PAMANTASAN NG CABUYAOKatapatan Village Banay-Banay Cabuyao, Laguna

Submitted by:

Brofar, Paola Rica M.Buenafe, Mary Antonette D.

Garcia, EmmanuelGomez, Angel Lyn D.

Submitted to:Breezy Capinpin, RN, MAN

September 22, 2009

CASE ABSTRACT

A 47 years old, female patient was admitted at Panlalawigang Pagamutan ng Laguna with a chief complaint of loss of consciousness. Patient was accompanied by her relatives per stretcher with IVF of PNSS 1L to run @ 20gtts/min. she is unconscious upon admission to intensive care unit with right sided body weakness.

LEARNING OBJECTIVES

To fully understand the disease process and its implications to nursing care.

To identify the signs and symptoms and treatments of Cerebrovascular Accident, Diabetes Mellitus and Parkinson Disease.

To know and understand the nursing interventions and managements that is appropriate for the patient with Cerebrovascular Accident, Diabetes Mellitus and Parkinson Disease.

CASE DEFINITION

Cerebrovascular Accident

CVA is caused by disruption of the blood supply to the brain, causing neurologic deficit. The middle cerebral artery (MCA) is most commonly affected in CVA. The second most frequently affected side is the internal carotid artery. The most common cause of CVA is thrombosis, and then followed by embolism, then cerebral hemorrhage. CVA due to thrombosis and embolism may occur during sleep or rest period. CVA due to hemorrhage is associated with activities and occurs during waking hours. It is characterized by

extensive, permanent loss of function. There is rapid onset of Hemiplegia and rapid progression into coma. It is usually fatal.

Transient Ischemic Attacks (TIA) refers to transient cerebral ischemia with temporary episodes of neurologic dysfunction.

The clinical manifestations of CVA are as follows: Increased ICP Perceptual defects Aphasia Hemianopsia (loss of half of the visual field) Hemiplegia

The collaborative management for CVA are s follows: Emergency Care: Care of the client with increased intracranial pressure. Promote Communication

Care of the client with Aphasiao Say one word at a time.o Identify one object at a time.o Give simple commandso Anticipate needso Allow client to verbalize, no matter how long it takes him.o Reinforce success in speech.o Assist the client in speech therapy.

Care of the client with hemianopsia. Approach the client from the unaffected side of the visual field. Place frequently used articles on the unaffected side of the visual field. Teach the client scanning technique. Turn the head from side to be able to see the entire visual

field. Supportive Care:

Promote nutrition (Enteral Feedings, TPN). Promote activity (turn frequently, passive ROM exercises). Promote elimination (monitor I and O, urinary and bowel program). Provide emotional support. Assist in the rehabilitation of the client.

Diabetes Mellitus Type II

It is a Non-Insulin Dependent Diabetes Mellitus (NIDDM), maturity onset, ketosis-resistant DM. Onset is after age of 30 years. With relative lack of insulin or resistance to the action of insulin; usually insulin is sufficient to stabilize fat and

protein metabolism but not deal with carbohydrate metabolism. The client is obese. The client is prone to hyperglycemic, hyperosmolar, non-ketotic coma (HHNC). This is extreme hyperglycemia

without acidosis. It may result in dehydration and vascular collapse. The collaborative management for NIDDM include:

Diet Activity and exercise Oral Hypoglycemic Agents (OHA) or injectables Hypoglycemic Agents (IHA). If hypoglycemia is

uncontrolled. Insulin. In case of stress, surgery, infections, and pregnancy. These conditions trigger stress responses

and stimulate secretion of epinephrine, norepinephrine and glucocorticoids. These hormones cause hyperglycemia.

A deficiency in insulin result to hyperglycemia. The clinical manifestations of DM are as follows:

Polyuria, polydypsia, polyphagia (3Ps) Weight loss Blurred vision Slow wound healing Weakness and paresthesia Signs of inadequate circulation to the feet Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral)

Complications includes: CAD Cardiomyopathy Hypertension CVA Retinopathy Nephropathy Neuropathy

Parkinson’s disease

It is a degenerative disease that affects the extrapyramidal system (EPS). This cause decreased dopamine production.

