I.

Introduction Stroke, also called brain attack or cerebral infarction, is a very serious condition in which the brain is not receiving enough oxygen to function properly. Stroke often results in permanent serious complications and disability and is a common cause of death. It is the second leading cause of death worldwide and the third leading cause of death in the U.S., according to the American Heart Association. A cerebrovascular accident often results in permanent serious complications and disability and is a common cause of death. Cerebrovascular accidents are the second leading cause of death worldwide and the third leading cause of death in the U.S., according to the American Heart Association. The brain requires a steady supply of oxygen in order to pump blood effectively to all of the body. Oxygen is supplied to the brain in the blood that flows through arteries. In a cerebrovascular accident, one or more of these arteries becomes blocked or ruptures or begins to leak. This deprives a portion of the brain of vital oxygen-rich blood. This damage can become permanent within minutes and result in the death of the affected brain tissue. This is called cerebral necrosis. There are two types of cerebrovascular accidents. An ischemic cerebrovascular accident occurs when a brain artery has been blocked. A hemorrhagic cerebrovascular accident occurs when an artery ruptures or leaks. There are three primary causes of cerebrovascular accidents: cerebral thrombosis, cerebral embolism and cerebral hemorrhage. A cerebrovascular accident caused by a cerebral thrombosis is the result of a build-up of plaque and inflammation in the arteries, called atherosclerosis. This process narrows the brain arteries and lowers the amount of oxygen-rich blood that reaches the brain tissue. Arteries narrowed by atherosclerosis are more likely to develop a blood clot that completely blocks blood flow to an area of the brain. Risk factors for atherosclerosis include having high cholesterol, diabetes, and hypertension. Cerebrovascular accident cause by a cerebral embolism occurs when a clot forms in another part of the body and travels in the bloodstream to a brain artery, blocking the flow of blood to the brain. A cerebrovascular accident caused by cerebral hemorrhage occurs when a brain artery breaks or leaks blood into the surrounding brain tissue. The brain is very sensitive to bleeding and damage can occur very rapidly. Page | 1

Bleeding irritates the brain tissue, causing swelling. Bleeding collects into a mass called a hematoma. Bleeding also increases pressure on the brain and presses it against the skull. Hemorrhagic strokes are grouped according to location of the blood vessel: Intracerebral hemorrhage and subarachnoid hemorrhage. Intracerebral hemorrhage most often results when chronic high blood pressure weakens a small artery, causing it to burst. In some older people, an abnormal protein called amyloid accumulates in arteries of the brain. This accumulation (called amyloid angiopathy) weakens the arteries and can cause hemorrhage. It is more likely to be fatal than ischemic stroke and the hemorrhage is usually large and catastrophic. Intracerebral hemorrhage accounts for about 10% of all strokes but for a much higher percentage of deaths due to stroke. Among people older than 60, intracerebral hemorrhage is more common than subarachnoid hemorrhage. It will begin abruptly. In about half of the people, it begins with a severe headache, often during activity. However, in older people, the headache may be mild or absent. Some symptoms, such as weakness, paralysis, loss of sensation, and numbness, often affect only one side of the body. Doctors can often diagnose intracerebral hemorrhages on the basis of symptoms and results of a physical examination. However, computed tomography (CT) or magnetic resonance imaging (MRI) is also done. The treatments include anticoagulants (heparin and warfarin) and Vitamin K which is usually given intravenously. A subarachnoid hemorrhage is bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the tissue covering the brain (meninges). The most common cause is rupture of a bulge (aneurysm) in an artery. It is the only type of stroke more common among women than among men. It is considered a stroke only when it occurs spontaneouslythat is, when the hemorrhage does not result from external forces, such as an accident. Aneurysms typically occur where an artery branches. It may be present at birth (congenital), or they may develop later, after years of high blood pressure weaken the walls of arteries. Most subarachnoid hemorrhages result from congenital aneurysms. A rupture usually causes a sudden, severe headache that peaks within seconds. It is often followed by a brief loss of consciousness. Almost half of affected people die before reaching a hospital. Some people remain in a coma or unconscious. Others wake up, feeling confused and sleepy. They may also feel restless. Within hours or even minutes, people may again become sleepy and confused. They may become unresponsive and difficult to arouse. Within 24 Page | 2

