STROKE

PATRICIA ABUBAKAR
BSN IV-D
 PATIENT’S BIODATA
 Name of Patient: Janella Myles B. Cabanting
 Age: 3 years old
 Address: Camino Nuevo, Zamboanga City
 Sex: Female
 Date of Birth: April 2, 2015
 Religion: Roman Catholic
 Chief Complaint: Left- sided weakness
 Date of Admission: February 4, 2019
 Admitting Diagnosis: Stroke in the young
 PATIENT
ASSESSMENT
 VitalSigns:
 Temperature: 39.1 celsius
 Pulse Rate: 160 bpm
 Respiratory Rate: 32 bpm
 O2 Sat: 99%
 Blood Pressure: 90/60 mmHg

 General Assessment:
 Patient is awake, crying
 Skin
 Patienthas a fair brown skin complexion.
Texture is soft and smooth, skin snaps
rapidly back to its normal structure when
held. Presence of red rashes in patient’s
whole body.

 Hair
 Patient’shair color is black. Hair is evenly
distributed. No presence of parasites.
 Nails:
 Nailsare pinkish and a shape of convex
curve. Clean and well-trimmed. No
presence of biting in nails and
inflammation.

 Head:
 Rounded in shape and symmetrical,
centered-head position. No presence of
scars or masses.
 Eyes
 Eyesare symmetrical. Eyebrows are
symmetrically aligned. Fair hair distribution in
eyebrows and eyelashes. Irises equally round and
pupils are equal in size and reactive to light.
Sclera appeared white in color.

 Ears
 Bothears are symmetric in shape. Auricles are
aligned with the outer canthus of the eye, firm,
and not tender. No presence of infection or
discharges.
 Nose and Sinuses:
 Nose is symmetrical. No presence of
deformities or discharges. No tenderness.

 Mouth and Throat:

 Lips is lightly pink in color. No signs of
bleeding in gums. Tongue is centrally
positioned and pink in color, no lesions
noted. The uvula is positioned in the midline
of the soft palate and light pink in color.
 Neck:
 Neck
is within centered head position. No bulging
masses noted. Presence of red rashes in her neck.

 Chest:
 Breastis symmetrical. No presence of lumps.
Thorax is in a full and symmetric expansion of both
sides. No abnormalities noted in breath sounds.

 Heart:
 No abnormal heart sound is heard. No presence of
thrills and heaves.
 Abdomen:
 Abdomen has a symmetric contour, no masses
palpated around umbilicus. Globular in shape. Bowel
sounds are present in all four quadrants.

 Genitalia:
 Normalin size. Presence of red rashes noted. No
presence of discharges.

 Extremities:
 Symmetrical in length and size. Complete number of
fingers and toes. No presence of cyanosis, clubbing,
or disorder of nails-spoon shape.
 Muscles:
 Presence of muscle weakness in left-
side of the body.

