CASE PRESENTATIONof

“CEREBROVASCULAR ACCIDENT, HYPERTENTION STAGE II

INTRODUCTION

• HYPERTENSION is a persistent elevation of the systolic blood pressure (SBP) at a level of 140 mmHg or higher.

• Types of Hypertension:• Primary Hypertension- is also known as

essential or idiopathic hypertension, the blood pressure remains elevated and continues to rise over time because of the persistent progressive increase in peripheral arterial resistance.

INTRODUCTION

• Secondary Hypertension-

INTRODUCTION

• Hypertension is also related to increased severity of atherosclerosis, stroke nephropathy peripheral vascular disease aortic aneurysms, and heart failure.

• Stroke is primary ‘Cerebrovascular is order’, is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs that when the normal blood supply to the brain is disrupted.

INTRODUCTION

Stroke can be divided into 2 major categories:

1. Ischemic in which vascular occlusion and significant Hypoperfussion occur.

2. Hemorrhagic in which there is extravasation of blood into the brain or subarachnoid space.

INTRODUCTION

Ischemic stroke are subdivided into 5 different types based in the cause:

1. Large artery thrombotic strokes – are caused by atherosclerotic plaques in the large blood vessel of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction (deprivation of blood supply.

INTRODUCTION

2. Small penetrating artery thrombotic strokes – affect one or more vessels and the most common type of ischemic stroke. Small artery thrombotic strokes are also called lacunar strokes because of the cavity that is created after the death of infarcted brain tissue.

INTRODUCTION

3. Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. Embolic strokes can also be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulant therapy in patients with atrial fibrillation.

INTRODUCTION

4. Cryptogenic strokes – which have known cause.

5. And strokes from other causes, such as illicit drug use, coagulopathies, migraine and spontaneous dissection of the carotid or vertebral arteries.

CASE REPORTNAME: MRS.AAGE: 59 YEARS OLDGENDER: FEMALECIVIL STATUS: MARRIEDADDRESS: SAN ANTONIO, BINAN LAGUNADATE OF BIRTH: OCTOBER 04, 1959PLACE OF BIRTH: BINAN, LAGUNARELIGION: ROMAN CATHOLICEDUCATIONAL AATAINMENT: COLLEGE GRADUATEOCCUPATIONAL: BUSINESSWOMANDIALECT/ LANGUANGE SPOKEN: TAGALOGDATE OF ADMISSION: SEPTEMBER 10, 2012 1:00PMDATE OF DISCHARGE: SEPTEMBER 11, 2012 5:00PMADMITTING DIAGNOSIS: CEREBROVASCULAR ACCIDENT, HYPERTENSION STAGE 2, UNCONTROLLED

NURSING HISTORYCHIEF COMPLAINT: Slurring of speech, weakness on the right side of

the body.

HISTORY OF PRESENT ILLNESS:3 Days prior to admission patient experienced of speech and an

elevated blood pressure. Since then, she preferred to stay lying on her bed. No medication and consultation done.

2 Days prior to admission patient still experiencing slurring of speech and elevated blood pressure. Patient still preferred to stay lying on her bed, still no consultation done.

1 Day prior to admission patient already felt weakness on the right side of the body. And she decided to bring her to university of perpetual help Jose L. Tamayo university medical center for consultation. She was seen and subsequently admitted to Jonelta ICU.

NURSING HISTORYPAST MEDICAL HISTORY(-) PREVIOUS HOSPITALIZATION(+) HPN(-) DM(-) ASTHMA(-) ALLERGY(-) SURGERY

FMILY MEDICAL HISTORY W\GENOGRAM

PERSONAL\SOCIAL\ENVIRONMENTAL HISTORY:• Born and raised in San Antonio, biñan, laguna, finished.

College, married at the age of 25. Worked as businesswoman for long years, owns a house in a congested community living with her husband and one son who is not yet married.

• Patient has no vices (smoking,drinking,alcoholic drinks.) No history of allergy to food and drugs.

