Professional Documents
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INTRODUCTION
Symptoms
Include numbness or weakness of face, arm or leg; confusion or change in mental
status; trouble speaking or understanding speech; visual disturbance, loss of
balance, dizziness, difficulty walking, or sudden severe headache.
• Motor loss
-hemiplegia, hemiparesis
-flaccid paralysis and loss of our decrease in the deep tendon reflexes
(initial clinical features) followed by (alter 48 hours) abnormally increased
muscle tone (spasticity).
• Communication loss
-dysarthria( difficulty speaking)
-Pysphasia or aphasia (defective speech or loss of speech)
-apraxia (inability to perform as previously learned action)
• Perceptual disturbances and sensory loss
-visual percetual dysfunctions (homonymous hemianopia [loss of half of the
field])
-disturbances in visuospatial relationships (perceiving the relation of two or
more objects in spatial areas), frequently seen in patients with left
hemispheric damage.
-sensory losses: slight impairment of touch or more severe with loss of
proprioception, difficulty in interrupting visual, tactile, and auditory stimuli
• Impaired cognitive and psychological effects
-frontal lobe damage; learning capacity, memory , or other higher cortical
intellectual functions may be impaired. Such dysfunction may be reflected
in a limited attention span, difficulties in comprehension, forgetfulness, and
lack of motivation.
-depression, other psychological problems: emotional ability, hostility,
frustration, resentment, and lack of cooperation.
• Bladder dysfunction
-transient urinary incontinence
-persistent urinary incontinence or urinary retention (may be symptomatic
of bilateral brain damage)
-continuing bladder and bowel incontinence (may reflect extensive
neurologic damage)
Causes
• The causes of stroke: An artery to the brain may be blocked by a clot
(thrombosis) which typically occurs in a blood vessel that has previously
been narrowed due to atherosclerosis ("hardening of the artery"). When a
blood clot or a piece of an atherosclerotic plaque (a cholesterol and calcium
deposit on the wall of the artery) breaks loose, it can travel through the
circulation and lodge in an artery of the brain, plugging it up and stopping
the flow of blood; this is referred to as an embolic stroke. A blood clot can
form in a chamber of the heart when the heart beats irregularly, as in atrial
fibrillation; such clots usually stay attached to the inner lining of the heart
but they may break off, travel through the blood stream, form a plug
(embolus) in a brain artery and cause a stroke. A cerebral hemorrhage
(bleeding in the brain), as from an aneurysm (a widening and weakening) of
a blood vessel in the brain, also causes stroke.
Diagnosis
• Complete urinary incontinence
• Persistent urinary incontinence or urinary retention (may be symptomatic
of bilateral brain damage)
• Continuing bladder and bowel incontinence (may reflect extensive
neurologic damage)
Risk factors
• Hemorrhagic strokes are caused by arteriovenous malformations
(AVMs),aneurysm ruptures, certain drugs, uncontrolled hypertension,
hemangioblastomas, and trauma. These strokes can occur in epidural,
subarachnoid, or intracerebral hemorrhage.
• Ischemic strokes can be caused by cardiovascular disease (cerebral
embolism may originate in the heart) and dysrythmia (atrial fibrillation); risk
factors for coronary also be caused by vasospasm, migraines, and
coagulopathies 9eg, high hematocrit)
Treatment
• Help patients alter risk factors for stroke
• Prepare and support patient through carotid endarterectomy
• Administer anticoagulant agents as ordered (eg,low-dose aspirin therapy)
Mortality/ morbidity
• The incidence is 2.5 times greater in black than whites. Black between the
ages of 55 & 64 who live in the southern states are about 50% more likely
to die of stroke than blacks of the same age who live in the north.
Race
• High risk group are African Americans, the incidence of first stroke in
Africans is almost twice that in Caucasian Americans.
Sex
• Man has a higher rate of stoke than women do.
Age
• High risk groups include people older than 55 years old the incidence of
stroke more than double in each successive decade.
This study will aid us, student nurses, in revealing and educating individuals and
family members about neurologic disorder, treatment and recovery. This would permit
the development of appropriate strategies to target high risk group.
A. PATIENT’S PROFILE
Name: Mr. M
Address: Mapalad, San Agustin, Isabela
Sex: Male
Age: 61 years old
Civil Status: Married
Occupation: Farmer
Religion: Roman Catholic
Admission Data:
Chief Complain: Left sided body weakness and numbness.
Date of Admission: Dcember 1, 2009
Time of Admission: 3:25pm
Mode of Arrival: Assisted by his son and wife.
Attending Physician: Dra. NS Ipac
E. Socio-Economic History
Mr. M is an elementary undergraduate. He works and earns money for
his family – his wife and 2 children.
