I.

INTRODUCTION

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 damages the blood vessel lining, endothelium, exposing the underlying
collagen where platelets aggregate to initiate a repairing process which is not
always complete and perfect. 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 stroke is caused by the interruption of the blood supply to the brain, usually
because a blood vessel bursts or is blocked by a clot. This cuts off the supply of
oxygen and nutrients, causing damage to the brain tissue.

The most common symptom of a stroke is sudden weakness or numbness of the

face, arm or leg, most often on one side of the 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 or 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 death.

The 1990 Global Burden of Disease (GBD) study provided the first global estimate
on the burden of 135 diseases, and cerebrovascular diseases ranked as the
second leading cause of death after ischemic heart disease.

During the past decade 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 availability 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 cerebrovascular diseases (stroke) accounted for 5.5
million deaths world wide, equivalent 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.

Additionally, cerebrovascular disease is the leading cause of disability in adults

and each year millions of stroke survivors has to adapt to a life with restrictions in
activities of daily living as a consequence of cerebrovascular disease. Many
surviving stroke patients will often depend on other people’s continuous support
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
occurrence of this disease.
2. To be able to discuss the anatomy and the physiology of the 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 discuss the patient activities of daily living. To know if
there’s a factor that triggers 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 diagnostic test that being perform for the patient.
7. Lastly, to be able to discuss 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, conscious, coherent, afebrile with
monitoring devices.

A. VITAL SIGNS

Date Shift Time Temp BP RR PR Intake Output

07/18/09 7am- 36.8 210/100 58 20

1pm

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 I- can smell
CN II- (2-3) ERTL
CN III, IV, VI- EDM, intact
CN V- (+) corneal reflex
CN VII- no facial asymmetry
CN IX- (+) gag reflex
CN XI- can shrug shoulder
CN XII- tongue at midline

D. PULMONARY SYSTEM

-Respiratory rate was 58 cpm

-SCE, no vesicular breath sounds.
-AP, Apical beat at the 6th ICS anterior axillary line normal
sounds.

E. GASTROINTESTINAL SYSTEM
Flabby, NaBS, no abdominal bruit, (-) edema,(-) cyanosis.

F. MUSCULOSKELETAL SYSTEM
 The patient manifested good posture and moved
voluntarily; 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 yellow in

color.

V. LABORATORY AND DIAGNOSTIC EXAMINATION

Laboratory Findings

Laboratory Exam Result Normal Range

July 15, 2009

1. GRAM STAIN
Specimen: Sputum

 Gram ( - ) cocci
singly:
 Gram ( + ) cocci
Short chain:
 Gram ( + ) cocci in
Few
large chain:
 Pus cells:
 Epithelial cells:
2. URINALYSIS Few
Macroscopic
 Color:
 Transparency:
Microscopic Few

 RBC: 2-4/010
 Pus cells:
 Bacteria: +1
 Epithelial cells:
 Mucus threads:
 Amonphous unates:
3. HbAlC:
4. Glucose:
5. LIPID PROFILE
 Cholesterol: Light yellow
 Triglycerides:
  HDL cholesterol: SL. Turbid
 LDL cholesterol:
 Na:
 K:
 Ca:
 Cl:
 SGPT: 4-6/HPF

0-2/HPF

6. HEMATOLOGY Few
 PT:
 Control:
 INR:
7. CHEMICAL ANALYSIS Few
 S.G:
 pH: Few
 nitri:
 protein: Few
 glucose:
 ketone: 12.2%
 urobilinogen:
7.36mmol/L 7.2 – 6.2
 bilirubin:
4.22 – 6.11
 blood:
 leukocyte:

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 80 – 120mg/dl

-shows a low
attenuation focus on
the left occipital
lobe

Consistent with a
recent infarction

-ventricles are not

dilated

-midline structure are

in place

-mild cortical
atrophy is
demonstrated

-rest of the findings

are unbreakable.

July 17, 2009

 Na: 137 138-146

 K:
 Ca: 4.3 3.6-5.0
 Cl:

1.33 1.15-1.29

100 96-110

VI. ANATOMY AND PHYSIOLOGY

The Brain

Three cavities, called the primary brain vesicles, form during the early
embryonic development of the brain. These are the forebrain
(prosencephalon), the midbrain (mesencephalon), and the hindbrain
(rhombencephalon).