 Neuromuscular:
 STROKE
 A stroke is the interruption of blood to the
brain. The brain cells in the immediate
area die and those in the surrounding
areas are affected by the reduced blood
flow.
 Two out of every 100,000 children are
affected worldwide each year.
ORGAN INVOLVED
 NORMAL FUNCTIONS OF
THE BRAIN
 Brain is the command center for the human nervous system.
It receives signals from the body’s sensory organs and
outputs information to the muscles.
 Cerebrum –is the largest part of the brain. Interprets touch,
vision and hearing, as well as speech, reasoning, emotions,
learning, and fine control of movement.
 Cerebellum –coordinate muscle movements, maintain
posture, and balance.
 Brainstem –acts as a relay center connecting the cerebrum
and cerebellum to the spinal cord. It performs many
automatic functions such as; breathing, heart rate, body
temperature, wake and sleep cycles, digestion, sneezing,
coughing, vomiting, and swallowing.
 Hypothalamus –it plays a role in controlling
behaviors such as; hunger, thirst, sleep, and
sexual response. It also regulates body
temperature, blood pressure, emotions, and
secretion of hormones.
 Pituitary Gland –known as the “master gland”, it
controls other endocrine glands in the body. It
secretes hormones that control sexual
development, promote bone and muscle growth,
and respond to stress.
 Thalamus –it plays a role in pain sensation,
attention, alertness and memory.
PATHOPHYSIOLOGY
A stroke is essentially a neurological deficit
caused by decreased blood flow to a portion
of the brain. They will be classified as either
hemorrhagic or ischemic.
Ischemic stroke is the result of an
obstruction of blood flow within a blood
vessels.
Hemorrhagic stroke is when a weaken blood
vessels ruptures and blood spills into the
brain where it shouldn’t be.
CONTRIBUTING
FACTORS
 Arteriopathy –diseases of the arteries of the brain
 Sickle cell disease –may cause blockage of blood
vessels of the brain
 Chronic anemia
 Clotting disorders
 Infections –bacterial meningitis, HIV
 Blood vessel narrowing of any kind
 Trauma –especially head trauma
 TYPES OF STROKE
 Ischemic Stroke
• Caused by a blood that blocks on
artery and cut-off blood flow to the
brain.
 Hemorrhagic Stroke
• Caused by the breakage or “blowout”
of a blood vessels in the brain.
SIGNS AND SYMPTOMS
 Trouble walking due to weakness or loss of
coordination
 Problems speaking or understanding language
 Severe headache especially with vomiting and
sleepiness
 Trouble seeing clearly in one or both eyes
 New onset seizures –focal seizures
 Seizures followed by paralysis on the side of
the seizure
Remembering the acronym
“F.A.S.T.” helps people recognize
the most common symptoms of
stroke.
 Face drooping
 Arm weakness
 Speech difficulty
 Time to call an ambulance
 DIAGNOSTIC TESTS
 Brain scan –MRI scan or CT scan
 Echocardiogram
 CT angiogram
 MRA
 ECG monitoring
 Blood tests
 Lumbar puncture
 Brain biopsy
 TREATMENTS
 Medications:
 Anticoagulants may be given orally or intravenously. These
drugs work by thinning the blood and preventing clotting. They
are also used for deep vein thrombosis and pulmonary emboli.

 Antiplatelet agents work by preventing or reducing the

occurrence in the bloodstream of a phenomenon known as
platelet aggregation. When there is damage or injury to a blood
vessel, platelets (one type of blood particle) migrate to the
scene to initiate a healing process. Large numbers of platelets
clump together (aggregate) and form what is essentially a
plug.
 Surgery:
 Surgery is an option for preventing stroke for patients with certain
conditions. There are a number of conventional surgical techniques
that have been in use for some time, including "clipping" aneurysms
to prevent further bleeding and removing AVMs.

 Carotid endarterectomy –procedure used to remove atherosclerotic

plaque from the carotid artery when this vessel is blocked.

 Stereotactic microsurgery for AVMs and aneurysms –during the

procedure, a custom-fitted frame is attached to the patient's head and
three-dimensional reference points are established using CT or MRI.
This technique allows neurosurgeons to locate the AVM within one or
two millimeters so they can operate, using microscope-enhanced
methods and delicate instruments, without affecting normal brain
tissue.
 Stereotactic radiosurgery for AVMs –stereotactic
radiosurgery is a minimally invasive, relatively low-
risk procedure, that uses the same basic techniques
as stereotactic microsurgery to pinpoint the precise
location of the AVM.

 Revascularization of the blood supply –is a surgical

technique for treating aneurysms or blocked cerebral
arteries. The technique essentially provides a new
route of blood to the brain by grafting another vessel
to a cerebral artery or providing a new source of blood
flow to the brain.
NURSING INTERVENTIONS
1. Monitor vital signs
2. Encourage adequate fluid intake.
3. Encourage to ambulate patient every 2 hours.
4. Advise significant others to maintain bed rest and schedule
activities providing frequent rest periods and uninterrupted night
time sleep.
5. Inspect skin regularly for any signs of breakdown, with emphasis on
bony areas and dependent body parts.
6. Begin active or passive ROM exercises for both the affected and
unaffected sides.
7. Instruct significant others not to leave patient alone.
8. Provide comfort measures .
9. Instruct significant others to assist patient in doing the activities of
daily lives.
NURSING DIAGNOSES
 Impaired physical mobility related
to weakness of left-side body
 Acute pain
 Activity intolerance
 Risk for fall
 Self-care deficit