HEALTHY LIFESTYLE

A Case of a 52 year old Male Diagnosed with Cerebrovascular Accident or

STROKE
Camino, Sarah Joy Madrigalejo, Lea Aimee Padawang, Jennybe Sanchez, Janine Tibar, Joanna Marie Tuboro, Danvy Matiga, Chavala

INTRODUCTION

Stroke is a disorder in which the arteries to the brain become blocked or rupture, resulting in death of brain tissue. According to the World Health Organization (WHO), it is a clinical syndrome consisting of rapidly developing signs of focal (or global) disturbance of cerebral function lasting more than 24hrs. or leading to death, with no apparent cause other than of vascular origin. In the Philippines, it is one of the leading causes of death of the Filipinos (2002). In the year 2008, stroke affects 486 out of 100,000 Filipinos or roughly half a million Filipinos. It usually occurs among men aging 60-70, but as of year 2008, stroke occurs in patients as young as 30-40 years old because of the change in lifestyle. There are two types of stroke: ischemic and hemorrhagic. About 80% of strokes are ischemic due to a blocked artery. Brain cells, thus deprived of their blood supply, do not receive enough oxygen and glucose (sugar), which are carried by blood. A transient ischemic attack (TIA), sometimes called a ministroke, is often an early warning sign of an impending ischemic stroke. TIAs are caused by an inadequate blood supply to part of the brain but only for a brief time. Because the blood supply is restored quickly, brain tissue does not die, as it does in a stroke. The other 20% of strokes are hemorrhagic due to bleeding in or around the brain. In this type of stroke, a blood vessel ruptures, interfering with normal blood flow and allowing blood to leak into brain tissue. Blood that comes into direct contact with brain tissue irritates the tissue and can cause scarring, leading to seizures. The major risk factors for both types of stroke are atherosclerosis (the narrowing or blockage of arteries by patchy deposits of fatty material in the walls of arteries) high

blood pressure, diabetes, and smoking. Atherosclerosis is a more important risk factor for ischemic stroke and high blood pressure is a more important risk factor for hemorrhagic stroke. Other risk factors for hemorrhagic stroke include use of anti coagulants, cocaine, or amphetamines, aneurysms in arteries within the skull, blood vessel (arteriovenous) malformations and vasculitis. The most common early symptoms of an ischemic stroke are sudden weakness or paralysis of the face and leg on one side of the body, slurred speech, sudden confusion with difficulty speaking or understanding speech, sudden dimness or loss of vision, particularly in one eye, loss of balance and coordination, leading to falls, sudden severe headache and abnormal sensations or loss of sensation in an arm or a leg or on one side of the body. Symptoms of a hemorrhagic stroke are largely the same as those of an ischemic stroke but may also include sudden severe headache, nausea and vomiting, temporary or persistent loss of consciousness and very high blood pressure.

BIOGRAPHICAL DATA

Name: Raul De Paz Age: 52 years old Sex: Male Weight: 52 Kg Height: 158 cm BM: 20.83 (Normal) Address: 103 Kalayaan St.Marikina Heights, MarikinaCity Nationality: Filipino Religion: Roman Catholic Birth Date: April 08, 1959 Occupation: Bus Conductor Educational Attainment: High School Graduate Date of Interview: November 29, 2011

HISTORY OF PRESENT ILLNESS

The Client used to be a Bus Conductor but stopped working immediately after he was diagnosed to have cerebrovascular accident last November at year 2009. Client does not smoke but he drink alcoholic beverage like beer one to two times a month. He loves eating salty foods such as fatty foods and street foods like barbeque, isaw. He lives in a bungalow type of house, easily accessible to hospital and health centers.

The client lives with his wife and his five children. His family is dependent on his eldest son job profit.

A. Family History

DM HPN Cancer Asthma

Father (-) (-) (-) (-)

Mother (-) (-) (-) (-)

ANATOMY

Nervous System

Parts and function of the brain The nervous system is your body's decision and communication centre. The central nervous system (CNS) is made of the brain and the spinal cord and the peripheral nervous system (PNS) is made of nerves. Together they control every part of your daily life, from breathing and blinking to helping you memorize facts for a test. Nerves reach from your brain to your face, ears, eyes, nose, and spinal cord... and from the spinal cord to the rest of your body. Sensory nerves gather information from the environment, send that info to the spinal cord, which then speed the message to the brain. The brain then makes sense of that message and fires off a response. Motor neurons deliver the instructions from the brain to the rest of your body. The

spinal cord, made of a bundle of nerves running up and down the spine, is similar to a superhighway, speeding messages to and from the brain at every second. The brain is made of three main parts: the forebrain, midbrain, and hindbrain. The forebrain consists of the cerebrum, thalamus, and hypothalamus (part of the limbic system). The midbrain consists of the tectum and tegmentum. The hindbrain is made of the cerebellum, pons and medulla. Often the midbrain, pons, and medulla are referred to together as the brainstem.

