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The world as a whole has been facing different constant changes not only in the environment but also in people s lives. As changes occur, the more people become in need to adopt with these changes, thus, and we expose ourselves to illness that could even lead to unwanted events in our lives. Our nursing case presentation is about Cerebrovascular Accident discussing Ischemic stroke. The content includes the patient s general data and physical assessment, anatomy, physiology and pathophysiology, review of related literature, laboratory and pharmacology. The highlight if the presentation deals with the nursing care presentation with the nursing care plan of our patient revolving on his priority nursing problems, goals of care, appropriate nursing intervention and its feedback evaluation. Our group is composed of 11 Nursing students. We have chosen this case as a help for studies to eliminating and prevent through health education the enlarging occurrence of Cerebrovascular diseases like this. We greatly acknowledge the cooperation extended by the patient. We also appreciate the effort of Our Lady of Fatima University Medical Center staff and the guidance provided to us by our Clinical Instructor, Mrs. Anna Liza Morales, and most importantly, we thank our God Almighty for all the graces he bestowed on us.
Name: Age: Civil Status: Date of Birth: Place of Birth: Nationality: Religion: Address: Date of Admission: Date of Discharge: Admitting Diagnosis: Physician-in-charge: Estrellia, Remedios Salazar 54 F October 25 1956 Valenzuela City Filipino Roman Catholic 618 Caloong I, Valenzuela City December 6 2010 December 10 2010 Cerebrovascular Accident Dra. Rebecca W. Deguyo, MD
History of Present Illness: One day prior to admission, patient complained of headache, associated with nape pain and dizziness. There was also a noted limitation of motion of the neck area. There was no associated vomiting, blurring of vision and loss of consciousness. No medications taken and no consult were done. Few hours prior to admission, above symptoms have persisted which prompted patient to seek consult of his physician s clinic. Patient was advised to
be admitted for further evaluation and management, hence the subsequent admission.
Past Medical History: (+) HPN- DX 2002 -on maintenance medication (-) DM (-) Asthma (+) Previous hospitalization 2007 FUMC (+) CVO Bleed CVD bleed vs. infarct
Personal/ Social History: (-) Smoker (-) Alcoholic drinker
Family History: (+) HPN on both sides (+) DM on mother side (+) CA both sides -Cervical CA, Breast CA
with good skin turgor and skin texture. moist HEENT: 100/90 81 18 36.III. Vital Signs: BP: PR: RR: Temp: Skin: Warm. coherent.8 December 6 2010 7 . NICRD. General Survey: Musculoskeletal disorder R/to CVD re-intant S/p CVD infarct Left with sensory deficit Right extremely. PHYSICAL ASSESSMENT Done on Admission: General Assessment: Conscious. ambulatory.
(-) Retractor CBS Heart AP. (-) murmurs Abdomen: Flabby. NARR. (-) CLAD (-) TPC Neck: (+) Limitation of the RAM of neck Chest: SCE. soft (-) tenderness Extremities: GME (-) edema (-) cyanosis PEP 8 .PPC. AS. nabs.
infarct. VI V VII VIII IX. Cranial Nerves: I II III.Neurological Examinations: Cerebrum: Convulsion. coherent for 3 spheres Cerebellum: Can perform RAM No nystagmus Impression t/c CVD bleed vs. X XI XII N/A PERTL 2-3 mm Intact EDMs Intact bicorneal reflexes No facial symmetry Can hear Can swallow Can shrug shoulders Tongue at the midline 9 . IV.
Motor R 5/5 5/5 Sensory R 75 % L 100 % L 5/5 5/5 75 % 100 % 10 .
IV. The Anatomy of the Brain 11 .1. Anatomy of the Brain Figure 4. ANATOMY AND PHYSIOLOGY A.
language and speech functions Parietal lobes are involved with sensation Occipital lobes are the primary vision centers The surface of the cerebrum appears wrinkled and is made up of deep grooves (called sulci) and bumps or folds (called gyri). The cerebrum is responsible for: y y y y y y y y y y Movement Body temperature Touch Vision Hearing Judgment Reasoning Problem solving Emotions Learning The cerebrum has 2 parts: the right cerebral hemisphere and the left cerebral hemisphere. makes up the skull). The inner part is called white matter and contains connections of nerves. and the left cerebral hemisphere controls the right. Each lobe is responsible for a variety of bodily functions: y y y y Frontal lobes are involved with personality. 12 . The hemispheres of the cerebrum are divided into lobes. speech. along with the bones of the face. or broad regions of the brain. Inside the cranium. The meninges are made up of 3 layers of tissue: y y y Pia mater the layer closest to the surface of the brain Arachnoid membrane the middle layer of tissue Dura mater the outer-most layer The cerebrum the front of the brain The largest part of the brain located in the front is called the cerebrum. the right cerebral hemisphere controls the left side of the body. the brain is surrounded by the meninges. They are connected at the bottom and have a deep groove running between them. The right side is involved with creativity and artistic abilities. and motor development Temporal lobes are responsible for memory.The cranium The brain is protected by a bony covering called the cranium (which. The left side is important for logic and rational thinking. In general. The outer part of the cerebrum is called gray matter and contains nerve cells.
