CHAPTER ONE
Introduction
Cerebrovascular disease can be defined as a functional abnormality of the central nervous system that occurs when the normal blood Supply to the brain is disrupted.
Cerebral refers to the brain and vascular refers to vessels. Stroke can result from blood vessel conditions, such as aneurysm (blood vessel weakness which can result in a rupture) and thrombosis (blood vessel blockage).
Atherosclerosis is a common cerebrovascular condition where fatty deposits are laid down inside arteries causing them to become increasingly narrowed (WD writers).
Cerebrovascular disorder comprises pathological conditions that cause deprivation of the brain cells of adequate oxygen supply and nutrition with consequent physical and mental disabilities (Famakinwa 1994).
Approximately, 500,000 people experience a new stroke, 100,000 experiences a recurrent stroke and approximately 160,000 die of stroke each year with over 4.5 million survivors (2.2 million men and 2.3 million women).
Stroke is the leading cause of serious long-term disability in the United States (America Heart Association 2000).
Also, cerebrovascular disease is an abnormal condition of the brain characterized by occlusion by an embolus, cerebrovascular haemorrhage or vasospasms resulting in ischaemia of the brain tissue normally perfuse by the damaged vessels, paralysis, weakness, speech defect, sensory change, aphasia (disorder of language following brain damage) and death may occur.
The Essay on Stroke Blood Flow
... a stroke is known as a cerebrovascular accident (! SS cerebro!" refers to a part of the brain! SS vascular!" refers to the blood vessels and ... neck. These blockages stem from three conditions; the formation of a clot within a blood vessel of the brain or neck, called Thrombotic; The ...
Stroke is the primary cerebrovascular disorder in the world. Stroke can be divided into two major categories:
Ischaemic (85%) and Hemorrhagic (15%)
Ischaemic strokes are sub-divided into five different types according to their causes:
• Small penetrating artery thrombosis 25%
• Large artery thrombosis 20%
• Cryogenic 30%
• Cardiogenic embolic stroke 20%
• Others
Only 8% of ischaemic strokes result in death.
The patient may present with any of the following sings and symptoms:
• Trouble speaking or slurred speech
• Difficulty in walking
• Dizziness
• Numbness or weakness of the fore-arm or leg especially on one side of the body.
• Confusion or change in mental status
• Severe headache
• Loss of balance
Early treatment results in fewer symptoms and less loss of function.
The possible complications include:
• Cerebral ischaemia
• Hydrocephalus
• Epilepsy
• Bleeding
• Intracranial haematoma
PURPOSE OF WRITING
1. The study is carried out to meet the requirement of registered nurses certificate as required by Nursing and Midwifery Council of Nigeria.
2. To compare the patients presenting complains and textbook’s signs and symptoms and treatment of the condition for more comprehension.
3. To understand the effective management of cerebrovascular disease in the hospital to reduce complications of the condition and its effect on other body systems.
4. It helps to establish good nurse patient and relatives relationship that will foster quick recovery of the patient.
REASONS FOR CHOOSING THE PATIENT
To have a comprehensive understanding about the management of the disease condition.
To identify problems of the patient, plan how to solve them and implement the plans.
To evaluate the patient’s progress in response to implemented plans.
To educate and improve the knowledge of the relatives and members of the public on clinical manifestation of the disease.
To foster nurse – patient interpersonal relationship.
PHILOSOPHY OF THE CARE STUDY
The philosophy of this care study based on advertisement propounded by African philosopher in 1926, Gesgalt Wertheimer who is a psychologist and the self care model propounded by Dorothy Orem in 1980. Human being in whom all the parts interact to make up a unified whole and alteration in any part of the system either anatomically or physiologically will surely affect the well being.
The Essay on Tuberculosis: Infectious Disease And Health Care Facilities
What are some communicable diseases or threats currently affecting public and community health in your area? Pulmonary tuberculosis also referred to as (TB) is a contagious bacterial infection that generally affects the lungs; however TB can attack other organs in the body such as the brain, spine, and kidney. Tb can most often be treated however, if it is not properly treated, the disease can ...
This care study focuses on the holistic care of the patient with cerebrovascular disease and full understanding of the patient’s needs such as bed bath, oral care, personal hygiene, and problems such as impaired physical mobility, anxiety, self care deficit, impaired verbal communication and risk for injury.
SPECIFIC OBJECTIVES
Developing broader knowledge, comprehension and understanding human behaviour in relation to illness.
Participating in the treatment and total nursing care required for cerebrovascular disease.
Making use of the knowledge gain from this study in providing solutions to similar problems in the future.
Enabling me to educate the patient as regards the cause management and prevention of the disease condition.
Map out strategies for the prevention of complications that may arise from this condition.
CHAPTER TWO
LITERATURE REVIEW
DEFINITION
Cerebrovascular disorder is a disease in which the arteries to the brain become blocked or ruptured resulting in death of brain tissue (Mark Beers 2003).
Cerebrovascular disease; broad category of disease of blood flow in the arteries and veins which supply the brain includes cerebral infarction, brain ischaemia, brain hypoxia, intracranial embolism and thrombosis.
Furthermore cerebrovascular diseases, cerebrovascular accident otherwise known as stroke are words that have the same meaning. They are used to describe the condition in which there is an interruption in oxygen supply to the brain due to the presence of cerebrovascular lesion.
Cerebrovascular disease comprises pathological condition that causes deprivation of the brain cells of adequate oxygen supply and nutrition with consequent physical and mental disabilities (Famakinwa T.T. 1994).
Also, cerebrovascular disease involves an interruption of the blood supply to a part of the brain and the development of neurological deficits (MikeWalsh2002).
The Essay on The Brain S Cerebral Cortex
The brain is three pounds of tissue that are part of the nervous system. Itis one of the two basic parts and contains a bout 100 billion nerve cells. The g lilia is the cells that take care of the neuron cells and's allow cells to carry out all of the impulses and messages that they must send. It is divided in to parts that give you the ability to do everything from swimming to math and more. The ...
In addition, cerebrovascular disease is a functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted (Smeltzer and Brenda 2004).