The Cerebrum: The cerebrum or cortex is the largest part of the human brain, associated with higher brain function such as thought and action. The cerebral cortex is divided into four sections, called "lobes": the frontal lobe, parietal lobe, occipital lobe, and temporal lobe. Here is a visual representation of the cortex:

Different lobes of the brain

Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving

y y y

Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli Occipital Lobe- associated with visual processing Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech

The Cerebellum: The cerebellum, or "little brain", is similar to the cerebrum in that it has two hemispheres and has a highly folded surface or cortex. This structure is associated with regulation and coordination of movement, posture, and balance.

Limbic System: The limbic system, often referred to as the "emotional brain", is found buried within the cerebrum. Like the cerebellum, evolutionarily the structure is rather old.

This system contains the thalamus, hypothalamus, amygdala, and hippocampus.

Thalamus- a large mass of gray matter deeply situated in the forebrain at the topmost portion of the diencephalon. The structure has sensory and motor functions. Almost all sensory information enters this structure where neurons send that information to the overlying cortex. Axons from every sensory system (except olfaction) synapse here as the last relay site before the information reaches the cerebral cortex.

Hypothalamus- part of the diencephalon, ventral to the thalamus. The structure is involved in functions including homeostasis, emotion, thirst, hunger, circadian rhythms, and control of the autonomic nervous system. In addition, it controls the pituitary.

Amygdala- part of the telencephalon, located in the temporal lobe; involved in memory, emotion, and fear. The amygdala is both large and just beneath the surface of the front, medial part of the temporal lobe where it causes the bulge on the surface called the uncus. This is a component of the limbic system

Hippocampus- the portion of the cerebral hemispheres in basal medial part of the temporal lobe. This part of the brain is important for learning and memory for converting short term memory to more permanent memory, and for recalling spatial relationships in the world about us.

Brain Stem: Underneath the limbic system is the brain stem. This structure is responsible for basic vital life functions such as breathing, heartbeat, and blood pressure. Scientists say that this is the "simplest" part of human brains because animals' entire brains, such as reptiles (who appear early on the evolutionary scale) resemble our brain stem.

Midbrain/ Mesencephalon- the rostral part of the brain stem, which includes the tectum and tegmentum. It is involved in functions such as vision, hearing, eyemovement, and body movement. The anterior part has the cerebral peduncle, which is a huge bundle of axons traveling from the cerebral cortex through the brain stem and these fibers (along with other structures) are important for voluntary motor function. Pons- part of themetencephalon in the hindbrain. It is involved in motor control and sensory analysis... for example, information from the ear first enters the brain in the pons. It has parts that are important for the level of consciousness and for sleep. Some structures within the pons are linked to the cerebellum, thus are involved in movement and posture. Medulla Oblongata- this structure is the caudal-most part of the brain stem, between the pons and spinal cord. It is responsible for maintaining vital body functions, such as breathing and heart rate.

PATHOPHYSIOLOGY
Precipitating Factors Predisposing Factors
y y Hyperlipidemia Atherosclerosis y y y Lifestyle Age sex

Accumulation of fatty materials

Blockage of the blood vessel (artery)

Vasoconstriction

Lack of oxygen and nutrients supply

Cerebral Ischemia

Hypoxia

-cell death - decreased oxygen level

Altered Cerebral Metabolism

Decreased cerebral perfusion Local acidosis

Cytotoxic edema

Aneurysm

ISCHEMIC STROKE

Acute hemiparesis or hemiplegia Dysarthria or aphasia Sudden decrease in consciousness

Ataxia

Head of the Family: Raul De Paz Birthday: April 08, 1959 Address: 103 Kalayaan St. Marikina Heights Marital status: Married

Family Number: 7

Highest education completed: High School graduate Occupation: Bus Conductor A. Home and Environment Home a. Ownership: OWNED b. Construction Material Used: Mixed c. Number of rooms used for sleeping: 1 room only d. Lightning facilities: electricity e. General Sanitary Condition: No bathroom, they share bathroom with their neighbors Drinking Water Supply Kitchen Cooking Facilities: Firewood or Charcoal Sanitary Condition: They don t have kitchen at all. There are flies and the surroundings is dirty Drainage Facility: Blind drainage Source: Public Distance from House: 2meter Storage: large covered container with faucet Date Assessed: November 29, 2011