The brainstem the middle of the brain The brainstem is located in front of the cerebellum. etc. The brainstem controls vital functions of the body. the cerebellum. and the right cerebellum controls the right side of the body. and equilibrium Unlike the cerebrum. and the medulla oblongata. including: y y y y y y y y Breathing Consciousness Cardiac function Involuntary muscle movements Swallowing Movement of the eyes and mouth Relaying sensory messages (pain.) Hunger The cerebellum the back of the brain Behind the cerebrum at the back of the head is the cerebellum. heat. the left cerebellum controls the left side of the body. noise. The cerebellum is primarily a movement control center. and the spinal cord are all connected to the brainstem. the left cerebellum controls the left side of the body. the pons. responsible for: y y y y Voluntary muscle movements Fine motor skills Maintaining balance. 13 . The brainstem is like the hard-drive of a computer. The cerebrum. However. the cerebellum contains more nerve cells than both hemispheres combined. The brainstem has three main parts. Unlike the cerebrum. posture. cerebellum means little brain. It is the main control panel for the body that passes messages back and forth between the brain and other parts of the body. the midbrain. and the right cerebellum controls the right side of the body. In Latin.
2. Sensory and Association Areas of the Cerebral Cortex. The Motor.Figure 4. 14 .
The pituitary gland. its arteries fill from below and the veins drain from above. B. or 750 ml per minute. The brain also contains 12 pairs of cranial nerves each responsible for specific functions in the body: y y y y y y y y y y y y Olfactory nerve smell Optic nerve vision Oculomotor eye movements. There are fluid-filled cavities within the brain called ventricles. as well as the hormones responsible for normal growth and sexual maturation. is responsible for a number of functions including producing hormones for the thyroid and adrenal glands. swallowing Vagus swallowing. The ventricular system produces and processes cerebrospinal fluid a clear. The internal carotids 15 . watery substance that flows around the brain and helps cushion and protect it. In contrast to other organs that may tolerate decrease in blood flow because of their adequate collateral circulation. The ventricles are important in providing nourishment to the brain. which may result in irreversible tissue damage when blood flow is occluded for even short periods of time. The brain is not a solid organ. The pituitary gland is located in the center of the brain and is about the size of a dime. Cranial nerves. facial expressions Vestibulocochlear hearing. balance Glossopharyngeal taste. taste Accessory neck and shoulder muscles Hypoglossal tongue movement Pituitary gland. Arteries. eyelid opening Trochlear eye movements Trigeminal facial sensations.Other important parts of the brain Ventricular system. The brain does not store nutrients and has a high metabolic demand that requires the high blood flow. often referred to as the master gland. Two internal carotid arteries and vertebral arteries and their extensive system of branches provide the blood supply to the brain. The brain s blood pathway is unique because it flows against gravity. chewing Abducens eye movements Facial taste. Cerebral Circulation The cerebral circulation receives approximately 15% of the cardiac output. the brain lacks additional collateral blood flow.
Cerebral veins and sinuses are unique because. join larger veins. they do not have valves to prevent blood from flowing backward and depend on both gravity and blood pressure. At the base of the brain surrounding the pituitary gland. enters the cranium through the foramen magnum. the neurons distal to the occlusion are deprived f their blood supply and the cells die quickly. Functionally. The vertebrobasilar arteries supply most of the posterior circulation of the brain. The effects of the occlusion depend on which vessels are involved and which areas of the brain these vessels supply. This ring is called the circle of Willis and is formed from the branches of the internal carotid artery.arise from the bifurcation of the common carotid and supply much of the anterior circulation of the brain. Veins. The result is hemorrhagic stroke (cerebrovascular accident or infarction). The network of sinuses carries venous outflow from the brain and empties into the internal jugular vein. If an artery with an aneurysm bursts or becomes occluded by vasospasm. The arterial anastomoses along the circle of Willis are frequent sites of aneurysms. The veins reach the brain s surface. a ring of arteries is formed between the vertebral and internal carotid artery chains. The arteries of the circle of Willis can provide collateral circulation if one or more of the four vessels supplying to become occluded or are ligated. then cross the subarachnoid space and empty into the dural sinuses. Venous drainage for the brain does not follow the arterial circulation as in other body structures. an embolus. 16 . or a thrombus. The vertebral arteries branch from the subclavian arteries. which are vascular channels lying within the tough Dura mater. unlike other veins in the body. The vertebral arteries join to become the basilar artery at the level of the brain stem. the posterior portion of the circulation and the anterior or carotid circulation usually remain separate. and anterior and anterior and posterior communicating arteries. returning the blood to the heart. the basilar artery divides to form the two branches of the posterior cerebral arteries. Aneurysms may be congenital or the result of degenerative changes in the vessel wall associated with atherosclerotic vascular disease. Theses can be formed when the pressure at a weakened arterial wall causes the artery to balloon out. and anterior and middle cerebral arteries. flow back to and upward on either side of the cervical vertebrae.
Figure 4. including the Circle of Willis. 17 . as viewed from ventral surface. The Arterial Blood Supply of the Brain.3.
B. Higher levels of Von Willebrand factor are more common amongst people who have had ischemic stroke for the first time. However. The results of this study found that the only significant genetic factor was the person's blood type. REVIEW OF RELATED LITERATURE A. but causes of these disparities have not been explained. including the existence of a "stroke belt" in the southeastern United States. or leg. Having had a stroke in the past greatly increases one's risk of future strokes. 18 . and etiology varies by age. they are older on average when they have their strokes and thus more often killed (NIMH 2002). arm. Advanced age is one of the most significant stroke risk factors. Men are 25% more likely to suffer strokes than women. ranking after heart disease and before cancer. the size of the area of inadequate perfusion. The patient may present with any of the following signs and symptoms: -Numbness or weakness of the face. -Confusion or change in mental status. and the amount of collateral (secondary or accessory) blood flow. 95% of strokes occur in people age 45 and older. stroke can occur at any age. and two-thirds of strokes occur in those over the age of 65. especially on ne side of the body. A person's risk of dying if he or she does have a stroke also increases with age. depending on the location of the lesion (which vessels are obstructed). Incidence Stroke could soon be the most common cause of death worldwide. Clinical Presentation and Medical Management An ischemic stroke can cause a wide variety of neurologic deficits. Since women live longer. Primary among these are pregnancy. Stroke is currently the second leading cause of death in the Western world. Geographic disparities in stroke incidence have been observed. and causes 10% of deaths worldwide. menopause and the treatment thereof (HRT).V. yet 60% of deaths from stroke occur in women. The incidence of stroke increases exponentially from 30 years of age. childbirth. Some risk factors for stroke apply only to women. including in childhood. Family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke.