The cause of Parkinson’s disease is as follows: unknown, viral infections, drugs, disequilibrium between dopamine and acetylcholine, encephalitis, arteriosclerosis and carbon monoxide poisoning. The initial sign is tremors.

Resting tremors (non-intention tremors). Shakings are more severe when the client is not performing physical activities.

Rigidity occurs due to decreased dopamine production. Dopamine is a neurotransmitter that promotes muscle relaxation.

Cogwheel rigidity and absence of arm swing when walking. Bradykinesia - Is slow muscle movement, not associated with muscle weakness. Akinesia - Is absence of muscle movement, not associated with muscle weakness. The other signs and symptoms of Parkinson’s Disease are as follows:

Flattened affect (mask-like facial expression) Stooped posture Moist, oily skin Emotional instability Fatigue Soft, monotonous voice Shaky, small handwriting

The collaborative management of Parkinson’s Disease are as follows: Thickened liquid diet to soft diet for Dysphagia. Firm bed to prevent contractures. Aspiration precaution. Keep client in upright position when feeding. Increase fluid intake and fiber in the diet to prevent constipation. Pharmacotherapy

o Anticholinergics – reduce rigidity and some of the tremors in Parkinson’s disease.- Artane (Trihexyphenidyl)- Cogentin (Benztropine)- Akineton (Biperiden)- Norflex (Orphenadine)

o Dopaminergics – improves muscle flexibility.- Levodopa- Carbidopa with Levodopa (Sinemet). Carbidopa reduces destruction of levodopa at the

periphery. A single dose per day is administered.- Dopamine cannot cross blood brain barrier.- Levodopa, a precursor of dopamine can cross the blood brain barrier.

ANATOMY AND PHYSIOLOGY

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 cerebral cortex. 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. This region 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.

Basal Ganglia Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's

Brainstem Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons

Broca's Area Speech production Understanding language

Central Sulcus (Fissure of Rolando) Deep grove that separates the parietal and frontal lobes

Cerebellum Controls movement coordination Maintains balance and equilibrium

Cerebral Cortex Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes

Cerebral Cortex Lobes Frontal Lobes -involved with decision-making, problem solving, and planning Occipital Lobes-involved with vision and color recognition Parietal Lobes - receives and processes sensory information

Temporal Lobes - involved with emotional responses, memory, and speech Cerebrum

Largest portion of the brain Consists of folded bulges called gyri that create deep furrows

Corpus Callosum Thick band of fibers that connects the left and right brain hemispheres

Cranial Nerves Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck and torso

Fissure of Sylvius (Lateral Sulcus) Deep grove that separates the parietal and temporal lobes

Limbic System Structures Amygdala - involved in emotional responses, hormonal secretions, and memory Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and the regulation of

aggressive behavior Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the hypothalamus Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage

and retrieves them when necessary Hypothalamus - directs a multitude of important functions such as body temperature, hunger, and homeostasis Olfactory Cortex - receives sensory information from the olfactory bulb and is involved in the identification of

odors Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum

Medulla Oblongata Lower part of the brainstem that helps to control autonomic functions

Meninges Membranes that cover and protect the brain and spinal cord

Olfactory Bulb Bulb-shaped end of the olfactory lobe Involved in the sense of smell

Pineal Gland Endocrine gland involved in biological rhythms Secretes the hormone melatonin

Pituitary Gland Endocrine gland involved in homeostasis Regulates other endocrine glands

Pons Relays sensory information between the cerebrum and cerebellum

Reticular Formation Nerve fibers located inside the brainstem Regulates awareness and sleep

Substantia Nigra Helps to control voluntary movement and regulates mood

Tectum The dorsal region of the mesencephalon (mid brain)

Tegmentum The ventral region of the mesencephalon (mid brain).

Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth ventricle Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the cerebellum Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow

Wernicke's area Region of the brain where spoken language is understood.

The pancreas is located retroperitoneal, posterior to the stomach in the inferior part of the left upper quadrant. It has a head near the midline of the body and a tail that extends to the left where it touches the spleen. It is a complex organ composed of both endocrine and exocrine tissues that perform several functions. The endocrine parts of the pancreas consist of pancreatic islets (islets of Langerhans). The islet cells produce the hormones insulin and glucagon, which enter the blood. These hormones are very important in controlling blood levels of nutrients such as glucose and amino acids.