AETIOLOGICAL FACTORS
o Cerebral arteriosclerosis
o Syphilis
o Trauma
o Hypertension
o Embolism
o Thrombosis
o Haemorrhage
o Vasospasm
o Diabetes
ANATOMY AND PHYSIOLOGY OF THE BRAIN
The brain constitutes about one fifth of the body weight and lies within the cranial cavity. The meninges are membrane that surrounds and cover the brain which has three layers:
Dura mater, the outer layer
Arachnoid mater, the middle layer
Pia mater, the inner layer
It has a potential space called sub-arachnoid space which contains cerebrospinal fluid. It lies in between the sub-arachnoid space and pia mater.
The structures forming the brain are:
(1) The cerebrum or forebrain
(2) The mid brain (3) The pons varolli
(4)The medulla oblongata
(5)The cerebellum or hind brain}
(Anne Waugh and Allison Grant, 2001)
THE CEREBRUM
The cerebrum occupies the anterior and middle cranial fossae. It constitutes the largest part of the brain. It is divided by a deep cleft called the longitudinal cerebral fissure into two parts, the right and left cerebral hemisphere each of which contains one of the lateral ventricles deep within the brain, these hemisphere are connected by nerve fibres called corpus callosum. The dura mater formed the falx cerebri, separates the two hemisphere and penetrates to the depth of the corpus callosum. The superficial part of the cerebrum is composed of nerve cell bodies or grey mater, forming the cerebral cortex and the deeper layer consist of nerve fibres or white mater
The cerebral cortex shows many folding of varying depth. The exposed areas of the folds are the gyri or convolutions and these are separated by sulci or fissures. These gyri greatly increase the surface area of the cerebrum.
Each hemisphere of the cerebrum is divided into lobes which take the name of the bone of the cranium under which they lie:
The Term Paper on Brain Facts
... the hippocampus, as well as in the cerebral cortex and other brain areas involved in various forms of memory. LTP ... nerve impulses in nerves that control the muscles and the viscera, both through reflex activities and through voluntary commands from the cerebrum. ... main sections of the cerebral cortex: the frontal lobe, the parietal lobe, the occipital lobe, and the temporal lobe. Functions such as ...
• Frontal
• Temporal
• Parietal
• Occipital
The boundaries of the lobes are marked by deep sulci
The cerebral sulcus: This separates the frontal from the parietal lobe.
The lateral sulcus: It separates the frontal and parietal from the temporal lobe.
The parieto-occipital sulcus: This separates the parietal and temporal lobes from the occipital lobe.
The cerebrum is divided into three parts which are:
1. Cerebral cortex
2. Sub-cortical structure
3. Cerebral medulla
1 CEREBRAL CORTEX
It is composed of many layers of cell bodies which are the grey mater of the cerebrum. The cerebral cortex shows many folding of varying depth which are called gyri and they are separated by sulci. The gyri greatly increase the surface area of the cerebrum.
The cerebral cortex is divided into various areas which is called functional areas:
Motor area
Sensory area
The motor area (pre Central): This lies in the frontal lobe immediately
anterior to the central sulcus. This area of cortex contains large cells called pyramidal cells which form the beginning of the motor pathway which contains the movement of the opposite side of the body.
The Pre motor area: This lies in the frontal lobe immediately anterior to the motor area. The cells are thought to exert a controlling influence over the motor area, ensuring an orderly series of movement.
The lowest part of the motor area is called Brocas area and is concerned with speech. It is dominant in the left hemisphere in right handed people and in the right hemisphere in left handed people.
The frontal area: This extends anteriorly from the pre-motor area. The communications between this and the other regions in the cerebrum are responsible for the behaviour, character and emotional state of the individual.
The Sensory area (Post central): This is the area behind the central sulcus. Here sensations of pain, temperature, pressure and touch, knowledge of muscular movement and the position of joints are perceived. The sensory area of the right hemisphere receives impulses from the left side of the body.
a) The parietal area: This lies behind the post central area and includes the greater part of the parietal lobe of the cerebrum. Its functions are believed to be associated with obtaining and retaining accurate knowledge of objects.
The Essay on Strokes Area Of The Brain
Strokes Though the ultimate result of a stroke or intracranial accident is neurological damage, the primary cause of this condition stems from a catastrophe of vascular origin affecting intracranial blood flow. From a technical perspective, a stroke is defined by the World Health Organisation as rapidly developing clinical sign of cerebral function, lasting more then 24 hours or leading to death, ...
b) The sensory speech area: This is situated in the lower part of the parietal lobe and extends into the temporal lobe. It is here that the spoken word is perceived.
c) The auditory area: This lies immediately below the lateral sulcus within the temporal lobe. The cell receives and interpretes impulses transmitted from the inner ear by the cochlear part of the vestibulocochlear nerves (8th cranial nerves).
(Waugh and Grant2001).
d) The olfactory area: This lies deep within the temporal lobe where impulses from the nose via the olfactory nerves (1st cranial nerves) are received and interpreted
e) The taste area: This is thought to lie just above the lateral sulcus in the deep layers of the sensory area. This is the area where impulses from special nerve endings in taste buds in the tongue and in the lining of the cheeks, palate and pharynx are perceived as taste.
f) The Visual area: This lies behind the parieto-occipital sulcus and includes the greater part of the occipital lobe. The optic nerves (2nd cranial nerves) pass impulses from the eye o this area which receives and interprete the impulses as visual impressions.
The white matter of the cerebral hemisphere consists of nerve fibres running to and fro the cortex linking up the various area or centers of the brain with the spinal cord.
2 SUBCORTICAL STRUCTURES
This is the layer that is found in between the cerebral cortex and cerebral medulla. It comprises of:
Basal Nuclei
The Thalamus
The Hypothalamus
BASAL NUCLEI
These are areas of grey matter, lying deep within the cerebral hemispheres, with connections to the cerebral cortex and thalamus.
The basal nuclei form part of the extra pyramidal tract and are thought to be involved in initiating muscle tone in slow and coordinated activities; If control is inadequate or absent, movement are jerky, clumsy and uncoordinated.
THE THALAMUS
The thalamus consists of two masses of nerve cells and fibres situated within the cerebral hemisphere just below the corpus callosum, one on each side of the third ventricle. Sensory input from the skin viscera and special sense organs is transmitted to the thalamus before redistribution to the cerebrum.