or loss of balance or coordination. cranial nerve. -Avoid night driving or other risky activities in the darkness -Place objects in center of patient s intact visual field. -Sudden severe headache Motor sensory. Neurologic Deficits of Stroke: Manifestations and Nursing Implications Neurologic Deficit Manifestation Nursing Implication/ Patient Teaching Application -Place objects within intact field of vision. cognitive and other functions may be disrupted. Table 5-1. Loss o peripheral vision y y Difficulty seeing at night Unaware of objects or the borders of objects Diplopia y Double of vision 19 . -Approach the patient from side of the intact field of vision -Instruct/remind the patient to turn the head in the direction of visual loss to compensate for loss of visual field -Encourage the use of eye glasses if available -when teaching the patient.-Trouble speaking or understand speech. -Encourage the use of a cane or other object to identify objects in the periphery of visual field. -Visual disturbances. Difficulty judging distances. do so within the patient s intact visual field. -Explain to the patient the location of an object when Visual field deficits Homonymous hemianopsia (loss of half of the visual field) y y y Unaware of the persons or objects on side of the visual loss. -Difficulty walking. Neglect of one side of the body. dizziness.
-Provide immobilization as needed on the affected site. strength and use. arm. -Provide the patient with alternative methods of communicating. and leg on the same side (due to a lesion in the opposite hemisphere) -Place objects within the patient s reach on the non affected site. Instruct the patient not to walk without assistance or supporting device. -Allow the patient sufficient time to respond to verbal communication. needs a broad base to stand Dysarthria y Difficulty in forming words Dysphagia y Difficulty swallowing -Encourage the patient to provide range-of-motion exercises to the affected site. cane). -Test the patient s pharyngeal reflexes before offering food or fluids. -Support patient during the initial ambulation phase -Provide supportive device for ambulation (walker.placing it near the patient. Ataxia y y Staggering. -exercise unaffected limb to increase mobility. -Consistently place patient care items in the same location. 20 . arm. Motor Deficits Hemiparesis y Hemiplegia y Weakness of the face. -Support patient and family to alleviate frustration relate to difficulty communicating. _-Maintain body alignment in functional position. and leg on the same side (due to a lesion in the opposite hemisphere) Paralysis of the face. unsteady gait Unable to keep feet together.
Sensory deficit Paresthesia (occurs on the site opposite to the lesion) y y Numbness and tingling of extremity Difficulty with proprioception -Instruct the patient to avoid using this extremity as the dominant limb due to altered sensation. can speak but may not make sense. Provide familiar objects ( family photographs.-Assist the patient with meals. Verbal deficits Expressive aphasia y Unable to form words that are understandable. -Reorient patient to time. -Match visual tasks with a Global (mixed) aphasia y Cognitive Deficits y y y y y Short and long term memory loss Decreased attention span Impaired ability to concentrate Poor abstract reasoning Altered judgment 21 . -Speak clearly and in simple sentences. -Place food on the affected site of the mouth. favorite objects) -Use no complicated language. -Establish alternative means of communication. may be able to speak in single word responses Unable to comprehend the spoken word. -Encourage patient to repeat sounds of the alphabet. place and situation frequently. -Allow ample time to eat. use gestures or pictures when able. -Use verbal and auditory cues to orient patient. Combination of both receptive and expressive aphasia Receptive aphasia y -Speak slowly and clearly to assist the patient in forming sounds. -Provide range of motion to affected areas and apply corrective devices as needed.
Emotional Deficits y y y y y y y Loss of self control Emotional lability Decreased tolerance to stressful situations Depression Withdrawal Fear.) -Minimize distracting noises and views when teaching the patient. cardiovascular status (including blood pressure. A system that uses the time course to classify patients along this continuum may be used to guide treatment. -Discuss with the patient and family that the outbursts are due to the disease process. carotid bruit). stimulate brushing of teeth while saying. Stroke patients may present to the acute care facility at any point along a continuum of neurologic involvement. Initial assessment will focus on airway patency. holding a toothbrush. I would like you to brush your teeth now. C. -Repeat and reinforce instructions frequently. -Encourage patient to express feelings and frustrations related to disease process. and gross neurologic losses. Strokes 22 . -Provide a safe environment. cardiac rhythm and rate. hostility. -Control stressful situations. if possible. Laboratory and Radiologic Examination Any patient with neurologic deficits needs a careful history and a complete physical and neurologic examination. -Provide stimulation for the patient.verbal cue. -Encourage the patient to participate in group activity. and anger Feelings of isolation -Support patient during uncontrollable outbursts. which may be compromised by loss of gag or cough reflexes and altered respiratory pattern.