 The telencephalon generates the cerebrum (which contains the

cerebral cortex, white matter, and basal ganglia).

 The diencephalon generates the thalamus, hypothalamus, and pineal

gland.

 The mesencephalon generates the midbrain portion of the brain stem.

 The metencephalon generates the pons portion of the brain stem and
the cerebellum.

 The myelencephalon generates the medulla oblongata portion of the

brain stem
 Figure 1 The four divisions of the adult 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, the cerebrum, appears as folded ridges and
grooves, called convolutions. The following terms are used to describe
the convolutions:

 A gyrus (plural, gyri) is an elevated ridge among the

convolutions.

 A sulcus (plural, sulci) is a shallow groove among the

convolutions.
  A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named
after bordering skull bones)—the frontal lobe, the parietal love, the
temporal lobe, the occipital lobe, and the insula. All but the insula are
visible from the outside surface 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

activities as speech, evaluation of stimuli, conscious thinking,
and control of skeletal muscles occur here. These activities are
grouped into motor areas, sensory areas, and association
areas.

 The cerebral white matter underlies the cerebral cortex. It

contains mostly myelinated axons that connect cerebral
hemispheres (association fibers), connect gyri within
hemispheres (commissural fibers), or connect the cerebrum to
the spinal cord (projection fibers). The corpus callosum is a
major assemblage of association fibers that forms a nerve tract
that connects the two cerebral hemispheres.

 Basal ganglia (basal nuclei) are several pockets of gray matter

located deep inside 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 modifying
nerve impulses passing from the cerebral cortex to the spinal
cord. Arm swinging while walking, for example, is controlled
here.

The diencephalon connects the cerebrum to the brain stem. It

consists of the following major regions:

 The thalamus is a relay station for sensory nerve impulses

traveling from the spinal cord to the cerebrum. Some nerve
 impulses are sorted and grouped here before 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 autonomic nervous system and regulates
emotion, behavior, hunger, thirst, body temperature, and the
biological clock. It also produces two hormones (ADH and
oxytocin) and various releasing hormones that control hormone
production in the anterior pituitary gland.

The following structures are either included or associated with the

hypothalamus.

 The mammillary bodies relay sensations of smell.

 The infundibulum connects the pituitary gland to the

hypothalamus.

 The optic chiasma passes between the hypothalamus and the

pituitary gland. Here, portions of the optic nerve from each eye
cross over to the cerebral hemisphere on the opposite side of
the brain.
The brain stem connects 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 gray matter. The brain stem
consists of the following four regions, all of which provide connections
between various parts of the brain and between the brain and the
spinal cord

Figure 2 Prominent structures of the brain stem.

 The midbrain is the uppermost part of the brain stem.

 The pons is the bulging region in the middle of the brain stem.
  The medulla oblongata (medulla) is the lower portion of the
brain stem that merges with the spinal cord at the foramen
magnum.

 The reticular formation consists of small clusters of gray matter

interspersed within the white matter of the brain stem and
certain regions of the spinal cord, diencephalon, and
cerebellum. The reticular activation system (RAS), one
component of the reticular formation, is responsible for
maintaining wakefulness and alertness and for filtering out
unimportant sensory information. Other components of the
reticular formation are responsible for maintaining muscle tone
and regulating 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 cerebellum is convoluted, but the gyri, called folia,
are parallel and give a pleated appearance. The cerebellum
evaluates and coordinates motor movements by comparing actual
skeletal movements to the movement that was intended.

The limbic system 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 memories. Emotions such as pleasure, fear,
anger, sorrow, and affection are imparted 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 encircles the inside border
of the cerebrum. The following components are included:

 The hippocampus (located in the cerebral hemisphere)

 The denate gyrus (located 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 limbic
system)

VII. PATHOPHYSIOLOGY

Modifiable factors:

Smoking

Ingesting fatty foods

hypertension

Embolus that
vasospasm dislodge

Increase oxygen Decrease oxygen

demand supply in the blood

Inadequate blood perfusion

 Cell injury and death

Motor, sensory, cranial nerves

disrupted

Cerebrovascular
disease

Dizziness, stiffening of
extremeties, and non projectile
vomiting

Cerebrovascular disease or brain attack happened due to modifiable

factors possessed by the patient such as smoking, ingesting fatty foods, and
hypertension that 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

