University of LuzonCollege of Nursing

Dagupan City

CASE STUDY

OF

CEREBRAL INFARCTION

Submitted By:

Rodolfo A. Morla

Submitted To:

Mrs. Divina Gracia Corrigan RN; MAN

OBJECTIVES

GENERAL OBJECTIVES :

Me, as a student nurse of Medical ward(R1MC),7-3 shift aim to develop useful, skillful and effective nursing care and furthermore is aim to learn and be knowledgeable on the nature of the disease as well as its management that would be helpful and therapeutic to that person

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 explain 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 patient’s teachings.

To formulate appropriate nursing care plans based on the assessment , to render health teachings as part of holistic care to alleviate problems identified

PATIENT’S PROFILE

Wilma Vejano Aquino a 42 years old,born on August 10, 1969, female, from Bonuan Binloc Dagupan City a fiipino citizen was admitted at the Region 1MedicalCenter last August 15, 2011 at 7:10AM with chief complaint of Right sided body weakness admitted by Dr. Diana Bernal with the diagnosis of Left sided Cerebral Infarction.

Present Complaints:Few hours prior to admission, patient suddenly experienced right sided body

weakness associated with aphasia.

Past History:The patient has no previous hospitalization. With history of hypertension

(Systolic Blood Pressure of 170mmHg). Claimed that she is NOT taking alcohol; NOT smoking and no known allergies.

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 localisation of cerebral lesion. If the infarct is located in primary motor cortex- contralateral hemiparesis 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 marrowin 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 intravenous rtPA therapy can be advocated in patients who arrive to stroke unit and can be fully evaluated within 3 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.

ANATOMY AND PHSIOLOGY

Major regions of the brain and their functionsThe major regions of the brain (are the cerebral hemispheres, diencephalon,

brain stem and cerebellum.

Cerebral hemispheresThe cerebral hemispheres (Figure 2–6), located on the most superior part of the

brain, are separated by the longitudinal fissure. They make up approximately 83% of total brain mass,and are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4 mmthick grey matter surface layer and, because of its many convolutions, accounts for about40% of total brain mass. It is responsible for conscious behaviour and contains threedifferent functional areas: the motor areas, sensory areas and association areas. Located

internally are the white matter, responsible for communication between cerebral areas andbetween the cerebral cortex and lower regions of the CNS, as well as the basal nuclei (orbasal ganglia), involved in controlling muscular movement.

DiencephalonThe diencephalon is located centrally within the forebrain. It consists of the thalamus,hypothalamus and epithalamus, which together enclose the third ventricle. The thalamusacts as a grouping and relay station for sensory inputs ascending to the sensory cortex andassociation areas. It also mediates motor activities, cortical arousal and memories. Thehypothalamus, by controlling the autonomic (involuntary) nervous system, is responsiblefor maintaining the body’s homeostatic balance. Moreover it forms a part of the limbicsystem, the ‘emotional’ brain. The epithalamus consists of the pineal gland and the CSFproducing choroid plexus.29

Brain stemThe brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded by white matter fibre tracts. Its major regions are the midbrain, pons and medulla oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways between higher and lower brain centres, contains visual and auditory reflex and subcortical motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the regulation of respiration and cranial nerves. The medulla oblongata takes an important role as an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in the medulla regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves. Moreover, it provides conduction pathways between the inferior spinal cord and higher brain centres.

CerebellumThe cerebellum, which is located dorsal to the pons and medulla, accounts for about 11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum processes impulses received from the cerebral motor cortex, various brain stem nuclei and sensory receptors in order to appropriately control skeletal muscle contraction, thus giving smooth, coordinated movements.

The cerebral circulatory systemBlood is transported through the body via a continuous system of blood vessels. Arteriescarry oxygenated blood away from the heart into capillaries supplying tissue cells. Veinscollect the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys. All the circulation besides the heart and the pulmonary circulation is called the systemic circulation. Since it is the ultimate aim of this research project to image cerebral oxygenation and haemodynamics some aspects of the cerebral circulatory system are described below.

PATHOPHSIOLOGY

DOCTOR’S ORDER

Causes:

 atherosclerotic plaques  embolus a traveling particle or debris in the

arterial bloodstream originating elsewhere

weakness and loss of sensation on the opposite side of the body

abnormal pupil dilation, light reaction and lack of eye movement on opposite side

slurred speech

Death of the other brain part

Loss of blood supply in the brain

 Blood vessel that supplies a part of the brain becomes:

blocked  leakage occurs outside the vessel walls

Disturbance in the blood vessels supplying blood to the brain

Risk Factors:

Diabetes ,  Tobacco smoking , Hypercholesterolemia ,  hyperlipoproteinemia ,  High blood pressure ,  Obesity

8/15/11 @ 7:10 AM Admit to medical ward Secure consent (BP 170/100) low fat low saltdiet Diagnostic Test:

- CBC- U/A- Serum Electrolytes- Chest X-ray- ECG- RBS- BUN- Lipid Profile- Cranial CT-Scan

Treatment:- PNSS 1Lx10gtts/min- Citicoline 500mg IVP every 8 hours- Ranitidine 50mg IVP every 8 hours- Sinivastatin 20mg 1 tab ODHS- Manitol 150 cc IV bolus now then 100ccevery 6hourswith BP precaution

SBP < 100mmHG- Amlodipine 10mg1tab OD

Monitor VS and NVS every hour I and O every hour HOD high back rest O2 inhalation @ 3LMP Insert IFC CBR with no BRP

CASE READING

Cerebral Infarction TherapyCerebral infarction is not as dangerous as cerebral hemorrhage, but it should treat as soon as possible. As for most patients are in old age and weak, with several chronic diseases, there are many precautions in treatment. In addition, the infarction area will expend in a short time, and complications may occur, therefore the death rate of cerebral infarction presents high, and its disability rate is higher than cerebral hemorrhage.

