CHAPETR I

INTRODUCTION

BACKGROUND OF THE STUDY

The Philippines is one of the developing countries with many morbid and
mortality cases, one of them is a Cerebrovascular accident or commonly called
stroke, which causes a lot of mortality and disability in our country.
A stroke is a sudden interruption in the blood supply to the brain. Most
strokes are caused by an abrupt blockage of arteries leading to the brain (ischemic
stroke), Other strokes are caused by bleeding into brain tissue when a blood vessel
bursts (hemorrhagic stroke). stroke occurs rapidly and requires immediate
treatment, it is also called a brain attack. When the symptoms of a stroke last only
a short time (less than an hour), this is called a transient ischemic attack (TIA) or
mini-stroke. 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.
Ischemic stroke is the most common type of stroke, accounting for almost
80 percent of all strokes, is caused by a clot or other blockage within an artery
leading to the brain.
Globally, according to the World Health Organization (WHO), stroke is the
second leading cause of death which killed 6.7 million people yearly and latest
World Health Organization (WHO) data published in May 2014 stroke deaths in
the Philippines reached 63,261 or 12.14% of total deaths and it is the second
leading cause of mortality in the country. In Zamboanga City, stroke is the 4th
leading cause of mortality, according to the health-related statistics of Zamboanga
city government.
This comprehensive clinical case study presents a client with a Cardiovascular
Problem (cerebrovascular accident) with right sided weakness secondary to
infarct (multiple) Hypertension II. Assessment, differential diagnosis,
management of the client and appropriate assessment tools, theories, and NOC-
NIC used are discussed in preceding chapters.
 DISEASE CONDITION
Cerebrovascular accident is the sudden death of some brain cells due to
lack of oxygen when the blood flow to the brain is impaired by blockage or rupture
of an artery to the brain. Ischemic stroke is by far the most common kind of stroke,
accounting for about 88 percent of all strokes. Stroke can affect people of all ages,
including children. Many people with ischemic strokes are older (60 or more years
old), and the risk of stroke increases with age.
Ischemic stroke occurs when an artery to the brain is blocked. The brain
depends on its arteries to bring fresh blood from the heart and lungs. The blood
carries oxygen and nutrients to the brain, and takes away carbon dioxide and
cellular waste. If an artery is blocked, the brain cells (neurons) cannot make
enough energy and will eventually stop working. If the artery remains blocked for
more than a few minutes, the brain cells may die. This is why immediate medical
treatment is critical.

Figure 1. an ischemic stroke Fig.2 Deprived of oxygen and

occurs when an artery in the other nutrients, the brain suffers
brain becomes blocked. damage as a result of the stroke.

CAUSES
Common causes of stroke come from blood vessels both outside and inside the
brain. Atherosclerosis (hardening of the arteries) can occur when plaque (deposits of
cholesterol, calcium, fat, and other substances) builds up and narrows the vessel making
it easy for clots to form and further occlude the vessel. The clots can break free only to
occlude smaller blood vessels inside the brain. The blood vessels inside the brain itself can
accumulate this plaque. Occasionally, weakened vessels can burst and bleed into the
brain.
 Figure 3

DIAGNOSTIC TEST

 MEDICAL HISTORY & Physical examination-the doctor will ask you or a family
member about your risk factors for stroke. Examples of risk factors include high
blood pressure, smoking, heart disease, and a personal or family history of stroke.
the doctor also will ask about your signs and symptoms and when they began.
During the physical exam, the doctor will check your mental alertness and your
coordination and balance. He or she will check for numbness or weakness in your
face, arms, and legs; confusion; and trouble speaking and seeing clearly.
 Blood tests A blood glucose test measures the amount of glucose (sugar) in your
blood. Low blood glucose levels may cause symptoms similar to those of a stroke.
 Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a
detailed image of your brain. A CT scan can show a hemorrhage, tumor, stroke
and other conditions. Doctors may inject a dye into your bloodstream to view your
blood vessels in your neck and brain in greater detail (computerized tomography
angiography).
 Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and
magnets to create a detailed view of your brain. An MRI can detect brain tissue
damaged by an ischemic stroke and brain hemorrhages. Your doctor may inject a
dye into a blood vessel to view the arteries and veins and highlight blood flow
(magnetic resonance angiography, or magnetic resonance venography).