• OBSTETRIC\GYNECOLOGIC HISTORY: - (G1-P1-T1-P0-A0-L1) - AGE OF MENARCHE:16YEARS OLD -MENOPAUSAL AGE:57YEARS OLD

GROWTH AND DEVELOPMENT TASK:MIDDLE ADULTHOODPSYCHOSOCIAL STAGE BY ERIK ERIKSON: GENERATIVITY VS. SELF

ABSORPTION• During this time, the most important in this stage of patient is

parenting, by having children or creating a positive change that benefits other people in some way to satisfy and support next generation. Her success leads to feelings of usefulness and accomplishment.

COGNITIVE DEVELOPMENT THEORY BY JEAN PIAGET-FORMAL OPERATIONAL STAGE.

• During this time, patient develops the ability to think about abstract concepts. Skills such as logical thought, adductive reasoning, and systematic planning also emerge during this stage.

PHYSICAL EXAMINATIONGENERAL SURVEY:• Mrs. X was lying supine on her bed that appears weak looking

and looks older than her stated age. Her level of consciousness is alert and awake. She is coherent and cooperative in answering questions. She is oriented to place, person and time. She is well groomed with combed hair and clean clothing since her sister has helped her to take a sponge bath and groomed her.

Vital signs:BP: 160/90PR: 57bpmRR: 18cpmT: 36.0 C

REGIONAL EXAMINATION:• SKIN: dry and scaly, warm to touch, no presence of macules, well skin

turgor • HEAD AND NECK: Normocephalic, hair evenly distributed, straight hair,

symmetrical face (eyebrows, eyes, ears, nose and mouth), symmetrical facial movements.

• EENT: Drooping eyelids, pupils easily round and reactive to light and accommodation, auricle aligned with outer canthus of the eye, symmetrical ears, no alar flaring, pink and soft lips and has missing teeth.

• CHEST AND LUNGS: Scapula and shoulder symmetrically aligned, symmetrical chest, clear breath sound on both lung fields

• HEART: No abnormal pulsations visible, No pulsations or vibrations are palpated in the areas of the apex, left sterna border, or base. Heart rate is normal with regular rhythm. No extra sounds, no murmurs are heard; S1 and S2 heart sounds are normally present.

• ABDOMEN: flat, soft, no presence of discoloration, non-tender, normal bowel sounds.

• EXTREMETIES: no cyanosis, strong pulse, normal capillary refill.

• NEUROLOGIC• MENTAL STATUS: Conscious, Coherent oriented with good

communication skills.• MOTOR SENSORYDEEP TENDON REFLEX•

CRANIAL NERVES:I- N/AII- 20/20 visual activityIII, IV, V I - Patient was able to visualize moving object. - Patient pupil dilates and constrict in response to light.V- Patient able to sense the touch over forehead, cheek and jaw

as well as she the ability to move and clench her jaw. VII- There is asymmetry and left facial lagging while evaluating

patient’s facial movements.VIII- Patient was able to detect the sounds and ability to

maintain balance.IX, X- (-) gag reflexXI- Patient was able to move her head and her trapezius muscle

can shrugs shoulders against resistance.XII- Patient was able to move her tongue in various positions.

REVIEW OF SYSTEMS

• GENERAL:( ) weight gain ( ) fever ( ) chills( ) weight loss (+) weakness (+) loss of appetite( ) easy fatigability• INTEGUMENTARY:(+) dry and scaly skin• HEAD AND NECK:NO SIGNIFICANT FINDINGS• EYES:(+) corrective lenses ( ) icteric sclera ( ) pruitis( ) redness (+) blurring of vision ( ) diplopia( ) pain ( ) discharge• EARS:NO SIGNIFICANT FINDINGS• NOSE AND SINUSES:NO SIGNIFICANT FINDINGS• MOUTH AND THROAT:NO SIGNIFICANT FINDINGS• RESPIRATORY:NO SIGNIFICANT FINDINGS• CARDIOVASCULAR:NO SIGNIFICANT FINDINGS• GIT:NO SIGNIFICANT FINDINGS• GUT:NO SIGNIFICANT FINDINGS

LABORATORY RESULTSURINALYSIS RESULT

EXAMINATION DONE RESULTS NORMAL VALUES SIGNIFICANCECOLOR YELLOW CLEAR-PALE- DARK

YELLOWNORMAL

TRANSPARENCY SLIGHT HAZY CLEAR Cloudiness may be caused by excessive cellular material or protein in the urine or may reflect from crystallization.