hours, blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), causing a stiff neck as well as continuing headaches, often with vomiting, dizziness, and low back pain. Frequent fluctuations in the heart rate and in the breathing rate often occur, sometimes accompanied by seizures. About 25% of people have symptoms that indicate damage to a specific part of the brain, such as the following: Weakness or paralysis on one side of the body (most common), loss of sensation on one side of the body, difficulty understanding and using language. Fever is common during the first 5 to 10 days. Computed tomography (CT) is done to check for bleeding. A spinal tap (lumbar puncture) is done if CT is inconclusive or unavailable. It can detect any blood in the cerebrospinal fluid. A spinal tap is not done if doctors suspect that pressure within the skull is increased. Cerebral angiography was done to confirm the diagnosis and to identify the site of the aneurysm. About 35% of people die when they have a subarachnoid hemorrhage due to an aneurysm because it results in extensive brain damage. Another 15% die within a few weeks because of bleeding from a second rupture. People who survive for 6 months but who do not have surgery for the aneurysm have a 3% chance of another rupture each year. a. Statistics The American Heart Association Statistics Committee and Stroke Statistics Subcommittee produce estimates and facts about stroke and other cardiovascular diseases in the United States. Below are some interesting facts about stroke, obtained from their 2007 report. Percent of adults from each race: American Indians/Alaska Natives: 5.3% African Americans: 3.2% Whites: 2.5% Asians: 2.4%

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Stroke is the third leading cause of death and a leading cause of serious, long-term disability in the United States. According to the American Heart Association, approximately 600,000 Americans suffer a stroke each year; about 25 percent of these strokes are fatal. Someone suffers a stroke every 53 seconds, and every 3.3 minutes someone dies of a stroke. Ischemic strokes account for 87% of all strokes; while the other 13% are hemorrhagic strokes; up to 70% of strokes seen in the hospital are ischemic, while the remaining 30% are a mixture of transient ischemic attacks and hemorrhagic strokes. Men Thrombotic Stroke 61.5% Embolic Stroke 23.5% Intracerebral Hemorrhage 8.6% Subarachnoid Hemorrhage 5.4% Other 1.1%

Women Thrombotic Stroke 59% Cerebral Embolus 26.2% Intracerebral Hemorrhage 8.0% Subarachnoid Hemorrhage 5.4% Other 1.3%

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Top 10 Causes of Deaths in the Philippines in 2009 Heart disease is still the top killer in the country, based on National Statistics Office (NSO) data as of 2009. Here are the top 10 causes of deaths in the Philippines in 2009. Diseases 1 Diseases of the heart 2 Cerebrovascular diseases 3 Malignant neoplasm 4 Pneumonia 5 Tuberculosis 6 Chronic lower respiratory diseases 7 Diabetes mellitus 8 Nephritis, nephrotic syndrome and neprosis 9 Assault 10 Perinatal-period illnesses 12,227 11,514 2.5 % 2.4 % 25.9 % 100 % 22,345 13,799 4.6 % 2.9 % No. of Deaths 100,908 56,670 47,732 42,642 25,470 22,755 Percentage 21.0 % 11.8 % 9.9 % 8.9 % 5.3 % 4.7 %