 Carotid ultrasound. In this test, sound waves create detailed images of the inside of
the carotid arteries in your neck. This test shows buildup of fatty deposits (plaques)
and blood flow in your carotid arteries.

 Cerebral angiogram. In this test, your doctor inserts a thin, flexible tube (catheter)
through a small incision, usually in your groin, and guides it through your major
arteries and into your carotid or vertebral artery. Then your doctor injects a dye into
your blood vessels to make them visible under X-ray imaging. This procedure gives
a detailed view of arteries in your brain and neck.
  Echocardiogram. An echocardiogram uses sound waves to create detailed images
of your heart. An echocardiogram can find a source of clots in your heart that may
have traveled from your heart to your brain and caused your stroke

SIGNS & SYMPTOMS

The most common sign of stroke is sudden weakness of the face, arm or leg, most
often on one side of the body.

Other warning signs can include:

 Sudden confusion, trouble speaking or understanding speech

 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of balance or coordination
 Sudden severe headache with no known cause
The signs of a stroke depend on the side of the brain that’s affected, the part of the brain
affected, and how severely the brain is injured. Therefore, each person may have different
stroke warning signs. Stroke may be associated with a headache, or may be completely
painless.

these are the signs and symptoms occurring after stroke:

 Hemiplegia
 Aphasia
 Apraxia
 Hemianopia
 Agnosia
 Dysarthia
 Kinesthesia
 Bowel or bladder incontinence
 Shoulder pain
 Unilateral neglect
 Memory and spatial perception or loss of direction
 Mood swings
 Social withdrawal
 Inappropriate sexual behavior
 Sudden outbursts of anger
 Regression
RISK FACTORS

Medical conditions that increase the risk of stroke:

 Previous stroke or “mini-stroke” (transient ischemic attack, TIA)
Depending on the most likely cause of your stroke, your doctor may prescribe
specific medication or consider surgery to remove fatty deposits in your carotid
artery.
 High blood pressure
Hypertension is one of the leading risks for heart disease and stroke. Your
 physician may advise dietary or lifestyle changes, or specific medications to lower
your blood pressure.
 Diabetes
we may think this disorder affects only the body's ability to use sugar, or glucose.
But it also causes destructive changes in the blood vessels throughout the body,
including the brain. Also, if blood glucose levels are high at the time of a stroke,
then brain damage is usually more severe and extensive than when blood glucose
is well-controlled. Treating diabetes can delay the onset of complications that
increase the risk of stroke.
 Heart disease
Common heart disorders such as coronary artery disease, valve defects, irregular
heartbeat, and enlargement of one of the heart's chambers can result in blood
clots that may break loose and block vessels in or leading to the brain. The most
common blood vessel disease, caused by the buildup of fatty deposits in the
arteries, is called atherosclerosis. the doctor will treat your heart disease and may
also prescribe medication, such as aspirin, to help prevent the formation of clots.

CONTROLLABLE RISK FACTORS AND LIFESTYLE CHOICES:

 Cigarette Smoking
Cigarette smoking has been linked to the buildup of fatty substances in the carotid
artery, the main neck artery supplying blood to the brain. Blockage of this artery is
the leading cause of stroke. Also, nicotine raises blood pressure; carbon monoxide
reduces the amount of oxygen your blood can carry to the brain; and cigarette
smoke makes the blood thicker and more likely to clot.
 Obesity, elevated cholesterol, and elevated lipids
Reducing your dietary intake of saturated fats and cholesterol may help reduce
your risk of a stroke.
 Physical inactivity
A sedentary lifestyle void of regular exercise can contribute to heart disease which
may lead to stroke.
 Excessive alcohol intake
  Illegal drug use

UNCONTROLLABLE RISK FACTORS:

 Increasing age
Stroke is more common in people over 60.
 Male sex
Men and women both have strokes but stroke is more common at younger ages
in men.
 Heredity and ethnicity
Stroke is more common in people whose close relatives have had stroke at an
early age. African-Americans and Hispanic Americans are at higher risk than white
Americans. This may be due in part to high blood pressure and dietary
differences.

