Chapter 2

METHOD

Presented in this chapter are the study design, anatomy and physiologic
review and the pathophysiology of the disease.

STUDY DESIGN

A case study of individual patients often involve in-depth interviews with

participants and key informants, review of medical records, observation, and
excerpts from patients’ personal writings and diaries. Case studies have a
practical function in that they can be immediately applicable to the participant’s
diagnosis or treatment. Case study research provides nurses with a form of
inquiry that is holistic and appropriate for a variety of populations and it would
help the student nurses employ their decision-making skills, use critical thinking
to analyze different situations and develop cognitive reasoning abilities without
harming patients.

ANATOMIC AND PHYSIOLOGIC REVIEW

Cerebrovascular Accident (CVA)

Cerebrovascular Accident (CVA) or stroke is the onset and persistence of
neurologic dysfunction lasting longer than 24 hours and resulting from disruption
of blood supply to the brain and indicates infarction rather than ischemia. Strokes
are classified as ischemic or hemorrhagic. Ischemic stroke is caused by a
thrombotic or embolic blockage of blood flow to the brain. Bleeding into the brain
tissue or the subarachnoid space causes a hemorrhagic stroke (Lippincott,
2006).

Middle Cerebral Artery

Middle cerebral artery stroke describes the sudden onset of focal
neurologic deficit resulting from brain infarction or ischemia in the territory
supplied by the middle cerebral artery (MCA). Thee middle cerebral artery is the
largest branch of the internal carotid. The artery supplies a portion of the frontal
lobe and the lateral surface of the temporal and parietal lobes, including the
primary motor and sensory areas of the face, throat, hand and arm and in the
dominant hemisphere, and areas for speech. The middle cerebral artery is the
artery most often occluded in stroke.

The parts of the middle cerebral artery are:

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● Horizontal Segment: This segment “burrows into” the brain tissue via
branches called the lateral lenticulostriate arteries. These arteries are
responsible for supplying blood to the basal ganglia. The basal ganglia are
vas clusters of nerve cells, called neurons that are responsible for
involuntary movements.
● Sylvian Segment: ​Supplies blood to the temporal lobe and insular cortex.
The temporal lobe is involved in the processing of sound. The insular
cortex, also called the insula, regulates some motor function and helps
pair emotions with experiences. The branches of the Sylvian segment may
bifurcate (split in two) or trifurcate (split in three) into trunks. This area of
the brain also contains the operculum, a covering of the brain, which
extends from insula in the direction of the cortex, the outer layer of the
brain. The Sylvian segment is sometimes separated into the opercular
segments and the insular segment.
● Cortical Segments: Provides blood to the cortex

Anatomy of the Brain

The brain has three primary components. Each is responsible for different
functions:

PATHOPHYSIOLOGY

A. Etiology

Table 4. Predisposing Factors

PREDISPOSIN
G JUSTIFICATION RATIONALE
FACTOR
Advanced age She was diagnosed Anyone could have a stroke, even
(53 years old) Cerebrovascular babies in the womb. Generally, the
Accident Left Middle chances go up as we get older. They
Coronary Artery; double every decade.
Hypertension II
Heredofamilial The patient’s Strokes can run in families. You and
disease grandfather, your relatives may share a tendency
grandmother on to get high blood pressure. Some

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both sides had (+) stroke can b brought on by a genetic

hypertension and his disorder that blocks blood flow to the
brother died due to brain.
cardiac arrest.
Sex Women are slightly less likely to have
(Male) a stroke than men of the same age.
But women have strokes at a later
age, which make them less likely to
recover and more likely to die as a
result.
Socioeconomic An inverse relationship between better
-middle class socioeconomic status (total household
income, education or occupation) and
stroke has been established in
developed communities. The overall
prevalence of diagnosed stroke was
1.54% in all 29,340 eligible
participants. An elevated prevalence
of stroke was associated with
increasing levels of Family Average
Income(FAI). After adjustment for
basic demographic variables (age,
urban/rural area and gender) and a
group of defined conventional risk
factors, this gradient still remained
significant, with participants in the
highest (OR = 1.94, 95% CI = 1.40,
2.70) and middle (OR = 1.43, 95% CI
= 1.01, 2.02) categories of FAI having
higher risks compared with the lowest
category.
https://www.ncbi.nlm.nih.gov/pmc/artic
les/PMC2416447/
Carotid or The inner lining of the artery, called
atherosclerosis the endothelium, can be damaged due
to high cholesterol and triglyceride
levels, toxic substances in cigarette
smoke, high sugar levels, and other
factors in the blood. High blood
pressure can also cause damage to
the inner lining of an artery. Once the
blood vessel is damaged,
atherosclerosis begins and plaque
forms.The carotid arteries in our neck

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supply most of the blood to the brain.