(3) stroke in involution. transcranial flow studies. (Ischemic strokes are caused by a clot that blocks an artery. magnetic resonance imaging of the brain and/or neck. works and gets its blood supply. Hemorrhagic strokes result from a ruptured blood vessel in the brain causing bleeding into brain tissue. The initial diagnostic test for a stroke is a non contrast computed therapy (CT) scan performed emergently to determine of the event is ischemic or hemorrhagic (which determines treatment). (2) reversible ischemic neurologic disease. which ones to use. iv. The following tests are described in this section: i. and single photon emission CT.) CT scanning takes from 5 to 10 minutes to complete (mostly less than 5 minutes). and if so. transthoracic or transesophagel echocardiography. vii. This scanner has a magnetic field in which the head is subjected to bursts of energy of a known magnetic frequency. in many cases these tests are ordered when a patient is hospitalized with a stroke. Further diagnostic work up for ischemic stroke involves attempting to identify the source of thrombi or emboli. MRI can give very 23 . Doctors use CT to determine whether a stroke has occurred and. ii.use the time course is commonly classified in the following manner: (1) transient ischemic attack. These tests can outline the affected part of the brain and help define the problem created by stroke. However. Other studies may include Cerebral Angiography. The response of the brain cells to these bursts of energy is detected as signals that ultimately generate an image of the brain. Remarkable advances in technology now make it possible to examine how the brain looks. and (4) compensated stroke. Magnetic resonance imaging scanning (MRI) The stroke patient is placed into the MRI scanner. if so. viii. Carotid phonoangiography Computerized axial tomographic scan (CT or CAT scan) Digital subtraction angiography (DSA) Doppler ultrasound test Electroencephalogram (EEG) Evoked response test Magnetic resonance imaging scanning (MRI) Radionuclide angiography What imaging tests are done on the brain? y y Computerized axial tomographic scan (CT or CAT scan) Uses X-rays to generate an image of the brain. iii. A 12-lead electrocardiogram and a carotid ultrasound are standard tests. painless and can be done as an outpatient. xenon CT. vi. Most of these tests are safe. A doctor must decide on a case-by-case basis whether such tests will be useful. v. The test causes no discomfort. what kind.
By observing such impulse characteristics as intensity (the size of the impulse).y accurate images of the brain. a doctor produces a sound in one of the patient's ears. Evoked response test a diagnostic procedure that provides a measurement of the brain's ability to process and react to different sensory stimuli. Ordinarily. now returning to the probe at a different frequency. For auditory evoked responses. and causes no discomfort. very close to the carotid artery. in a 24 . This test is performed in 40 minutes to one hour. The electrodes can detect the electrical activity in the form of impulses that are then transcribed to paper. to record sounds. What tests show blood flow? y y Doppler ultrasound test Uses high-frequency sound waves to detect blockages in the carotid artery. and this test will help doctors determine if seizures are present and if treatment with medications is needed. A doctor evokes a visual response by flashing a light or checkerboard pattern in front of a patient. This test takes an hour or more. Radionuclide angiography Radioactive compounds are injected into a vein in the arm. The change in frequency of the sound waves relates to the speed of the blood cells and thus the blood flow. Carotid phonoangiography a sensitive microphone is placed on the neck. For bodily evoked responses. These are used to determine the presence. What tests show the brain's electrical activity? y y Electroencephalogram (EEG) Small metal disks (electrodes) are placed at strategic locations on a person's scalp. these bursts of radiation are detected and used to form an image of the brain. A Doppler probe or instrument capable of generating ultrasound waves is placed on the neck very near to the carotid artery. frequency (how often impulses occur during a given time) and location (what region of the brain produces these impulses). which are potential sources for hemorrhagic stroke. duration (the width of the impulse). Ultrasound waves from the probe travel through the neck and bounce off the moving blood cells. and causes no discomfort. one of the nerves in an arm or leg is electrically stimulated. location and size of aneurysms and arteriovenous malformations. Some people who have strokes are prone to seizures. is then detected by the same probe. it constantly emits bursts of radiation. an EEG can provide valuable information about underlying problems in the brain. the bloodstream then carries them toward the head. The reflected sound wave. The responses from these sensory stimuli can indicate abnormal areas of the brain. Once the radioactive compound reaches the brain. As the radioactive compound circulates in the bloodstream. This imaging procedure can show areas where the brain has been deprived of blood flow and is damaged.
The NIH stroke scale measures several aspects of brain function. the presence of blockages. causes the blood flow to become turbulent. Current guidelines as of 2008 allow strokes with scores greater than 4 points to be treated with tPA. but its main use in clinical medicine is during the assessment of whether or not the degree of disability caused by a given stroke merits treatment with tPA. This imaging technique lets the doctor identify and localize the source of a blocked blood vessel that caused the stroke. direct visualization. The presence of a bruit may indicate a blockage in the carotid artery and is cause for more tests. This turbulent blood flow can create a sound. A certain number of points are given for each impairment uncovered during a focused neurological examination. Oculoplethysmography measures the pulsation of blood flow through the ophthalmic artery. movement. The NIH stroke scale serves several purposes. such as those caused by atherosclerosis. an X-ray machine quickly takes a series of pictures of the head and neck. D.y normal artery. Digital subtraction angiography (DSA) gives an image of the brain's major blood vessels. Diagnostic tests for TIA may include carotid phonoangiography. 25 . Digital subtraction angiography is used to define carotid artery obstruction and provides information on patterns of cerebral blood flow. The images track the movement of the contrast dye as it moves through the brain's blood vessels. NIH Stroke Scale The National Institute of Health (NIH) stroke scale (NIHSS) is a standardized method used by physicians and other health care professionals to measure the level of impairment caused by a stroke. A thin plastic tube (a catheter) is inserted into a major artery of the leg and advanced through the body's major vessels until it reaches the brain's blood vessels. where it allows for the objective comparison of efficacy across different stroke treatments and rehabilitation interventions. At that point. speech. including consciousness. Some people may feel a warm sensation as the contrast medium is injected into the blood vessels. In patient with TIA. and photographic recording of carotid bruits. There are diminished or absent of carotid pulsationsin the neck. sensation. called a bruit (BROO'e). Carotid angiography allows visualization of intracranial and cervical vessels. this involves auscultation. a bruit (abnormal sound heard on auscultation resulting from interference with normal blood flow) may be heard over the carotid artery. and language. A maximal score of 42 represents the most severe and devastating stroke. vision. blood flows in a smooth and controlled manner. Another important use of the NIHSS is in research. which can be detected and registered by the microphone. A contrast dye is injected through the catheter and allowed to circulate in the bloodstream. However.
