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CP ON MOYAMOYA

Mr. Madhurjya Kishor Das, a 19-year-old male student, was admitted with sudden dizziness, left-side weakness, and vomiting, diagnosed with Moyamoya disease and intracerebral hemorrhage. He has a history of craniotomy in 2017 and 2018 and lives in a nuclear family with no significant hereditary illnesses. His current treatment includes medications such as Mannitol and Valprol, and he is being monitored for various health parameters.

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0% found this document useful (0 votes)
18 views49 pages

CP ON MOYAMOYA

Mr. Madhurjya Kishor Das, a 19-year-old male student, was admitted with sudden dizziness, left-side weakness, and vomiting, diagnosed with Moyamoya disease and intracerebral hemorrhage. He has a history of craniotomy in 2017 and 2018 and lives in a nuclear family with no significant hereditary illnesses. His current treatment includes medications such as Mannitol and Valprol, and he is being monitored for various health parameters.

Uploaded by

febbylamare13
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DEMOGRAPHIC DATA

Name of the patient: Mr. Madhurjya Kishor Das


Age: 19 years
Sex: Male
IP No: 250130/00017
Marital Status: Unmarried
Religion: Hinduism
Educational Level: Class 11
Occupation: Student
Income: Nil
Diagnosis: MoyaMoya disease with Craniotomy
Date of Admission: 30/01/2025 at 01:45 PM
Date of Operation: Craniotomy done in 2017 and 2018
Address: Barpeta, Assam
CHIEF COMPLAINT
Mr. Madhurjya Kishor Das was admitted to GNRC, Dispur on 30/01/25 at 01:45 PM
with the chief complaint of
 Sudden onset dizziness since last 2 days.
 Weakness of left side of the body since last 2 days.
 Deviation of the angle of mouth towards right for since last 2 days.
 2 episodes of vomiting.

HISTORY OF PRESENT ILLNESS


My patient Mr. Madhurjya Kishor Das was apparently well. Suddenly, he started
having dizziness and weakness of the left side of the body, deviation of the angle of mouth
towards right which lasted for 2 days and 2 episodes of vomiting. So, the patient was taken to
Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta initially where CT scan was
done that shows Intracerebral hemorrhage (ICH) with Intraventricular hemorrhage (IVH).
Patient was then brought to GNRC, Dispur Hospital for further management where he was
diagnosed as a case of Moyamoya disease with Craniotomy.
During history taking, patient was alert and conscious. On examination, BP – 130/70 mmHg,
PR – 105 b/m, RR – 20 b/m, SPO2 – 99% RA, RBS – 89 mg/dl, Temp – 98 F.

SOCIO ECONOMIC CONDITION


Source of Income – The patient is still a student and his father is the breadwinner of the
family with an income of Rs 60000/annually.

PHYSICAL - ENVIRONMENT HISTORY OF THE PATIENT


Mr. Madhurjya Kishor Das lives in his own house which is semi-concrete and
ventilation is adequate. They got electricity from Assam Board of Electricity Supply and the
drainage system is a closed system and they have their own toilet facilities and they got water
supply from their own well.

FAMILY HEALTH HISTORY


Mr. Madhurjya Kishor Das lives in a nuclear family and there are 5 members in the
family.
Family History: There is no significant history of hereditary illness in the family or any
history of communicable diseases like Tuberculosis or any congenital problems or others.
FAMILY STRUCTURE
SL NAME AGE/ RELATIONSHI EDUCATIO OCCUPATIO MARITA HEALTH
N SEX P N N L STATUS
O STATUS
1 Mr. Atul 48 Father Class 8th Labourer Married Healthy
Das yrs/M passed
2 Mrs. 45 Mother Class 6th Housewife Married Healthy
Rashtri yrs/F passed
Das
3 Mr. 24 Brother BA Student Unmarried Healthy
Roshan yrs/M
Das

4 Mr. 19 yrs/M Patient Class 11 Student Unmarried Unhealth


Madhurjy y
a Kishor
Das
5 Miss 15 yrs/ F Sister Class 9 Student Unmarried Healthy
Simran
Das
PEDIGREE

Patient’s Father Patient’s Mother


48 years/M 45 years/F
Healthy Healthy

Patient’s Brother Patient Patient’s Sister


24 yrs/M 19 yrs/M 15 yrs/F
Healthy Unhealthy Healthy

INDEX

- Male Patient

- Female Patient

- Marriage

- Male death

- Female death
PAST MEDICAL HISTORY
Mr. Madhurjya Kishor Das is a known case of Moyamoya disease and had undergone
craniotomy in 2017 and 2018 in Narayana Hospital, Bengaluru.
There is no other illness like DM, HTN, Tuberculosis etc.