The Essay on Stroke Brain Blood Patient
Cerebral vascular accident or a stroke is the destruction of brain substance, resulting from thrombosis, intracranial hemorrhage, or embolism, which causes vascular insufficiency. In addition, it is an area of the brain denied blood and oxygen that is required and damage is done to a part of the cells. The effect of the patient depends upon where the damage occurs and the severity of the stroke. ...
THE HYPOTHALAMUS
The hypothalamus is composed of a number of groups of nerve cells. It is situated below and in front of the thalamus, immediately above the pituitary gland. The hypothalamus is linked to the posterior lobe of the pituitary gland by nerve fibres and to the anterior lobe by a complex system of blood vessel. Through these connections, the hypothalamus controls the output of hormones from both lobes of the gland.
3 THE CEREBRAL MEDULLA
This is found within the cerebrum the lobes are connected by masses of nerve fibres, or tracts, which make up the white matter of the brain. The afferent and efferent fibres linking the different parts of the brain and spinal cord are as follows:
Association (arcuate) fibres: Connect different parts of a cerebral hemisphere by extending from one gyrus to another some of which are adjacent and some distant.
Commissural fibres : Connect corresponding areas of the two cerebral hemispheres, the largest and most important commissure is the corpus callosum.
Projection fibres: Connect the cerebral cortex with grey matter of lower parts of the brain and with spinal cord. E.g. The internal capsule.
The internal capsule is an important area consisting of projection fibres. It lies deep within the brain between the basal nuclei (ganglia) and the thalamus. Many nerve impulses passing to and from the cerebral cortex are carried by fibres that form the internal capsule. Motor fibres within the internal capsule form the pyramidal tracts (Corticospinal $tracts) that cross over (decussate) at the medulla oblongata.
FUNCTIONS OF THE CEREBRUM
o Sensory perception, including the perception of pain, temperature touch, sight, hearing, taste and smell.
o Metal activities involve in memory, intelligence, sense of responsibility, thinking, reasoning, moral sense and learning are attributed to the higher centre.
o Initiation and control of skeletal (voluntary) muscle contraction.
THE MIDBRAIN
This is situated around the cerebral aqueduct, below the cerebrum and above the pons. It consists of group of cell bodies and nerve fibres which connect the cerebrum with lower parts of the brain and with the spinal cord. (Anne Waugh & Allison Grant, 2001).
PONS
It is situated in front of the cerebellum, below the midbrain and above the medulla oblongata. It consists of many fibres running transversely through the Pons which link the two lobes of cerebellum with cerebral cortex. (Anne Waugh & Allis Grant, 2001).
THE MEDULLA OBLONGATA
It is situated below the Pons and continue with spinal cord below. It is about 2.5cm long and lies within the cranium above the foramen magnum. The outer aspect is composed of white matter which passes between the brain and the spinal cord and grey matter lies centrally. It constitute of some vital centers which are:
i) Respiratory centre
ii) Cardiac centre
iii) Vasomotor centre
iv) Reflex centers of vomiting, sneezing, coughing and swallowing
THE CEREBELLUM
The cerebellum is situated behind the Pons varolli and immediately below the posterior portion of the cerebrum occupying the posterior cranial fossa. It has two hemispheres separated by a narrow median strip called vermis. The grey matter forms the surface of the cerebellum and the white matter lies deeply.
The nerve fibres which enter and leave the cerebellum do so by three tracts called the cerebellum peduncles. These are:
o Superior cerebella peduncle: It connect the cerebellum with the midbrain cerebrum
o Middle cerebella peduncle: It connects the cerebellum with the Pons varolli
o Inferior cerebella peduncle: It connects cerebellum with medulla oblongata and the spinal cord.
FUNCTIONS OF THE CEREBELLUM
• It regulates posture and postural activities.
• It controls co-ordinates the movement of the various groups of muscles to ensure action.
• It co-ordinates activities associated with the maintenance of the balance and equilibrium of the body.
THE PARTS OF THE CENTRAL NERVOUS SYSTEM
BLOOD SUPPLY TO THE BRAIN CIRCULUS ARTERIOSUS
BLOOD SUPPLY TO THE BRAIN
Circulus arteriosus or the circle of Willis is arrangement of arteries with arterial blood that supply the greater part of the brain. Four large arteries contribute to its formation;
Two internal carotid arteries
Two vertebral arteries.
The vertebral arteries arise from the transverse process of the cervical vertebrae, enter the skull through the foramen magnum, then join to form he basilar artery. The arrangement in the circulus arteriosus is such that the brain as a whole receives an adequate blood supply when a contributing artery is damaged and during extreme movements of the head and neck.
Anteriorly, two anterior cerebral arteries arise from the internal carotid arteries and are joined by the anterior communicating artery. Posteriorly, two vertebral arteries join to form the basilar artery divides to form two posterior cerebral arteries, each of which is joined to the corresponding internal carotid artery by a posterior communicating artery completing the circle. The circulus arteriosus is therefore formed by;
2 anterior cerebral arteries
2 internal carotid arteries
1 anterior communicating artery
2 posterior communicating arteries
2 posterior cerebral arteries
1 basilar artery
From the circle, the anterior cerebral arteries pass forward to supply the anterior part of the brain, the middle cerebral arteries pass laterally to supply the sides of the brain, and the posterior cerebral arteries supply the posterior part of the brain. Branches of the basilar artery supply part of the brain stem.
VENOUS RETURN
The venous blood from the head and neck is returned by deep and superficial veins.
SUPERFICIAL VEINS: Superficial veins with the same names as the branches of the external carotid artery return venous blood from the superficial structures of the face and scalp and unite to form the external jugular vein.
The external jugular vein begins in the neck a the level of the angle of the jaw. It passes downwards in front of the sternocleidomastoid muscle, then behind the clavicle before entering the subclavian vein.
THE DEEP VEINS: The venous blood from the deep areas of the brain is collected into channels called the DURAL VENOUS SINUSES.
The dural venous sinuses of the brain are formed by layers of dura mater lined with endothelium. The dura mater is the outer protective covering of the brain. The main venous sinuses are:
1 Superior sagittal sinus
1 Inferior sagittal sinus
1 Straight sinus
2 Transverse or lateral sinuses
2 Sigmoid sinuses
The superior sagittal sinus carries the venous blood from the superior part of the brain. It begins in the frontal region and passes directly backwards in the midline of the skull to the occipital region where it turns to the right side and continues as the right transverse sinus.