Normal Partial Gaze Plasy Forced Deviation 3. visual (introduce No visual loss visual stimulus/ Partial Hemianopia threat to patient s visual field Complete Hemianopia quadrants) Bilateral Hemianopia 4. close eyes.Table 5-2. let go) Obeys both correctly Obeys one correctly Incorrect 2. Summary of NIH Stroke Scale Category Description Score 0 1 2 3 0 1 2 0 1 2 0 1 2 0 1 2 3 0 1 Baseline date/time Date/time 1a. Facial Palsy Normal Minor 26 . Level of Alert Consciousness (alert. etc.patient follows examiners fingers or face. Best Gaze (eyes open. drowsy. age) Answers both correctly Answers one correctly incorrect 1c. LOC questions (month. make fist.) Drowsy Stupotous Coma 1b. LOC commands (open.
Motor armRight (elevate extremity to 90 and score drift movement) No drift Drift Can t resist gravity No effort Against Gravity No movement Amputation joint fusion (explain) 6a.Left No drift (elevate extremity to 90 and score Drift drift movement) Can t resist gravity No effort Against Gravity No movement Amputation joint fusion (explain) 5b. Motor leg-Left (elevate extremity to 30 and score drift movement) No drift Drift Can t resist gravity No effort Against Gravity No movement Amputation joint fusion (explain) 2 3 0 1 2 3 4 9 0 1 2 3 4 9 0 1 2 3 4 9 27 . Motor arm.Partial Complete 5a.
describe a picture and read sentences) No Aphasia Mild to Moderate Aphasia Severe Aphasia Mute 0 1 2 3 0 1 2 10.) Normal Articulation Mild to Moderate Dysarthria Near to Unintelligible or Worse 9 28 . Sensory (pin prick to face. arm. Best Language (name items.6b. trunk and legcompare side to side) Normal Partial Loss Severe Loss 9. Dysarthria (evaluate speech clarity by patient repeating words. Limb ataxia Absent (finger-to-nose and Present in One Limb heel-to-shin testing) Present in Two Limbs 8. Motor leg-Right (elevate extremity to 30 and score drift movement) No drift Drift Can t resist gravity No effort Against Gravity No movement Amputation joint fusion (explain) 0 1 2 3 4 9 0 1 2 0 1 2 7.
Extinction and No Neglect 0 Inattention (use information from Partial Neglect 1 LOC and motor testing to identify Complete Neglect 2 neglect ________________________________________________________________________ Individual Administering Scale: The level of stroke severity as measured by the NIH stroke scale scoring system: 0 1-4 5-15 15-20 21-42 = no stroke = minor stroke = moderate stroke = moderate/severe stroke = severe stroke 29 .Intubated or Other Physical Barrier 11.
extending the stroke. the release of more calcium and glutamate. at this point. if continued. Early in the cascade. The ischemic cascade threatens cells in the penumbra because membrane depolarization of the cell walls leads to an increase in intracellar calcium and the release of glutamate. vasoconstriction. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. and the generation of free radicals. activate a number of damaging pathways that result in the destruction of the cell membrane. These processes enlarge the area of infarction into the penumbra. The ischemic cascade begins when cerebral blood flow falls less than 25 ml/100 g/min. The penumbra region is ischemic brain tissue that can be salvaged with timely intervention. Thus membrane pumps that maintain electrolyte balances begin to fail and the cells cease to function. 30 . and the influx of calcium can be limited with the use of cacium channel blocker. neurons can no longer maintain anaerobic respiration. The penumbra area can be revitalized with the administration of tissue plaminogen activator (t-PA). causing a change in pH level. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization process. exists around the area of infarction.VI. The mitochondria must then switch to anaerobic respiration. The influx of calcium and release of glutamate. PATHOPHYSIOLOGY In an ischemic brain attack. referred to as penumbra region. which generates large amounts of lactic acid. there is disruption of the cerebral blood flow due to obstruction of blood vessel. an area of low cerebral blood flow.
Ischemia Energy failure Acidosis Ion imbalance Increase Glutamate Depolarization Intracellular calcium increased Cell membranes and proteins break down Formation of free radicals Protein production decreased Cell injury and death Figure 6-1. Englewood. Process contributing to ischemic brain iinjury. Pathophysiology of the Cerebrovacular Accident. Colorado 31 . Courtesy of National Stroke Association.
