I. INTRODUCTION Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain.

Hypertension is the most i mportant cause; it damages the blood vessel lining, endothelium, exposing the un derlying collagen where platelets aggregate to initiate a repairing process whic h is not always complete and perfect. Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, unev en and more vulnerable to fluctuations in blood pressure. A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vesse l bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrien ts, causing damage to the brain tissue. The most common symptom of a stroke is s udden weakness or numbness of the face, arm or leg, most often on one side of th e body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting o r unconsciousness. The effects of a stroke depend on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden d eath. The 1990 Global Burden of Disease (GBD) study provided the first global es timate on the burden of 135 diseases, and cerebrovascular diseases ranked as the second leading cause of death after ischemic heart disease. During the past dec ade the quantity of especially routine mortality data has increased, and is now covering approximately one-third of the world’s population. The increase in data a vailability provides the possibility for updating the estimated global burden of stroke. Data on causes of death from the 1990s have shown that cerebrovascular diseases remain a leading cause of death. In 2001 it was estimated that cerebrov ascular diseases (stroke) accounted for 5.5 million deaths world wide, equivalen t to 9.6 % of all deaths Two-thirds of these deaths occurred in people living in developing countries and 40% of the subjects were aged less than 70 years. Addi tionally, cerebrovascular disease is the leading cause of disability in adults a nd each year millions of stroke survivors has to adapt to a life with restrictio ns in activities of daily living as a consequence of cerebrovascular disease. Ma ny surviving stroke patients will often depend on other people’s continuous suppor t to survive. II. OBJECTIVES GENERAL OBJECTIVES

1. To be able to discuss the effect, signs and symptoms of the disease, Cerebrovascular Disease. 2. How to diagnose, prevent and the treatment should the nurse give for the patient full recovery. SPECIFIC OBJECTIVES 1. To be able to discuss patients background ( lifestyle, history of the past illness, family health history) to show how may this effect on the occurren ce of this disease. 2. To be able to discuss the anatomy and the physiology of t he heart, for you to be able to understand where the infection takes place. 3. To be able to discuss the pathophysiology of cardiovascular diseases and also to know and understand the etiology of the disease. 4. To be able to di scuss the patient activities of daily living. To know if there’s a factor that tri ggers the disease 5. To be able to discuss, nursing care plan for our patient. 6 . To be able to discuss, the medication / drugs that the patient taken and the d iagnostic test that being perform for the patient. 7. Lastly, to be able to disc uss our discharge plan for fully recovery of our patient. III. PATIENT’S PROFILE IV. PHYSICAL ASSESSMENT GENERAL SURVEY Mr. X was lying semi-fowler’s on bed, consc ious, coherent, afebrile with monitoring devices. A. VITAL SIGNS Date Shift T Te mp BP RR PR Intak Outpu

ime 07/18/0 9 7am1pm 36.8 210/1 00 58 20 e t B. HEAD Pink papillary conjunctiva, no nuchal rigidity and no carotid bruit. C. NEUROLOGIC STATUS -Oriented to time, person and place. CRANIAL NERVES ASSESSMENT CN CN CN CN CN CN CN CN I- can smell II- (2-3) ERTL III, IV, VI- EDM, intact V(+) corneal reflex VII- no facial asymmetry IX- (+) gag reflex XI- can shrug sh oulder XII- tongue at midline D. PULMONARY SYSTEM -Respiratory rate was 58 cpm -SCE, no vesicular breath sound s. -AP, Apical beat at the 6th ICS anterior axillary line normal sounds. E. GAST ROINTESTINAL SYSTEM Flabby, NaBS, no abdominal bruit, (-) edema,(-) cyanosis. F. MUSCULOSKELETAL SYSTEM The patient manifested good posture and moved voluntaril y; he had symmetrical musculature on both sides of the body. Weakness was noted. G. GENITO- URINARY SYSTEM Patient voided 60 – 350 cc per shift as weighed and yel low in color.

V. LABORATORY AND DIAGNOSTIC EXAMINATION Laboratory Findings Laboratory Exam Jul y 15, 2009 1. GRAM STAIN Specimen: Sputum Gram ( - ) cocci singly: • Gram ( + ) co cci Short chain: • Gram ( + ) cocci in large chain: • Pus cells: • Epithelial cells: 2 . URINALYSIS Macroscopic • Color: • Transparency: Microscopic • RBC: • Pus cells: • Bacter ia: • Epithelial cells: • Mucus threads: • Amonphous unates: 3. HbAlC: 4. Glucose: 5. LIPID PROFILE • Cholesterol: • Triglycerides: • HDL cholesterol: • LDL cholesterol: • Na: • K: • Ca: • Cl: • SGPT: • Result Normal Range Few Few Few 2-4/010 +1 Light yellow SL. Turbid 4-6/HPF 0-2/HPF Few Few 6. HEMATOLOGY • PT: • Control: Few Few