The treatment principle is to improve cerebral circulation, prevent hydrocephalus, and treat complications.

1. Take proper exercise, so as to improve the cerebral circulation. For those who are unconscious, it is reasonable to stay in bed.

2. Improve the cerebral blood circulation; activate the collateral circulation to reduce the infarction area. D-40, Hydroxyethy Starch, Venoruton, Compound Injection of Red Sage Root, Chuangxiongzine and other medicines are adopted for daily injection for 7 to 10 days, 1 or 2 times /day, 250-500ml/ time. For those who have the symptoms of headache, nausea, vomit, unconsciousness, 20% mannitol can be applied within the treatment, 250 ml/ time.

3. Take the treatment of thrombolysis. Urokinase and streptokinase are usually used. Inject with 20,000 to 50,000 units of urokinase mixed with 10% 0.56mol/ L glucose liquid once daily for 10 days as a course of treatment. Or administrate streptokinase from the arteria carotis. This is usually taken within 24 hours after the attack. Since the administration is hard, it must carry out in hospitals. The thrombolysis treatment should be applied as early as possible, the reason lies in that during the first day of thrombosis the thrombus is full of water and easy to dissolve. The treatment will effect in a short time, and the course of treatment will not last long. But close attention should be paid in case of the cerebral hemorrhage.

4. Use of treatment of hyperbaric oxygen. It displays well clinically, and can decrease the deformity rate in a large degree. It should be used in the early stage, once daily with 10 days as a course of period. It is advisable to spend 90-110 minutes once, and conduct in the airtight and pressurized cabin.

5. Mediate the blood pressure and control hyperlipemia and hypertension. To control the risky causes of attack. Blood pressure should not decrease in a very short time; it should lift if blood pressure is too low. Cerebral infarction patients are usually with a high blood sugar; it will play negative effect during treatment, therefore it should be controlled.

6. For those stay in coma, some measures should be taken: draw off the phlegm to keep clear of the respiratory tract, turn the patient over and pat the back, move the limbs, and prevent from pneumonia and bedsore.

Traditional Chinese Medicine also works well on cerebral infarction, especially acupuncture. It is based on the differentiation theory and taking individualized treatment. Certain acupoints are chosen in the limbs, body and head to conduct needling or moxibustion to unobstruct meridians and collaterals, mediated blood and qi. As a result the symptoms will improve or disappear. The operating method of acupuncture is of significance; different acupoints and different operating methods will display different effect. If combined with Chinese Medicine to activate blood and dissipate stasis, tonify qi and benefit blood, the effect will increase. At the same time the patient should practice the speech and physical functions, so as to recover soon.Arcticle Source : http://bodycountry.com/stroke/2009/cerebral-infarction-therapy.html

DISCHARGE PLANNING

M Take the medicines religiously, especially the maintenance for hypertension.

E Perform passive range of motion to avoid atrophy of the muscle and to promote good circulation.

T Exercise is the best treatment at home.

H Practice hand hygiene every time.

O Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence Stitches removed between fifth and seventh day (usually in physicians office)

D Maintain low salt low fat diet.

NURSING CARE PLAN

ASESSMENT DIANOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:“ Nahihirapan akomagsalita”, asverbalized by theclient.OBJECTIVE:BP: 150/100PR: 74RR: 30T: 36.4As manifested by:Difficultyproducingspeech. left sided facial paralysis.Muscle andfacial tension

Impaired verbalcommunicationrelated to loss offacial or oral muscletone control as Evedence by

After 8 hr. of nursingintervention, thepatient will establishmethod ofcommunication inwhich needs can beexpressed.

Provide alternativemethods of communication, likepictures or visual cues,gestures or demonstration.

Anticipate and provide for patient’s needs.

Talk directly to patient.Speaking slowly anddirectly. Use yes or noquestion to begin with.

Speak in normal tonesand avoid talking too fast.Give patient ample timeto respond.

Encourage familymembers and visitors to

Provide communication needsor desires based on individual situation or underlying deficit.

Helpful in decreasingfrustration when dependent on others and unable tocommunicate desires.

It reduces confusion or anxiety and having to process and respond to large amount ofinformation at one time.

Patient is not necessary hearing impaired and raisingvoice may irritate or anger the patient.

It is important for family members to continue talking tothe patient to reduce patients isolation, promote establishment of effectivecommunication and maintain sense of connectedness orbonding with thefamily.

After 8 hr. ofnursingintervention, thepatient was able toestablish method ofcommunication inwhich needs can beexpressed.

persist efforts tocommunicate with thepatient.

DRUG STUDY

Generic Name

Dosage, Frequency & Route

Classification IndicationAdverse reaction

Nursing ImplicationPatient & Family Education

Amlodipine 1 tab OD cardiovascular agent; calcium channel blocker; antihypertensive agent

Treatment for Hypertension

Palpitation light-headedness dizziness nausea constipation

Monitor BP for therapeutic effectiveness. BP reduction is greatest after peak levels of amlodipine are achieved 6–9 h following oral doses.

Monitor for S&S of dose-related peripheral or facial edema that may not be accompanied by weight gain; rarely, severe edema may cause discontinuation of drug.

Monitor BP with postural changes. Report postural hypotension. Monitor more frequently when additional antihypertensives or diuretics are added.

Monitor heart rate; dose-related palpitations (more common in women) may

Report significant swelling of face or extremities.

Take care to have support when standing & walking due to possible dose-related light-headedness/dizziness.

Report shortness of breath, palpitations, irregular heartbeat, nausea, or constipation to physician.

Do not breast feed while taking this drug without consulting physician.

occur.