A C.A.R. ON P.B., 69 Y.O.

, FEMALE, DIAGNOSED WITH RIGHT THALAMIC INFARCTION, AND HYPERTENSIVE ATHEROSCLEROTIC CARDIOVASCULAR
DISEASE

Submitted by:

Cinderella L. Pacheco
CARDIOVASCULAR SYSTEM
Anatomy of the Heart:
- Mediastinum
= between 2 lungs; size of the fist
= positioned so the apex is directed towards the
left hip while the base is pointing to the right shoulder
*apex – 5th intercostal space
*base – 2nd intercostal space
= double layered serous membrane
- pericardium
Inner – visceral pericardium – attached to the
heart’s surface
Outer – parietal epicardium
Parietal – dense connective tissue & connects the
heart with the surrounding structures.
Three Layers:
1. Endocardium – thin layer if connective tissue line by
endothelium (simple squamous)
2. Myocardium – thickest layer made of cardiac muscle and
dense connective tissue (cardiac skeleton)
to support
3. Epicardium – thin layer of CT lined by mesothelium
Chambers of the Heart
Right – Pulmonary Circulation
Vena Cava → RA → Tricuspid Valve → RV→ Pulmonary
Artery → Lungs → Pulmonary Veins → LA
Left – Systemic Circulation
Pulmonary veins → LA → Mitral (Bicuspid) Valve
→LV → aorta → numerous branches →Body
Valves:
2 Atrioventricular Valves:
Bicuspid /Mitral Valve = 2 flaps; left AV valve
Tricuspid Valve = right AV valve; 3 flaps
Chordae Tendineae – tiny white chords that
anchor 3 edges of cusps to the walls of the
ventricles.
Semilunar Valves - 3 cusps
- aortic and pulmonary valves
- no chordae tendineae
Cardiac Circulation
- supplied by the coronary arteries
- coronary artery arise from the aorta (ascending part
of the aorta) → atrioventricular groove intracardia braches
blood coming from the heart → drained by cardiac veins →
empty into coronary sinus (post part of the heart) → RA.
Conduction:
- Cardiac muscle in contrast with other muscles are different.
If contracts independently, it can be controlled by:
1. Autonomic Nervous System - ↑ or ↓ heart rate
↑ - sympathetic (tachycardia)
↓ - parasympathetic (bradycardia)
2. Intrinsic Conduction System (ICS) / Nodal system
- specialized cardiac muscle cell
Main function: ensure cardiac muscles depolarization
occurs only in one direction (atria to ventricle) and to
regulate the contraction rate of the heart.
Events in the Cycle:
1. Middle – Late Diastole
- the heart us completely relaxed; intraventricular
pressure is low.
- blood is coming from the vena cava flows to the
heart
- semilunar valves are closed
- AV valves are open
- end of this phase: atria contracts & force blood
to go to the ventricles.
 2. Ventricular Systole - force that keeps blood circulating continuously
- Ventricles now contract; pressure inside is ↑; IV between heart beats.
pressure rise, semilunar valves are open , AV - highest in large arteries & continue to drop as
valves are closed; blood is rapidly injected to aorta arteries become smaller.
& pulmonary artery.
3. Early Diastole
- when the ventricles start to relax; semi lunar NERVOUS SYSTEM
valves close; ventricular pressure drops; blood 2 main divisions
flows from aorta to ventricles. 1. Central nervous system: brain and spinal cord
2. Peripheral nervous system: cranial and spinal
Heart Sounds nerves
1. Lub - longer, low pitched.
a. Sensory or afferent division
- closing of the AV valves
b. Motor or efferent division
2. Dup / Dubb - shorter / high pitched
- closure of semi lunar valves
Functional classification
Microscopic Anatomy: 1. Somatic or voluntary
Blood Vessels: 3 layers: 2. Autonomic or involuntary
1). Tunica Intima (Interna) a. Sympathetic
- composed of thin layer of CT covered by endothelium b. Parasympathetic
(simple squamous) Cells of the nervous system
2). Tunica Media *neuron is the basic functional unit
- thick layers made up of alternating smooth muscles & a. nerve cell body- ganglia or nuclei are nerve cell body in