TREATMENT AND MANAGEMENT

Emergency treatment with medications. Therapy with clot-busting drugs must start
within 3 hours if they are given into the vein — and the sooner, the better. Quick
treatment not only improves your chances of survival but also may reduce complications.
You may be given:
 Aspirin. Aspirin is an immediate treatment given in the emergency room to reduce
the likelihood of having another stroke. Aspirin prevents blood clots from forming.
 Intravenous injection of tissue plasminogen activator (TPA). Some people can
benefit from an injection of a recombinant tissue plasminogen activator (TPA),
also called alteplase. An injection of TPA is usually given through a vein in the arm.
This potent clot-busting drug needs to be given within 4.5 hours after stroke
symptoms begin if it's given in the vein.
TPA restores blood flow by dissolving the blood clot causing your stroke, and it may help
people who have had strokes recover more fully. the doctor will consider certain risks,
such as potential bleeding in the brain, to determine if TPA is appropriate for patient.
Emergency procedures. Doctors sometimes treat ischemic strokes with procedures that
must be performed as soon as possible, depending on features of the blood clot:
 Medications delivered directly to the brain. Doctors may insert a long, thin tube
(catheter) through an artery in your groin and thread it to your brain to deliver
TPA directly into the area where the stroke is occurring. The time window for this
treatment is somewhat longer than for intravenous TPA but is still limited.
 Mechanical clot removal. Doctors may use a catheter to maneuver a tiny device
into your brain to physically break up or grab and remove the clot.
Other procedures. To decrease your risk of having another stroke or transient ischemic
attack, the doctor may recommend a procedure to open up an artery that's narrowed by
fatty deposits (plaques). Doctors sometimes recommend the following procedures to
prevent a stroke. Options will vary depending on your situation:
 Carotid endarterectomy. In a carotid endarterectomy, a surgeon removes
plaques from arteries that run along each side of the neck to the brain (carotid
arteries). In this procedure, the surgeon makes an incision along the front of your
neck, opens your carotid artery and removes plaques that block the carotid artery.
 Angioplasty and stents. In an angioplasty, a surgeon gains access to your carotid
arteries most often through an artery in your groin. Here, he or she can gently and
safely navigate to the carotid arteries in your neck. A balloon is then used to
expand the narrowed artery. Then a stent can be inserted to support the opened
artery.

PREVENTION

 Managing medical condition

Common condition that increase risk for stroke include high blood pressure,
elevated cholesterol levels, diabetes and obesity.
 Lifestyle changes (smoking & alcohol)
A Person can reduce his/her stroke risk by changing his/her lifestyle. stop smoking,
smoking can damage and tighten the blood vessels and reducing the alcohol
consumption.
 Diet
One of the best ways to reduce stroke is to eat a diet that has low cholesterol to
reduce the chances of plaque formation in blood vessels. Foods high in salt may
increase blood pressure, cutting back on calories help reduces obesity. And diet
that contains a lot of vegetable, fruit and whole grains, along with more contains
fish and less meat (red meat) is suggested to lower stroke risk.
 Exercise
Physical activity can improve your fitness level and health. Before doing any
activity consults first your doctor about what types and amount of
exercise/activity is appropriate and safer for you.

COMPLICATION
The most common complications are:
 Brain edema – swelling of the brain after stroke
 Pneumonia – causes breathing problem, a complication of many major illness,
pneumonia occurs as a result of the not being able to move as a result of stroke.
 Swallowing problems after stroke can sometimes result in thing going down the
wrong pipe. Leading to aspiration pneumonia.
 Urinary tract infection (UTI) – it can occur as a result of a Foley catheter placed to
collect urine when stroke survivor cannot control bladder function.
 Seizures – abnormal electrical activity in the brain causing convulsions. These are
common in large stroke.
 Clinical depression – a treatable illness that often occurs with stroke and causes
unwanted emotional and physical reaction to changes and losses. This is very
common after stroke or maybe worsened in someone who had depression before
the stoke.
 Bed sore – pressure ulcers that result from decrease ability to move and pressure
on areas of the body because of immobility.
 Limb contractures – shortened muscle in an arm or leg from reduced ability to
move the affected limb or lack of exercise.
 Shoulder pain – stems from lack of support of an arm due to weakness or paralysis.
This usually is caused when the affected arm hangs resulting in pulling of the arm
on the shoulder.
 Deep vein thrombosis (DVT) – blood clots forms in the vein of the legs because of
immobility from stroke.
 Another stroke
 Comatose or if left untreated or not prevented it will lead to death.