• INR: 7. CHEMICAL ANALYSIS • S.G: • pH: • nitri: • protein: • glucose: • ketone: • urobili : • bilirubin: • blood: • leukocyte: 12.2% 7.36mmol/L 7.2– 6.2 4.22 – 6.11 5.10mmol/L 0.70 1.24 3.54 137 4.3 1.36 98 41U/L Male: up to 40U/L Female: up to 31U/L 15.31 12 – 15sec 14.1 1.35 1.010 6.5 (-) (-)

(-) (-) (-) (-) +1 (-) July 16, 2009 5:30 am 1. Capillary Blood Glucose: 2. Head CT scan: 142 -shows a low attenuation focus on the left occipital lobe Consistent with a recent infarction -ventricles are not dilated -midline structure are in place -m ild cortical atrophy is demonstrated -rest of the findings are unbreakable. 80 – 120mg/dl July 17, 2009 • • • Na: K: Ca: 137 4.3 138-146 3.6-5.0

• Cl: 1.33 100 1.15-1.29 96-110 VI. ANATOMY AND PHYSIOLOGY The Brain Three cavities, called the primary brain ve sicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rho mbencephalon). • • The telencephalon generates the cerebrum (which contains the cerebral cortex, wh ite matter, and basal ganglia). The diencephalon generates the thalamus, hypotha lamus, and pineal gland. • • • The mesencephalon generates the midbrain portion of the brain stem. The metencep halon generates the pons portion of the brain stem and the cerebellum. The myele ncephalon generates the medulla oblongata portion of the brain stem

Figure The four divisions of the adult 1 brain. • The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, th e cerebrum, appears as folded ridges and grooves, called convolutions. The follo wing terms are used to describe the convolutions:

• • • A gyrus (plural, gyri) is an elevated ridge among the convolutions. A sulcus (pl ural, sulci) is a shallow groove among the convolutions. A fissure is a deep gro ove among the convolutions. The deeper fissures divide the cerebrum into five lobes (most named after border ing skull bones)—the frontal lobe, the parietal love, the temporal lobe, the occip ital lobe, and the insula. All but the insula are visible from the outside surfa ce of the brain. A cross section of the cerebrum shows three distinct layers of nervous tissue: • The cerebral cortex is a thin outer layer of gray matter. Such a ctivities as speech, evaluation of stimuli, conscious thinking, and control of s keletal muscles occur here. These activities are grouped into motor areas, senso ry areas, and association areas. • The cerebral white matter underlies the cerebral cortex. It contains mostly myel inated axons that connect cerebral hemispheres (association fibers), connect gyr i within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of associat ion fibers that forms a nerve tract that connects the two cerebral hemispheres. • Basal ganglia (basal nuclei) are several pockets of gray matter located deep ins ide the cerebral white matter. The major regions in the basal ganglia—the caudate nuclei, the putamen, and the globus pallidus—are involved in relaying and modifyin g nerve impulses passing from the cerebral cortex to the spinal cord. Arm swingi ng while walking, for example, is controlled here.

The diencephalon connects the cerebrum to the brain stem. It consists of the fol lowing major regions: • The thalamus is a relay station for sensory nerve impulses traveling from the sp inal cord to the cerebrum. Some nerve impulses are sorted and grouped here befor e being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also. • The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles). • The hypothalamus regulates numerous important body activities. It controls the a utonomic nervous system and regulates emotion, behavior, hunger, thirst, body te mperature, and the biological clock. It also produces two hormones (ADH and oxyt ocin) and various releasing hormones that control hormone production in the ante rior pituitary gland. The following structures are either included or associated with the hypothalamus . • • • The mammillary bodies relay sensations of smell. The infundibulum connects the p ituitary gland to the hypothalamus. The optic chiasma passes between the hypotha lamus and the pituitary gland. Here, portions of the optic nerve from each eye c ross over to the cerebral hemisphere on the opposite side of the brain. • The midbrain is the uppermost part of the brain stem. The pons is the bulging re gion in the middle of the brain stem. •

• The medulla oblongata (medulla) is the lower portion of the brain stem that merg es with the spinal cord at the foramen magnum. • The reticular formation consists of small clusters of gray matter interspersed w ithin the white matter of the brain stem and certain regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one compon ent of the reticular formation, is responsible for maintaining wakefulness and a lertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regu lating visceral motor muscles. The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the surface of the cereb ellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by compari ng actual skeletal movements to the movement that was intended. The brain stem c onnects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of gr ay matter. The brain stem consists of the following four regions, all of which p rovide connections between various parts of the brain and between the brain and the spinal cord Figure Prominent structures of the brain 2 stem. • The midbrain is the uppermost part of the brain stem. The pons is the bulging re gion in the middle of the brain stem. • • The medulla oblongata (medulla) is the lower portion of the brain stem that merg es with the spinal cord at the foramen magnum.