Mr. M was an active worker before because of being a farmer. He was an energetic
grandfather to his grandson and granddaughters. Client believed that proper diet,
exercises, and adequate financial support are the things needed to maintain proper
health diet are factors of having a healthy body. He also drank liquor irregularly and
smokes 3 sticks of cigarette daily. Once he felt wrong, he and his family sought medical
consultation. They also believed in “albularyo” and use herbal medicines such as guava
leaves, pito-pito and oregano.
DURING HOSPITALIZATION
Now that he is currently confined, her wife is also advised by his attending
physician to take only the prescribe medicines. He has no known allergies on both food
and medicine.
2. Nutritional-Metabolic
BEFORE HOSPITALIZATION
According to his wife, when he was not paralyzed yet, he was able to play with his
grandchildren. Drink beer with his friends and mingle with them. He was also eating what
he wants regarding those foods that are prepared and able to eat on his own.
DURING HOSPITALIZATION
His wife is advised to prepare low salt, low fat diet, soft with aspiration precaution
where he is assisted by his wife. He cannot eat on his own now because half of his body
was paralyzed; he is assisted by his wife always.
An IVF of D5NM 1L as ordered by his physician was infused.
3. Elimination
BEFORE CONFINEMENT
Mr. M, according to his wife defecate once a day, and felt normal when urinating.
DURING HOSPITALIZATION
According to his wife, he is still defecate once a day but cannot go in the rest room
on his own, also in urinating - he needs to be assisted always.
4. ACTIVITY-EXERCISE
BEFORE CONFINEMENT
Mr. M is a farmer, visiting his farm and doing farm works is considered as a dorm
of exercise.
DURING HOSPITALIZATION
Now that he has right hemisphere stroke, he is only allowed to move the right side
of his body where his movements are very limited.
His pulse is normal, well palpable with the total 57bpm.
5. Sleep-Rest
BEFORE CONFINEMENT
Mr. M according to his wife sleeps early and wake up early. He had his
maximum sleep of 8 hours.
DURING HOSPITALIZATION
Mr. M can take his sleep easily.
6. Cognitive-perceptual
BEFORE CONFINEMENT
He can do works easily with his bare hands. He communicates to people
through Ilocano language.
DURING HOSPITALIZATION
Mr. M is an elementary undergraduate, he has ability to read and write. He
communicates through his movements and slurred speech.
In terms of his visual, Mr. M cannot visualize people easily, there are abnormalities
due to an infarct in the brain, vision and normal eye function can be affected. In his ears,
it is clean though there are some white scales because of the cold weather.
Now, his movements are limited that he can grasp through his right hand only and
kick with his right foot only.
7. Role-relationship
BEFORE CONFINEMENT
The client lives in a nuclear family, considering that his two children live with their
own family and he is still living with his two remaining children. They live peacefully even
there are hardship and difficulties that arrives to their lives. By means of good
conversation they can easily fixed family problems. When family experienced difficulty of
caring for the client they just take it as trials given by god. They have harmonious
relationships with the family and their neighbors.
DURING HOSPITALIZATION
The client’s family maintains a harmonious relationship even though he is in this
condition.
8. Self-perception
BEFORE CONFINEMENT
According to Mr. M’s wife, he was strong and confident to do farm
works.
DURING HOSPITALIZATION
Now that he is paralyzed, the confidence that he had will change into lesser
confidence.
9. Sexuality-Reproductive
BEFORE CONFINEMENT
Our patient is sexually active regarding of his age according to his wife. He also
use contraceptive before, a condom and never tried it again, as said by his wife. He is
already circumcised when he was still a child.
Mr. M is having a loving wife, four children and three grandchildren that can prove
him being a real man.
DURING HOSPITALIZATION
Now, he’ll have hard time to get back the active phase of having sexual
intercourse.
He is still a man regarding of his condition.
10.Coping-Stress Tolerance
BEFORE CONFINEMENT
The patients engage himself with his work and to his family according to his wife.
He is family centered and gain strength from them.
DURING HOSPITALIZATION
Now that he is hospitalized, stress is increased that is observable through his
nonverbal cues, especially being paralyzed.
11.Value-Belief
Before Hospitalization
Mr. M is a Roman Catholic member, he do not attend mass, but he is listening the
preaches of the priest through radiocast.
During Hospitalization
He cannot listen a mass through radio because he is hospitalized and any kind of
noise is prohibited.
L10%
R100%
3/5
5/5
5/5
100
%
Mr. M is suffering from Right hemisphere stroke that indicates weakness or
paralyzed of the left side of the body. Where he cannot move his left hand and left leg
like he moves before confinement and also the left side of the brain damage that it
cannot think fast like before.
PSYCHOSOCIAL INTERPRETATION
Significant others The patient is visited by A very supportive family who
his daughter’s, son and shows comfort and care that
nieces. can relieve stress that is felt
by the patient
Occupation Farming
Weak in appearance
Due to decreased O2 supply
and perfusion in the brain.
Due to illness.
