[ishy25]

guys i badly need help, 5 days from now will have my first individual case presentation about our patient's case and i'm having a hard time making some of my requirements on it,, my case was about a 58 yrs old woman who has been admitted due to 2nd stroke atttack she has a diabetes mellitus and was diagnosed to have a brain cancer 2 days ago, im having a diificulty in making a pathophysiology on which i could connect all of this underlying disease that may lead to CVA or if not just to have some nice patho about it. my pt. guardian says that she has diff. in naming names and objects and is paralyzed on the left side of the body she also felt some headache and dizziness at some intervals, she also felt numness at the right side of her bodyand loss of appetite. she has several drugs such omeprazole, glimepride, dexamethasone etc. i also need to make a diet for a day suitable for her case. and some a couple of nursing care plans about it.there are also some lab. exam that i really dont know how to interpret esp. the MRI scan. she was diagnosed with CVA s/p left CVA.hope you could help me thanks for all who will reply in my post.

[Daytonite]

I'm having a hard time trying to figure out everything that you need. I get that you need help with the pathophysiology. I don't understand what you mean by "make a diet for a day suitable for her case" or "how to interpret esp. the MRI scan". Nurses don't interpret MRI scans. We can only take the results of them and fit them into the pathophysiology.

[Daytonite]

This is a group project? Did I understand that correctly? If so, what exactly is your part of the project that you have to complete? Also, please clarify. . ."some a couple of nursing care plans about it [the diet?]". A patient only gets one nursing care plan, but they can have several nursing diagnoses within the nursing care plan. I can't help you if I don't know what it is that you need help with.

There are a lots of example of nursing student case studies on these two web sites, including strokes, that you can look at for ideas:

• http://learn.sdstate.edu/craigg/ERCases.html
• http://learn.sdstate.edu/craigg/ERSp01.html

[Daytonite]

Here is some of the pathophysiology:

A stroke, or cerebrovascular accident, is a sudden impairment of cerebral circulation in one or more blood vessels. A stroke interrupts or diminishes oxygen supply, and commonly causes serious damage or necrosis in the brain tissues. The sooner the circulation returns to normal after a stroke, the better the chances are for a complete recovery. However, about one-half of the patients who survive a stroke remain permanently disabled and experience a recurrence within weeks, months, or years. Strokes are classified as ischemic or hemorrhagic. There are three types of ischemia strokes: thrombotic, embolic and lacunar.

• Cerebral thrombosis. Thrombosis of the cerebral arteries supplying the brain or of the intracranial vessels occluding blood flow is the most common cause of strokes in middle-aged and elderly people. It is commonly the result of atherosclerosis, but also associated with hypertension, smoking and diabetes. A thrombus in an extracranial or intracranial vessel blocks blood flow to the cerebral cortex. The carotid artery is the most commonly affected extracranial vessel. Common intracranial sites include the bifurcation of the carotid arteries, distal intracranial portion of vertebral arteries, and proximal basilar arteries. Thrombotic stokes commonly occur during sleep or shortly after awakening, during surgery, or after a myocardial infarction.
• Cerebral embolism. An embolism from outside the brain, such as in the heart, aorta, or common carotid artery can occur at any age, especially among patients with a history of rheumatic heart disease, endocarditis, posttraumatic valvular disease, myocardial fibrillation and other cardiac arrhythmias, or after open heart surgery. These embolisms float into the cerebral bloodstream and lodge in the middle cerebral artery or one of its branches. It is the second most common type of stroke. These types of strokes typically occur during activity and develop rapidly. These emboli commonly originate during atrial fibrillation.
• Cerebral Lacunar stroke. This is a type of thrombotic stroke. Hypertension creates cavities deep in the white matter of the brain which affects the internal capsule, basal ganglia, thalamus and pons. The lipid coat lining the small penetrating arteries thickens and weakens the walls of these blood vessels causing microaneurysms.

Hemorrhagic stroke. This is the third most common type of stroke. A rupture occurs in an intracranial artery or vein as a result of hypertension, aneurysm, arteriovenous malformations, trauma, hemorrhagic disorders or a septic embolism. Hypertension and ruptured aneurysms are the most common causes. It can occur at any age. As a result there is diminished blood supplied to the tissues fed by the ruptured artery and compression of the brain cells by accumulated blood. When hemorrhage has occurred the blood that has spilled among the brain cells acts as a space-occupying mass that exerts pressure on the brain tissue. At first, ruptured cerebral blood vessels may constrict to limit blood loss which further restricts blood flow to the area of stroke and promotes ischemia. Blood cells can also migrate into the spaces where cerebral spinal fluid circulates and cause blockages of this fluid circulation resulting in hydocephalus.

When any type of stroke occurs, there is deprivation of oxygen and nutrients to the affected area of the brain. When blood flow in a blood vessel remains blocked for more than a few minutes, oxygen deprivation leads to infarction of brain tissue. The brain cells cease to function because they can neither store glucose or glycogen for use nor engage in anaerobic metabolism.