• The reticular formation consists of small clusters of gray matter interspersed w ithin the white matter of the brain stem and certain regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one compon ent of the reticular formation, is responsible for maintaining wakefulness and a lertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regu lating visceral motor muscles. The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the surface of the cereb ellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by compari ng actual skeletal movements to the movement that was intended. The limbic syste m is a network of neurons that extends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to behaviors, experiences, and mem ories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparte d to events and experiences. The limbic system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and e ncircles the inside border of the cerebrum. The following components are include d: • The hippocampus (located in the cerebral hemisphere) The denate gyrus (locate d in cerebral hemisphere) The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate nucleus of the basal ganglia) • • • • The mammillary bodies (in the hypothalamus) The anterior thalamic nuclei (in the thalamus) The fornix (a bundle of fiber tracts that links components of the lim bic system) •

VII. PATHOPHYSIOLOGY

Cerebrovascular disease or brain attack happened due to modifiable factors posse ssed by the patient such as smoking, ingesting fatty foods, and hypertension tha t leads to vasospasm and an embolus that dislodged from an area of origin to the brain that results to increase oxygen demand and decrease oxygen supply in the blood. Because of inadequate blood perfusion it leads to brain cells injury and death, at this point neurons are no longer able to maintain aerobic respiration that caused to produce neurological dysfunction. VIII. COURSE ON THE WARD Date/Shift Approach/Intervention 07/14/09 - Admitted a 66 y/o male with the chief complaint of body weakness and vomiting and fetched in a stretcher - routine care done 3.11

- S/C ERMEOD Dr. Anluete, and MROD Dr. Solero, MIOD with made and carried out hooked to O2 inhalation with 2-3 LPM via nasal cannula - hooked to cardiac monit or BP 260/100 mmHg HR 60 bpm 3:00pm - venicolysis started hooked IVF of PNSSL x KVO - Lab: CBG: 156mg/dl; CBC: TF; Serum electrolytes: TF; CT Scan: (plain head) done: TF - Meds: nicardipine drip(D5W 90cc+ 1 amp nicardipine) @ 5ugtts ↑ 10 ugtt s @ 3:10 pm; zantac 1 amp given @ 3:20 pm - FC inserted connected to urobag - ma nnitol 75mg x 1st dose - UO drained- 1000cc - fixed and brought to room of choic e - endorsed 5:00pm accompanied - received patient on bed awake via stretcher ER MEOD, transferred to bed safely - on NPO except meds with ongoing IVF of PNSSL @ 750 cc level regulated @ 10gtts/minand SD nicardipine10mg + 90ml of D5W reg. @ 10gtts/min infusing well and hooked to infusion pump @ 5:20pm 5:30pm - hooked to cardiac monitor and pulse oximetry - with NGT connected to bedside bottle - wit h the ff. labs: cranial CT scan-TF and CBG @5:30pm - urinalysis-TF as endorsed BUN, Creatinine, HDL, HBA1C, FBS, TL, TC, LDL, HDL, PROTiME

6;00pm carried S/E by Dr. Somson-Crux with orders made and Out - nexicum 40mg tab OD - refer to Dr. Soccom Rosales for Co. Mgt. Dr. Solero info rmed - for sputum AFB 3x; GS/CS with SB initial V/S BP:180/90mmHg @ ER; T:36.4 C, HR:68, RR:28, - with the ff. meds mannitol 75cc x 3doses started Nexicum 40mg OD; olmesartan 3 0mg tab OD; liticolin TID given 9:00pm - on CBR without BPR - seen and examined by Dr. Martinez with orders meds and carried out - clopidogel 5 tabs stat then O D given - for 2Decho with Doppler- to request AAC 10:25pm - shift citicoline dro ps to IV as ordered by Dr. Solero - adequate UO - V/S q hour, medicine clerk inf ormed - no complaints - needs attended - endorsed 11-7 - flaccid patient on bed - with IVF of PNSSL @ 650 level q 6hr - with nicardipin e hold

- on NPO except meds - assess; BP 170/100 without BPR - on CTscan-TF - urinalysis, um GS/CS - CBG monitoring q 12 - for FBS, d - due meds given - above IVF hooked and attended - endorsed

- O2 @ 2LPM via nasal cannula - on CBR creatinine - for sputum AFB - for sput hemoglobin,A1C - V/S taken and recorde consumed @ same rate - (-) BM - needs