All Other Causes of Deaths 124,758 Total Deaths 480,820

b. Reasons for choosing the Case Page | 5

Upon arriving at the hospital, the group was oriented about conducting a case study as a partial fulfillment the researchers have to submit at the end of hospital rotation. The researchers were given the chance to glance at each chart and the group was challenged to do a study about hemorrhagic stroke. This case was interesting to do a study because it will provide more information and knowledge to the researchers about the disease as Alexander Pope said, Little Knowledge is a dangerous thing. c. Objectives Nurse-Centered Objectives After one day of nurse-patient interaction, the student nurses should be able to: Cognitive Choose a patient appropriate for the case study Interpret diagnostic and laboratory procedures done with the client Explain the anatomy and physiology of the body organs involved Identify and explain the rationale of patients medical management composed of medications, contraptions, diet and activity Formulate and prioritize nursing diagnoses based on signs and symptoms presented Affective Establish rapport with the client and his significant others Encourage change of unhealthy lifestyle in accordance with provided health teachings Appreciate the whole course of the study as an opportunity of learning

Psychomotor Conduct a physical assessment cephalocaudally Collect personal data and other data pertinent to the case Page | 6

 Create book-based and client centered pathophysiology of the disease Render appropriate nursing interventions Construct nursing care plans for the patient Conduct health teachings to promote wellness

II. NURSING HISTORY A. Biographic Data Mr. Love Koto is a 36 year old male who currently resides at San Joaquin Mabalacat Pampanga. He was born on October 26, 1975. Mr. Love Koto is single and lives with his parents together with a brother and a sister. He is a Roman Catholic by religion and grew up as a Kapampangan. He finished his education up to high school and was not able to attend college due to financial problem. He was admitted at a hospital in Mabalacat last February 05, 2012 with the chief complaint of right-sided body weakness. B. Socio Economic and Cultural Factors Mr. Love Koto works as a flower arranger in an on-call catering service for eight years. When he had no service to attend, he usually stays at their house and spends his time watching the television, mingling with the neighbors, doing few household chores and sleeping. He is the one who cooks for their family at home. According to his brother, Mr. Love Koto is not fond of eating meat and eats vegetables instead. Five years ago, he had a mild stroke and he started to modify his diet and only eats oatmeal but sine he works in a catering service, the family suspects that he could possibly eat food from his work and that could have vary his healthy diet. Mr. Love Koto is a previous smoker and is fond of drinking alcoholic beverages. He usually sleeps at around 11pm but this varies whenever he has catering services to attend then wakes up at around 5 in the morning and barely sleeps or takes a nap in the afternoon. Health problems are always brought to hospitals and they let doctors and other medically inclined individuals handle their condition. C. Family Health Illness History Page | 7

Mr. Love Kotos father has Diabetes Mellitus while his mother has Hypertension. His brother died due to hypertension at the age of 47. His brother who resides in Bulacan has hypertension as well. No history of anemia, cancer and other chronic diseases noted. D. History of Past Illness Included in the past illnesses of Mr. Love Koto are the usual childhood illnesses like chickenpox and measles. He had completed his vaccines. According to his brother, he is not the type of person who has a weak immune system. Mr. Love Koto does not have any allergies or sensitivities with the food he eats. He had experienced a mild stroke five years ago and a maintenance drug was given to him but he did not take it. His brother could not remember the specific drug prescribed to him. Mr. Love Koto never had any surgical operations. E. History of Present Illness It was 10 in the evening when Mr. Love Koto came home from an on-call catering service, he rested for few minutes then he took a bath. After taking a bath, as he was to catch his sleep, he decided to watch television, while watching he felt dizzy with accompanying right sided body weakness and then vomits a little. He called his brother and decided to bring him to a hospital near their house and it was noted that he had elevated blood pressure and slurred speech. He was then transferred at a hospital in Mabalacat with a chief complaint of right-sided body weakness noting 1/5 in the right side of his body and 5/5 on his left.

