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I.

GENERAL OBJECTIVES:

We aim to develop skillful and effective nursing care and to be knowledgeable on the
nature of the disease as well as its management that would be helpful and therapeutic to the
patient.

SPECIFIC OBJECTIVES:

To establish rapport with the patient.
To gather necessary information regarding biographic data and present and past illness
To present the definition and description of the complete diagnosis that would explains the
illness of the patient.
To study and understand the anatomy and physiology of nervous system
To understand the medical management and to be familiarize myself with the
different pharmacological treatment including its indication, action, contraindication,
implications and patients teachings.
To formulate appropriate nursing care plans based on the assessment, to render health
teachings as part of holistic care to alleviate problems identified

MEDICAL DIAGNOSIS:

A cerebral infarction is the ischemic kind of stroke due to a disturbance in the blood
vessels supplying blood to the brain. It can be atherothrombotic or embolic. Stroke caused by
cerebral infarction should be distinguished from two other kinds of stroke: cerebral hemorrhage
and subarachnoid hemorrhage. A cerebral infarction occurs when a blood vessel that supplies a
part of the brain becomes blocked or leakage occurs outside the vessel walls. This loss of blood
supply results in the death of that area of tissue. Cerebral infarctions vary in their severity with
one third of the cases resulting in death.

Symptoms

Symptoms of cerebral infarction are determined by topographical localization of cerebral
lesion. If the infarct is located in primary motor cortex- contra lateral hemi paresis is said to
occur. With brainstem localization, brainstem syndromes are typical: Wallenberg's syndrome,
Weber's syndrome, Millard-Gubler syndrome, Benedikt syndrome or others. Infarctions will
result in weakness and loss of sensation on the opposite side of the body. Physical examination
of the head area will reveal abnormal pupil dilation, light reaction and lack of eye movement on
opposite side. If the infarction occurs on the left side brain, speech will be slurred. Reflexes may
be aggravated as well.
Causes



In thrombotic cerebral infarction a thrombus usually forms around atherosclerotic
plaques. An embolic stroke refers to the blockage of an artery by an embolus , a traveling particle
or debris in the arterial bloodstream originating elsewhere. An embolus is most frequently a
thrombus, but it can also be a number of other substances including fat(e.g. from bone marrow
in a broken bone),air, cancer cells or clumps of bacteria(usually from infectious endocarditis. The
embolus may be of cardiac origin or from atherosclerotic plaque of another (or the same) large
artery.

Risk factors

Risk factors for cerebral infarction are generally the same as for atherosclerosis: Diabetes,
Tobacco smoking Hypercholesterolemia, hyperlipoproteinemia, High blood pressure, Obesity.
Treatment In last decade, similar to myocardial infarction treatment, thrombolytic drugs were
introduced in the therapy of cerebral infarction. The use of intra venous rtPA therapy can be
advocated in patients who arrive to stroke unit and can be fully evaluated within3 h of the
onset. If cerebral infarction is caused by a thrombus occluding blood flow to an artery supplying
the brain, definitive therapy is aimed at removing the blockage by breaking the clot
down(thrombolysis), or by removing it mechanically(thrombectomy). The more rapidly blood
flow is restored to the brain, the fewer brain cells die. In increasing numbers of primary stroke
centers, pharmacologic thrombolysis with the drug tissue plasminogen activator(tPA), is used to
dissolve the clot and unblock the artery. Another intervention for acute cerebral ischaemia
is removal of the offending thrombus directly. This is accomplished by inserting a catheter into
the femoral artery, directing it into the cerebral circulation, and deploying a corkscrew-like
device to ensnare the clot, which is then withdrawn from the body. Mechanical embolectomy
devices have been demonstrated effective at restoring blood flow in patients who were unable
to receive thrombolytic drugs or for whom the drugs were ineffective, though no differences have
been found between newer and older versions of the devices. The devices have only been tested
on patients treated with mechanical
clot embolectomy within eight hours of the onset of symptoms.