The inferior sagittal sinus lies deep within the brain and passes backward to form the straight sinus.
The straight sinus runs backwards and downwards to become the left transverse sinus.
The transverse sinuses begin in the occipital region. They run forward and medially in a curved groove of the Skull, to become continuous with the sigmoid sinuses.
The sigmoid sinuses are a continuation of the transverse sinuses. Each curves downwards and medially and lies in a groove in the mastoid process of the temporal bone. Inferiorly, it continues as the internal jugular vein.
The internal jugular veins begin at the jugular foramina in the middle cranial fossa and each is the continuation of a sigmoid sinus. They run downwards in the neck behind the sternocleidomastoid muscles. Behind the clavicle they unite with the subclavian veins, carrying blood from the upper limbs, to form the brachiocephalic veins.
The brachiocephalic vein are situated one on each side in the root of the neck. Each is formed by the union of the internal jugular and subclavian veins. The left brachiocephalic vein is longer than the right and passes obliquely behind the manubrium of the sternum, where it joins the right brachiocephalic vein to form the superior venacava.
The superior venacava, which drains all the venous blood from the head, neck and upper limbs, is about 7cm long. It passes downwards along the right border of the sternum and ends in the right atrium of the heart. (Ross and Wilson 2001).
PATHOPHYSIOLOGY
A transient ischaemic attack (TIA), a brief episode of reversible neurologic deficits, lasts for a few minutes to less than 24 hours. It results from temporary reduction of blood flow to a specific area of the brain. Usually TIA is caused by atherosclerosis or a small embolus, which obstructs a small cerebral blood vessel. TIA is often a warning signal of a future CVA. The client may experience several TIA before a CVA. The time between the TIA and CVA ranges from hours to months. Manifestation include dizziness, visual loss in one eye, one-sided numbness or weakness of the fingers, arms, leg or aphasia.
A cerebrovascular accident is the sudden loss of neurologic function. There are three causes of the disease condition which are:
i) Thrombus
ii) Embolus
iii) Haemorrhage
CVA caused by thrombus occurs most often in older adults who are resting or sleeping. Anyone of these causes can partially or completely reduce blood flow to cerebral tissues. This decreases oxygen to the area of the brain supplied by the involved blood vessels. Initially, the brain cells are ischemic but quickly die, resulting in a cerebral infarction. If the brain experiences anoxia (lack of oxygen to the brain) for more than 10 minutes, irreversible brain damage occurs. Adequate collateral blood supply can decrease the amount of damage. Collateral circulation occurs when areas of the brain have decreased blood flow over a long period of time. Smaller blood vessels develop to supply blood to areas with reduced blood supply. Large areas of infarction usually result in severe disability or death.
When cerebral blood supply is altered, there is temporary or permanent loss of neurologic function. The signs and symptoms of CVA vary, depending on the area of the brain involved, the size of the area, and collateral blood flow. Typical manifestations alter movement, sensation, thought, memory, behaviour or speech. However, the effects of a CVA are not limited to the nervous system. Complications of a CVA can affect respiration, elimination and muscle function. (Burke.Lemone. Mohn-Brown, 2007).
RISK FACTORS
• Hypertension
• Cardiac impairment e.g. congestive cardiac failure.
• Diabetes Mellitus
• Stress
• Obesity
• Smoking
• Blood lipid abnormalities
• Alcohol consumption
• Use of oral contraceptives
• Excessive or prolonged fall of blood pressure.
(Anne Waugh & Allison Grant, 2001)
CLINICAL MANIFESTATIONS
Flaccid paralysis
Dysphasia (loss of speech)
Forgetfulness
Difficulty in comprehension
Apraxia (Inability to perform a previously learned action)
Difficulty in interpreting tactile and auditory stimuli
Hemiplegia (Paralysis of one side of the body).
(Famakinwa T.T. 2002)
COMPLICATIONS
Hemiplegia
Aphasia (communication disorder)
Hemianopsia (partial blindness)
DIAGNOSTIC PROCEDURES AND NURSING RESPONSIBILITIES
A).
COMPUTED TOMOGRAPHY SCANNING
Computed tomography is a computer enhanced scanning technique for analyzing a series of X-ray taken from different angles. A compiler generates two dimensional high resolution images that resemble anatomic slices of the organ being imaged.
Computed tomography provides clearer images of abnormalities affecting the skull and spine.
NURSING RESPONSIBILITIES
The nurse instructs the patient to lie still during the procedure.
The nurse informs the patient about the test
The nurse informs the patient that the procedure may take 15 minutes to 1 hour depending on the part of the body being scanned.
CEREBRAL ANGIGRAPHY
Cerebral angiography is an invasive procedure used to detect abnormalities in the blood vessels of the brain.
Cerebral angiography can detect a bulge in the weakened wall of an artery, inflammation of arteries, a blood vessel malformation or a blocked blood vessel
NURSING RESPONSIBILTIES
Inform patient that a local anaesthetic will be given to numb the insertion site.
Inform the patient that a catheter will be inserted through an incision into an artery.
The nurse explains the procedure to the patient.
ECHOCARDIOGRAPHY
It is a non–invasive ultrasound test used to examine the shape, size and motion of cardiac structure. It involves transmission of high frequency sound waves into the heart through the chest wall and recording of the return.
NURSING RESPONSIBILITIES
The patient is made to know that he or she will have to turn onto the left side or hold a breath periodically. The patient is informed that test take about 30-45 minutes.
He or She should be assured that procedure does not cause electric shock and that it is a diagnostic procedure.
The nurse informs the patients about the tests, explaining that it is painless.
SPECIAL MANAGEMENT
ADMISSION: Admit patient in a well ventilated room, which is of particular value and that add greatly to the patient’s comfort.
OBSERVATION: The patient body temperature, pulse, respiration, blood pressure are monitored at intervals of 4 hours depending on the severity of the condition. Neurologic flow sheet is used to monitor all body systems with particular attention to neurologic status.
DIET: This is as important as rest. Easily digestible diet of high protein, low salt or salt free when given patient, diet something are considered which are the family background, ethnic values, social cultural. Fruit rich in vitamin B&C also can be added.