OTHER RELEVANT HISTORY


Mr. Madhurjya Kishor Das is both vegetarian and non-vegetarian. Sleep pattern of the
patient is not regular due to dizziness. During hospitalization, Mr. Madhurjya Kishor Das
could not be able to sleep properly.
Mr. Madhurjya Kishor Das does not take betel nut. He does not have any significant
history of allergy to any food items and any substances or any medications till date. His
bladder and bowel pattern is regular.

PHYSICAL EXAMINATION
SYSTEMS FINDINGS
General Assessment The patient is conscious and alert at the time
of examination.
GCS – 14/15. Pupil reaction – 2(+) B/L

Height 175 cm
Weight 50 kg
BMI 16.33 kg/m2
Integumentary System

Skin  Skin is intact, peripheries are warm.


 Skin is brownish in color, Turgor
return quickly.

Nail  Shape of the nails are normal.

 Colour is normal.
 Capillary refill time is normal < 3
secs

 Oedema – Bilateral pedal oedema is


absent.

 No Icterus present.

 Body temperature is afrebile.

 Hair is black and well distributed.


Head and Neck  Head is asymmetry in shape due to
craniotomy.
 No mass present in the neck.
 No stiffness of neck.

 Both eyes are symmetry.


Eyes  Lens are clear.
 No redness seen in both eyes.
 No discharge present.
 Facial numbness absent.

 Pinna is intact, proper alignment.


Ears  External ear canal. No Cerumen
seen.
 No Ear Discharge seen.
 External nose: There is no deviated
nasal septum.
 Internal nose: Hair present on both
nasal canal.
 No polyps, discharge seen.

 Deviation of the angle of the mouth


towards right.
Mouth and Pharynx  Lips are pinkish in colour.
 Teeth are all present.
 There is no bleeding gum.
Respiratory System

Neck  There is no stiffness of neck.


 The trachea is in midline and no
tender.

 Chest movement is bilaterally


Chest present.
 Dyspnea is absent.
 Normal breath sound.
 Vesicular sound is present.

Cardiovascular System  Assessment of pulse.


 Peripheral pulse present in radial,
popliteal, posterior tibial, femoral,
brachial and dorsalis pedis.
 Heart rate – 105 b/m.
 Heart rhythm is normal.
 Blood pressure – 130/70 mmHg.
 Heart sound is normal.
Gastrointestinal System

Abdomen  Inspection – There is no scar mark


present. Presence of skin rashes.
Abdominal distension is not seen.
 Palpation – Abdominal tenderness is
present.
 Percussion – Normal resonance
sound is heard. There is no
abnormality.
 Auscultation – Peristalsis present,
Normal bowel sound heard.
Musculo-skeletal System

Upper Extremities  Movement of the upper extremities


is present
 Weakness of the left upper
extremities is present.

Lower Extremities  Movement of the lower extremities


is present.

 Weakness of the left lower


extremities is present.
 No varicose vein is seen.
 Pedal oedema is absent.
 No bluish discoloration seen.
Genital System  No penile discharge seen.
 Normal bowel habit.
 Urinary catheter is present.

