Capitol University

College of Nursing

A CASE STUDY

On
A patient with
CEREBROVASCULAR DISEASE

A written Requirement Presented to

MR. JonathAn Gesta, R.N
Clinical Instructor

In Partial Fulfillment of the Final Requirement In

RELATED LEARNING EXPERIENCE 40

By
Kristine Jean R. Tampus

BSN-3
December 9, 2010
 Table of contents

I. Introduction

II. Client’s Profile

III. Anatomy and Physiology

IV. Pathophysiology

V. Diagnostic Procedures and Lab Results

VI. Drug Study

VII. Nursing Care Plans

VIII. Discharge Plan

IX. Learning Insights

X. Reference
 I. INTRODUCTION

Cerebrovascular Disease

The word cerebrovascular is made up of two parts – "cerebro" which refers to the large part of the
brain, and "vascular" which means arteries and veins. Together, the word cerebrovascular refers to
blood flow in your brain. The term cerebrovascular disease includes all disorders in which an area
of the brain is temporarily or permanently affected by ischemia or bleeding and one or more of the
cerebral blood vessels are involved in the pathological process. Cerebrovascular disease includes
stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular
malformations.

Restrictions in blood flow may occur from vessel narrowing (stenosis), clot formation (thrombosis),
blockage (embolism), or blood vessel rupture (hemorrhage). Lack of sufficient blood flow
(ischemia) affects brain tissue and may cause a stroke.

Blood Flow to the Brain

Your heart pumps blood up to the brain through two sets of arteries, the carotid arteries and the
vertebral arteries. The carotid arteries are located in the front of your neck and are what you feel
when you take your pulse just under your jaw. The carotid arteries split into the external and
internal arteries near the top your neck with the external carotid arteries supplying blood to your
face and the internal carotid arteries going into the skull. Inside the skull, the internal carotid
arteries branch into two large arteries – the anterior cerebral and middle cerebral arteries, and
several smaller arteries – the ophthalmic, posterior communicating, and anterior choroidal arteries.
These arteries supply blood to the front two-thirds of your brain.

The vertebral arteries extend along side your spinal column and cannot be felt from the outside. The
vertebral arteries join to form a single basilar artery near the brain stem, which is located near the
base of your skull. The vertebrobasilar system sends many small branches into the brain stem and
branches off to form the posterior cerebellar and posterior meningeal arteries, which supply the
back third of your brain. The jugular and other veins carry blood out of the brain.

Because the brain relies on only two sets of major arteries for its blood supply, it is very important
that these arteries are healthy. Often, the underlying cause of an ischemic stroke is carotid arteries
blocked with a fatty buildup called plaque. During a hemorrhagic stroke, an artery in or on the
surface of the brain has ruptured or leaks, causing bleeding and damage in or around the brain.
Whatever the underlying condition and cause are, it is crucial that proper blood flow and oxygen be
restored to the brain as soon as possible. Without oxygen and important nutrients, the affected brain
cells are either damaged or die within a few minutes. Once brain cells die, they cannot regenerate,
and devastating damage may occur, sometimes resulting in physical, cognitive and mental
disabilities.

Causes:
•Intracerebral hemmorhage (rupture of a blood vessel in the pia mater or brain
•Emboli (blood clots)
•Atherosclerosis (formation of plaque) of the cerebral arteries
•

Stroke

Stroke is an abrupt interruption of constant blood flow to the brain that causes loss of
neurological function. The interruption of blood flow can be caused by a blockage, leading
to the more common ischemic stroke, or by bleeding in the brain, leading to the more
deadly hemorrhagic stroke. Ischemic stroke constitutes an estimated 80 percent of all
stroke cases. Stroke may occur suddenly, sometimes with little or no warning, and the
results can be devastating.

Types of Stroke by Etiology:

•Hemorrhage stroke (intracranial hemorrhage)

•5% of all strokes
•two division
•Intracerebral (10%) – due to rupture of weakened vessels within brain
parenchyma as result of Hypertension, arteriovenous malformation
or tumor
•Subarachnoid (5%) – result from aneurismal rupture of a cerebral
artery with blood loss into space surrounding the brain; evolve over
1 –2 hours.
 •Ischemic Strokes (remaining 85%)
•Large (40%) or small (20%) vessel thrombosis
-most commonly occur in presence of atherosclerotic cerebrovascular disease
-vascular changes or lipohyalinosis found in small deep penetrating arteries as
associated with chronic hypertension can lead to small vessel thrombosis.
-rapid or prolonged interval of onset and may lead last many hours
•Cerebral embolism (20%)
-usually a cardiac origin
-frequently result of chronic ischemic cardiovascular disease with secondary
ventricular wall hypokinessis or artial arrhythmia – both conditions increase risk
of intracardiac thrombus formation
-quick onset and fully develop in a matter of minute

•Background of the study

Cerebrovascular disease (CVD) in HIV may be associated with multiple concurrent
etiologies and with varying presentations, from chronic asymptomatic microvascular
calcifications or vascular anomalies to intracerebral hemorrhage to thrombotic stroke. A
pattern of fusiform aneurysmal dilatations of intracerebral arteries, particularly in the circle
of Willis, has been identified as a characteristic of HIV-associated vasculopathy in
congenitally HIV-infected children.

