report irregular heartbeat, shortness of breath, and constipation

Generic name: Diazepam 5 mg IV

Classification: Antiepileptic; Anxiolytic
Dosage: Usual dosage is 2-20 mg IM/IV
Route: IM/IV

Therapeutic actions:
 Acts mainly as the limbic system and reticular formation; may act in spinal cord and at
supraspinal sites to produce skeletal muscle relaxation

Indications:
 Management of anxiety d/o
 Acute alcohol withdrawal
 Muscle relaxant

Contraindications and cautions:

 Contraindicated w/ hypersensitivity to benzodiazepines
 Use cautiously w/ elderly, impaired renal function

Adverse effects:
 CNS: Sedation, depression, fatigue, and restlessness
 CV: Bradycardia, CV collapse, and hypertension
 Skin: Rash and dermatitis
 GI: Constipation and diarrhea
 GU: Urinary retention
 Hematologic: Decreased Hct
 Other: Phlebitis and thrombosis in IV site, fever, diaphoresis, and muscular disturbances
Nursing considerations:
 Hypersensitivity to benzodiazepines
 Pregnancy and lactation
 Carefully monitor P, BP, respiration, during IV administration

Patient teachings:
 Take this drug exactly as prescribed
 Tell patient to report drowsiness, and weakness

Generic name: Mannitol

Classification: Osmotic; Urinary irrigant
Dosage: 50-200g/day
Route: IV
Therapeutic actions:
 Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsortion of
water leading to a loss of water, sodium, chloride: creates an osmotic gradient in the eye
between plasma and ocular fluids thereby reducing IOP.

Indications:
 Prevention and treatment of oliguric phase of renal failure
 Promotion of urinary excretion of toxic substances
 Irrigant in transurethral prostatic resection

Contraindications and cautions:

 Contraindicated w/ anuria due to severe renal disease
 Use cautiously w/ pulmonary congestion, dehydration, heart failure
 Lactation
 Pregnancy

Adverse effects:
 CNS: Dizziness, headache , blurred vision, SEIZURES
 CV: Hypertension, edema, thrombophlebitis and chest pain
 Skin: Skin necrosis w/ infiltration
 GI: Nausea, dry mouth
 GU: Diuresis, urine retention
 Hematologic: Fluid and electrolyte imbalance
 Respiratory: Pulmonary congestion
Nursing Considerations:
 Do not expose solution to low temp crystallization may occur
 Make sure infusion set contains a filter if giving concentrated mannitol
 Monitor serum electrolytes periodically w/ prolonged therapy

Patient teachings:
 Patient may experience these side effects: Increased urination, GI upset, dry mouth,
headache, blurred vision- ask for assistance
 Report difficulty of breathing, pain at the IV site and chest pain

Generic name: Simvastatin

Classification:Antihyperlipidemic
Dosage: 20-40 up to 80 mg PO daily in the evening
Route: Oral

Therapeutic actions:
 Inhibits HMG-CoA reductase, the enzyme that catalyze the first step in the cholesterol
synthesis pathway

Indications:
 To reduce the risk of coronary disease
 Treatment of patients w/ isolated hyper triglyceridemia
 Treatment of type III hyperlipoproteinemia

Contraindications and cautions:

 Contraindicated w/ allergy to simvastatin
 Use cautiously w/ impaired hepatic and renal function
 Cataracts

Adverse effects:
 CNS: Headache, sleep disturbances
 GI: Flatulence, diarrhea, abdominal cramps, constipation, nausea, heartburn, LIVER
FAILURE
 Respiratory: Sinusitis
 Other: ACUTE RENAL FAILURE, myalgia

Nursing considerations:
 Allergy to simvastasin
 Give in evening; highest rate of cholesterol synthesis are bet midnight and 5 am
  Advise patient that this drug cannot be taken during pregnancy

Patient teachings:
 Take drug in the evening
 Patient may experience these side effects: Nausea, headache, muscle and joint pains,
sensitivity to light
 Report severe GI upset, changes in vision, unusual bleeding/bruising, dark urine or light
colored stool, fever, muscle pain or soreness

E. Pathophysiology

Stroke or cerebrovascular accident also known as the brain attack is a vascular disorder

that injures the brain function. Stroke remains one of the leading causes of mortality and

morbidity. The term brain attack has become a popular substitute for stroke, with the intent of

equating stroke with a heart attack in terms of the timetable associated with the development of

neurologic deficits and the need for prompt emergency treatment.

A brain attack is a sudden impairment of cerebral circulation in one or more blood

vessels. It occurs when a blood clot blocks the blood flow in a vessel or artery or when a blood

vessel breaks, interrupting blood flow to an area of the brain. Regardless of the cause, the

underlying event is deprivation of oxygen and nutrients. Normally, if the arteries become

blocked, autoregulatory mechanisms help maintain cerebral circulation until collateral circulation

develops to deliver blood to the affected area. If the compensatory mechanism becomes

overworked, or if cerebral blood flow remains impaired for more than a few minutes, oxygen

deprivation leads to infarction of brain tissue. Stroke interrupts or diminishes oxygen supply and
commonly causes serious damage or necrosis in the brain tissues. When either of these things

happens, brain cells begin to die.