BIO-PHYSICAL MEASUREMENT
Blood Pressure – 130/70 mmHg
Heart rate - 105 b/m
Respiratory Rate – 20 b/m
Temperature – 98 F
RBS – 89 mg/dl
GCS Scale – E4 V5 M5 (14/15)

INVESTIGATION
Date Name of Investigation Findings Normal Value Remarks

30/01/25 TLC
(Total Leucocyte Count) 10800/cumm 4000-10000 High
WBC

DLC: Polymorphs 74% 40 – 80 Normal


Lymphocyte 18% 20 – 40 Low
Monocyte 7% 2 – 10 Normal
Eosinophil 1% 1–6 Normal
Hemoglobin 13.1 gm% 13 – 16.5 gm Normal
Platelet count 1.6 lac/cmm 1.5 -4.1 Normal
lac/cmm
30/01/25 LFT (Liver Function Test)

AST/SGOT 21 IU/L 15 – 37 IU/L Normal

ALT/SGPT 36 IU/L 16 – 63 IU/L Normal

Alkaline Phosphatase 130 IU/L 46-116 IU/L High

Total Bilirubin 1.0 mg/dl 0.1-1.2 mg/dl Normal

Total Protein 7.5 g/dl 6.4-8.2 g/dl Normal

Albumin 3.6 g/dl 3.5 – 5.0 g/dl Low

Globulin 3.9 g/dl 2.3 – 3.5 g/dl High

30/01/25 KFT (Kidney Function Test)

Serum Urea 18 mg/dl 15-40 mg/dl Normal

Sodium 143 mmol/L 136-148 Normal

Potassium 4.0 mmol/L 3.6-5.2 Normal

Creatinine 0.6 mg/dl 0.8-1.3 mg/dl Low

 CT Scan Cerebral Angio done on 30/01/25 and shows:


- Significant luminal narrowing with multiple stenotic segments in bilateral
supraclinoid ICAS and proximal MACS and ACAS with multiple
surrounding collaterals formation-Suggestive of residual disease.

 6 Vessel Cerebral DSA done on 04/02/25 and shows


- Present DSA features are consistent with Grade 3 Moyamoya disease
(Extensive involvement of the left side noted). Bilateral distal MCA branches
seen filling from collaterals and STA-MCA bypass.

 CT Brain done on 30/01/25 and shows


- Multiple Intraparenchymal hemorrhages in right basal ganglia and
periventricular regions with associated intraventricular hemorrhage. Post
operative changes in bilateral temporal region.
 Digital X-ray Chest (PA view) and ECG done on 31/01/25 and shows normal study.

MEDICATIONS

1) Inj. Mannitol, 100 ml, TDS × IV

2) Inj. Valprol, 300 mg, TDS × IV

3) Inj. Rhumacort, 1 amp, BD × IM

4) Inj. Pansa 40 mg, OD x IV


SL DRUG DOSE ROUTE TIME/ ACTION INDICATION/ SIDE NURSES
NO NAME FREQUENCY CONTRAINDICATION EFFECTS RESPONSIBIL
ITY
1 Inj. 100 ml IV TDS Increases osmolarity Indication CNS: Dizziness, Assessment
Mannitol of glomerular filtrate, Edema; promote systemic headache, Assess
which raises osmotic diuresis in cerebral edema, seizures, neurologic status
pressure of fluid in decrease intraocular rebound Assess for
renal tubules; there is pressure, improve renal increased ICP. vision changes
a decrease in function in acute renal CV: Edema, or eye
reabsorption of water, failure, chemical hypotension, discomfort or
electrolytes; increases poisoning, urinary bladder hypertension, pain before,
in urinary output, irrigation tachycardia, during
sodium, chloride, Contraindication CHF, treatment.
potassium, calcium, Active intracranial thrombophlebiti Assess patient
phosphorus, uric acid, bleeding, hypersensitivity, s, angina-like for tinnitus,
urea, magnesium. anuria, severe pulmonary chest pains, hearing loss.
congestion, edema, severe fever, chills, Assess fluid
dehydration, progressive circulatory volume status.
heart disease, renal failure, overload. Patient/family
acute MI, aneurysm, stroke EENT: Loss of education.
hearing, blurred Teach patient
vision, nasal reason for and
congestion, method of
ELECT: treatment
Fluid, Evaluation
electrolyte Positive
imbalances, therapeutic
acidosis, outcome
electrolyte loss, Decreased
GI: Nausea, intraocular
vomiting, dry pressure
mouth, diarrhea Prevention of
GU: Marked hypokalemia.
diuresis, retent.

