PATHOPHYSIOLOGY

Predisposing Factor:

Precipitating factor: - Age (53 years old)

- Stress on work - Family history of Hypertension

(technician)
- Cigarette smoking

- Alcohol consumption

- Kidney Failure

Kidney Failure Chronic Hypertension

Failure of Renin-
Angiotensin I-
Angitension II
Conversion

Increase Increased blood flow to the

Creatinine, UREA brain
in Urinalysis

Compromise of the integrity of

cerebral arterioles

Weakening of the walls

Formation of Chalcot-
Bouchard aneurysm

Rupture of the anterior cerebral artery

 - Fever

- leukocytosis

Bleeding or hemorrhage on at the

affected area
Inflammation of the frontal lobe

Alteration in the cerebral Hematoma Presence of free blood in the

component formation interstitial areas

-ABG, Cerebral
Angiography, MRI, CT
SCAN,Subarachoid Screw,
Ventriculostomy, Epidural Thrombus Cell membrane
ICP Monitoring. Increase in the formation destruction
Continuation……….. Intracranial pressure
-Restlessness,
drowsiness,confusion,
CT SCAN
and MRI

Decrease
Compression Compensatory
oxygen
of the brain mechanism
supply
components

Stimulates
further
swelling and Cellular
inflammation edema Vasospasm Electrolyte Acidosis
imbalance

-projectile
vomiting,
Ischemia Stimulation of
numbness of
vasomotor
extremiities ,
centers
visual
disturbances -SERUM
Scar ELECTROLYTE TEST
Formation (decrease Mg, K),
ABG(Respiratory
Alteration in Increase
alkalosis)
the frontal systemic
lobe function pressure
X RAY, -changes in the v/s
CT
scan,
MRI

-Broca’s aphasia,
hemiparesis,
- Increase
hemianopsia,
BP
dysarthria, Without Medical With Medical
incapable of intervention Intervention
abstract thinking
 Brain stem Management:
herniation
SURGICAL: craniectomy, craniotomy

MEDICAL: Pharmacologic Therapy

Comatose stupor (citicholine, mannitol, dilatin, captopril,
Nitroglycerin, furosemide, remopain,
Kalium Durule, MgSO4)

Worsening of the Bad Prognosis

condition

DEATH
 Physical Assessment

Assessment of Normal Findings Actual Findings Analysis

Body Parts

Body odors absence (-) body odor Normal

Signs of illness No illness noted The client is obviouslyDeviation

ill
(skin color and
breath)

Skin color Light to deep brown, (+) paleness Paleness may be the
etc. result of decreased blood
supply to the skin (cold,
fainting, shock,
hypoglycemia) or
decreased number of red
blood cells (anemia).
(www.nlm.nih.gov/medline
plus)

Skin moisture Moisture in skin folds (+) skin dryness The skin loses moisture
and axillae and may crack and peel,
or become irritated and
inflamed. Bathing too
frequently, especially with
harsh soaps, may
contribute to dry skin.
Eczema may cause dry
skin.
(www.nlm.nih.gov/medline
plus)

Skin Uniform ;within 39.0 temp A client with a temperature

Temperature normal range of 37.5 and above is
positive for hyperthermia

Skin Turgor Skin intact or springs (+) skin turgor Skin turgor is an
back abnormality in the skin's
When pinched, the ability to change shape
skin doesn’t return and return to normal
 immediately to its (elasticity). Decreased skin
original state. turgor is a late sign in
dehydration. It occurs with
moderate to severe
dehydration. Fluid loss of
5% of the body weight is
considered mild
dehydration, 10% is
moderate, and 15% or
more is severe
dehydration.

(www.nlm.nih.gov/medline
plus)

Lips Pinkish, or darker, The client’s lips are A dark lip is due to varied
symmetric symmetrical but it is reasons, such as,
dry and dark. smoking, and excessive
intake of caffeinated
beverages.

Dry lips are usually

indicative of lack of
moisture in the
atmosphere. Our lips do
not have inbuilt
mechanisms which will
help them secrete oil when
there is a change in
weather.

(home-remedies-for-
you.com)

Anterior
Thorax

Inspect breathing Quiet, rhythmic, and (+) dyspnea Dyspnea is a difficulty in

patterns effortless respirations. breathing, often associated
(+) prolonged with lung or heart disease
expiratory phase and resulting in shortness
of breath. Also called air
hunger.

Jugular veins
 Inspect jugular Veins not visible (-) jugular veins Normal
veins (indicating right side
of heart is functioning
normally).

Abdomen

Inspect the Flat, rounded The abdomen is Resulting from thinning or

abdominal (convex) or scaphoid slightly rounded wasting of the skin due to
contour (profile (concave). lost of collagen and
line from rib (-) striae. elastin.
margin to the
pubic bone) * Fundamentals of Nursing
while standing by Kozier et al, pg. 537
at the clients
side while the
clients in dorsal
recumbent
position

Test for the (-) resistance A comatose person cannot

strength (neck) be awakened,and does not
take voluntary actions.