PHYSICAL CARE: All physical care of the patient must be ensured. These include; Bed bath, Mouth care, as the condition improve serving the patient food and attending to other needs are also necessary.
PSYCHOTHERAPY: Patient should be encouraged to continue with hobbies, recreational and leisure interests. Ensure also that there is good interpersonal relationship between the nurse and the patient.
EXERCISE: Affected extremities should be exercised passively motion four or five times daily to maintain joint mobility, retain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system and enhance circulation.
HEALTH EDUCATION: The patient is given health education on the pathophysiology of the case and what can be done to prevent it. Health education can include types of diet, the use of prescribed drug, coming to the clinic on appointment day, avoidance of stimulant like coffee, alcohol. The reason for all these should be properly explained to the patient.
CHEMOTHERAPY
Patients who are not candidates for surgical intervention may be placed on medications to prevent future attacks.
A) HEPARIN
GROUP: Anticoagulant
ACTION: It is used to prevent thrombus formation in the slower moving venous side of the circulation.
INDICATION: Deep venous thrombosis, pulmonary embolism
DOSAGE: 5000-10000 units every 12hour
ROUTE: Intravenously, subcutaneously.
SIDE EFFECTS: Haemophilia, Severe hypertension, peptic ulcer, skin necrosis, severe liver disease.
NURSING CONSIDERATIONS
Watch for any bleeding
Estimate the blood clotting time
In case of over dosage, give intravenous antidote like protamine soleplates to neutralise the effect.
Do not administer to patients who are contraindicated to it.
B) PLATELET INHIBITION MEDICATION
ASPIRIN
GROUP: Antipyretic, Anti-inflammatory, Analgesic
ACTION: It inhibits prostaglandin synthesis thereby reducing painful impulses produce by prostaglandin.
INDICATION: Influenza, Headache, colds, sore throat, osteoarthritis
ROUTE: Orally, suppository.
SIDE EFFECTS: Nausea, Rashes, Vomiting, Peptic ulcer, Gastritis, Dizziness.
CONTRAINDICATION: Anaemia, Dyspepsia, Peptic ulcer, Haemophilia, Asthmatic patient.
NURSING IMPLICATION
It should not be administered to children below 12 years old and in later stage of pregnancy.
Advice patient to notify physician if tinnitus occur.
It should not be administered to peptic ulcer patient or patient with empty stomach
C. ANTI HYPERTENSIVE
METHYLDOPA (Aldomet)
GROUP: Antihypertensive and vasodilator
ACTION: it blocks renin release and interferes with synthesis and release of norepinphrine thereby helping to reduce the peripheral vascular resistance and lowering the blood pressure.
INDICATION: hypertension (moderate to severe)
ROUTE: orally, intravenously.
DOSAGE: 250-500mg, twice or thrice daily.
SIDE EFFECTS: orthostatic hypertension, malaise, Diarrhoea, Dizziness, dry mouth.
CONTRA INDICATION: Acute hepatic disease, phaeochromocytoma, Hypersensitivity reaction.
NURSING IMPLICATIONS
Do not administer to patient who are contraindicated to it
Watch for any side effects.
Teach patient how to get up form bed gradually to avoid postural hypotension.
Monitor the patients vital sign especially pulse and blood pressure
SURGICAL MANAGEMENT
Surgical intervention for managing transient ischemic attacks and preventing stroke are
1. Angioplasty
2. Carotid endarterectomy
1. ANGIOPLASTY
A catheter with a balloon at its tip is threaded into the narrowed artery. The balloon is inflated for several seconds to widen the artery
2. CAROTID ENDARTERECTOMY
This involves the removal of fatty deposits (atheromas) and dots in the internal carotid artery.
REHABILITATION
Rehabilitation starts right from the day of admission
Inform the family that the patient may be easily tired, become irritable an upset by small events
Inform the patient and family that the recovery and rehabilitation process after stroke may be prolonged and require patience.
Teach necessary modification of diet.
Encourage patient to keep to active, adhere to exercise programme and remain as self sufficient as possible
Remind patient and family members of the need for continuing health promotion and screening.
Support and encouragement are provided to prevent the patient from becoming excessively fatigued and discouraged.
PREVENTION AND CONTROL OF CEREBROVA SCULAR DISEASE
Healthy lifestyle including eating low cholesterol, low salt diet and increasing exercise should be encouraged.
Avoid emotional disturbances e.g. stress producing situations
There should be dietary health education to avoid obesity. Adequate diet should be encouraged.
Periodic physical examination, history taking routine monitor of vital signs, weight, strict intake and output monitoring fore early detection
Interventions that alter the major risk, factors such as treating of high blood pressure, diabetes and stops smoking.
CHAPTER THREE
PATIENT’S IDENTITY
Name: Ayodeji Bolaji
Age: 78 years
Sex: Male
File number: 2000928
Address: At 34 Ogudu Str. Ilesa
Diagnosis: Cerebrovascular Disease
Occupation: Retired Teacher
Religion: Christianity
Ethnicity: Yoruba
Next of kin: Mr. Bolaji Olawale
Relationship: SON
Address: AT 34 Ogodu Streets, Ilesa
Nursing officer in charge: Mr. Oyedare
Medical Officer in charge: Dr. Olugbodi
Date of admission: 04/02/09
Date of discharge: 16/02/09
Patient’s Ward: Male Medical Ward
Bed number: 22
ADMISSION ACTIVITIES
Present Diagnosis: Left Hemispheric Cerebrovascular Disease likely ischemic
HISTORY OF PRESENT ILLNESS
This 78years old man was a known diabetic hypertensive patient diagnosed 8years ago in a private hospital with poor drug compliance.
He was apparently well until about 10days before he was admitted when he noticed weakness of his upper and lower right limbs at the early hours of the morning following sleep.
He was later diagnosed to be having cerebrovascular disease, brought into the ward from the casualty around 4:30pm on 05/02/09 for proper management. He was accompanied by he wife, children and a staff nurse.
PAST MEDICAL HISTORY
Childhood illness: He hardly falls sick, but one in a while has malaria and this is usually treated with the prescribed antimalaria drug.
Immunization: he has all his immunization at birth.