When brain cells die during a stroke, abilities controlled by that area of the brain are lost.

These include functions such as speech, movement, and memory. The specific abilities lost or

affected depend on the location of the stroke and its severity.

There are two types of “brain attacks” – ischemic and hemorrhagic. With ischemic

strokes, a blood clot blocks or plugs a blood vessel in the brain. With hemorrhagic strokes, a

blood vessel in the brain breaks or ruptures.

An ischemic stroke can occur in several ways – embolic, thrombotic, Transient ischemic

attack, and lacunar infarcts. Embolic stroke occurs when a blood clots forms in the body (usually

the heart) and travels through the blood stream to the brain. Once in the brain, the clot eventually

travels to a blood vessel small enough to blocks its passage. The clot lodges there, blocking the

blood vessel causing a stroke. In the thrombotic stroke, blood flow is impaired because of the

blockage to one or more arteries supplying blood in the brain. Blood-clot strokes can also happen

as the result of unhealthy blood vessels clogged with the build up with fatty acids and

cholesterol. So your body reacts in these injuries just as it would if you were bleeding from a

wound- it responds by forming clots. Transient ischemic attacks, or TIAs, are brief episodes of

stroke symptoms resulting from temporary interruptions of blood flow to the brain. It can last

anywhere from a few seconds up to 24 hours. Lacunar infarcts are small (1.5 to 2.0 cm) to very

small (3 to 4 mm) infarcts located in the deeper noncortical parts of the brain or in the brain

stem. They are found in the territory of single deep penetrating arteries supplying the internal

capsule, basal ganglia, or brain stem. They result from occlusion of the smaller branches of large
cerebral arteries, commonly the middle cerebral and posterior cerebral arteries and less

commonly the anterior cerebral, vertebral, or basilar arteries. In the process of healing, lacunar

infarcts leave behind small cavities, or lacuna. Six basic causes of lacunar infarcts have been

proposed: embolism, hypertension, small-vessel occlusive disease, hematologic abnormalities,

small intracranial haemorrhages, and vasospasm. Because of their size and location, lacunar

infarcts do not usually cause profound deficits such as aphasia or apracticagnosia of the minor

hemisphere. Instead, they often produce syndromes such as pure motor hemiplegia, pure sensory

hemiplegia, and dysarthria with the clumsy hand syndrome.

Overview

The Neurological System is divided into two major parts: the Central Nervous System

(CNS) and the Peripheral Nervous System (PNS).

The Central Nervous System is the body’s information headquarters, ultimately

regulating nearly all body functions. It CNS includes the brain and spinal cord.

The brain processes incoming information from within the body, and outside the body by

way of the sensory nerves of sight, touch, smell, sound, and taste. In other words, the brain is

where all thinking and decision-making takes place.

The spinal cord is the main pathway for information connecting the brain and peripheral

nervous system. Electrical impulses travel through the nerves and allow the brain to

communicate with the rest of the body.

 The Peripheral Nervous System is responsible for the remainder of the body. It includes

cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal

cord) and all the major sense organs.

The PNS is divided into the somatic (SNS) and autonomic nervous system (ANS).

The Somatic Nervous System (SNS) is responsible for all muscular activities that we

consider voluntary or that are within our conscious control.

The Autonomic Nervous System (ANS) is responsible for all activities that occur

automatically and involuntarily, such as breathing, muscle contractions within the digestive

system, and heartbeat.

The ANS is further divided into two- the sympathetic and parasympathetic system.

The Sympathetic System stimulates cell and organ function. It is activated by a perceived

danger or threat: by very strong emotions such as fear, anger or excitement; by intense exercise;

or when under large amounts of stress.

The Parasympathetic System inhibits cell and organ function. It slows down heart rate,

resumes digestion, and increases relaxation throughout the body.

The brain is the center of our body functioning. Once it is injured the total functioning of our

body will be affected. Physical activities are hampered and other vital organs will also be

affected as well. Once vital organs are not in their optimum functioning, it will aggravate the

seriousness of the condition of the patient.

 Due to thrombosis, or Hemorrhagic
embolism, some neurons
die because of lack of
oxygen and nutrients

Infarction of the Cerebral Vessels known as

Stroke

Tissue injury triggers an Space – occupying blood

inflammatory response clots put more pressure in
which increases intracranial the brain tissues
pressure.