5x10/2 L 88-96 27-33 pg 330-360 g/L 12.42 % 5.36 11.01 0.69 4.9 Normal values 123-152 g/ L 0.02 0.7 % 150-450x 10 g/L 4.VII.17-39.98 73 23.37-0.01 0. LABORATORY RESULTS A.20-0.47 Normal Normal Normal Normal Higher Normal Lower Lower Lower Normal Normal Higher B.01-0. 1-3 mins.08 0.2mmol/L 135 mmol/L 4.40-0.9 mmol/L 32 .5 3.5% 0-20 mm/hr Interpretation Lower Slightly lower Higher 0.40 0.12 mmol/L 92 mmol/L C.1 2-4 mins. Clinical Chemistry Cholesterol Triglycerides Didevet HDL Cholesterol 5.3 mmol/L 1.3 210 9. 05-1.5-5.0-10.5-7.02-0. Complete Blood Count Dec 06 2010 Hemoglobin Hematocrit WBC count Differential Count Lymphocytes Monocytes Eosinophils Basophils Neutrophils RBC MCV MCH MCHC RDW Platelet MPV PDW CT BT Reticular Count ESR 117 g/L 0.0 mmol/L 0.32 mmol/L 1.03 0-0.7-22.22 0.0 x 10 g/L 0.60 4.07 0. Electrolytes Creatinine Sodium Potassium Calcium Chloride 88.5 321 14.
LDL Cholesterol 3.66 mmol/L D. -Thecal sac is intact. -There is no evidence of canal stenosis -Osteophytic formation is ruled at C5 and C6 vertebral bodies. 33 . CT Scan December 7 2010: Impression: Cortical cerebral atrophy. E. -No other findings noted. -Visualized soft tissue planes within normal. December 7 2010 Findings: -Scannogram shows mild reversal of the cervical lordesis most likely due to muscular spasm. CT Scan: Cervical Spine with settings for the soft tissues and bone detail revealed.
5-2 g/kg as a 25% solution.VIII. If used preoperatively. thereby hindering the reabsorption of water and leading to a loss of water. Mannitol Brand name Patient s Dosage Classification Indication Osmitrol 75 mg prn Diagnostic agent. PHARMACOLOGY A. Adjust dosage to maintain urine flow of 30-50 ml/hr. Evidence of reduced pressure should be seen in 15 minutes. y Reduction of intracranial pressure and cerebral edema: 1. use 60-90 34 . may enter breast milk Excretion Urine Dosage and Administration Adults: IV infusion only. Or 15% solution over 30 minutes. 20% solution.5-2g/kg IV as a 15%-25% solution over 30-60 minutes. thereby reducing IOP. y Reduction of IOP: infuse 1. y Prevention of oliguria: 50-100 g IV as a 5% -25% solution y Treatment of oliguria: 50-100 g IV of a 15%-25% solution. urinary irrigant Prevention and treatment of oliguric phase of renal disease y Reduction of intracranial pressure and treatment of cerebral edema. Dosage is 50-200g/day. chloride (used for diagnosis of glumerular filtration rate). creates an osmotic effect. y Action Pharmacokinetics Route Onset Peak Duration IV 30-60 minutes 1 hour 6-8 hours Irrigant Rapid Rapid Short Metabolism T 1/2 : 15-100 minutes Distribution Crosses placenta. individualized concentration and rate of administration. of elevated IOP when the pressure cannot be lowered by other means y Promotion of the urinary excretion of toxic substances y Diagnostic use: measurement of GFR y Irrigant in transurethral prostatic resection or other transurethral precedures Elevates the osmolarity of the glomerular filtrate. creates an osmotic gradient in the eye between plasma and oclular fluids. leading to decreased swelling in posttransurethral prostatic resection. osmotic diuretic. sodium.
chest pain Dermatologic Urticaria. y Urologic irrigation: use prepared 5g/ 100ml distilled water solution. heart failure. Infuse this 280 ml of 702% solution IV at rate of 20 ml/ min. urinalysis . renal disease. Respiratory pattern. If no response to second dose. pulses. hydration. pupils. Adverse Reactions and Side effects Central Nervous Dizziness. repeat dose. thromboplebitis. reflexes. rhinitis Nursing Considerations Assessment y History Pulmonary congestion. blurred vision. irrigate as needed. lactation. adventitious sounds. active intracranial bleeding (except during crainiotomy). renal function tests y Physical 35 . collect urine with a catheter for the specified time for measurement of mannitol in mg/min. pregnancy. pregnancy. Pediatric patients: Dosage for children younger than 12 yr not established. lactation Skin color. HF. y Measurement of glumerular filtration rate: dilute 100 ml of a 20% solution with 108 ml of sodium chloride injection. If urine flow does not increase. dehydration. headache. active intracranial bleeding. edema. seizzures System Cardiovascular Hypotension.2 g/kg IV (about 50 ml of 25% solution. dry mouth. 75 ml of a 20% solution) in 3-5 minutes to produce urine flow of 30-50 ml/hour. heart failure. muscle strength . urinary output patterns. reevaluate patient situation. y Test dose of mannitol for patients with inadequate renal function: 0. anorexia. tachycardia. dehydration. hypertension. serum electrolytes. perfusion. Contraindications Contraindicated with anuria due to severe renal disease Precaution Use cautiously with pulmonary congestion. edema. lesions. renal disease. skin necrosis with infiltration Gastrointestinal Nausea. draw blood at the start and at the end of the time for measurement of mannitol in mg/ml plasma. orientation.minutes before surgery for maximal effect. thirst Genitourinary Diuresis. urine retention Hematologic Fluid and electrolyte imbalances Respiratory Pulmonary congestion. BP. y Adjunctive therapy to promote dieresis in intoxications: maximum of 200 g IV of mannitol with other fluids and electrolytes.