elastic fibers. clusters
b. dendrite: branch-type structure with synapses; receive
*middle/small arteries, more smooth muscles than elastic messages
fibers c. axon: long projection; carry impulses away from the cell
- under influence of sympathetic body
3). Tunica Adventitia (Tunica Externa) Neurotransmitters: communicate messages from one
- made up of CT neuron to another or another target tissue
- = to support & protect the BV from injury
These processes may belong to different types of neurons.
Capillaries:  Afferent neuron: carries sensory information from
- thin walled minute vessels composed only of
the periphery to the CNS
endothelium & its basement membrane.
 Efferent neuron: carries motor commands form
Blood Pressure – pressure exerted by blood against the the CNS to the periphery of the body
walls of the blood vessel
Schwann cells- form the myelin sheaths around nerve fibers
that forms in the PNS
*neuroglial cells- nerve cell that protect, support, and
nourish neurons
a. astrocytes- supply nutrients and help maintain electrical
potential; form part of the BBB, repair damaged neural
tissue
b. ependymal cells- line the 4 ventricles and choroid plexus;
help produce CSF
c. microglial- phagocytic cells; remove cellular debris
d. oligodendroglia- support and electrically insulate CNS
axons forming the myelin sheaths
A.Central Nervous System
Brain- approximately 2% of body weight
3 major areas: Cerebrum, Brain stem, Cerebellum
*Cerebrum
4 lobes
-frontal lobe: personality, judgement,
concentration, abstract thought, information
storage, movement, social behaviour, language
expression
-parietal: sensory lobe, orientation to space and
awareness of body shape
-temporal: hearing, language and comprehension,
storage and recall of memories
-occipital: visual interpretation
Brain stem- relays messages between the Cerebrum,
Diencephalon and spinal cord
Cerebellum- has both excitatory and inhibitory actions and
functions for smooth muscle movement
Structures protecting the Brain
*skull: frontal, temporal, parietal, and occipital
*meninges: fibrous connective tissue; protect, support, and
nourishes brain and spinal cord
LAYERS:
o Dura matter: outermost layer; gray; covers the
brain and spinal cord
o Arachnoid layer: contains the choroid plexus
which produce and arachnoid villi that absorbs CSF
(surrounds and cushions the CNS)
CSF: 500ml; 125 to 150 ml is reabsorbed
*subarachnoid space
o Pia mater: hugs the brain closely and extends into
every fold of the brain’s surface
Cerebrospinal fluid- clear and colorless fluid with similar
characteristics with plasma; no RBC and low WBC
 500 ml is produced everyday; only 150ml stays in
the ventricular system at one time
 CSF circulation
1. Choroid plexus in the 2nd ventricle
2. Foramen of Monro (intraventricular foramen)
3. 3rd ventricle
4. Aqueduct of Sylvius (cerebral aqueduct)
5. 4th ventricle
6. 3 opening
a. 2 foramina of Luschka
b. Foramen of Magendie
7. Subarachnoid space
8. Superior sagittal sinus
9. Arachnoid villi
Blood-Brain-Barrier- mechanism that controls the passage
of substances from the blood into the cerebrospinal fluid
and thus into the brain and spinal cord
Spinal cord: primary pathway for nerve impulses travelling
between peripheral areas of the body and the brain
  45cm (18 inches) long about the thickness of a  Focused on the conservation of
finger energy, replenishing and storage
 Ends in the cauda equine
Structure protecting the Spinal Cord
 Vertebral column- surrounds and protect the
spinal cord
B. Peripheral nervous System
Cranial nerves: 12 pairs;
 3 entirely sensory: CN I, II, VIII
 5 are motor: CN III, IV, VI, XI, XII
 4 are mixed: CN V, VII, IX, X
Peripheral/ spinal nerves: 31 pairs= 8 cervical, 12 thoracic,
5 lumbar, 5 sacral and 1 coccygeal