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GENOGRAM

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III. PHYSICAL ASSESSMENT A. GENERAL APPEARANCE February 9, 2012 The patient is conscious but a bit sleepy as evidenced by inability to respond quickly to questions and cannot express himself by speech and comprehend spoken language. Slurred speech is noted. He is oriented to persons, time, place, and self as evidenced by his recognition thereof. His tongue is deviated on the right side. Weakness on the right side of the body is noted. He has a dark tan complexion. Regarding general body hygiene and grooming, his clothes has pungent smell of sweat but his diaper is kept dry; his face and skin are dry, fingernails and toenails are untrimmed and her hair is uncombed. His glasgow coma scale is 14/15. Presence of Babinski reflex is noted. His vital signs as of 2:30pm are as follows: BP: 120/80 mmHg; Temp: 36.4C; PR: 88 beats per minute; and RR: 20 breaths per minute

B. PHYSICAL ASSESSMENT A. Integumentary SKIN Warm to touch Fair complexion With good skin turgor (<2 seconds) NAILS Convex curvature Fingernails and toenails untrimmed and appears thick Nail beds has brown pigmentation in longitudinal streaks Capillary refill test: prompt return of usual color in less than 2 seconds

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B. HEAD SKULL AND FACE Smooth skull contour Absence of nodules or masses Asymmetrical facial features Asymmetrical facial movements HAIR Evenly distributed Thin, dry hair No infection/infestations With variable amount of body hair C. EYES EYEBROWS Evenly distributed hair Skin is intact Symmetrically aligned With equal movement EYELASHES Equally distributed Curled slightly outward EYELIDS Skin is intact No discharge No discoloration Lids close symmetrically Bilateral blinking CONJUCTIVA Transparent Page | 11

 Capillaries sometimes evident Sclera appears white Pale in color Smooth CORNEA Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact PUPILS Dark brown in color Equal size Round Pupils are sluggish WATCH TICK TEST able to hear ticking in both ears D. NOSE AND SINUSES EXTERNAL NOSE Symmetric and straight No discharge or flaring Uniform in color No lesions Not tender Air moves freely as the clients breathes through the nares (during NPI) NASAL CAVITIES Nasal septum is intact and in midline E. MOUTH AND THROAT OUTER LIPS Uniform dark colored lips Symmetry of contour Page | 12

 Soft, moist, smooth texture Inability to purse lips TEETH AND GUMS Has 28 teeth Dark colored gums No retractions of gums, no lesions Moist, firm texture to gums Smooth, white to yellow in color, shiny tooth enamel SURFACE OF THE TONGUE Tongue is deviated on the right side Moist Pale in color Tongue cannot move freely SALIVARY GLANDS Same as color of buccal mucosa and floor of the mouth No inflammation TONSILS Not inflamed No discharges seen F. NECK Muscles equal in size Head centered Not well coordinated, movement with a little discomfort Lymph nodes are not palpable, non-tender Trachea is in central placement in the midline of the neck and tracheal spaces are equal on both sides

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G. BREASTS AND AXILLAE Skin uniform color, smooth and intact No palpated mass or nodules Absence of tenderness I. RESPIRATORY/CHEST Full symmetric chest expansion Quiet, rhythmic and effortless respirations Absence of cough Chest symmetrical in shape Skin intact No tenderness No masses No wheezes and rales upon auscultation J. CARDIOVASCULAR/HEART Jugular veins are not visible Capillary refill test: immediately return of color within 2 seconds With pulse rate of 88 beats per minute Blood Pressure of 120/80mmHg K. ABDOMEN No evidence of enlargement of liver or spleen. Presence of bowel sounds noted. Flabby and soft L. URINARY Absence of burning sensation or pain when urinating Light yellowish urine M. REPRODUCTIVE/GENITALIA Absence of pain, itching, tenderness Page | 14

N. MUSCOLOSKELETAL Equal size on both sides of the body Range of Motion is not coordinated Weakness on the right side of the body No deformities No tenderness or swelling Presence of Babinski reflex Glasgow Coma Scale Eye Response (E) Open Spontaneously Open to Verbal Command Open in Response to Pain No response Talking/Oriented Confused Speech/ Disoriented Inappropriate Words Incomprehensible sounds No response Obeys commands Localizes to Pain Flexion/Withdrawal Abnormal Flexion Extension No response 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 14

Verbal Response (V)

Motor Response (M)

Total

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Diagnostic/Laboratory Procedure Computed Tomography Scan of Brain

Indication or Purpose Provides threedimensional cross sectional view of tissues. Computerconstructed picture interprets densities of various tissues. It is typically used to detect infarction, tumors, calcifications, hemorrhage and bone trauma.