SL DRUG DOSE ROUTE TIME/ ACTION INDICATION/ SIDE EFFECTS NURSE


NO NAME FREQUENCY CONTRAINDICATI RESPONSIBILIT
ON Y
2 Inj. 300 mg IV TDS Increases levels of Indication CNS: Sedation, Assessment
Valprol gaminobutyric acid Simple (petit drowsiness, •Monitor blood
(GABA) in the mal), complex dizziness, tests
brain, which (petit mal), headache, • Monitor liver
decreases seizure absence, mixed incoordination, function tests
activity. seizures, manic depression, • Monitor blood
episode associated hallucinations, CV: levels: therapeutic
with bipolar disorder, Hypotension/ level 50-125
prophylaxis of hypertension, mcg/ml
migraine, adjunct in chest pain, • Assess seizure
schizophrenia, tardive palpitations, disorder.
dyskinesia, aggression peripheral edema Assess bipolar
in children with ADHD, EENT: Visual disorder.
organic brain disturbances. Patient/family
syndrome, tonic-clonic GI: Nausea, education
(grand mal)/myoclonic vomiting, •Teach patient that
seizures constipation, physical
Contraindication diarrhea. dependency may
Hypersensitivity, urea GU: Enuresis, result from
cycle disorders, irregular menses extended use
Pregnancy, hepatic HEMA: •Instruct patient to
disease, pancreatitis, Thrombocytopenia, avoid driving, other
Breastfeeding. leukopenia, activities that
lymphocytosis, require alertness
increased pro-time. Advise patient not
INTEG: Rash, to discontinue
alopecia. medication quickly
Evaluation:
Decreased seizures.
SL DRUG DOSE ROUTE TIME/ ACTION INDICATION/ SIDE EFFECTS NURSE
NO NAME FREQUENCY CONTRAINDICATION RESPONSIBIL
ITY
3 Inj. 1 amp IM BD Rhumacort Indication CNS: Headache, Assessment
Rhumacort injection is a Osteoarthritis insomnia, • Assess patient
combination of two Rheumatoid Arthritis dizziness, fever, for previous
medicines: Ankylosing Spondylitis lethargy, sensitivity
Diclofenac and hallucinations, reaction to
Paracetamol. These Contraindication anxiety. rhumacort.
medicines work by It can be harmful in CV: Cardiac • Assess patient
blocking the action patients with known toxicity, edema for signs and
of chemical allergy to painkillers GI: Nausea, symptoms of
messengers (NSAIDs) or any of the vomiting, diarrhea, infection.
responsible for components or excipients abdominal pain, Assess for
pain, fever and of this medicine. The use glossitis, allergic
inflammation of this medicine should constipation. reactions.
(redness and preferably be avoided in GU: Oliguria, • Monitor for
swelling). patients with a history of proteinuria, bleeding.
stomach ulcers or in hematuria, Patient/family
patients with active, vaginitis, education
recurrent stomach moniliasis, • Teach patient
ulcer/bleeding. It should glomerulonephritis to report any
also be avoided in patients HEMA: Anaemia, signs and
with the history of heart increased bleeding symptoms.
failure, high blood time, bone marrow • Advise patient
pressure, and liver or depression, to notify
kidney disease. agranulocytosis. prescriber of
INTEG: Rash, diarrhea or any
pruritus. kidney disease.
META:
Hypokalemia,
hypernatremia.

SL DRUG DOS ROUT TIME/ ACTION INDICATION/ SIDE EFFECTS NURSE


N NAME E E FREQUENC CONTRAINDICATIO RESPONSIBILIT
O Y N Y
4 Inj. Pansa 40 mg IV OD Suppresses gastric Indication CNS: Headache, Assess bowel sound.
(Pantoprazole secretion by Gastroesophageal reflux Insomnia, asthma, Maintain all rights of
) inhibiting disease (GERD), severe fatigue, malaise. drug administration.
hydrogen/potassiu erosive esophagitis, GI: Diarrhea, Assess for
m ATPase enzyme maintenance of long term abdominal pain, abdominal pain,
system in gastric pathologic hypersecretory flatulence, swelling, anorexia.
parietal cell, conditions, including pancreatitis, Hepatic studies,
characterized as Zollinger Ellison weight changes. AST, ALT, Alk-pho
gastric acid pump Syndrome. INTEG: Rash during treatment.
inhibitor because it Hyperglycemia, Evaluate for absence
block the final step Contraindication Hyponatraemia, of epigastric pain,
of acid production. Hypersensitivity to this Hypomagnesemia swelling.
product or , myalgia. Teach patient/family
benzimidazole. to report severe
diarrhea and black
tarry stools.
DISEASE CONDITION: MOYAMOYA DISEASE
INTRODUCTION
Moyamoya disease (MMD) was first described in Japanese literature in 1957. The term "moyamoya" was
coined in 1969 by Suzuki and Takaku. The puff of smoke is a description of the hazy appearance of the
collateral vasculature on angiography. Recently, it has become increasingly apparent that the
term moyamoya encompasses many different arteriopathies with distinct genetic and environmental drivers
that share a common end-stage radiographic appearance.