C. Somatic/ Involuntary- governed primarily by the

cerebral hemisphere of the brain

D. Autonomic Nervous System

 Regulates the activites of internal organs such as
the heart, lungs, blood vessels, digestive organs
and glands
 Maintenance and restoration of internal
homeostasis
DIVISIONS:
1. Sympathetic NS:
 “fight and flight” response;
norepinephrine
 Regulates body temperature, blood
flow, blood pressure
 Catabolic in nature
2. Parasympathetic NS
Date Identified: February 22,2013
Fatigue r/t decreased oxygen supply to the
brain and other parts of the body secondary to
impaired blood circulation in right thalamic
infarction as manifested by observable lack of
energy and verbalization of “gikapoy ko”
Scientific Basis:
Fatigue is a very common complaint and it is
important to remember that it is a symptom
and not a disease. Many illnesses can result in
the complaint of fatigue and they can be
physical, psychological, or a combination of the
two.
Source:
http://www.medicinenet.com/fatigue/article.h
tm
INTERVENTION Desired Outcome
Within the course of nursing interventions, the
Independent Interventions patient will report improved sense of energy,
perform ADLs and participate in desired
1. Determined the ability to participate in activities at level of tolerance.
activities/level of mobility.
R: Fatigue can limit the person’s ability o Actual Outcome
participate in self-care and to perform her After 2 days of student nurse-patient
responsibilities. interaction:
February 22, 2013
2. Assessed presence/degree of sleep
Patient was able to have adequate rest periods
disturbances.
R: Changes in the person’s sleep pattern may
be a contributing factor in the development of February 23, 2012
fatigue. Patient’s sense of energy improved
3. Arranged things within the reach of the
patient.
R: To provide an environment conducive to
relief of fatigue and to prevent physical
exhaustion.
4. Taught the patient how to perform deep
breathing exercises.
R: To provide a way of minimizing fatigue
through relaxation.
5. Reduced environmental stimuli.
R: To promote relaxation and to prevent any
disturbances.
6. Placed care with consistent rest periods
between activities.
R: To conserve energy

Date Identified: January 22, 2013
Disturbed Sleeping Pattern r/t uncomfortable
sleep environment as manifested by daytime
naps and SO’s verbalization of “mag-sige man
na siya ug mata-mata kada gabii”.
Scientific Basis:
Sleep is a form of hibernation when the body
shuts down in order to repair damage done
through use, to conserve energy
Source:
http://drmyhill.co.uk/wiki/Sleep_is_vital_for_g
ood_health_-_especially_in_CFS
Independent Interventions:
1. Assesses the normal sleeping pattern, rituals and environment of the patient at home.
R: In order for activities and surroundings to be modified based on client usual pattern.
2. Encouraged to do deep breathing exercises.
R: Deep breathing promotes relaxation and diverts attention.
3 Suggested abstaining from daytime naps.
R: Daytime naps impair ability to sleep at night.
4. Supported continuation of usual bedtime rituals such as taking half-baths before going to sleep.
R: to promote relaxation and readiness for sleep.
5. Encouraged not to drink a lot of fluids before bedtime.
R: to minimize going to the comfort room in the middle of the night.
6. Recommended quiet activities such as reading or imagery or listening of music.
R: to reduce stimulation to promote relaxation and cover up noise if present.
7. Minimized going in and out of room.
R: Allows patient to attain periods of restful sleep.
8. Provided adequate rest periods.
R: To promote rest and to maximize energy.
9. Encouraged patient to restrict caffeine intake and other stimulating substances.
R: They disrupt sleep patterns
10. Encouraged to drink milk
R: L-tryptophan in milk induces sleep February 23, 2013
Patient was able to verbalize “mao ra
gihapon, wa ko’y tarong nga tulog”. Patient
was noted to resort to daytime naps to regain
energy.
Desired Outcome:
Within the course of nursing interventions, the
patient will be able to identify factors that
impair sleep and report improvement of sleep-
rest pattern.
Actual Outcome:
After 2 days of nursing interventions:
February 22, 2013
Patient was able to rest and sleep. Increased
energy level noted.
Clopidogrel
Classification: Antiplatelet, Thienopyridine
inhibitor
Action: Inhibits the ADP-dependent pathway
of platelet activation
Indication: HACVD
Contraindication: Retinal Hemorrhage, Blood
Clotting Disorder, Recent Operation, Serious
Kidney Problems, Bleeding of the Stomach or
Intestines
Adverse effects: Easy bleeding/bruising,
stomach upset/pain, diarrhea or constipation,
itching, dizziness
Nursing Intervention:
Observed signs and symptoms of bleeding
such as epistaxis, hematoma, hematuria.
Kept sharp objects such as knife, fork away
from patient.
No nosepicking, toothbrushing, chocolate
colored foods, toothpicking.
Cefuroxime
Classification: 2nd gen cephalosporin
Action: Binds to bacterial wall, causing cell
death
Indication: HACVD, R thalamic infarction
Contraindication: Hypersensitivity
Adverse effects: diarrhea, nausea, rash,
pruritus
Nursing Intervention:
Give oral drug with food to decrease GI upset
and enhance absorption.
Have vitamin K available in case
hypoprothrombinemia occurs
Discontinue if hypersensitivity reaction occurs
Avoid alcohol while taking this drug and for 3
days after because severe reactions often
occur