1. Waste Disposal Refuse and Garbage Container: Open Method of Disposal: Garbage Collection

Toilet type: Water sealed latrine Distance from house: 5meter Sanitary condition: there are flies. Dirty

2. Domestic Animals NONE

1. The community in general a. General Sanitary Condition Depressed area

b. Housing congestion: YES c. Presence of Breeding Sites of Vectors of Diseases: YES, Slow flowing fountain stream d. Recreational facilities: basketball court e. Availability of Health Care Services: There is a near Health Care Center in the community.

NURSING CARE PLAN

Assessment

Nursing Diagnosis Ineffective cerebral tissue perfusion related to decreased cerebral blood flow as evidenced by difficulty of swallowing, flacid right sided of the body and disturbed thought process

Inference Ischemic Stroke Decreased cerebral oxygenation Failure to nourish the bran tissues Brain tissue damage Right hemiplegia, difficulty of swallowing, and disturbed thought process

Planning Long term: After 2 days of holistic nursing intervention, the patient will have improved level of consciousness, cognition, and motor and sensory function. The patient will demonstrate stability of vital signs and absence of signs of increased ICP and will not display further deterioration.

Interventions Independent: Determine factors related to individual situation/cause for coma/ decreased cerebral perfusion, and potential for IICP.

Rationale

Evaluation

Sujective Data: No subjective cue taken Objective Data: > dry skin > changes in motor/sensory responses (left) > unable to speak clearly > BP- 120/70

Influences choice of interventions. Deterioration in nuerologic signs and symptoms or failure to improve after intial insult may require surgical intervention and/or that the patient be transferred to critical care area for monitoring of intracranial pressure. Assesses trends in LOC and potential for IICP and is useful in determining location, extent, and progression/resolution of CNS damage. Variations may occur because of cerebral pressure/injury in vasomotor area of the brain; hypertension may have been a precipitating factor; hypotension may occur because of shock (circulatory collapse); IICP may occur . Subclavian artery blockage may be revealed by differenc in pressure readings between arms. Changes in rate, especially

Monitor/document nuerologic status frequently and compare with baseline.

Goal partially met. After 2 days of holistic nursing intervention, the patient maintains usual level of consciousness, cognition and motor/sensory function. Demonstrates stables vital signs and absence of signs of IICP. Displays no further deterioration. Latest BP 120/70

Monitor vital signs, note hypertension/hypotension, compare blood pressure readings in both arms;

Heart rate and rhythm,

auscultate for murmurs;

bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (e.g., Stroke after MI or from valve dysfunction). Irregularities can suggest location of cerebral insult/ increasing ICP and need for further intervention, including possible respiratory support. Pupil reactions are regulated by the occulomotor (III) cranial nerveand are useful in determining whether the brainstem is intact. Pupil size/equality is determined by balance betweenparasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and occulomotor (III) cranial nerves. Specific visual alterations reflect area of brain involved, indicate safety concerns and influence choice of interventions. Changes in cognition/speech content are an indicator of location/degree of cerebral involvement and may indicate deterioration/IICP.

Respiration, noting patterns and rhythm, e.g., periods of apnea after hyperventilation, CheyneStokes breathing. Evaluate pupils, noting size, shape, equality, light reactivity.

Assess for changes in vision, e.g., blurred vision, alterations in visual field/depth perception. Assess higher functions, including speech, if patient is alert.

Position with head slightly elevated and in neutral position.

Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation/perfusion. Continual stimulation/activity can increase ICP. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.

Maintain bedrest; provide quiet environment; restrict visitors/activities as indicated. Provide rest periods between care activities, limit duration of procedures. Prevent straining at stool, holding breath.

Valsalva maneuver increases ICP and potentiates risk of rebleeding Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect IICP/cerebral injury, requiring further evaluation and interventions.

Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.

Dependent: Administer supplemental oxygen as indicated. Reduces hypoxemia which can cause cerebral vasodilation and increase pressure /edema.

Administer medications as indicated: Mannitol To lower ICP and IOP Citicoline To increase oxygen consumption in the brain

Antihypertensives Preexisting /chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage. Transient hypertension often occurs during acute stroke and resolves often without therapeutic intervention. Collaborative: Monitor laboratory studies as indicated, e.g., prothrombin/PTT time, Dilantin level. Provides information about drug effectiveness/therapeutic level.