The pathophysiology of a generic cancer cell is as follows. The division, reproduction and replacement of all normal cells are controlled by regulator genes. A normal cell has regulator genes that produce hormones that act as on and off switches that begin or stop cell division and differentiation. A cell becomes cancerous when these regulator genes and the hormones they produce develop errors in function or stop functioning altogether. The normal cell then loses the ability to reproduce normally. The problem may be with the gene itself or in the synthesis of the hormones controlling this cell cycling process. What happens is that with the mechanism controlling their division and differentiation on the fritz these cells go into overdrive and begin unrestricted division and reproduction. Their rate of reproduction increases dramatically and in a very disorderly way compared to the normal cells around them. If they also lose their ability to differentiate a state called anaplasia results. As these cells continue to multiply they begin to lose some of their resemblance to the original cell they started from. This mutation continues if the process cannot be successfully stopped. The normal cells around them will try to "rescue" the situation by evoking the immune or inflammatory response and by releasing other growth factors, hormones and chemicals into the area in an attempt to stop what is going on. For one of these wayward cells to develop into a tumor, the body's immune system must fail to recognize or respond to it. In addition, there must be enough of a blood supply to bring oxygen and nutrients to nourish these mutated cells so they can thrive. Blood supply is a big factor in the early survival success of a tumor. However, once a tumor is able to successfully thrive and grow relentlessly, it will begin to produce it's own angiogenesis factors which will stimulate the formation of new blood vessels around them in order to meet its growth and nutrition demands. When tumor tissue extends close to or into blood or lymph circulation, cells will break off and travel to other sites in the body resulting in metastasis.

With brain cancer, central nervous system changes are caused by cancer cells invading and destroying tissues. The brain, cranial nerves and cerebral vessels are also compressed together within the cranium which increases the intracranial pressure. This will result in signs and symptoms of increased intracranial pressure (altered level of consciousness from restlessness to confusion and coma, headache, abnormal breathing patterns, elevated blood pressure with widening pulse pressure, slowing of pulse, elevation of temperature, vomiting, changes in the pupil of the eye, motor function changes such as weakness all the way to hemiplegia), visual disturbances, weakness, paralysis, aphasia, dysphagia, ataxia, incoordination of movements and seizures. Complications may be cerebral edema, neurological deficits, hydrocephalus and brain herniation.

There are many different symptoms that a patient can have depending on where in the brain the stroke occurred and the actual tumor is situated. Paralysis on the left side of the body usually indicates damage (a stroke) to the right side of the brain. You would have to confirm this is so by reading the detail in the MRI report. Other symptoms that can also occur with right sided strokes include:

• left-sided neglect
• spatial-perceptual deficits
• a tendency to deny or minimize problems
• short attention span
• impulsiveness
• safety problems
• impaired judgment
• impairment with time concepts
• tendency to perform actions rapidly

Your patient's left-sided paralysis, numbness in the right side of the body, dizziness, and difficulty in naming objects would be manifestations of this type of stroke.

Complications of stroke include:

• Malnutrition (is your patient headed down this road?)
• Infections
• Sensory impairment (your patient is already experiencing this)
• Aspiration
• Contractures
• Skin breakdown
• Deep vein thrombosis
• Pulmonary emboli
• Depression
• Seizures (with a brain tumor this needs to be monitored for)

Diabetes mellitus is a disorder of carbohydrate metabolism in which there is an interruption in the production and use of insulin by the body. It is classified as either Type I or Type II. Type II diabetes mellitus is of more frequent occurrence and is characterized by varying degrees of insulin resistance in the individuals who have it. It is often associated within families, race, sedentary lifestyle, obesity, with hypertension and occurs more frequently as people age, particularly over the age of 45. Type II diabetes mellitus develops over a long period of time or can be brought about during pregnancy or some other great stress or trauma that the body is undergoing. Cardiovascular disease (heart attack and stroke) is a long term complication of diabetes mellitus.

And, the medications certainly fit in with this scenario, as well:

• omeprazole (Prilosec) – proton pump inhibitor – GERD, severe erosive esophagitis, treatment of active ulcers (This is being given to prevent the occurrence of an ulcer because the patient is under a great deal of stress at this time. This is commonly ordered for stroke patients in the immediate aftermath of the stroke.)
• glimepride (Amaryl) – antidiabetic, sulfonylurea – type 2 diabetes – cause beta cells to release more insulin
• dexamethasone (Decadron) – synthetic coricosteroid - used to reduce swelling – cerebral edema, neoplasms

[ishy25]

hey thanks for the information you posted, actually its not a group project, its an individual project, that's why i'm having a problem on how to finish all these things within 5 days,

• i need to make 3 nursing diagnosis for her case.
• also i need to make a one day meal plan that is suitable in her case.
• seven drug analysis
• 4 nursing journals
• and a physical assessment
• pathophysiology of her disease

right now im done with my physical assessment and several drug anlalysis and roght now having a hard time doing the pathophysiology. hmm i hope i could really pass this stressful case presentation...

[Daytonite]

Hey! I gave you an extensive pathophysiology for the CVA and brain cancer. You should be able to find more for the diabetes. Your physical assessment should already be done and at this point is just a matter of writing it up.

You listed six symptoms:

• left sided paralysis
• right-sided numbness
• headache
• dizziness
• loss of appetite
• difficulty in naming objects

You can get 4 real nursing diagnoses from those:

• Impaired Physical Mobility
• Acute Pain
• Disturbed Sensory Perception
• Imbalanced Nutrition: Less than body requirements

http://www.nlm.nih.gov/medlineplus/diabeticdiet.html - diabetic diet page on Medline Plus
http://diabetes.health.ivillage.com/...dietnutrition/ - Diabetes Diet & Nutrition Center from iVillage Total Health (formerly Diabetes Health Online)
http://www.diabetes.org/nutrition-an...n/overview.jsp - Nutrition & Recipes from the American Diabetes Association. Suggest you link into the Frequently Asked Questions (at left side of page)