The injury disrupts The regulatory mechanisms

metabolism leading to of the brain attempt to
changes in ionic transport, maintain equilibrium by
localized acidosis, and free increasing BP and ICP.
radical formation

Calcium, Sodium, water

The ruptured cerebral
accumulate in the injured
F. Prioritizing Nursing Diagnosis

1. Ineffective Cerebral Tissue Perfusion related to cerebral edema as evidenced by altered

level of consciousness, stiffening of extremities, slurred speech
2. Impaired Physical Mobility r/t neuromuscular/musculoskeletal impairment

3. Self-Care Deficit r/t impaired mobility status

4. Disturbed Sensory Perception r/t altered sensory perception

5. Impaired Verbal Communication r/t decreased circulation to the brain

 Cues Nursing Diagnosis Outcome Criteria Nursing Intervention Rationale Evaluation Discharge Planning
Subjective:  Ineffective Short Term: Independent: PARTIALLY M – Instruct the
“ Budlayan siya Cerebral After 8 hours of 1. Determine factors  Influences choice of MET folks and the
maghulag kag Tissue effective nursing related to individual interventions. Short Term: patient to take
maluya na ang Perfusion intervention the situation /decreased After 8 hours of drugs as ordered.
tuo nga parti related to patient will be able cerebral perfusion. effective nursing Emphasize the
sang iya lawas. cerebral to: intervention the importance of
Nabudlayan sya edema as 1. Demonstrate 2. Monitor/document  Assesses trends in level patient was taking the drugs
maghambal daw evidenced by stable vital neurological status of consciousness partially able to: at the right timing
indi altered level of signs. frequently and (LOC) and useful in 1. Demonstrate of intake and
maintindihan.” consciousness, 2. Prevent / compare with determining location, stable vital right dosage.
as verbalized by stiffening of minimize baseline. extent, and signs. Explain to
the folk. extremities, complications. progression/resolution 2. Prevent / patient/folks the
slurred speech 3. Daily needs are of CNS damage. May minimize adverse effects of
Objective: met either by also reveal presence of complications. the drugs.
 T–36.5 himself or TIA, which may warn 3. Daily needs are
 P - 88 others. of impending met either by E–
 R - 22 4. Be free from thrombotic CVA. himself or Provide/maintain

 BP – 180/100 injury and fall others. stress free

 GCS – 11 3. Monitor vital signs.  Monitor Alterations 4. Free from environment for

 Stiffening of Long Term: injury and fall the client to

extremities After 2 weeks of 4. Provide safety  Prevent falls and injury lessen discomfort.
effective nursing measures
 Slurred
intervention the Long Term: T – Instruct
speech
patient will be able 5. Evaluate pupils,  Pupil reactions are After 2 weeks of patient to perform
to: noting size, shape, regulated by the effective nursing exercise treatment
1. Maintain equality, light oculomotor (III) cranial intervention the given by physical
 usual/improved reactivity. nerve and are useful in patient was therapist. Advice
level of determining whether partially able to: folks to assist
consciousness, the brainstem is intact. 1. Maintain patient.
cognition, and Pupil size/equality is usual/improved
motor/sensory determined by balance level of H – Instruct folks
function. between consciousness, to place patient
2. Increased parasympathetic and cognition, and on moderate
cerebral sympathetic enervation. motor/sensory backrest.
function and Response to light function. Encourage active
decrease reflects combined ROM for
neurological function of the optic 2.Increased unaffected
deficits. (II) and oculomotor cerebral extremities and
(III) cranial nerves function and perform passive
decrease ROM for affected
6. Assess higher  Changes in cognition neurological extremities.
functions, including and speech content are deficits.
speech, if patient is an indicator of O – Explain to the
alert. location/degree of patient and folks
cerebral involvement the importance of
and may indicate keeping follow-
deterioration/increased up appointments
ICP. with health care
providers and to
7. Position with head  Reduces arterial report any
slightly elevated pressure by promoting untoward signs
and in neutral venous drainage and and symptoms.
position. may improve cerebral
 circulation/perfusion D – Instruct the
patient/folks to
8. Maintain bedrest;  Continual follow the diet
provide quiet stimulation/activity can intended for the
environment; increase ICP. Absolute patient. Healthy
restrict rest and quiet may be and rich in
visitors/activities as needed to prevent vitamins and
indicated. Provide rebleeding in the case minerals.
rest periods of hemorrhage. Collaborate with
between care the dietician.
activities, limit
duration of S – Encourage
procedures. folks to provide
physical,
Dependent: emotional,
1. Administer oxygen  Reduces hypoxemia, financial, and
at 2 Lpm as which can cause spiritual support
ordered. cerebral vasodilation to the patient.
and increase
pressure/edema
formation.
2. Administer the
following as
ordered:
-Baclofen1tab BID  For skeletal muscle
and ValproicAcid spasticity of spinal
-Mannitol &cerebral origin
25cc IV q8H  To increase urine flow
in patients w/ acute
renal failure, reduce
raised intracranial
pressure & treat
cerebral edema.
-Levetriacetam  Adjunctive therapy in
500mg 1tab OD the treatment of partial
seizures w/ or w/o
secondary
generalization.
-Losartan  To manage HTN
50mg/tab 1tab OD
-Citicoline 500mg  To treat
1tab BID cerebrovascular
disorders including
ischemic stroke,
Parkinsonism & head
injury.
-Amlodipine 20mg  To manage HTN &
1tab OD angina pectoris.
-Simvastatin  To treatment
40mg/tab 1tab OD hyperlipidemia;
prophylaxis in
hypercholesterolemic
patients w/ ischemic
heart disease.