Date ordered and Date Result Released Ordered: February 6, 2012 Released: February 6, 2012 Results There are irregular hyperdense foci with surrounding in the left limb of left internal capsule, lentiform nucleus and immediate corona radiata. It has an approximately volume of 20.26ml. Minimal seepages of blood are seen in the left lateral, third and fourth ventricles. There is Normal Findings Normal findings on a CT exam show, bone the white areas. will show as various shades of gray and fat will be dark gray or look black and darker than fat tissue. Intravenous, oral, appear as white areas.

Analysis and Interpretation of Results 1. Acute hemorrhage, left thalamo-capsuloganglionic area and left corona radiata. 2. Positive for intraventricular hemorrhagic lateral, third and fourth ventricles. 3. Bilateral frontomatter hypodensities may present ischemic changes. Page | 16

hyperdensity noted densest tissue, as thalamus, posterior Tissues and fluid

black. Air will also extensions, left

and rectal contrasts parietal white

effacement of left lateral and third ventricles. The rest of the ventricles, sulci and cistems are normal in size and shape. There is no midline shift. Almost symmetrical bilateral frontoparietal white matter hypodensities are also noted. The parenchymal graywhite matter interface is well differentiated.

Nursing Responsibilities:

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Before

Obtain informed consent. Explain the procedure to the patient. Assess for iodine allergy. Check for claustrophobia. Remove any metal objects including jewelry, false teeth and glasses Initiate NPO status 4 to 6 hours prior to scan. Obtain medical history of past illnesses.

During After Instruct the patient to drink plenty of clear fluids to help flush the iodinated contrast out of their kidneys. Observe for signs of anaphylaxis if dye is used. Indication or Purpose Date ordered and Date Result Results Normal Values Analysis and Interpretation of Page | 18 If a contrast dye is needed, it will be given in a barium solution drink or it will be injected into a vein. Patient will be positioned on a special movable table part-way inside the CT scanner.

Diagnostic/Laboratory Procedure

Clinical Chemistry:

It is generally concerned with analysis of bodily fluids.

Released Ordered: February 6, 2012 Released: February 6, 2012

Results

Potassium

Shows the level of potassium in the blood. Determines the role of muscle contractions and cell function.

3.58

3.4 5.3 mmol/L

The result shows no problem in muscle contractions and cell function.

The result is Sodium Shows the amount of sodium present in the blood. Determines excitability of nerves and muscles. Page | 19 133.5 135 155 mmol/L slightly below normal which may result from excess water or fluid in the body.

The result is below Creatinine Detects damage of renal function specifically the GFR. 351.8 354 124 mmol/L normal which can be seen in conditions that result in decreased muscle mass or inadequate dietary protein and muscle atrophy.

Diagnostic/Laboratory Procedure Clinical Chemistry:

Indication or Purpose It is generally concerned with analysis of bodily fluids.

Date ordered and Date Result Released Ordered: February 7, 2012 Released: February 7, 2012 . Results Normal Values

Analysis and Interpretation of Results

Potassium

Shows the level of

3.97

3.4 5.3 mmol/L

The result shows Page | 20

potassium in the blood. Determines the role of muscle contractions and cell function.

no problem in water rearbsorption and neuromuscular functioning

Sodium

Shows the amount of sodium present in the blood. Determines excitability of nerves and muscles.

133.8

135 155 mmol/L

The result is slightly below normal which may result from excess water or fluid in the body.