Assessment Sujective Data: No subjective cue taken Objective Data: > Impaired coordination > limited ROM > flaccid paralysis right-sided of the body > decreased physical mobility > inability to purposefully move within the physical environment >BP- 120/70

Nursing Diagnosis Impaired physical mobility related to generalized weakness and paralysis as evidenced by right-sided body paralysis

Inference Ischemic stroke Decreased cerebral oxygen on the frotal lobe Brain tissue damage affecting the motor function Generalized weakness Right-sided body paralysis Impaired physical mobility

Planning Long term: After 2 days of holistic nursing intervention, the patient will maintain optimal position of function by absence of contractures and footdrop. The patient will increase strength and function of affected or compensatory body part, will demonstrates techniques or behaviors that enable resumption of activities, and will maintain skin integrity.

Interventions Independent: Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 0-4 scale.

Rationale

Evaluation

Identifies strength/defeciencies and may provide information regarding recovery. Assists in choices of interventions, because different techniques are used for flaccid and spastic paralysis. Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus. Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breath. Minimizes muscle atrophy, promotes circulation , helps prevent contractures. Reduces risk of hypercalciuriaand osteoporosis if underlying problem is hemorrhage.

Change position at least every 2 hours (prone, supine, side-lying) and possibly more often if placed on affected side.

Position in prone position once or twice a day if patient can tolerate.

Begin active/passive range of motion (ROM) to all extremities (including splinted). Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet. Prop extremities in functional position, use footboard during the period of flaccid paralysis. Maintain

Goal partially met. After 2 days of holistic nursing intervention, the patient maintains optimal position of function as evidenced by absence of contractures, footdrop. Increases strength and function of affected or compensatory body part with a motor response of the unaffected side of 6/6. Partially demonstrates techniques or behaviors that enable resumption of activities. Maintains skin integrity.

Prevents contractures/footdrop and facilitate use when/if function returns. Flaccid paralysis may interfere with

neutral position of head.

ability to support head, whereas spastic paralysis may lead to deviation of head to one side. During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome. Flexion contractures occur because flexor muscles are stronger than extensors. Prevents adduction of shoulder and flexion of elbow. Promoted venous return and helps prevent edema formation. Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position. Maintains functional position. Prevents external hip rotation. Continued use (after change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and

Use arm sling when patient in upright position as indicated.

Evaluate use of/need for positional aids and/or splints during spastic paralysis: Place pillow under axilla to abduct arm; Elevate arm and hand;

Place hard hand rolls in the palm with fingers and thumb opposed;

Place knee and hip in extended position; Maintain leg in neutral position with a trochanter roll; Discontinue use of foot board.

actually increases plantar flexion. Assess affected side for color, edema, or other signs of compromised circulation. Inspect skin particularly over bony prominences regularly. Gently massage any reddened areas and provide aids sch as sheepskin pads as necessary. Encourage patient to assist with movement and exercise using unaffected extremity to support/move weaker side. Collaborative: Provide egg crate mattress or other flotation device as indicated. Promoted even weight distribution decreasing pressure on bony points and helping to prevent skin breakdown/decubitus formation. Individualized program can be developed to meet particular needs/deal with deficits in balance, coordination, strength. Edematous tissue is more easily traumatized and heals more slowly. Pressure points over bony prominences are most at risk for decreased perfusion/ischemia. Circulatory stimulation and padding helps prevent skin breakdown and decubitus development. May respond as if affected side is no longer part of body and need encouragement and active training to reincorporate it as a part of own body.

Consult with physical therapist regarding active, resistive exercises and patient ambulation.

Assessment Sujective Data: No subjective cue taken Objective Data: > Dry oral mucosa > produces incomprehensible sounds >Right-sided hemiplegia >Impaired articulation (right) >BP-120/70

Nursing Diagnosis Impaired verbal communication related to loss of oral muscle control as evidenced by inability to speak

Inference Blood flow to the brain was disrupted Damage to brain cells Cells located to the cerebral speech center was damaged Loss of facial/oral muscle control Impaired verbal communication

Planning Long term: After 2 days of holistic nursing intervention, the patient will indicate an understanding of the communication problems, will establish method of communication in which needs can be expressed, and will use resources appropriately.

Interventions Independent: Assess type/degree of dysfunction: e.g., patient does not seem to understand words or has trouble speaking or making self-understood.