REACTION (PH) 7.5 4.5-8 PHGLUCOSE NEGATIVE NONESPECIFIC GRAVITY 1.010 1.010 PUSCELLS 1.4/HPO <10/HPFRBC 0-2/HPO <4/HPFEPITHELIAL CELLS MODERATE 0 HIGH

With nephrotic syndrome and in conditions leading to tabular degeneration, the number sloughed into the urine is increased.

DATE EXAMINATION DONE

RESULTS NORMAL VALUES

SIGNIFICANCE

9/10/12 HEMOGLOBIN 135 mg/L 110-140 NORMAL

HENATOCRIT 0.427 .370-.470 NORMAL

RBC COUNT 4.95 4.00-5.50 NORMAL

WBC COUNT 10.7 5.00-10.00 HIGH

NEUTROPHIL 7.85 1.63-6.96

EOSINOPHIL .190 0.030-0.440

BASOPHIL 0.096 0.00-0.080

RELATED STUDIES

ANATOMY OF THE NERVOUS SYSTEM Anatomic and Physiologic Overview Nervous systems consist of 2 major parts:1. The Central Nervous System (CNS)

– The Brain– And the Spinal Cord

2. The Peripheral Nervous System (PNS)– Cranial nerves– Spinal Nerves– and Autonomic Nervous system

Functions of Nervous system:• control motor, sensory, autonomic, cognitive, and behavioural

activities• The brain itself contain 100 billion cells that link the motor

and sensory pathways• Monitor the body processes• Respond to external and internal environment • Maintain homeostasis• Direct all psychological, biological and physical activity

through complex chemical and electrical messages.

Cells of the Nervous System • The basic functional unit of the brain is the neuron

– Composed of a cell body, a dendrite, and an axon. – The dendrite - is a branch-type structure with synapses for receiving

electrochemical messages. – The axon- is a long projection that carries impulses away from the cell

body.

• Nerve cell bodies occurring in clusters are called ganglia or nuclei.

• A cluster of cell bodies with the same function is called a center (eg, the respiratory center).

• Neuroglial cells, another type of nerve cell, support, protect, and nourish neurons.

Neurotransmitters• Neurotransmitters -communicate messages from one neuron to

another or from a neuron to a specific target tissue.• Neurotransmitters - are manufactured and stored in synaptic

vesicles. – They enable conduction of impulses across the synaptic cleft.

• The neurotransmitter has an affinity for specific receptors in the postsynaptic bulb. – When released, the neurotransmitter crosses the synaptic cleft

and binds to receptors in the postsynaptic cell membrane.– The action of a neurotransmitter is to potentiate, terminate, or

modulate a specific action and can either excite or inhibit the target cell’s activity.

• There are usually multiple neurotransmitters at work in the neural synapse.

• There are various types of neurotransmitters.• There are two types of receptors: direct and indirect.• Direct receptors - are also known as inotropic; because they are linked to

ionchannels and allow passage of ions when opened. – They can be excitatory or inhibitory and are rapid-acting (measured in

milliseconds). • Indirect receptors- affect metabolic processes in the cell, which can take

from seconds to hours to occur. • Receptor sites are an expanding area of research; because they are often

the target for the action and development of new medications. • These medications either block or stimulate neurotransmitters at receptor

sites and thus provide relief from symptoms (Blows,2000). • Receptor sites are also sites for the action of addictive drugs.• Another important area of on-going research is diagnostic testing that can

detect abnormal levels of neurotransmitters in the brain.

The Central Nervous SystemANATOMY OF THE BRAIN

• The brain accounts for approx. 2% of the total body weight.• The brain is divided into three major areas:

– the cerebrum,– the brain stem, – and the cerebellum.

• The cerebrum - is composed of two hemispheres, the thalamus, the hypothalamus, and the basal ganglia.

• The brain stem -includes the midbrain, pons&medulla, • The cerebellum -is located under the cerebrum and behind the brain stem.

• Cerebrum • Gyri – wrinkled appearance outside the surface of the hemispheres.• Between each gyrus is a sulcus or fissure that serves as an anatomic

division. • In between the cerebral hemisphere is the great longitudinal fissure• The two hemispheres are joined at the lower portion of the fissure

by the corpus callosum. • The external or outer portion of the cerebrum (the cerebral cortex)

is made up of gray matter approximately 2 to 5 mm in depth; it contains billions of neurons/cell bodies, giving it a gray appearance.