07/15/09 7.3 received patient ongoing PNSS with same regulation and rate; afebri le - with O2 @ 2LPM connected to nasal cannula - with NGT intact - with CBG moni toring q 12 - for sputum AFB - for 2Decho with Doppler - BP: 130/90 mmHg - endor sed

Addendum - start feeding AP order - for SGOT - (-)gag reflex 3-11 PNSSL diet received patient on bed with ongoing IVF of with NGT to start of 1600 kcal in fe edings, DM - with O2 inhalation @ 2LPM via nasal cannula - with FC to urobag - with CBG mon itoring - for 2Decho with Doppler - sputum GS/CS-TF - still for sputum AFB 4:30p m carried out S/E by Dr. Martinez, orders were made and - start dilantin suspension, to load 12ml x 6doses q 4 then 4ml q 6 - for repeat scan (plain) on Thursday to reg. AAC 5:00pm 7:30pm Simon - dilantin 100mg IV gi ven slow push - s. electrolytes and SGPT result in referred to Dr. - due meds gi ven - refer prn - no BM, afebrile - endorsed 11.7 - received patient on bed - with ongoing IVF PNSS @ level of 100cc regulated @ 2 1gtts/min

- on1600kcal feedings DM diet - sputum GS/CS-TF - CBG monitoring q 12 - for sput um AFB - for repeat plain CTscan 1;15am - above IVF consumed and hooked same IVF and rate - V/s taken and recorded - due meds given - I&O monitored and recorded - no BM, afebrile - refer prn - needs attended - endorsed 07/16/09 7-3 - received patient lying on bed - with ongoing IVF PNSS with same r eg. and rate - afebrile, BP: 100/70mmHg - with NGT intact - with O2 @ 2LPM via n asal cannula - for sputum AFB x 5 days - for 2Decho - needs attended - endorsed 3.11 - received patient awake on bed

- with ongoing IVF PNSS reg. @ same rate - with FC connected to urobag - with OF 1600kcal; 6 feedings - for 2Decho - for sputum GS/CS - on CBR without SBR - rep eat CTscan plain-TF - due meds given 8;00pm - (+) restlessness- MROD endorsed to give Diphenhydramine 1 amp- given as ordered 9;30pm to - Dr, Martinez made roun ds with new order made Carried out - if no restless until tomorrow may TROC, if (+) restless @ 11pm, to give rizomil 2mg tab sat - dilantin 125mg/5ml was ↓ freq. @ q 8- carried out - V/S monitored and recorded - I&O monitored and recorded - n eeds attended - endorsed 07/17/09 7.3 - received on bed with ongoing PNSS IVF @ 250cc level With same reg . - afebrile, BP: 130/70mmHg - repeat CTscan (plain) 10:35am - due meds given

- possible TPOC - BP: 140/80mmHg - endorsed 3-11 - with NGT, OF 1600kcal feedings - for sputum GS/CS - for CTscan-TF - V/S taken and recorded 07:00pm - (+) restlessness; refer to Dr. Solero - diazepam 5mg given - for CBG and Creat inine - seen from time to time - I&O monitored and recorded - V/S taken and reco rded - refer prn - endorsed 11.7 - received patient lying on bed, asleep - with IVF PNSS @ 900cc - with cardiac m onitoring q 12 - with NGT, OF 1600kcal and 6 feedings - with 02 @ 2LPM via nasal cannula - on CBR without BPR - T:36.5C, HR:53bpm, RR:20cpm BP:130/70mmHg - with FC connected to urobag - still for sputum AFB - for 2Decho - repeat CTscan plai n-TF - due meds given

- morning care done - (-)BM, afbrile - needs attended - endorsed 07/18/09 7.3 received patient on bed - with IVF PNSS @ 520cc level with same reg. - afebrile, BP: 130/80mmHg - with patent NGT - with FC connect to urobag - 2Decho - sputum GS/CS - due meds given -endorsed IX. NURSING CARE PLAN XI. DISCHARGE PLANNING

M- Instructed immediate relatives to facilitate the patient to continue taking the drugs given to her on the right time and with the right dose to facil itate continuity of care. E- Encouraged brisk walking y heavy loads raged patient immediaterelatives to facilitate regular exercise such as but not making herself too much tired. -Encouraged her not to carr and do not force herself too much in doing household chores. Encou to limit number of hours in playing domino.

T- encouragedpatient to have enough rest and comply to the physicians when ever health problems occur H-Encouraged and explained to her the benefits and advantages of proper hygiene to promote wellness. O- instructed patient to come back for follow up check up on the date ordered. D- advised patient to eat nutritional foods like fruits and vegetables. Eat a well balanced diet. Instructed patient to limit eating foods high in fats and wi th cholesterols. And also avoid salty foods. S- Encouraged pt to continue her habits in going to church every day and always seek God helps when ever problems occur. XII. DEVELOPMENTAL TASK

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