The exocrine part of the pancreas is a compound acinar gland. The acini produce digestive enzymes. Clusters of acini are connected by small ducts, which join to form larger ducts, and the larger ducts join to form the pancreatic duct. The pancreatic duct joins the common bile duct and empties into the duodenum.

Functions of PancreasThe exocrine secretions of the pancreas include HCO3-, which neutralize the acidic chyme that enters the small

intestine from the stomach. The increased pH resulting from the secretion of HCO3- stops pepsin digestion but provides the proper environment for the function of pancreatic enzymes. Pancreatic enzymes are also present in the exocrine secretions and are important for the digestion of all major classes of food. Without the enzymes produced by the pancreas, lipids, proteins, and carbohydrates are not adequately digested.

The major proteolytic enzymes are trypsin, chymotrypsin, and carboxypaptidase. These enzymes continue the protein digestion that started in the stomach, and pancreatic amylase continues the polysaccharides digestion that began in the oral cavity. The pancreatic enzymes also include a group of lipid-digesting enzymes called pancreatic lipases. Nucleases are pancreatic enzymes that reduce DNA and ribonucleic acid to their component nucleotides.

The exocrine secretory activity of the pancreas is controlled by both hormonal and neural mechanisms. Secretin initiates the release of a watery pancreatic solution that contains a large amount of HCO3-. The primary stimulus for secretin release is the presence of acidic chime in the duodenum. Cholecystokinin stimulates the pancreas to release enzyme-rich solution. The primary stimulus for cholecystokinin release is the presence of fatty acids and amino acids in the duodenum, and the enzymes secreted by the pancreas digest fatty acids and amino acids. Parasympathetic stimulation through the vagus nerves also stimulates the secretion of pancreatic juices rich in pancreatic enzymes. Sympathetic action potentials inhibit pancreatic secretion.

PATHOPHYSIOLOGY

Predisposing Factors Precipitating Factors

Parkinson’s disease Diabetes Mellitus (Type II) eats too much rice Fatty foods as favorite food

Can trigger autonomic decreased insulin production increased carbohydrate increased fat depositsNervous system to stimulate breakdown in blood vesselsSympathetic nervous system increased blood glucose Increased production increased peripheralVasoconstriction blood becomes viscous of glucose resistance

Blood Pressure increases

May cause rupture in brain capillaries

Brain tissue compression

Increased ICP brain herniation

Further tissue damage

Neurologic deficits

PART I – PATIENT ASSESSMENT DATA BASE

HEALTH HISTORY

PHYSICAL ASSESSMENTI. General Survey II. Vital SignSeptember 14, 2009

Vital Signs 10:00 am 1:00 pmBlood Pressure 120/80 120/80Temperature 36.2 °C 36.5 °C

Respiratory Rate 16 20Pulse Rate 76 76

III. IntegumentaryA. Skin: Palpation

-dry skin-skin turgor returns to 2-3 seconds

B. Nails: Inspection-pinkish color-without clubbing

Palpation-capillary refill of 2-3 seconds

C. Hair and Scalp: Inspection-black with some white hairs-equally distributed

Palpation-thick-fine course

Patient: X

Age: 47 years old

Birth date: October 17, 1961

Sex: Female

Nationality: Filipino

Civil Status: Married

Religion: Roman Catholic

Address: Lamot I Calauan, Laguna

Inclusive Date of Confinement

Admission date and Time:September 07, 2009/ 07:45 am

Discharge Date and Time: N/A

Attending Physician: Dr. Pestaňo

Initial Diagnosis: CVA Infarct R/O Hemorrhagic T/C Parkinsons

Final Diagnosis: Acute Intracerebral Hematoma 2° to CVA; DM II

Source of History: Relatives and Chart

Chief Complain: Loss of consciousness

IV. HEENTA. Head: Palpation

-without massesB. Face: C. Eyes: Inspection

-Both eyes, eyelids and eyebrows are symmetrical-Pinkish conjunctiva-Moist conjunctiva-Tears are present in both eyes-Reactive to light