warm the bottle in a hot water bath. blurred vision (use caution when moving for assistance). constipation . GI upset (eat frequent small meals). If crystals are seen. do not exceed 400 mg/day 36 . y Report difficulty of breathing. enters breast milk Excretion Urine Dosage and Administration Adults: y Patients who require rapid analgesic effect: 50-100mg PO every 4-6 hr. Ultral ER 50 mg PO q 6h Analgesic (centrally acting) Opoid Analgesic y relief of moderate to moderately severe pain y relief of moderate to severe chronic pain in adults who need RTC Treatment for extended periods (ER tablets) y Unlabelled uses: Premature ejaculation. Action Pharmacokinetics Route Onset Peak Oral 1 hour 2 hours Metabolism Hepatic.Interventions Warning: Do not give electrolyte free mannitol with blood.but does not have the respiratory depressant effects. Tramadol hydrochloride Brand name Patient s Dosage Classification Indication Ultral. pain in the IV site. dry mouth (suck sugarless lozenges). nausea. add at least 20 mEq of sodium chloride to each liter of mannitol solution y Do not exposesolutions to low temperatures. crystallization may occur.dizziness. t ½ : 6-7 hours Distribution Crosses placenta. If blood must be given. Teaching Points y You may experience these side effects: Increased urination. y Monitor serum electrolyte periodically with prolonged therapy. y Make sure the infusion set contains a filter if giving concentrated mannitol. causes many effects similar to opoids. restless leg syndrome Binds to mu-opiod receptors and inhibits the reuptake of norepinephrine and serotonin. then cool to body tempearature before administering. B. headache. somnolence. chest pain.
50-100mg every 4-6 hours. and titrate in 25-mg increments every 3 days to reach 100 mg/day. Alternatively. tachycardia. SSRIs. seizures. headache. lactation. After titration. renal impairment. Pediatric Patients Safety and efficacy not established. rash. lactation. 100-mg ER tablet once daily. renal ore hepatic impairment.y Patients with moderate to moderately severe chronic pain: Initiate at 25 mg /day in the morning. do not exceed 300 mg/day. confusion. seizures Cardiovascular Hypotension. sweating. or opoids or acute intoxication with alcohol opoids and psychoactive drugs. dry mouth. pruritus. Maximum 200 mg/day. titrated by 100-mg increments every 5 days. flatulence Others Potential abuse. pregnancy. seizures. opoids. pallor. MAOIs. Adverse Reactions and Side effects Central Nervous Sedation. psychotropic drugs or other centrally acting analgesics. anxiety. anaphylatoid reactions Drug Interactions y Devreased effectiveness with carbamazepine y Increased risk of tramadol toxicity with MAOIs or SSRIs Contraindications Nursing Considerations Assessment y History Hypersensitivity to tramadol. vomiting. Then increase every 3 days to reach 200 mg/day. concomitant use of CNS depressants or MAOIs. past or present history of opoid addiction 37 . concomitant use of CNS depressants. constipation. bradycardia Dermatologic Sweating. dizziness or vertigo. Contraindicated with allergy to tramadol. ER tablets should not be used in patients with creatinine clearance less than 30 ml/min. acute intoxication with alcohol. urticaria Gastrointestinal Nausea. hepatic impairment. Geriatric Patients or patients with hepatic or renal impairment Older than 75 years old: do not exceed 300 mg/day Patients with cirrhosis: 50 mg every 12 hour ER tablets should not be used in severe hepatic impairment Patients with creatinine clearance less than 30ml/min: 50-100 mg PO every 12 hours. Precaution Use cautiously with pregnancy. System dreaming. do not exceed 400 mg/day. TCAs.
orientation. does not affect the COX-1 enzyme. severe constipation. Warning: Limit use in patients with past or present history of addiction to or dependence on opoids. which is activated I inflammation to cause the signs and symptoms associated with inflammation. reflexes. sedation. affect. bowel sounds. LFTs. impaired visual acuity (avoid driving or performing tasks that require alertness). loss of appetite. lesions. bilateral grip strength. nausea. dizziness. t ½ : 11 hours Peak 3 hours Indication Action Pharmacokinetics Route Oral Metabolism 38 . drowsiness. lighting. texture.y Physical Skin color. Analgesic and anti-inflammatory activities related to inhibition of the COX-2 enzyme. Celecoxib Brand name Patient s Dosage Classification Celebex 100 mg PO bid Analgesic (nonopoid) NSAID Specific COX-2 enzyme inhibitor y acute and long term treatment of Signs and symptoms of rheumatoid arthritis and osteoarthritis y reduction of the number of colorectal polyps in familial adenomatous polyposis (FAP) y management acute pain y treatment of primary dysmenorrhea y relief of signs and symptoms of ankylosing spondylitis y Relief of signs and symptoms of juvenile rheumatoid arthritis. normal output. which protects the lining of the GI tract and has blood clotting and renal functions. (lie quietly. Pulmonary auscultation. C. renal function tests Interventions y Control environment (temperature. eat frequent small meals) y Repot severe nausea. Onset Slow Hepatic.) if sweating or CNS effects occur. Teaching points y You may experience these side effects: dizziness. BP.