Medical/surgical history: he claimed to have once been hospitalized for the cases of hypertension and he has been coming to receive treatment in the medical outpatient department until 10days ago when he developed weakness of his upper and lower right limbs. He has never had surgical operation before.
Reproductive history: He has 7children all delivered in the hospital.
Family background: he is from a polygamous family and the first child out of three children.
Childhood history: he grew up with his other siblings with whom he share feelings, emotions and also make friend.
PATIENT PERSONAL CHARACTERISTICS
Personality
He is light in complexion. He is lively and friendly. He is an extrovert and also an endomorph. The level of interaction is tolerated and he interacts mostly in English Language.
He has been co-operating with me in his care, the nurses who are always on duty to care for him and also with other health personnel.
Religion
He is a Christian and attends Methodist church.
NURSING HISTORY USING GORDON’S HEALTH FUNCTIONAL PATTERN
Department: Mr. Ayodeji Bolaji
STATE OF HEALTH
PAST HISTORY: patient claimed to be a known Diabetic hypertensive patient for the past eight years who has been coming to the medical out patient department on clinic days for treatment. He has been admitted before for the case of Hypertension
NUTRITION: he looks well nourished. He eats all types of Yoruba food like Eba, Amala, fufu etc. He is on special diet low salt, low cholesterol.
ELIMINATION: He empties his bowel once daily with no abnormalities like blood or mucus. He micturates at least three times in a day without pain or discomfort. He has ability to control his urge
ACTIVITY/EXERCISE: he like to play football, listen to news on radio and television. He also likes reading newspapers.
SLEEP AND REST
He sleeps for a least 5hours in the night with out sedation and rests during the day after meal.
COMMUNICATION/SPECIAL SENSES
He has no problem with special senses. He hears well and communicates fluently in English & Yoruba language.
FEELING ABOUT SELF/IMAGE
He is concerned about the deformity/paralysis of his body and still believes that there is nothing impossible for God to do.
FAMILY RELATIONSHIP
He was born into polygamous family, the first child three children. He relates well with her family members friends co-workers and neighbor.
SEXUALITY/REPRODUCTION:
He is married with 7 children in a polygamous setting. He is still sexually active.
COPING WITH STRESS
He prays to God whenever challenges come by his way and believe in God for solution.
VALUES AND BELIEFS
He is a Christian and believers in God as the only one that can heal him.
HABITS:
He like helping people. He neither smokes cigarette nor takes alcohol.
EXAMINATION:
Temperature: 37.50C
Pulse: 72 b/m
Respiration: 32 c/m
Blood Pressure: 170/110 mmtlg
GENERAL INSPECTION FROM HEAD TOES
Head: There was no rash on the scalp, the hair distribution colour and texture is normal.
Eyes: No blurred vision nor redness, no discharges from the eyes.
Neck: There was no stiffness, no swelling
Hands: There was not rash but there is deformity of the right hand.
Chest & Abdomen: There is no papule, macule nor scar from a previous surgery
Legs: There is deformity of the right leg.
Palpation: There was no palpable mass on the body
Percussion: There was no abnormal sound from the abdomen.
RADIOLOGICAL INVESTIGATION
ECHORCARDIOGRAPHY was done on 05/02/08
Electrocardiogram was done on 04/02/08
LABORATORY INVESTIGATIONS
Electrolyte, urea and creatinine level
04.02.08
Creatinine – 85 mmo l/l
HC03 – 22 mmol/l
Potassium – 4.2 mmol/l
Sodium – 135mmol/l
Urea – 10.4mmol/l
05/02/08
Urinalysis
Glucose: Negative
Protein: Negative
BLOOD INVESTIGATION CARRIED OUT AND THE RESULTS.
LABORATORY INVESTIGATION RESULTS NORMAL RANGE INTERPRETATION
Packed cell volume 34% 40-50% Normal
White blood cell 10,000/ml 5-10,000 Normal
Eosinophil 0.1%
Neutirophil 67% 30-60% Normal
NEUROLOGICAL EXAMINATION
Category Description
Level of consciousness Alert
Orientation to time, place, person Present
Memory Intact
Speech Slurred
Intelligence Intact
Meningeal Irritation Absent
Visual field No visual loss
Cranial nerve 3, 4, 6 and 12 Intact
Left facial Paralysis Present
Reflexes on left side normal
Reflexes planter responses Responds
Left planter responses Responds
Gait Hemiplegia
Reflexes on Right side Brisk
NURSING CARE AND OTHER THERAPIES
Mr. Ayodeji Bolaji was admitted into the male medical ward on 05/02/08 with the complaints of weakness of his upper and lower right limbs and was diagnosed to be having cerebrovascular disease.
On admission, he was neatly dressed but ill looking. He was carefully assessed, made comfortable in bed and therapeutic nurse relationship was established.
OBSERVATION
Throughout the admission of Mr. Ayodeji Bolaji frequent and keen observation was made so as to detect any complications early and to treat accordingly. Intake and output were monitored; he was monitored for increase in the symptoms of the disease condition like slurred speech. Vital signs were taken 4hourly and careful attention was given to the blood pressure and pulse rate. Relations were also carried along in observation as they report changes.
PHYSICAL CARE
He was giving bed bath, His oral hygiene was attended to through oral care, assisted feedings was done for him his immediate environment was clean and made tidy throughout the period of hospitalization. Bed linen was changed frequent.
PSYCHOLOGICAL CARE
He was made to know that several other have the disease and they are still moving on with life as normal as possible. Patient was made to ask questions about his health which were answered adequately.
PERSONAL HYGIENE
Patient was given bed bath throughout the time of admission since he cannot do it without assistance. His skin integrity and oral hygiene was maintained throughout the period of hospitalization.
EXERCISE
He was assisted by the physiotherapist in moving his body part. Exercise reduces blood pressure and the level of cholesterol and so he was encouraged to engage in exercise regularly.
DIET
Patient was given high protein, green leafy vegetables, vitamins and the amount of carbohydrates and fat reduced.