-wikipedia.org

Test for strength (-) resistance A comatose person cannot

( upper be awakened,and does not
extremities) take voluntary actions.

-wikipedia.org

Test for strength (-) resistance A comatose person cannot

(lower be awakened,and does not
extremities) take voluntary actions.

-wikipedia.org

ECOLOGIC MODEL

Hypothesis:

There is a significant relationship between the disease process of

Cerebrovascular disease and the Web Model being used
Predisposing Factors:

• Host
-Male
- 53 years old
-sedentary lifestyle
-family history of hypertension
-food intake (high fat high salt)
-smoker
-kidney failure
-alcohol consumption
• Agent
• Environment

Ecologic Model:
WEB MODEL
Analysis:
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 dam-
ages the blood vessel lining, endothelium, exposing the underlying collagen where
platelets aggregate to initiate a repairing process which is not always complete and per-
fect. 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 fall in blood pressure during sleep can then lead to a marked reduction in blood
flow in the narrowed blood vessels causing ischemic stroke in the morning. Conversely,
a sudden rise in blood pressure due to excitation during the daytime can cause tearing
of the blood vessels resulting in intracranial hemorrhage. Cerebrovascular disease
primarily affects people who are elderly or have a history of diabetes, smoking, or
ischemic heart disease. The results of cerebrovascular disease can include a stroke, or
occasionally a hemorrhagic stroke. Ischemia or other blood vessel dysfunctions can af-
fect the person during a cerebrovascular accident.
(http://en.wikipedia.org/wiki/Cerebrovascular_disease)

Changes in the blood pressure are sensed by the renal barroreceptors .

if the blood pressure is high release of rennin is decreased. Renin circulates
in the blood and act as enzyme to convert the protein angiotensin to an-
giotensin I. Angiotensin II it is powerful vasoconstrictor that primarily causes con-
striction of the small arterioles . This causes an increase in resistance to
blood flow and increase in blood pressure .
Sedentary lifestyle and food intake greatly affect the blood vessel because
of possible hyperlipidemia. If the client usually eat high salt and high fat food
it will constrict the blood vessel. ( handbook of Pathophysiology by Elizabeth J.
Corwin )

Interpretation:
Web Model explains and related to Cerebrovascular Accident (Intracranial
Hemorrhage) and its disease process. We used web model to easily define many
factors that would affect and contribute to the patients underlying condition.
Web model explains the multifactorial effect that could contribute to the pa-
tients condition. Factors such as a hereditary disease of hypertension. This is
one of the big factor that could contribute to the patients condition because if
there is a continues increase in blood pressure it will damage the blood vessel lin-
ing that could contribute to intracranial hemorrhage. Relatives also mentioned that
there is a kidney failure that could impede in balancing hypertension.

Conclusion and Recommendation:

We therefore conclude that the disease process of Cerebrovascular
disease is related to Web Model being used. Since it has different risk factor, we
recommend that the goal of therapy must focus on Nursing management such
measure of the client and medication regimen. The pharmacologic treatment on the
other hand is based on the state of the disease, the existence of other conditions and
the preference of the health professional/ physician.

Far Eastern University

 Institute of Nursing

SUBMITTED BY:

GROUP 85- BSN022

SUBMITTED TO:

Prof. Josephine Robinos

Clinical Instructor

INTRODUCTION

Cerebrovascular accident is the term that refers to any functional abnormality

of the Central Nervous System that occurs when the normal blood supply to the brain is
disrupted, as by a blood clot or a ruptured blood vessel, and vital brain tissue dies.
Cerebrovascular accident is commonly called Strokes.
Cerebrovascular accident may be caused by any of three mechanisms.

• Cerebral Thrombosis – blockage in the thrombus (clot) that has built up on the
wall of the brain artery.
• Cerebral Embolism – blockage by an embolus (usually a clot) swept into the
artery in the brain.
• Hemorrhage – Rupture of a blood vessel and bleeding within or over the surface
of the brain.

Thrombosis and embolism both lead to cessation of blood supply to part of the
brain thus to infarction (tissue death). Rupture of a blood vessel in or near the brain may
cause an intracerebral hemorrhage or subarachnoid hemorrhage.

The symptoms of a stroke usually develop over minutes or hours occasionally

over several days. Depending on the site, cause and extent of damage, any or all of the
symptoms at right may be present, in any degree of severity. The more serious cases
lead to rapid loss of consciousness, coma, and death or to severe physical or mental
handicap.