Rationale

Evaluation

Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process. Patient may have trouble understanding spoken words, speaking words correctly, or experience damage to both areas. Choice of intervention is dependent on type of impairement. Aphasia is a defect in using and interpreting symbols of language and may and may involve sensory and/or motor components, e.g., inability to comprehend written/spoken words. adysarthric person can understand, read, and write language but has difficulty pronouncing words due to weakness, paralysis of oral musculature. Patient may lose ability to monitor verbal output and be unaware that communication is not sensible. Feedback helps patient realize why care givers are not understanding appropriately and provides opportunity to clarify content/meaning. Tests for receptive aphasia.

Differentiate aphasia from dysarthria;

Goal partially met. After 2 days of holistic nursing intervention, the patient will indicate an understanding of the communication problems, will establish method of communication in which needs can be expressed, and will use resources appropriately.

Listen for errors in conversation and provide feedback;

Ask patient to follow simple commands (e.g.,

Shut your eyes, Point to the door) repeat simple words/sentences; Point to objects and ask patient to name them; Have patient produce simple sounds, e.g., Sh, Cat; Tests for expressive aphasia; e.g., patient may recognize item but not be able to name it. Identifies dysarthria as motor components of speech (tongue, lip movement, breath control) can affect articulation and may/may not be accompanied by expressive aphasia. Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia. Provides for communication of needs/desires based on individual situation/underlying deficit.

Ask the patient to write name and/or a short sentence. If unable to write, have patient read a short sentence. Provide alternative methods of communication, e.g., writing or felt board, pictures. Provide visual clues (gestures, pictures, needs list, demonstration). Anticipate and provide for patients needs.

Helpful in decreasing frustration when dependent on others and unable to communicate desires. Reduces confusion/anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further

Talk directly to patient, speaking slowly and distinctly. Use yes/no questions to begin with, progressing in complexity as patient responds.

enhances work/idea association. Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Talk without pressing for a response. Patient is not usually hearingimpaired, and raising voice may anger patient/cause irritation. Forcing responses can result in frustration and may cause patient to automatic speech, e.g., garbled speech, obscenities, etc. Reduces patients social isolation and promotes establishment of effective communication. Promotes meaningful conversation and provides opportunity to practice skills. Enables patient to feel esteemed, because intellectual abilities often remain intact.

Encourage SO to persist in efforts to communicate with patient, e.g., reading mail, discussing family happenings. Discuss familiar topics, e.g., job, family, hobbies. Respect patients preinjury capabilities; avoid speaking down to patient or making patronizing remarks. Collaborative: Consult with speech therapist.

Assess individual verbal capabilities and sensory, motor, and cognitive functioning and develops therapy plan for rehabilitation.

Drug

Classification

Action

Dosage, Route, Frequency

Nursing Consideration

Evaluation

Generic name: Amplodipinebe sylate

-calcium channel blocker -antianginal -antihypertensive

nhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells.

10 mg PO OD

y Monitor patient carefully (BP, cardiac rhythm and output) while adjusting drug to therapeutic dose. y Administer drug without regard to meal.

Inhibits calcium flow Brand name: Norvasc Depression of impulse formation in specialized cardiac pacemaker cells Slowing the velocity of conduction of the cardiac impulse. Depression of myocardial contractility and dilation of coronary arteries and arterioles and peripheral arterioles.

Patient received the therapeutic effect of the medication and doesnt experience any signs of complication.

y Report irregular heartbeat, shortness of breath, swelling of the hands or feet.

Decreased cardiac work

Decreased cardiac oxygen consumption

Drug

Classification

Action

Dosage, Route, Frequency 100mg/ 125 mg PO

Nursing Consideration

Evaluation

Generic name: Losartan Brand name: cozaar

Angiotensinreceptor blockers -antihypertensive

Blocks the angiotensin receptor

Dilates the blood vessels

Reduces blood pressures

y Assess if the patient has an allergy on losartan potassium y Can be take with or without meals y Patient may experience side effects such as dizziness, lightheadedness, blurred vision, or a stuffy nose as your body adjusts to the medication y Report if the patient experience vomiting or diarrhea, or if sweating more than usual y Monitor patient blood pressure y Do not discontinue the drug abruptly y Provide safety

The patient received the therapeutic action of the drug as evidenced by lowering the high blood pressure.

Drug

Classification

Action

Dosage, Route, Frequency 500 mg BID PO y

Nursing Consideration

Evalution

Generic name: Citicoline Brand name: somazine

Neurotonics nootropics

It decreases further brain tissue damage.

It can be taken with food or without Monitor patients neurologic status

y Promote neural activity. y

The patient received the therapeutic action of the drug.

Note for any adverse reaction Should be administered within 24 hours of stroke Should be taken on morning to avoid difficulty in sleeping.