II. ANATOMY AND PHYSIOLOGY

The adult human brain weighs on average about 1.5 kg (3.3 lb) with a volume of around
1130 cubic centimetres (cm
3
) in women and 1260 cm
3
in men, although there is substantial
individual variation. Neurological differences between the sexes have not been shown to
correlate in any simple way with IQ or other measures of cognitive performance. The human
brain is composed of neurons, glial cells, and blood vessels. The number of neurons, according
to array tomography, a technique far more accurate than earlier microscopic methods, has
shown about 200 billion neurons in the human brain with 125 trillion synapses in the cerebral
cortex alone.



The cerebral hemispheres (the cerebrum) form the largest part of the human brain and
are situated above other brain structures. They are covered with a cortical layer (the cerebral
cortex) which has a convoluted topography Underneath the cerebrum lies the brainstem,
resembling a stalk on which the cerebrum is attached. At the rear of the brain, beneath the
cerebrum and behind the brainstem, is the cerebellum, a structure with a horizontally furrowed
surface, the cerebellar cortex, that makes it look different from any other brain area. The same
structures are present in other mammals, although they vary considerably in relative size. As a
rule, the smaller the cerebrum, the less convoluted the cortex. The cortex of a rat or mouse is
almost perfectly smooth. The cortex of a dolphin or whale, on the other hand, is more
convoluted than the cortex of a human.
The living brain is very soft, having a consistency similar to soft gelatin or soft tofu.
Despite being referred to as grey matter, the live cortex is pinkish-beige in color and slightly off-
white in the interior.
Brain Divisions

The forebrain is responsible for a variety of functions including receiving and processing
sensory information, thinking, perceiving, producing and understanding language, and
controlling motor function. There are two major divisions of forebrain: the diencephalon and
the telencephalon. The diencephalon contains structures such as the
thalamus and hypothalamus which are responsible for such functions as motor control, relaying
sensory information, and controlling autonomic functions. The telencephalon contains the
largest part of the brain, the cerebrum. Most of the actual information processing in the brain
takes place in the cerebral cortex.

The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion
of the brainstem that connects the hindbrain and the forebrain. This region of the brain is
involved in auditory and visual responses as well as motor function.

The hindbrain extends from the spinal cord and is composed of the metencephalon and
myelencephalon. The metencephalon contains structures such as the pons and cerebellum.
These regions assists in maintaining balance and equilibrium, movement coordination, and the
conduction of sensory information. The myelencephalon is composed of the medulla
oblongata which is responsible for controlling such autonomic functions as breathing, heart
rate, and digestion.
General features
The human brain has many properties that are common to all vertebrate brains, including a
basic division into three parts called the forebrain, midbrain, and hindbrain, each with fluid-
filled ventricles at their core, and a set of generic vertebrate brain structures including
the medulla oblongata, pons, cerebellum, optic tectum, thalamus, hypothalamus, basal
ganglia, olfactory bulb, and many others.

Cerebral cortex


Bisection of the head of an adult female, showing the cerebral cortex, with its extensive folding,
and the underlying white matter
The dominant feature of the human brain is corticalization. The cerebral cortex in humans
is so large that it overshadows every other part of the brain. A few subcortical structures show
alterations reflecting this trend. The cerebellum, for example, has a medial zone connected
mainly to subcortical motor areas, and a lateral zone connected primarily to the cortex. In
humans the lateral zone takes up a much larger fraction of the cerebellum than in most other
mammalian species. Corticalization is reflected in function as well as structure. In a rat, surgical
removal of the entire cerebral cortex leaves an animal that is still capable of walking around and
interacting with the environment. In a human, comparable cerebral cortex damage produces a
permanent state of coma. The amount of association cortex, relative to the other two categories,
increases dramatically as one goes from simpler mammals, such as the rat and the cat, to more
complex ones, such as the chimpanzee and the human
The cerebral cortex is essentially a sheet of neural tissue, folded in a way that allows a
large surface area to fit within the confines of the skull. When unfolded, each cerebral
hemisphere has a total surface area of about 1.3 square feet (0.12 m
2
). Each cortical ridge is
called agyrus, and each groove or fissure separating one gyrus from another is called a sulcus.