VITAL SIGNS THROUGHOUT THE PERIOD OF HOSIPITALIZATION
DATE TEMP PULSE RESP. BLD. PRESSURE
04/02/09 37.50C 72 b/m 32c/m 170/100 mmltg
05/02/09 38.00C 60 b/m 28 c/m 190/100 mmltg
06/02/09 37.00C 100 b/m 24 c/m 180/100 mmltg
07/02/09 36.00C 80 b/m 20 c/m 160/90 mmltg
08/02/09 36.80C 60 b/m 20 c/m 150/90 mmltg
09/02/09 37.0 0C 72 b/m 28 c/m 130/80 mmltg
10/02/09 37. 20C 70 b/m 28 c/m 120/90 mmltg
11/02/09 36.20C 70 b/m 24 c/m 140/100 mmltg
12/02/09 36.10C 64 b/m 20 c/m 150/100 mmltg
13/02/09 36.90C 70 b/m 20 c/m 120/90 mmltg
14/02/09 36.10C 68 b/m 28 c/m 140/100 mmltg
15/02/09 36.20C 70 b/m 24 c/m 140/100 mmltg
16/02/09 36.10C 64 b/m 20 c/m 130/90 mmltg
MEDICATION
Prescribed drugs were given at the correct time, correct dosage and they help in improving pati
ent health condition.
Drugs given include:
Lisinopril
Warfarin
Vitamin C
Vitamin E
Aspirin
LISINOPRIL
ACTION: it is an antihypertensive and vasodilator drug
MODE OF ACTION: It inhibits the conversion of angiotensin 1 to a vasoconstrictor called angiotensin ii by inhibiting angiotensin converting enzymes, thereby reducing the vasoconstriction and peripheral resistance and consequently causing vasodilatation and lowering of the blood pressure.
INDICATION: hypertension, congestive cardiac failure
DOSAGE: for hypertension- initially 2.5mg – 10mg daily. Then increase gradually to 10-20mg daily.
For congestive Cardiac failure-Initially 2.5mg daily then increase gradually to 5-20mg daily.
ROUTE OF ADMINISTRATION: ORALLY
SIDE EFFECTS: fatigue, cough, rash, diarrhea, orthostatic effects, asthenia, hepatitis, alopecia, abdominal pain, Gl irritation, hypotension.
CONTRAINDICATION: hypersensitivity to ACE inhibitors, history of angioneurotic oedema either hereditary or associated with previous ACE inhibitors.
NURSING IMPLICATION
Tech patient how to get up from bed gradually to avoid postural hypotension.
Monitor the vital signs closely before administering the drug.
Care must be taken not to give the patient potassium supplement so as not to cause hyperkalaemia.
WARFARIN
ACTION: if is an Anticoagulants
MODE OF ACTION: it blocks the hepatic synthesis of blood clotting factors like factors 2, 7, 9 and 10 which are concerned with coagulation. It also inhibits the action of vitamin K from being used for synthesis of prothrombin needed in blood clotting mechanism
INDICATIONS
1) Prophylaxis of embolism in rheumatic heart disease and atrial fibrillation.
2) Prophylaxis after insertion of prosthetic heart valve
3) Prophylaxis and treatment of venous thrombosis and pulmonary embolism.
DOSAGE: 2.5mg daily
ROUTE: Orally
SIDE EFFECTS:
Hemorrhage, hypersensitivity, rash, alopecia, diarrhea, skin necrosis, jaundice hepatic dysfunction, nausea, vomiting, pancreatits
CONTRAINDICATION
Pregnancy, peptic ulcer, sever hypertension, bacteria or endocarditic.
NURSING IMPLICATION
1. Give alone and not with food
2. Advice patient to use soft tooth, brush to prevent bleeding.
3. Watch for skin rash and fever, this may indicate adverse effect.
4. Advise patient to avoid the use of other drugs except on prescription. This is to avoid drug interaction which may impede the action of the drug.
VITAMIN C (ASCORBIC ACID)
ACTION: it is an antiscurvy vitamin
MODE OF ACTION: it is for proper absorption of ferric and ferrous forms of iron in the intestine for haemoglobin formation.
INDICATION: scurvy, viral respiratory infections, cancer, process of wound healing.
DOSAGE: 100mg-500mg as daily dietary intake
ROUTE OF ADMINISTRATION: Orally
SIDE EFFECT: very rare
NURSING IMPLICATION
Serve the correct dose
VITAMIN E
Action: it is a synthetic androgen, a vitaminous drug.
Mode of action: it is a co-enzyme that catalyses protein, fat, carbohydrate and facilitates metabolism
Dosage: 60-75mg daily up to 300mg.
ROUTE OF ADMINISTRATION: orally, intramuscularly
SIDE EFFECTS: rare, over dosage may cause diarrhea, abdominal pain, fatigue and weakness
NURSING IMPLICATION
Serve the correct dose and avoid intravenous route during administration of vitamin E
ASPIRIN
Action: it is an Antipyretics & analgesics, Anti-Inflammatory
Mode of action: As an analgesic, it interferes with transmission of pain impulses at sub cortical brain centers such as the Thalamus. It blocks prostaglandin synthesis this decreasing sensitivity of peripheral pain receptors to mechanical or chemical activation.
As an Antipyretic, it reduces outflow of vasoconstrictor impulses from hypothalamus thus promoting vasodilatation, sweating and heat loss.
Dosage: 75mg dly
Route of administration: orally
Side effect: gastric irrigational and bleeding, skin rashes, asthmatic attacks “salicylism” characterized by deafness, dizziness, tinnitus confusion, vomiting and hyperventilation.
NURSING IMPLICATION
1. Use aspirin cautiously impatiens on anticoagulants.
2. Keep aspirin tablets in a cool dry place. Exposure to moisture or excessive heat will hasten hydrolysis and cause loss of potency.
3. caution individual with aspirin hypersensitivity to real labels of over the counter medication carefully because many contain aspirin or other salicylates
4. Aspirin should not be giving to a child les than 7yers because of Ray’s syndrome
CONTRAINDICATION
History of severe gastro-intestinal disorder was encouraged to do this at home
PREVENTION AND CONTROL
Avoid emotional disturbances e.g. stress producing situations
There should be dietary health education to avoid obesity adequate diet should be encouraged
Periodic physical examination, history, taking, routine monitor of vital signs, strict intake and output monitoring for early detection.
Interventions that alters the risk factors such as treating of high blood pressure, diabetes and stops smoking.