• White matter makes up the innermost layer and is composed of nerve fibersand neuroglia (support tissue) that form tracts or pathways connecting various parts of the brain with one another (transverse and association pathways) – These pathways also connect the cortex to lower portions of the brain

and spinal cord (projection fibers). • The cerebral hemispheres are divided into pairs of lobe as follows:

The four lobes are as follows (see Fig. 60-2):• Frontal—the largest lobe; located in the front in the brain.- The major functions of this lobe are concentration, abstract thought, information

storage or memory, and motor function. - It also contains Broca’s area, critical for motor control of speech.- The frontal lobe is also responsible in large part for an individual’s affect, judgment,

personality, and inhibitions. • Parietal—a predominantlysensory lobe posterior to frontal lobe.- The primary sensory cortex, which analyzes sensory information and relays the

interpretation of this information to the thalamus and other cortical areas, is located in the parietal lobe.

- It is also essential to an individual’s awareness of the body in space, as well as orientation in space and spatial relations.

• Temporal— located inferior to the frontal lobe and parietal lobe- Contains the auditory receptive areas. - Plays a role in memory of sound and understanding of language and music. • Occipital— located posterior to the parietal lobe - Responsible for visual interpretation and memory

• The corpus callosum - is a thick collection of nerve fibers that connects the two hemispheres of the brain and is – Responsible for the transmission of information from one side of the brain to the other.

• Information transferred includes sensation, memory, and learned discrimination.

• Right-handed people and some left-handed people have cerebral dominance on the left side of the brain for verbal, linguistic, arithmetical, calculating, and analytic functions.

• The nondominant hemisphere - is responsible for geometric, spatial, visual, pattern, and musical functions.

• • The basal ganglia - are masses of nuclei located deep in the cerebral hemispheres .• Responsible for control of fine motor movements, including those of the hands

and lower extremities. • The thalamus - lies on either side of the third ventricle and

– acts primarily as a relay station for all sensation except smell.• All memory, sensation, and pain impulses also pass through this section of the

brain.

• The hypothalamus -located anterior and inferior to the thalamus, and beneath and lateral to the third ventricle.

• The infundibulum of the hypothalamus connects it to the posterior pituitary gland.

• The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production.

• It works with the pituitary to maintain fluid balance and maintains temperature regulation by promoting vasoconstriction or vasodilatation.

• The hypothalamus is the site of the hunger center and is involved in appetite control.

• It contains centers that regulate the sleep–wake cycle, blood pressure, aggressive and sexual behavior, and emotional responses

• The hypothalamus also controls and regulates the autonomic nervous system.

• It includes the optic chiasm (the point at which the two optic tracts cross) and the mamillary bodies (involved in olfactory reflexes and emotional response to odors).

The pituitary gland is located in the sellaturcica at the base of the brain and is connected to the hypothalamus.

• The pituitary is a common site for brain tumors in adults; • Having entered the pons and the medulla, each bundle

crosses to the corresponding bundle from the opposite side. • Some of these axons make connections with axons from the

cerebellum, basal ganglia, thalamus, and hypothalamus; some connect with the cranial nerve cells.

• Other fibers from the cortex and the subcortical centers are channeled through the pons and the medulla into the spinal cord.

• Although the various cells in the cerebral cortex are quite similar in appearance, their functions vary widely, depending on location.

Brain Stem.• The brain stem consists of the midbrain, pons, and medulla oblongata• The midbrain connects the pons and the cerebellum with the cerebral

hemispheres; – it contains sensory and motor pathways and serves as the center for auditory

and visual reflexes. • Cranial nerves III and IV originate in the midbrain. • The pons is situated in front of the cerebellumbetween the midbrain

and the medulla and is a bridge between the two halves of the cerebellum, and between the medulla and the cerebrum.

• Cranial nerves V through VIII connect to the brain in the pons. • The pons contains motor and sensory pathways. • Portions of the pons also control the respiration• Cranial nerves IX through XII connect to the brain in the medulla.• The medulla oblongata contains motor fibers from the brain to the

spinal cord and sensory fibers from the spinal cord to the brain. • Reflex centers for respiration for BP, HR, coughing, swallowing, and

sneezing.