Cortical divisions
Four lobes


The four lobes of the cerebral cortex
The cerebral cortex is nearly symmetrical with left and right hemispheres that are
approximate mirror images of each other. Each hemisphere is conventionally divided into four
"lobes", the frontal lobe, parietal lobe, occipital lobe, and temporal lobe. With one exception, this
division into lobes does not derive from the structure of the cortex itself, though: the lobes are
named after the bones of the skull that overlie them, the frontal bone, parietal bone, temporal
bone, and occipital bone. The borders between lobes lie beneath the sutures that link the skull
bones together. The exception is the border between the frontal and parietal lobes, which lies
behind the corresponding suture; instead it follows the anatomical boundary of the central
sulcus, a deep fold in the brain's structure where the primary somato sensory cortex and
primary motor cortex meet.
Because of the arbitrary way most of the borders between lobes are demarcated, they
have little functional significance. With the exception of the occipital lobe, a small area that is
entirely dedicated to vision, each of the lobes contains a variety of brain areas that have minimal
functional relationship. The parietal lobe, for example, contains areas involved in
somatosensation, hearing, language, attention, and spatial cognition. In spite of this
heterogeneity, the division into lobes is convenient for reference. The main functions of the
frontal lobe are to control attention, abstract thinking, behavior, problem solving tasks, and
physical reactions and personality. The occipital lobe is the smallest lobe; its main functions are
visual reception, visual-spatial processing, movement, and color recognition. The temporal lobe
controls auditory and visual memories, language, and some hearing and speech.
Although there are enough variations in the shape and placement
of gyri and sulci (cortical folds) to make every brain unique, most human brains show
sufficiently consistent patterns of folding that allow them to be named. Many of the gyri and
sulci are named according to the location on the lobes or other major folds on the cortex. These
include:
Superior, Middle, Inferior frontal gyrus: in reference to the frontal lobe
Medial longitudinal fissure, which separates the left and right cerebral hemispheres
Precentral and Postcentral sulcus: in reference to the central sulcus, which separates
the frontal lobe from the parietal lobe
Lateral sulcus, which divides the frontal lobe and parietal lobe above from the temporal lobe
below
Parieto-occipital sulcus, which separates the parietal lobes from the occipital lobes, is seen to
some small extent on the lateral surface of the hemisphere, but mainly on the medial
surface.
Trans-occipital sulcus: in reference to the occipital lobe


Functional divisions
Researchers who study the functions of the cortex divide it into three functional
categories of regions. One consists of the primary sensory areas, which receive signals from
thesensory nerves and tracts by way of relay nuclei in the thalamus. Primary sensory areas
include the visual area of the occipital lobe, the auditory area in parts of the temporal
lobeand insular cortex, and the somatosensory cortex in the parietal lobe. A second category is
the primary motor cortex, which sends axons down to motor neurons in the brainstem and
spinal cord. This area occupies the rear portion of the frontal lobe, directly in front of the
somatosensory area. The third category consists of the remaining parts of the cortex, which are
called the association areas. These areas receive input from the sensory areas and lower parts of
the brain and are involved in the complex processes ofperception, thought, and decision-
making.
Cytoarchitecture

Brodmann's classification of areas of the cortex
Different parts of the cerebral cortex are involved in different cognitive and behavioral
functions. The differences show up in a number of ways: the effects of localized brain damage,
regional activity patterns exposed when the brain is examined using functional imaging
techniques, connectivity with subcortical areas, and regional differences in the cellular
architecture of the cortex. Neuroscientists describe most of the cortexthe part they call
the neocortexas having six layers, but not all layers are apparent in all areas, and even when a
layer is present, its thickness and cellular organization may vary. Scientists have constructed
maps of cortical areas on the basis of variations in the appearance of the layers as seen with a
microscope. One of the most widely used schemes came from Korbinian Brodmann, who split
the cortex into 51 different areas and assigned each a number (many of these Brodmann
areas have since been subdivided). For example, Brodmann area 1 is the primary somatosensory
cortex, Brodmann area 17 is the primary visual cortex, and Brodmann area 25 is the anterior
cingulate cortex.