Creatinine

Detects damage of renal function specifically the GFR

265.2

354 124 mmol/L

The result shows no problems in the excretory functions of the kidneys.

Diagnostic/Laboratory

Indication or

Date ordered and

Results

Normal Values

Analysis and Page | 21

Procedure Clinical Chemistry:

Purpose It is generally concerned with analysis of bodily fluids.

Date Result Released Ordered: February 9, 2012 Released: February 9, 2012

Interpretation of Results

Potassium

Shows the level of potassium in the blood. Determines the role of muscle contractions and cell function

3.79

3.4 5.3mmol/L

The result shows no problem in rearbsorption of water and neuromuscular functioning.

Creatinine

Detects damage of renal function specifically the GFR.

265

354 124 mmol/L

The result shows no problem in excretory function of the kidneys.

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Nursing Responsibilities Before: Verify the doctors order. Explain the procedure and purpose of the test. Tell the patient that a blood sample will be taken. Inform the patient that she may feel some discomfort from the needle puncture and tourniquet.

During: After: Apply pressure on the venipuncture site Monitor for signs of infection. Assess for bleeding. Indication or Date ordered and Results Normal Values Analysis and Page | 23 Collect a venous sample according to the protocol of the laboratory. Transport time for culture specimen must be minimized. Handle specimen carefully.

Diagnostic/Laboratory

Procedure Hematology:

Released It is concerned with Ordered: February the study of blood, the blood-forming organs, and blood diseases. Released: February 6, 2012 122 140 180 g/L 6, 2012

Purpose

Date Result

Interpretation of Results

Hemoglobin

This provides information on how effective red blood cells in carrying oxygen to cells.

The result is below normal. This may indicates presence of anemia or bleeding.

Hematocrit

This test measures the volume of blood in percent that is comprised of the red blood cells.

36%

39 52 %

A low hematocrit represents anemia which can be caused by blood loss.

5 10 x 10 /L WBC This reveals if

0.5

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there is infection present. This also used to monitor bone marrow function and immune response. Differential count: Segmenters One of the types of neutrophils which indicates presence of bacterial infection Lymphocytes Measures viral infections and chronic bacterial infections It is within the Basophils Used to analyze 2 4% 2.8 normal range which Page | 25 25 35% 26 55 65% 60 It is within the normal range which indicates absence of bacterial infection. It is within the normal range which shows no infection.

allergic reaction.

shows no allergic reactions. It is within the

Monocytes

Used to evaluate and manage blood disorders, certain problems with the immune system, and cancers, including monocytic leukemia

2 6%

4.5

normal range which indicates absence of problems with the immune system

Diagnostic/Laboratory Procedure Hematology:

Indication or Purpose

Date ordered and Date Result Results Normal Values

Analysis and Interpretation of Results

Released It is concerned with Ordered: February the study of blood, the blood-forming organs, and blood diseases. Released: February 9, 2012 9, 2012

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Hemoglobin

This provides information on how effective red blood cells in carrying oxygen to cells.

107 g/L

140 180 g/L

The result is below normal. This may indicates presence of anemia or bleeding.

Hematocrit

This test measures the volume of blood in percent that is comprised of the red blood cells.

34 %

39 52 %

A low hematocrit represents anemia which can be caused by blood loss.

5 10 x 10 /L WBC This reveals if there is infection present. This also used to monitor bone marrow function and immune

0.5

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response. Differential count: Segmenters One of the types of neutrophils which indicates presence of bacterial infection Lymphocytes Measures viral infections and chronic bacterial infections It is within the Basophils Used to analyze allergic reaction. 2 4% 3.1 normal range which shows no allergic reactions. It is within the Monocytes Used to evaluate and manage blood 2 6% 4.7 normal range which indicates absence Page | 28 25 35% 28 55 65% 65 It is within the normal range which indicates absence of bacterial infection. It is within the normal range which shows no infection.

disorders, certain problems with the immune system, and cancers, including monocytic leukemia Nursing Responsibilities Before: Verify the doctors order. Explain the procedure and purpose of the test. Tell the patient that a blood sample will be taken. Inform the patient that she may feel some discomfort from the needle puncture and tourniquet.

of problems with the immune system

During: Collect a venous sample according to the protocol of the laboratory. Transport time for culture specimen must be minimized. Handle specimen carefully. Page | 29

After: Apply pressure on the venipuncture site Monitor for signs of infection. Assess for bleeding.