D. Ears: Inspection-Bean- shaped-Bilateral & symmetrical-With some cerumen-No lesions

Palpation-No masses

E. Nose: Inspection- Nasal septum is at midline without deviation-Pinkish nasal mucosa with few cilia-with Nasogastric tube (intact)

F. Mouth/ throat/ mucous membranes: Inspection-Lips: dry-Oral mucosa: pinkish, without inflammation-Gums: pinkish without bleeding and inflammation-With cloudy white sputum

D. Trachea:

E. Thyroid gland:

V. Neck/ Lymph nodesInspection-no scars

Palpation-no masses-lymph nodes are palpable

VI. Pulmonary (respiratory)Inspection-normal chest-without endotracheal tube

Palpation-no masses-no fractured ribs

Auscultation-with crackles

VII. CardiovascularInspection and Palpation-Apical pulse palpable, strong and visible-Carotid Pulse Palpable

VIII. AbdomenInspection-no scars, striae and visible veins-no herniations and inflammations

Auscultation- bowel sounds: 2-4 BS/min (decreased)

Percussion-dull on liver and abdomen

Palpation-no masses

IX. Cranial NervesI – Olfactory = normalII – Optic = normalIII – Oculomotor = normalIV – Trochlear = normalV – Trigeminal = VI – Abducens = normalVII – Facial = VIII – Acoustic = normalIX – Glossopharyngeal = normalX – Vagus = normalXI – Spinal Accessory =XII – Hypoglossal =

X. Glasgow Coma Scale Eye Openings

Spontaneous……….. 4To command……….. 3To pain…………………. 2Unresponsive………. 1

Findings: 4Best Verbal Response

Oriented……………….5Confused…………….. 4Inappropriate………..3Incomprehensible…2Unresponsive……….1

Findings: 6Best Motor Response

Obeys commands……..6Localizes pain…………….5Withdraws from pain…4Abnormal flexion……….3Abnormal extension….2Unresponsive…………….1

Findings: 3Total: 13

LABORATORY RESULT

Cranial CT Scan

Impression: Acute intracerebral hematoma in the left capsulo-ganglionic region and left deep temporal lobe, with associated significant perilesional edema, as described, for which possibility of tumoral bleed cannot be entirely ruled out, follow up examination with contrast is recommended.

Chest X-ray

Examination Performed: Chest PA lyingFindings: Essentially normal chest findings

Blood ChemistrySeptember 10, 2009

Normal Result InterpretationFBS 70-110 mg/dL 210.4 mg/dL Indicates that the pt. has possibility of

pancreatitis or brain tumors.September 07, 2009

Normal Result InterpretationBUN 8.0 – 25.0 mg/dL 15.9 mg/dL It is used to determine if the pt. has renal

disease, dehydration, urinary tract obstruction or malnutrition.

Creatinine 0.5 – 1.7 mg/dL 0.7 mg/dL It indicates that the pt. possibly had defective tubular absorption or acute

hepatic atrophy.FBS 70-110 mg/dL 189.2 mg/dL Indicates that the pt. has possibility of

pancreatitis or brain tumors.

Cholesterol Up to 200 189.0 mg/dL It indicates that the pt. is malnourished.Triglycerides 35-135 66.8 It is used to determine if the pt. has biliary

obstruction, diabetes, nephritic syndrome, endocrine disorders.

Electrolytes:Potassium 3.4 – 5.3 meq/L 3.0 meq/L It indicates that the pt. possibly had GI or

renal disorders.Sodium 135 – 155 meq/L 120.0 meq/L It indicates that the pt. possibly had adrenal

insufficiency.

UrinalysisSeptember 07, 2009

Normal Result InterpretationColor Yellow, Clear Light Yellow It screen for the abnormalities within the

urinary system as well as for systemic problem.

Transparency Clear Clear Used to determine if the urine of the patient has bacteria, pus, and presence of

WBC, RBC.Specific Gravity 1.003 -1.029 1.020 Indicator that the kidney has the ability to

reabsorb water.Albumin Positive The glomerulus is possibly damage.

Sugar Negative Negative Used to determine if the patient has significant hyperglycemia or DM.

RBC 1-2 1-2 The pt. is possibly had trauma or tumors.Bacteria Negative Positive It indicates the presence of infections.

Epithelial Cells Few Few Determine if the patient CHON tubular destruct.