3-11 - routine care done

- 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 monitor 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 ugtts @ 3:10 pm; zantac 1
amp given @ 3:20 pm

- FC inserted connected to urobag

- mannitol 75mg x 1st dose

- UO drained- 1000cc

- fixed and brought to room of choice

- endorsed

5:00pm - received patient on bed awake via stretcher

accompanied

ERMEOD, transferred to bed safely

 - on NPO except meds

- with ongoing IVF of PNSSL @ 750 cc level regulated

@ 10gtts/minand SD nicardipine 10mg + 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

- with 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 - S/E by Dr. Somson-Crux with orders made and

carried

Out

- nexicum 40mg tab OD

- refer to Dr. Soccom Rosales for Co. Mgt. Dr. Solero

informed

- for sputum AFB 3x; GS/CS with SB

- initial V/S T:36.4 C, HR:68, RR:28, BP:180/90mmHg

- with the ff. meds mannitol 75cc x 3doses started @

ER;

Nexicum 40mg OD; olmesartan 30mg 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 OD given

- for 2Decho with Doppler- to request AAC

10:25pm - shift citicoline drops to IV as ordered by Dr. Solero

- adequate UO

- V/S q hour, medicine clerk informed

- no complaints

- needs attended

- endorsed

11-7 - flaccid patient on bed

- with IVF of PNSSL @ 650 level q 6hr

- with nicardipine hold

- on NPO except meds

- assess; BP 170/100

- O2 @ 2LPM via nasal cannula

- on CBR without BPR

- on CTscan-TF

- urinalysis, creatinine

- for sputum AFB

- for sputum GS/CS

- CBG monitoring q 12

- for FBS, hemoglobin,A1C

- V/S taken and recorded

- due meds given

- above IVF hooked and consumed @ same rate

 - (-) BM

- needs attended

- endorsed

07/15/09

7-3 - received patient ongoing PNSS with same

regulation and rate; afebrile
- with O2 @ 2LPM connected to nasal cannula

- with NGT intact

- with CBG monitoring q 12

- for sputum AFB

- for 2Decho with Doppler

- BP: 130/90 mmHg

- endorsed

Addendum - start feeding AP order

- for SGOT

- (-)gag reflex

3-11 - received patient on bed with ongoing IVF of PNSSL

- with NGT to start of 1600 kcal in feedings, DM diet

- with O2 inhalation @ 2LPM via nasal cannula

- with FC to urobag

- with CBG monitoring

- for 2Decho with Doppler

 - sputum GS/CS-TF

- still for sputum AFB

4:30pm - S/E by Dr. Martinez, orders were made and carried

out

- 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 - dilantin 100mg IV given slow push

7:30pm - s. electrolytes and SGPT result in referred to Dr. Simon

- due meds given

- refer prn

- no BM, afebrile

- endorsed

11-7 - received patient on bed

- with ongoing IVF PNSS @ level of 100cc regulated @
21gtts/min

- on 1600kcal feedings DM diet

- sputum GS/CS-TF

- CBG monitoring q 12

- for sputum 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 reg. and rate

- afebrile, BP: 100/70mmHg

- with NGT intact

- with O2 @ 2LPM via nasal 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

 - repeat CTscan plain-TF

- due meds given

8;00pm - (+) restlessness- MROD endorsed to give

Diphenhydramine 1 amp- given as ordered

9;30pm - Dr, Martinez made rounds with new order made to

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

- needs 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 Creatinine

- seen from time to time

- I&O monitored and recorded

- V/S taken and recorded

- refer prn

- endorsed

11-7 - received patient lying on bed, asleep

- with IVF PNSS @ 900cc

- with cardiac monitoring 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 plain-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 facilitate
continuity of care.

E- Encouraged immediate relatives to facilitate regular exercise such as brisk

walking but not making herself too much tired.

-Encouraged her not to carry heavy loads and do not force herself too much in
doing household chores. Encouraged patient to limit number of hours in playing
domino.

T- encouraged patient 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 with
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