ANATOMY AND PHYSIOLOGY

The human brain weighs an average of 3 lbs. in men and 2 lbs. 12 oz. in women
and has about 100 billion cells called neurons. The brain’s structure is almost complete at
birth, although it continues to grow until about age 20, with increases in the size of
individual cells and the amount of tissue connecting the neurons. The brain is made up of
distinct parts that developed through human evolution. The oldest evolutionary parts,
which are responsible for life-supporting functions such as breathing, blood circulation
and sleeping, are found at the base of the brain, joined to the spinal cord. This area is
called the “brain stem” and includes the midbrain, pons and medulla oblongata. The more
recently developed areas — the cerebellum and the cerebrum — surround the brain
stem. The cerebellum is a cauliflower-shaped structure, located just above the brain
stem, beneath the occipital lobes at the base of the skull.

The cerebellum regulates muscle tone, coordinates movement and helps

maintain posture and balance. The cerebellum has two halves, similar to the cerebrum. It
does not initiate movements, but is responsible for their smooth and balanced execution,
for maintaining muscle tension and making movements work together in complex action
such as walking. It comprises approximately 10 percent of the brain’s volume, contains at
least half its neurons and is connected to the brain stem via three major bundles of input
and output fibers called peduncles. The cerebrum, a large rounded structure, is closely
related to functions including thought, reason, emotion and memory. It occupies most of
the cranial cavity and is divided into two hemispheres that are joined at the bottom by
the corpus callosum. The two hemispheres are mirror images of each other and control
opposite sides of the body. The left cerebral hemisphere controls speech and academic
and analytical processes; the right cerebral hemisphere deals with more artistic and
imaginative activities, and also controls facial perception and music.

figure 4

Each cerebral hemisphere is subdivided into four lobes: occipital, temporal, frontal and parietal.

 The occipital lobes are pyramid-shaped structures located at the back of the brain that
receive and analyze visual information.
 The temporal lobes, located on the skull side of each hemisphere (near the ears), deal
with hearing.
 The frontal lobes, at the front of each hemisphere behind the forehead, are responsible
for cognitive thought processes (knowing, thinking, learning and judging). They also
regulate voluntary movements. The prefrontal areas of these lobes are involved with
intelligence and personality.
 The parietal lobes, located above the occipital lobes, are mainly associated with our sense
of touch and balance and are important in interpreting sensory information from various
parts of the body, and in the manipulation of objects.
 figure 5
Both cerebral hemispheres are covered by the cerebral cortex, which has many folds and
resembles a walnut kernel. The gray outer layer of the cerebral cortex contains neurons
and dendrites — branched projections that conduct electrical stimulation to the cell body.
This outer layer surrounds a thicker layer of white matter made up of nerve fibers.

The brain stem contains the midbrain, pons and medulla oblongata. The midbrain — the
uppermost part — has fibers that connect the brain stem to the cerebrum and
cerebellum; this area is very important in the control of skeletal movements. The pons,
which lies between the midbrain and medulla oblongata, relays sensory information
between the cerebrum and cerebellum. The medulla oblongata contains centers for the
control of breathing and cardiovascular function.

figure 6
Another area, the forebrain, contains the thalamus, hypothalamus and pituitary gland. It
is almost completely surrounded by the cerebral hemispheres and contains a cavity
known as the third ventricle. The thalamus is a tightly packed cluster of nerve cells that
relays impulses
from the sense organs to the cortex. The hypothalamus controls hunger, thirst,
temperature, aggression and sex drive; it also controls the pituitary gland, which controls
the secretion of many hormones.
The reticular formation is an intricate network of nuclei and nerve fibers within the
medulla oblongata, pons, midbrain, thalamus and hypothalamus that functions as the
reticular activating system. This contains the sensory pathways from the spinal cord to
the brain and is important in maintaining a state of alert consciousness.

figure 7
Looped around the brain stem and hypothalamus are the structures of the limbic system,
which are thought to be involved in emotional responses such as fear, aggression and
mood changes. The brain also has four fluid-filled cavities called ventricles where
cerebrospinal fluid is produced.