ELIMINATION
Consistency: Normal
Stool
Amount: Approximately
9-10 inches in length
Color: Yellow
Current activity level Lie and sit on bed Patient moment varies due
to body weakness
SAFETY
Eye/vision
OXYGEN
Airway clearance
Mouth Clear
Depth Normal
Color
Edema None
NUTRITION
Ability to:
Chew Able
Swallow Able
HEMATOLOGY
RBC x1012/L
Neutrophils % 55-65 77
Lymphocytes % 25-40 16
Monocyte 2-8 1
Eosinophils 1-3 6
Intrepretation:
The decreased in Hemoglobin and hematocrit indicates that there is an internal
hemorrhage, particularly in the brain. It isn’t a simple bleeding but it leads the client to
suffer cerebrovascular accident.
Raised white blood cell count above the normal range indicates Leukocytosis. This
increase in WBC (primarily neutrophils) is usually accompanied by a "left shift" in the
ratio of immature to mature neutrophils. The increase in immature leukocytes increases
due to proliferation and release of granulocyte and monocyte precursors in the bone
marrow which is stimulated by several products of inflammation including C3a and G-
CSF. Although it may be a sign of illness, leukocytosis in-and-of itself is not a disorder,
nor is it a disease.
V. REVIEW OF SYSTEM
The Brain
BRAIN
➢ Made up of 1000 billion neurons and is one of the largest organs of the body,
weighing about 1300 kg (3 lbs).
➢ It is a mushroom shaped
4 Principal Parts
1. Brain Stem
➢ Stalk of the mushroom
➢ Consist of medulla oblongata, pons and midbrain
2. Diencephalon
➢ Consisting primarily of the thalamus and hypothalamus
1. Cerebrum
➢ Spreads over the diencephalons
➢ Constitute about seven-eights of the total weight of the brain and occupies
most of the cranium.
1. Cerebellum
➢ Inferior to the cerebrum and posterior to the brain stem
The brain is protected by the cranial bones. Like the spinal cord. The brain is also
protected by meninges. The cranial meninges surround the brain are continues with the
spinal meaninges and have the same basic structure and bear the same names as the
spinal meninges.
1. Dura meter – pachymenix, tough fibrous tissue
- outermost covering
1. Calcarine Sulcus
➢ This sulcus is surrounded by the visual receptive area.
The function of the cerebral cortex has been mapped out into areas by
Broadmann. These two major types of cortical areas are:
2. Parietal Lobe
3. Occipital Lobe
4. Temporal Lobe
Has presentation for both right and left sides as well as proximally
and distally.
All three areas with motor function (4, 6 & 8) receive inputs from the
thalamus, cerebellum, other cortical regions and other peripheral receptors.
Location : OCCIPITAL LOBE specifically along the lips of the calcarine sulcus;
this is called the visual or striate area.
Function : vision
Function : hearing
PARTS FUNCTION
BRAIN STEM
Blood
CEREBRAL ARTERIES
A. PATHOPHYSIOLOGY
Etiology (Unknown)
↓
Tissue injury in the brain
↓
Causing compression of tissue
↓
Expanding hematoma or hematomas
↓
Distort and injure tissue
↓
The pressure may lead to a loss of blood supply to affected tissue with resulting
infarction
↓
The blood released by brain hemorrhage appears to have direct toxic effects on brain
tissue and vasculature
↓
Left sided body weakness and numbness.
↓
Right Hemisphere stroke
12-01-09
3:25pm
➢ Turned pt.
slowly from ➢ To build
trusting
side to side
relations
hip
➢ To
provide
➢ Determined pt. proper
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both
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➢ To
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providing
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NURSING
INDICATIO CONTRAINDICA ADVERSE
DRUG CONSIDERATION
N TION REACTION
S
Generic name: Reduction -Contraindicated -CNS: -Assess patient’s
-Mannitol of elevated in patients dizziness, blood pressure
intracranial hypersensitive headache, history before
Brand name: pressure, to drug fever therapy. Monitor
-Osmofundan cerebral pulse and blood
20% edema or -Contraindicated -CV: pressure regularly
increased in patients with edema,
Classification: intraocular anuria, severe hypotensio -Check weight,
-Osmotic pressure. pulmonary n, renal function,
Diuretic congestion, tachycardia fluid balance and
ACTION frank pulmonary , vascular serum urine
Doctor’s order: Elevates edema, severe overload sodium and
-Manitol 100cc blood heart failure, potassium daily
IV q8 plasma severe -EENT:
osmolality, dehydration, blurred -Monitor CNS
resulting in metabolic vision, symptoms and
enhanced edema or active rhinitis changes in mental
flow of intracranial status.
water from bleeding. -GI: thirst,
tissues, dry mouth, -To relieve thirst,
including nausea, give frequent
the brain vomiting, mouth care or
and diarrhea fluids
cerebrospin -monitor allergic
al fluid, into -GU: urine reaction:
interstitial retention rash,fever,
fluid and pruritus,and
plasma. -Metabolic: urticaria.
dehydration
-Other:
chills
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