The following are the symptoms of Cerebrovascular accident:

• Headache
• Dizziness and confusion
• Visual disturbance
• Slurred speech or loss of speech
• Difficulty of swallowing

Risk factors:

• Age
• High blood pressure – weakens the walls of arteries
• Atherosclerosis – narrowed artery channels
 • Heart disease – cause blot clot in the heart that may break off and migrate to the
brain.
• Diabetes mellitus – accelerated degeneration of small blood vessel
• Smoking – increase the risk ofhypertension
• Polycythemia – a raised level of red cells in the blood.
• Hyperlipidemia – high level of fatty substances in the blood

I. Biographic Data

Name: Mr. EPJ

 Address: 17 Mabolo St., Signal Village Taguig City

Age: 53 y/o Gender: Male Religion: Roman Catholic

Marital Status: Married Occupation: Mechanical technician

Room and Bed no.: Room 215 Bed 1

Chief Complaint: Dizziness and Weakness

Provisional Diagnosis: Cardiovascular accident / intracranial hemorrhage

II. Nursing history

A. Past Health History

The past illnesses of the client include colds, cough, fever & flu. His wife added,
“Ang alam ko hindi naman siya sakitin nung bata pa siya, pero siyempre di maiiwasan
yung magkakaroon ng sakit paminsan minsan”. His wife stated that she is not sure with
her husband’s childhood illnesses and immunizations.
She also claimed that her husband is not allergic with any food. “Wala namang
pagkain na nakakapagdulot ng allergy sa kaniya, pati alikabok o halaman wala din.”
It is his first hospitalization. “Ito yung pinaka unang naconfine siya at
nagpaospital, hindi naman kasi siya mahilig magpacheck up o magpadoktor, hanggat
kaya pa niya, sariling paggamot na lang.” His wife said that he is not taking any
maintenance medication or multivitamins for his daily use.
When asked about the clients foreign travel, she reported that, “Hindi pa naman
siya nakakaalis ng bansa, dito lang kami sa.” She added that her husband has no
foreign travel for he is not interested in doing so nor he has money to finance for
traveling.

B. History of Present Illness

According to the client’s wife, her husband’s family have a hypertension disease.
Few minutes prior to admission, the client go to comfort room and afterwards he
complaint of having blurred vision and he said that he see things in opposite manner.
He also asked, is there earthquake. From there, the family rushed the client to the
nearest clinic but the clinic denied them and gives them medication. They decided to
bring the client to the hospital and diagnose him with cerebrovascular accident/
intracranial hemorrhage.

C. FAMILY HISTORY

According to his wife, her husband’s side has the following hereditary disease:
Hypertension, Heart Disease, Kidney Failure and Hernia. She claimed that all her
husband’s siblings have a hypertension.
 PRIORITIZATION

RANK NURSING CUES JUSTIFICATION

PROBLEM

Hyperthermia S: (the client is in This is our top

related to increased coma) priority because this
metabolic rate: problem is the most
illness possible easy to deal
1 with. If this is not
intervened as soon
O: as possible, it can
lead to dehydration,
Skin warm to touch
hyperventilation,
Flushed skin and tachycardia.
Therefore, this is the
Temperature: 38.6 fourth prioritized
problem.

Increased blood S: “nakakataas daw This is the second

pressure related to talaga na BP yung problem because it
drugs administration gamut niya sabi ng according to ABC it
doctor” as is part of the
verbalized by SO circulation, for the
blood is not

2 O:
distributed all
through out the body
and only
BP: 200/140 concentrated at the
upper part of the
body. His medicines
are the cause of this
problem and is
solved by
administering anti
high blood pressure
drugs that is can
only be orederd by
 the phycisian

Impaired skin S: “ This is the third

integrity related to priority in the
infiltration nursing problem
secondary to needle O: has many because it is also an
trauma previous needle actual problem that
insertion needs immediate

3 action. It is not life

threatening unlike
the first problem but
outweighs
subordinating
problems because it
interferes or delays
interventions needed
for problem #1.

Impaired mobility S: ayan sabi ng This is the fourth

related to neuro doctor comatose problem because; it
mascular sya” is not life-
impairment threatening since he
is in coma it is not
O: the patient is not the focus of our care

4 moving or even
reacting
but to other
problems that is
easier to manage

Self care deficit S: “comatose siya This problem is in

related to impaired kaya kahapon pa the fifth ranking
mobility status siya ganyan, because it is a
pinupunasan ko na problem, which is
5 lang minsan yung focusing on the
katawan niya pare patients hygienic
presko siya” needs, and also
feeding. It is
consequent to
O: the client is problem no. 1,
asleep because having
good selfcare will
Not reacting lead to better
wellness of self and
 health.

Uncooperative

Comatose

Activity intolerance S: “kahapon pa sya This is the sixth

related to walang malay at prioritized problem
immobility hindi makagalaw because if the
kasi sabi nung patient cannot
doktos xempre kasi perform his activity
comatose siya” like before there will
be insufficient
physiological and
O: psychological
energy to endure or
complete required
processes in the

6 body. It also
consequent with
problem no.1 and
when solved, will
help solving the top
problem

Risk for aspiration S: This is the seventh

related to situation prioritized problem
hindering elevation because it is not an
of upper body actual problem. It is
7 O:
only a risk. As the
The patient is problem has not
intubated occur proper nursing
interventions are
directed at the
prevention