FOLLOW UP VISIT
A visit was made to my patients’ house on the 12th March, 2009. He was in his house in a relaxed mood discussing with his children. He was neatly dressed the environment was clean, there was in dumped refuse around the building and the grass around the house was appropriately cut
I greeted him and he offered me a seat. He was very happy to see me an introduced me to his children who were not around during his period of hospitalization.
I asked about his general state of health and he replied he is such more better than before.
I asked if he has been taken the drugs as prescribed and he said yes. I encouraged mi to continue with the drugs and also to adhere strictly to prescribed drugs. He was health educate to avoid fried food and salt diets.
He was encourage to come for follow up regularly and to come to the hospital if there is any health problem .
CHAPTER FOUR
SUMMARY
The patient for this care study is Mr. A.B. with medical diagnosis of cerebrovascular disease. He stayed in the |Male Medical ward of Obafemi Awolowo Teaching Hospital Complex Wesley Guild Ilesa between 4th Feb. 2009 to 16th Feb. 2009. while on the ward, he was managed by skilful medical and nursing personnel and also by the dieticians. He was properly cared for using holistic approach.
Medication administered were: Lisinopril, Warfarin, Vitamin C, Vitamin E and Aspirin. During hospitalization, he was given his prescribed drugs, he meals were served to time and he was supported by family members.
He was visited after discharge there was evident that he had adjusted to normal living within home setting
Conclusion
Cerebrovascualr accident is a common cause of death and disability especially in the elderly. Atheroma, diabetes mellitus, obesity, cigarette smoking and hypertension are the predisposing factor.
Treatment an rehabilitation of patient in order to bring the patient back to the optimum level of functioning require full cooperation of both patient and relative.
Health education can help in providing adequate information to people and in relieving the incidence or cerebrovascular disease.
RECOMMENDATION
With the study carried out and h important finding discovered the following are thus recommended.
Strenuous exercises should be avoided by those with increased blood pressure it prevents the accumulations of fats in the blood vessels and rescues blood pressure of facts in the blood vessels and reduces blood pressure.
Lifestyle of those predisposed to the disease condition should be adjust.
The community should check their blood pressure regularly at least twice in month especially those that are predispose to this disease condition.
Diet that contains salt and fats which may cause the reoccurrence of the disease should also be avoided.
The health workers should update their knowledge by organizing seminars on cause, prevention and care for those with cerebrovascular disease.
Programmes on television, radio and magazines should be sponsor by government to create awareness about how to prevent the disease condition.
NURSING CARE PLAN OF PATIENT WITH CEREBROVASCULAR DISEASE
S/N OBSERVATION NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION NURSING RATIONALE EVALUATION
1 Patient was asking many question repeatedly Anxiety related to diseases condition Patient anxiety will be allowed within 2hours of nursing intervention. • Assess degree of anxiety and areas of questioning
• Encourage patient to express his feelings.
• Provides counsel for patient on outcome of disease process.
• Ensure the relatives are involved in the patient care.. • it helps to plan appropriate intervention.
• It assit patient in considering a realistic outcome.
• To make him knowledgeable about the disease.
• To make patient have sense of belonging. Patient anxiety was alleviated evidence by calm facial expression after 2 hours of nursing intervention.
2 Patient was not able to perform activities of daily living due to paralysis. Self care deficit related to paralysis Patient will participate in her own care within 72hours of nursing intervention. • Assess patient self care abilities.
• Assist patient with oral care twice daily.
• Assist patient with feeding.
• Give assisted bed bath daily. • It serves as baseline data.
• To improve appetite and to prevent halitosis.
• It increases nutritional status and promote intake of food.
• It promote comfort and boost patient morale. Patient was able to participate in our own care within 72hours of nursing intervention
3 Patient could not speak fluently Impaired verbal communication related to aphasia Patient will be able to communicate effectively within 1 week of nursing intervention • Assess communication deficit.
• Listen attentively when patient attempts to communicate
• Maintain eye contact with patient when speaking. • It help to plan appropriate intervention
• It reduce frustration and anger.
• It enhance good interpersonal relationship.
• It serve as rehabilitative measure. Patient was able to communicate after 1 week of nursing intervention.
S/N OBSERVATION NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION NURSING RATIONALE EVALUATION
4 He was unable to participate in his own care. Activities intolerance related to dizziness and fatigue Patient participate in activities that enhances his physical and psychological well being within 1 week of hospitalization. • Assess patient past and present activity pattern.
• Support patient to walk round the ward
• Assist patient to take his bath daily. • It helps to determine the type, duration, intensity and toleration of former activities.
• It increase blood circulation and prevent falls.
• It promote comfort and prevent infection. Patient was able to participate in activities that enhance his physical and psychological well being within 5days of hospitalization.
5 She was unable to change his position in bed. Risk for impaired skin integrity related to incontinent. Patient will not develop pressure sore throughout the period of hospitalization. • Assess the level of incontinent.
• Change patient position every 2 hours • It relives the bony prominences of constant pressure.
• To enhance voiding and prevent pressure.
• To improve blood circulation to areas of constant pressure. Patient did not develop pressure sore throughout the period of hospitalization.
6 Patient could not control urinary elimination. Impaired urinary elimination pattern related to impaired impulse to void. Patient’s urinary elimination pattern will be controlled within 48 hours of nursing intervention • Assess and record incontinent voiding.
• Catheterized the patient
• Monitor intake and output.
• Note colour and character of urine.
• Ensure bladder training 2 days before catheter removal. • It helps to plan appropriate intervention.
• To enhance voiding.
• To assess kidney function.
• To ensure early detection of urinary tract infection.
• For patient to gain bladder control.
Patient’s urinary elimination pattern was controlled after 48hours of nursing intervention.
S/N OBSERVATION NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION NURSING RATIONALE EVALUATION
7 Patient was observed to be imbalance during mobility Risk for injury related to neurological defects. Patient will not sustain any injury throughout the period of hospitalization. • Monitor patient closely.
• Put bedside rail
• Support the patient while walking.
• Teach patient and family members about the possible source of injury. • It facilitate prompt action incase patient wants to fall.
• To prevent fall
• It reduces opportunity for injury.
• It allows them to identify and correct disk for harmful situation. Patient did not sustain any injury throughout the period of hospitalization.
References
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