A carotid artery damaged by a fatty
build-up of plaque inside the artery
wall may become blocked by a blood
clot. This causes stroke.
http://www.strokeassociation.org/STROKEOR
G/LifeAfterStroke/HealthyLivingAfterStroke/
UnderstandingRiskyConditions/Atherosclerosi
s-and-Stroke_UCM_310426_Article.jsp#.W6f
UJGWXtG4
Heart disease This includes defective defective heart
valves as well as atrial fibrillation or
irregular heart beat, which causes a
quarter of all strokes among adult.

Table 5. Precipitating Factors

PRECIPITATIN
G JUSTIFICATION RATIONALE
FACTOR
Hypertension 150/110 mmHg Hypertension is the biggest cause of
stroke. If the blood pressure is
typically 140/90 or higher.
Smoking 2 packs/day Smoking or chewing it raises the odds
of a stroke. Nicotine makes the blood
pressure go up. Cigarette smoke
causes a fatty buildup in the main
neck artery. It also thickens the blood
and makes it more likely to clot.
Alcohol Previously he drink Alcohol (more than one drink per day)
alcohol 1-2 bottles a is associated with stroke risk.
day
Diet(Increase Always eating fatty Various studies that diet is an
salt and foods and junk foods. important risk factor in the
cholesterol development of stroke.
intake)

B. Symptomatology

Table 6. Clinical Manifestations

FACTOR JUSTIFICATION RATIONALE
Difficulty He experienced A stroke can cause problems with
Speaking difficulty speaking.

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communicating if there is damage to

the parts of the brain responsible for
language. This body, many people
who have communication problems
after functions are controlled by the
left side of the brain in most people.
As one side of the brain controls the
opposite side of the stroke also have
weakness or
paralysis on the right side of their
body.
http://www.stroke.org.uk/sites/default/fi
les/Communication%20problems%20
after%20stroke.pdf
Numbness of Prior on admission Stroke may develop sudden
the face patient experience numbness, weakness or paralysis in
facial numbness. the face, arm or leg. This often
happens just on the side of the body.
Try to raise both the arms over the
head at the same time. If one arm
begin begins to fall, you may be
having a stroke. Also, one side of your
mouth may droop when you try to
smile.
Diplopia(Doubl Patients experience In a ​stroke​, blood fails to reach the
e vision) double vision prior to brain due to an obstruction in the
admission. blood vessels. This can affect the
blood vessels supplying the brain or
nerves controlling the eye muscles
and cause double vision.
Headache Prior to admission You may have headaches if your
the patient stroke causes swelling in your brain.
experienced severe This is more common if your stroke
headache. was caused by bleeding in your
brain.Headaches can also be a side
effect of some medication, including
some drugs you may be given for high
blood pressure or to thin your blood.
Stress, depression or lack of sleep
can also cause headaches​.
https://www.stroke.org.uk/what-is-stro

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ke/effects-of-stroke/physical-effects-of
-stroke/pain-and-headaches

Hemiplegia Prior to admission Hemiplegia is a form of paralysis that

patient experienced affects just one side of the body, often
right sided body just one arm and one leg, but
paralysis. occasionally with symptoms extending
partially into the torso. The brain is
divided into two hemispheres,
separated by a bundle of fibers called
the corpus callosum. Generally
speaking, the right side of the brain
controls muscles and other functions
on the left side of the body, while the
left side of the brain controls much of
the right side of the body.
https://www.spinalcord.com/hemiplegi
a
Dizziness He complains feeling Reduced blood supply to the back part
of dizziness. of the brain can cause dizziness.
https://www.dizziness-and-balance.co
m/disorders/central/strokes/tia.html
Ataxia (Lack of There was presence Ataxia ​refers to​ a group of disorders
coordination) of uncoordinated that can affect coordination, speech,
movement when the and balance. It can also make it hard
patient trying to move to swallow and walk.
his affected side and https://www.healthline.com/health/mov
unaffected side. ement-uncoordinated
Decreased During our exposure Problems with bladder and bowel
Urine Output the patient urinate function are common but distressing
100cc for 8 hours for stroke survivors. These issues
occur when a stroke has damaged the
part of the brain that controls waste
removal or the brain signals for it.
http://www.strokesmart.org/article?id=
106
Shoulder pain During the our It’s very common for a stroke to cause
exposure the patient weakness in your muscles. This
complains pain in his usually happens on one side of your
shoulder body. This weakness can lead to
painful conditions such as muscle
stiffness (spasticity), shoulder
problems, or swollen hands.

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Some people also experience central

post-stroke pain. Many people
describe this kind of pain as an icy,
burning sensation or a throbbing or
shooting pain. This can happen if your
brain, spinal cord or the sensory
pathways that link your brain and
other parts of your body are
damaged.
https://www.stroke.org.uk/what-is-stro
ke/effects-of-stroke/physical-effects-of
-stroke/pain-and-headaches

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