There may be a similar pathological pattern in adult-acquired HIV infection, although

this is not as well described, and young adults certainly present with evidence of
cerebrovascular disease atypical for their age group. Here we present a case of a young
man, congenitally infected with HIV, who has headache and evidence of cerebrovascular
disease.

A rapidly-growing field, cerebrovascular research is unique in that it involves a variety

of specialties such as neurology, internal medicine, surgery, radiology, epidemiology,
cardiology, hematology, psychology and rehabilitation.Cerebrovascular Diseases is a new
international forum which meets the growing need for sophisticated, up-to-date scientific
information on clinical data, diagnostic testing, and therapeutic issues, dealing with all
aspects of stroke and cerebrovascular diseases. It contains original contributions, reviews
of selected topics and clinical investigative studies, recent meeting reports and work-in-
progress as well as discussions on controversial issues. All aspects related to clinical
advances are considered, while purely experimental work appears if directly relevant to
clinical issues.

•Scope and limitation

In this study, it is all about information and diagnosis of patient to determine what really
the causes of patient’s condition, to identify what is the student nurse responsibility on
dealing patients with this kind of disease condition. This was started last November 11-
November 26 ,2010 at NMMC Medical Ward.

 CLIENT’S PROFILE

 Demographic data

Patient X is 62 years-old male, married, Filipino, Roman Catholic, residing at the

Bulua, Cagayan De Oro City. Patient was admitted for the first time at Northern
Mindanao Medical Center last November 11,2010 @ 12:00 PM due to numbness left
side of the body.

Patient’s vital signs are: Blood Pressure of 120/100 mmHG, temperature of 35.4 degree Celsius,
respiratory rate of 20 cpm and a pulse rate of 76 bpm. At present he weighs 65 kls.

 HISTORY OF PAST ILLNESS

According to the spouse of our patient, he has already hypertension during her 30’s
and has no other sickness other than those. Difficulties of breathing sometimes were also
verbalized by the patient. Also, the son verbalized that the patient doesn’t have any
allergies in medications, foods and environment. She didn’t go in any surgery.

•HISTORY OF PRESENT ILLNESS

6 hours PTA, patient has onset of left sided weakness, vomiting, dizziness, change in
sensorium. Patient then immediately brought at the hospital: thus this admission.

FAMILY HEALH HISTORY

They have a history of Hypertension and 1died in their family. Her mother side has
a history of hypertension, and his father died with heart attack.
 •SOCIAL HISTORY
According to the son, his mother is a responsible mother. She gives all the necessary
needs of his children. She said that if his mother is mad, he was still quiet and keeps it to
himself .Very close to their neighbors, she spends time mingle with her family and friends,
also their neighbors.

GORDON’S FUNCTIONAL ASSESSMENT

•PSYCHOLOGICAL
• ROLE RELATIONSHIP PATTERN
• SEXUALITY AND REPRODUCTIVE
• COGNITIVE PERCEPTUAL PATTERN
• VALUE BELIEF PATTERN
• ELIMINATION
• REST AND ACTIVITY
• SLEEP REST PATTERN
• COPING STRESS TOLERANCE PATTERN:
• NUTRITION

 PHYSICAL ASSESSMENT
•Vital signs:

•General appearance

•Mental status

•Skin

•Nail

•Head and Face

•Eyes

•Ear

•Nose

•Mouth and Oropharynx

•Neck

•Breast
• Chest and Lungs

•Heart

•Abdomen

•Upper extremities

•Lower extremities

•Genital (according to the client)

 III. ANATOMY AND PHYSIOLOGY
BRAIN

Cerebrum- The biggest part of the brain is the cerebrum. The cerebrum makes up 85% of
the brain's weight, and it's easy to see why. The cerebrum is the thinking part of the brain
and it controls your voluntary muscles.

Cerebellum- The cerebellum is at the back of the brain, below the cerebrum. It's a lot
smaller than the cerebrum at only 1/8 of its size. But it's a very important part of the
brain. It controls balance, movement, and coordination (how your muscles work
together).
BrainStem- The brain stem sits beneath the cerebrum and in front of the cerebellum. It
connects the rest of the brain to the spinal cord, which runs down your neck and back.
The brain stem is in charge of all the functions your body needs to stay alive, like
breathing air, digesting food, and circulating blood.

Midbrain/ Mesencephalon- the rostral part of the brain stem, which includes the tectum
and tegmentum. It is involved in functions such as vision, hearing, eyemovement, and
body movement. The anterior part has the cerebral peduncle, which is a huge bundle
of axons traveling from the cerebral cortex through the brain stem and these fibers
 (along with other structures) are important for voluntary motor function.