Diagnostic/Laboratory Procedure Lipoprotein Profile:

Indication or Purpose Measures total levels of cholesterol in your blood stream The test requires a fast for 9-12 hours beforehand

Date ordered and Date Result Released Ordered: February 6, 2012 Released: February 6, 2012 Results Normal Values

Analysis and Interpretation of Results

Cholesterol

Used to help minimize the risk of stroke, heart

166.7 mg/dL

0.000 200.0

The result is within the normal range which minimizes Page | 30

attack, and peripheral artery disease

the risk of stroke, heart attack and peripheral artery disease.

Triglyceride

Used to identify the risk of developing heart disease.

123.6 mg/dL

44 148.0

The result is within the normal range which decreases the risk in developing heart disease. The result is above

Uric Acid

Checks to see how much uric acid you have in your blood which also evaluates the kidney function.

13.56 mg/dL

2.5 7.7

normal which indicates a decreased in kidney functions.

The result is within HDL Cholesterol Evaluate the risk of heart attacks, and heart failure. 67.20 mg/dL 30.00 70.00 the normal range which decreases the risk of heart attack Page | 31

and heart failure. The result is within the normal range LDL Cholesterol Is the most important when it comes to assessing your risk for heart disease. 74.83 mg/dL 68 - 178.0 which decreases the risk in developing heart disease.

Nursing Responsibilities Before: Verify Doctors order. Explain the procedure and purpose of the test. Instruct the patient to fast 9 to 12 hours before procedure. Tell the patient that a blood sample will be taken. Inform the patient that she may feel some discomfort from the needle puncture and tourniquet.

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During: After: Apply pressure on the venipuncture site. Monitor for signs of infection. Assess for bleeding. Collect a venous sample according to the protocol of the laboratory. Transport time for culture specimen must be minimized. Handle specimen carefully.

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V. THE PATIENT AND HER ILLNESS A. Anatomy and Physiology

In order to understand how stroke occurs and the damage it can cause, it is useful to understand the basic anatomy of the brain. The signs and symptoms of a stroke depend on which region of the brain is affected and how severely. The brain has three primary components. Each is responsible for different functions: The Cerebrum: The cerebrum is the largest and most developmentally advanced portion of the brain. It controls a number of higher functions, including speech, emotion, the integration of sensory stimuli, initiation of the final common pathways for movement, and fine control of movement. It is divided into a left and a right hemisphere. The left hemisphere controls the majority of functions on the right side of the body, while the right hemisphere controls most of functions on Page | 34