hepatic and CV condition. sweating.. after 6week. y Increased lithium level and toxicity. Pediatric Patients 10 kg or 25 kg or less: 50 mg capsule PO bid. impaired hearing. NSAID's or aspirin. dizziness. Nursing Considerations Assessment y History Renal impairment. eosinophilia. stomatitis Gastrointestinal Nausea. suggest another therapy. smoking. orientation. pregnancy (third trimester). significant renal impairment. 39 . ophthalmologic effects Cardiovascular MI. insomnia. abdominal pain. thrombocytopenia. CVA Dermatologic Rash. lactation. anaphylactoid reactions to anaphylactic shock Drug Interactions y Increased risk of bleeding if taken concurrently with warfarin. allergies hepatic and CV conditions. celecoxib. dysmenorrheal: 400mg. pruritis. System tiredness. somnolence. Adverse Reactions and Side effects Central Nervous Headache. y Physical Skin color and lesions. agranulocytosis. dyspepsia.Distribution Crosses placenta. More than 25 kg: 100 mg capsule PO bid. leucopenia. y acute pain. GI bleed Hematologic Neutropenia. reflexes. may enter breast milk Excretion Bile. 100mg PO bid. bone marrow depression. urine Dosage and Administration Adults Initially. Contraindications Contraindicated with allergies to sulfonamides. pancytopenia. fatigue. then 200mg PO bid y FAP: 400mg PO bid y Anyklosing spondylitis: 200mg/day PO. y Increased risk of GI bleeding with long term use of alcohol. decreased Hgb or Hct. menorrhagia Others Peripheral edema. may increase to 200 mg/day PO bid as needed. dizziness. Monitor patient closely and reduce warfarin dose as appropriate. lactation and pregnancy. granulocytopenia. flatulence. dry mucous membranes. tinnitus. ophthalmologic and audiometric evaluation. if no effect. Precaution Use cautiously with impaired hearing. aplastic anemia.
fever. renal function tests. Respiratory. positioning.peripheral sensation. drowsiness (avoid driving or the use of dangerous machinery while taking this drug). institute emergency procedures-gastric lavage. alone or in combination with other hypertensives. this action blocks the vasoconstricting effect of the renin-angiotensin system as well as the release of aldosterone leading to decreased BP. warmth. monitor accordingly. y You may experience these side effects: Dizziness. changes in vision. y Report sore throat. CBC. itching. adventitious sounds. serum electrolytes. y Establish safety measures if CNS or visual disturbances occur. Selectively blocks the binding Angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland. liver evaluation. Interventions Block Box warning: Be aware that the patient maybe at increased risk for CV events. positioning. GI Bleeding. induction of emesis. LFT s. enters breast milk Excretion Feces. may prevent the vessel remodeling associated with the development of atherosclerosis. y Arrange for periodic ophthalmologic examination during long term therapy. y Provide further comfort measures to reduce pain (e. T 1/2 : 13hours Distribution Crosses placenta. Pulmonary edema. Client/ Family Teaching y Take only the prescribed dosage. environmental control) and t reduce inflammation (e.g. swelling in ankles or fingers. rash. and rest). supportive therapy. do not increase dosage. Olmesartan medoxomil Brand name Patient s Dosage Classification Indication Action Benicar 20 mg/ day PO as a once-daily dose Angiotensin II receptor antagonist Antihypertensive Treatment of hypertension. Warning: If overdose occurs. D. y Administer drug with food or after meals if GI upset occurs. Pharmacokinetics Route Onset Peak Oral Varies 1-2 hours Metabolism Hydrolyzed in GI tract.g. urine Dosage and Administration 40 .
LFTs. hepatic or renal impairment hypovolemia. dry skin Gastrointestinal Diarrhea. pruritus. abdominal pain. pharyngitis. hyperglycemia. Suggest the use of barrier birth control while using olmesartan. constipation. BP. Hypotension may be reversed 41 . syncope. salt depletion. Pediatric Patients Safety and efficacy not established. lactation. renal function tests. The blockage of the renin-angiotensin system following the surgery can produce problems. hypertriglycemia Respiratory URI symptoms. pregnancy (use during the second or third trimester can cause injury or death to the fetus. fetal injury and deaths have been reported. tachycardia EENT Rash. dizziness. sinusitis. serum electrolytes. inflammation. Interventions y Administer without regard to meals. Warning: alert the surgeon and mark the patient s chart with notice that the olmesartan is being taken. nausea. reflexes. hypovolemia. dry mouth. Others Back pain. mat titrate to 40 mg/day if needed after 2 weeks. R. Adverse Reactions and Side effects Central Nervous Headache. Contraindications Contraindicated with hypersensitivity to any component of drug. alopecia. urticaria. arthritis Nursing Considerations Assessment y History Hypersensitivity to any component of the drug. muscle weakness System Cardiovascular Hypotension. salt depletion. pregnancy. respiratory auscultation. rhinitis. y Physical Skin lesions. affect. y Find an alternate method of feeding infant if given to a nursing mother. dental pain Hematologic Increased CPK. fatigue. Depression of the renin-angiotensin system in infants is potentially very dangerous. Precaution Use cautiously with renal impairment. turgor. flulike symptoms. bronchitis. hematuria.Adults 20 mg/day as a once-daily dose. cough. body temp. Black Box Warning: ensure that patient is not pregnant before beginning therapy.
diarrhea. vomiting. if you become pregnant or desire to become pregnant. consult your health care provider if this becomes uncomfortable). y Take special precautions to maintain your fluid intake and safety precautions in any situations that night cause a loss of fluid volumeexcessive perspiration. dehydration. Client/ Family Teaching y Take drug without regard of meals. excessive hypotension can occur. symptoms of the upper respiratory tract and cough (do not self medicate. Do not stop taking this drug without consulting your health care provider. chills.excessive perspiration. y Use barrier method of birth control while using this drug. dehydration. vomiting. y Report fever. 42 . pregnancy. consult dietician o maintain nutrition). y Monitor patient closely in any situation that may lead to decreased in BP secondary to reduction in fluid volume. dizziness. headache (medications may be available to help) nausea. excessive hypotension can occur. diarrhea. y You may experience these side effects: Dizziness (avoid driving a car or perform hazardous activitie0. and swelling. vomiting diarrhea (proper nutrition is important.with volume expansion. consult your health care provider.