PATHOPHYSIOLOGY
The primary pathophysiology of stoke is an underlying heart or blood vessel
disease. The secondary manifestations in the brain are the result of one or more of these
underlying diseases or risk factors. The primary pathologies include hypertension,
atherosclerosis leading to coronary artery disease, dyslipidemia, heart disease, and
hyperlipidemia. The two types of stroke that result from these disease states are ischemic
and hemorrhagic strokes.
In an ischemic brain attack, there is disruption of the cerebral blood flow due to
obstruction of a vessel. This disruption in blood flow initiates a complex series of cellular
metabolic events referred to as the ischemic cascade.
PHYSIOLOGY/PATHOPHYSIOLOGY

Ischemia

Energy failure

Acidosis Ion imbalance

Increase Depolarization
glutamate

Intracellular Calcium
increased

Cell membranes and proteins break down

formation of free radicals protein
production decreased

Cell injury and death

Figure 8
The ischemic cascade begins when cerebral blood flow falls less than 25ml/100
g/min. at this point, neurons can no longer maintain aerobic respiration. The
mitochondria must then switch to anaerobic respiration. Which generates large amounts
of lactic acid, causing a change in the 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 processes. Thus, the membranes
pumps that maintain electrolytes balance begin to fail and the cells cease to function.
 Early in the cascade, an area of low cerebral blood flow, referred to as the
penumbra region, exists around the area of infarction. Penumbra region is ischemic brain
tissue that can be salvaged with timely intervention. The ischemic cascade threatens cells
in the penumbra because membranes depolarization of the cell wall leads to an increase
in intracellular calcium and the release of glutamate (Hock, 1999). The penumbra area
can be revitalized by administration of tissue plasminogen activator (t-PA), and the influx
of calcium can be limited with the use of calcium channel blockers. The influx of calcium
and the release of glutamate, if continued, activate a number of damaging pathways that
results in the destruction of the cell membrane, the release of more calcium and
glutamate, vasoconstriction, and the generation of free radicals. These process enlarge
the area of infarction into the penumbra, extending the stroke.
B. OBJECTIVES
General Objectives
Application of concepts and theories in the care of client with
cardiovascular problem (cerebrovascular accident) utilizing the nursing process.

Specific Objectives
At the end of ten (10) days intensive practicum, I will be able to:
a. Assess the client using physiological, psychological and cultural and
spiritual needs utilizing the appropriate health assessment tool:
Physical examination by patricia Dillon, 11 functional health pattern by
Marjory Gordon, Barthel index rating scale, Braden scale, Tinetti
balance & gait evaluation.
b. Identify problem based on abdellah’s 21 nursing problem and Prioritize
client’s problem based on the Maslow hierarchy of needs.
c. Formulate a comprehensive nursing care plan based on the identified
prioritized problem utilizing Nursing outcome classification (NOC) and
nursing intervention classification (NIC).
d. Implement plan of care integrating Faye Abdellah’s theory
e. Evaluate the effectiveness of nursing care rendered through the
client’s response.
SIGNIFICANCE

This case study is design to gain and provide comprehensive knowledge on the
nursing process, nursing outcome classification (NOC) and nursing intervention
classification (NIC), concepts and theories (Faye Glenn Abdellah) and disease condition.
(cerebrovascular accident).

This study can contribute to the nursing knowledge by providing comprehensive

better understanding and utilization of nursing process, different assessment tools,
concepts and theories, nursing outcome classification (NOC) and nursing intervention
classification (NIC), theory of Faye Abdellah (21 nursing problems) and cerebrovascular
disease.

The client can benefit from the study by providing basic information on the effect
of disease condition on the well-beings of client, how to prevent further complication,
proper caring of a stroke survivor and with right education, understanding and
participation, it can promote and maintain optimum health of the client.

This study can provide and serve as a guidance to the nursing profession and how
to manage, take care and promote comfort of the stroke survivor. The introduction and
utilization of nursing outcome classification and nursing intervention classification in the
nursing practice. Identifying and prioritizing the health problems according to the needs
of the client using the 21 nursing problem and Maslow hierarchy of needs. This study can
enhance the knowledge and skills of the nurse as well as the client.

This will also serve as an additional information and reference to the student who
will take comprehensive clinical case study, to institution and other health care provider
for future related researches.