the left side of the body. Thus, injury to the left cerebral hemisphere produces sensory and motor deficits on the right side, and vice versa. The cerebrum is composed of the frontal, parietal, temporal, and occipital lobes: The frontal lobe is involved in planning, organizing, problem solving and selective attention. The portion known as the prefrontal cortex controls personality and various higher cognitive functions such as behavior and emotions. The back of the frontal lobe consists of the pre-motor and motor areas, which produce and modify movement. The left and right parietal lobes contain the primary sensory cortex, which controls sensation (touch and pressure), and a large association area that controls fine sensation (judgment of texture, weight, size, and shape). Damage to the right parietal lobe can cause visuo-spacial deficits, making it hard for the patient to find his/her way around new or even familiar places. Damage to the left parietal lobe may disrupt a patients ability to understand spoken and/or written language. The left and right temporal lobes, located around ear level, allow a person to differentiate smells and sounds. They also help in sorting new information and are believed to be responsible for short-term memory. The right lobe is primarily involved in visual memory (i.e., memory for faces and pictures). The left lobe is primarily involved in verbal memory (i.e., memory for words and names). The occipital lobe processes visual information. It is mainly responsible for visual reception and contains association areas that help in the visual recognition of shapes and colors. Damage to this lobe can cause visual deficits. The Cerebellum: The cerebellum is the second largest area of the brain. It controls reflexes, balance and certain aspects of movement and coordination. The Brain Stem: The brain stem is responsible for a variety of automatic functions that are critical to life, such as breathing, digestion and heart beat as well as alertness and arousal (the state of being awake). Symptoms Point to Stroke Location A stroke can occur anywhere in the brain or just outside it. The symptoms that a stroke Page | 35

victim experiences depend on which area(s) of the brain are involved. When a stroke occurs in the right hemisphere of the cerebrum, the result may be paralysis on the left side of the body, difficulty reasoning or thinking out solutions to even the simplest problem. A stroke in the left hemisphere can result in paralysis of the right side of the body and may disrupt the ability to speak. A stroke involving the cerebellum may result in a lack of coordination (ataxia), clumsiness and balance problems, shaking, or other muscular difficulties. This can interfere with a persons ability to walk, talk, eat and perform other self-care tasks. Brain stem strokes are the most devastating and life threatening because they can disrupt the involuntary functions essential to life. People who survive may remain in a vegetative state or be left with severe impairments. Blood Flow to the Brain The heart pumps oxygen- and nutrient-laden blood to the brain, face, and scalp via two major sets of vessels: the carotid arteries and the vertebral arteries. The jugular and other veins bring blood out of the brain. The carotid arteries run along the front of the neck one on the left and one on the right. They are what you feel when you take your pulse just under your jaw. The carotid arteries split into external and internal arteries near the top of the neck. The external carotid arteries supply blood to the face and scalp. The internal carotid arteries supply blood to the front (anterior) three-fifths of cerebrum, except for parts of the temporal and occipital lobes. The vertebral arteries travel along the spinal column and cannot be felt from the outside. They join to form a single basilar artery (hence the name vertebrobasilar arteries) near the brain stem at the base of the skull. The arteries supply blood to the posterior two-fifths of the cerebrum, part of the cerebellum, and the brain stem. 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 when an ischemic stroke occurs, the carotid or vertebral artery system is blocked with a fatty buildup called plaque, allowing little or no blood to flow to the brain. During a hemorrhagic stroke, an artery in or on the surface of the brain has ruptured or is leaking, causing bleeding and damage in or around the brain. Page | 36

These arteries that conduct blood to the brain the internal-carotid and vertebral arteries connect through the Circle of Willis, which loops around the brainstem at the base of the brain. From this circle, other arteries the anterior cerebral artery (ACA), the middle cerebral artery (MCA), and the posterior cerebral artery (PCA) arise and travel to all parts of the brain. Because the carotid and vertebrobasilar arteries form a circle, if one of the main arteries is blocked, the smaller arteries that the circle supplies can receive blood from the other arteries. This phenomenon is called collateral circulation. Collateral circulation is a process in which small (normally closed) arteries open up and connect two larger arteries or different parts of the same artery. They can serve as alternate routes of blood supply. Sometimes when an artery in the brain is blocked due to ischemic stroke or transient ischemic attack (TIA), open collateral vessels can allow blood to "detour" around the blockage, restoring blood flow to the affected part of the brain. Everyone has collateral vessels, at least in microscopic form. These vessels normally aren't open. However, they grow and enlarge in some people with coronary heart disease or other blood vessel disease. While everyone has collateral vessels, they don't open in all people. The Circle of Willis has a downside, however. Cerebral aneurysms tend to occur at the junctions between the arteries that make up the Circle.

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