Pons- part of the metencephalon in the hindbrain. It is involved in motor control and
sensory analysis... for example, information from the ear first enters the brain in the pons.
It has parts that are important for the level of consciousness and for sleep. Some
structures within the pons are linked to the cerebellum, thus are involved in movement and
posture.

medulla oblongata is the lower portion of the brainstem. It deals with autonomic functions,
such as breathing and blood pressure. The cardiac center is the part of the medulla
oblongata responsible for controlling the heart rate.

Hypothalamus- The hypothalamus is like your brain's inner thermostat (that little box on
the wall that controls the heat in your house). The hypothalamus knows what temperature
your body should be (about 98.6° Fahrenheit or 37° Celsius).

IV. PATHOPHYSIOLOGY

V. Diagnostic Procedures and Lab Results

BLOOD CHEMISTRY RESULT

LAB TEST RESULTS UNITS NORMAL INTERPRETATI

VALUES ON
GLUCOSE 101.1 mg/dL 59.9-110.1 NORMAL
TRIGL 103 mg/dL 43.0-149.0 NORMAL
LDL 121.8 mg/dL 0.0-151.0 NORMAL
CHOL 195.8 mg/dL 0.0-261.0 NORMAL
HDL 57.4 mg/dL 40.0-120.0 NORMAL
 URINALYSIS REPORT
PHYSICAL
PROPERTIES
TEST
Color Light yellow
Clarity clear
pH 6.5
Specific gravity 1.02

Sediment
microscopic
examination:
Pus cells(WBC) 01/03/10
Red Blood Cells 0-3
CASTS:
Mucus threads few

CT SCAN REPORT

EXAMINATION: Cranial CT Plain

Multiple sequential axial tomography seton of the head from the skull base to the vertex
without contrast reveal the following findings: A hyperdense area measuring
3.0x2.0x3.0 cm (about 6 ml) is seen in the right frontal lobe woth minimal surrounding
edema. No abnormal density changes in the brain parenchyma. Gray-white matter
differentiation is maintained. No evidence of intracerebral hemorrhage.
A thin-walled cyst measuring 6.0x5.0x6.5 cm is seen in the posterior horn of hte right
ventricle. There is dilatation of the temporal horn of the right lateral ventricle. The rest
of the ventricles are unremarkable.
No abdominal extraaxial fluid collection or hematoma. No shifting of midline structures.
Cerebellum and pons are unusual. Cell, petromastiods, orbits and paranassal sinuses
are intact.

Impression:
 1.) Acute intracerebral hemmorhage, right frontal lobe with minimal surrounding
edema.
2.) Intraventricular cyst, posterior horn of the right lateral ventricles.
3.) Dilated temporal horn of the right lateral ventricle.

VI. DRUGSTUDY

VII. NURSING CARE PLAN

VIII. DISCHARGE PLAN

Medication

•Instructed to complied strictly with the following home

medications

Exercise

•Encourage mild exercise and perform active and passive range of motion exercise to the patient
at both upper and lower extremities.
Treatment

•Advise patient to avoid stress related factors.

Health Teachings

•Encourage patient in deep breathing and coughing exercise.

•Advise patient increase fluid intake at least 2-3L/day to prevent hydration.
•Encourage patient to have a proper skin care
•Provide opportunities for rest; limit activities to level of respiratory tolerance.
•Instruct patient to use of relaxation activities, exercises/techniques to decrease tension level.
•Encourage use of assistive devices as needed to extend active time/conserve energy for other
tasks.
Out Patient

•After the patient will discharge, he will be able to come back to the hospital for monthly check-
ups or for any follow ups and also able to visit any clinics.
Diet

•Encourage patient to eat fruits and green leafy vegetables.

Spiritual

•Encourage patient to pray always to be thankful to God for his goodness.

IX. LEARNING EXPERIENCE

Our hospital exposure at NMMC Medical Ward gave us the opportunity to develop a sense
of responsibility. Being in this chosen field entails a lot of tasks in which a lot of responsibility
rests on our shoulders in caring for the people who need it most. This led us towards acquisition
of knowledge as well as giving effective therapeutic care to those who have been deprived of
health. Our efforts and sincerity to serve patients on our day to day duty could not be expressed
by mere words.

Hence, this worthwhile experience is unforgettable. It made us strived more in spite of the
hardships that we have encountered in inculcating the significance of the procedures that we
performed to be able to provide our patients comfort and wellness. We have developed
ourselves to persevere and to be patient. Patient cooperation was a big factor for they gave us
more encouragement and motivation to go on and meet our goals to promote optimum care. All
in all, this experience made us apply our learning from the classroom theory which made us
survive this very challenging profession.
X. REFERENCES

Medical-Surgical Nursing Sixth Edition Vol.2, Joyce M. Black et al,

Springhouse Nurse’s Drug Guide 2007

2004 Lippincott’s Nursing Drug Guide, Amy M. Karch

MIMS.coms

Scribd.com