DEFINITION
Moyamoya disease is a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of
the brain in an area called the basal ganglia. Moyamoya means “puff of smoke” in Japanese and is used to
describe the tangled appearance of tiny vessels compensating for the blockage.
Moyamoya disease is an uncommon blood vessel ailment that results in constriction or obstruction of
the carotid artery in the head. The carotid artery is a significant blood vessel that provides blood to the brain.
When the brain's blood flow is blocked, it is reduced. Then, tiny blood vessels start to grow at the base of the
brain, trying to supply it with blood.
RELATED ANATOMY AND PHYSIOLOGY

ANATOMY OF THE BRAIN


The brain is an amazing three-pound organ that controls all functions of the body, interprets information
from the outside world, and embodies the essence of the mind and soul. Intelligence, creativity, emotion,
and memory are a few of the many things governed by the brain. Protected within the skull, the brain is
composed of the cerebrum, cerebellum, and brainstem.
BRAIN
The brain is composed of the cerebrum, cerebellum, and brainstem
Cerebrum: is the largest part of the brain and is composed of right and left hemispheres. It performs higher
functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions, learning, and
fine control of movement.
Cerebellum: is located under the cerebrum. Its function is to 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.
The cerebrum is divided into two halves: the right and left hemispheres. They are joined by a bundle of
fibers called the corpus callosum.
In general, the left hemisphere controls speech, comprehension, arithmetic, and writing. The right
hemisphere controls creativity, spatial ability, artistic, and musical skills.
Lobes of the brain
The cerebral hemispheres have distinct fissures, which divide the brain into lobes. Each hemisphere has 4
lobes: frontal, temporal, parietal, and occipital
Frontal lobe

 Personality, behaviour, emotions


 Judgment, planning, problem solving
 Speech: speaking and writing (Broca’s area)
 Body movement (motor strip)
 Intelligence, concentration, self-awareness

Parietal lobe

 Interprets language, words


 Sense of touch, pain, temperature (sensory strip)
 Interprets signals from vision, hearing, motor, sensory and memory
 Spatial and visual perception
Occipital lobe

 Interprets vision (colour, light, movement)

Temporal lobe

 Understanding language (Wernicke’s area)


 Memory
 Hearing
 Sequencing and organization
MENINGES:
Meninges are three layers of membranes that cover and protect your brain and spinal cord (your
central nervous system [CNS]). They’re known as:
 Dura mater: This is the outer layer, closest to your skull.
 Arachnoid mater: This is the middle layer.
 Pia mater: This is the inner layer, closest to your brain tissue.
Together, the arachnoid mater and pia mater are called leptomeninges.
There are three spaces within the meninges:
 The epidural space is a space between your skull and dura mater and the dura mater of your
spinal cord and the bones of your vertebral column.
 The subdural space is a space between your dura mater and your arachnoid mater. Under normal
conditions, this space isn’t a space, but can be opened if there’s trauma to your brain (such as a brain
bleed) or other medical condition.
 The subarachnoid space is a space between your arachnoid mater and pia mater. It’s filled with
cerebrospinal fluid. Cerebrospinal fluid cushions and protects your brain and spinal cord.

BLOOD SUPPLY TO BRAIN


The brain receives blood from two sources: the internal carotid arteries, which arise at the point in
the neck where the common carotid arteries bifurcate, and the vertebral arteries. The internal carotid
arteries branch to form two major cerebral arteries, the anterior and middle cerebral arteries. The right and
left vertebral arteries come together at the level of the pons on the ventral surface of the brainstem to form
the midline basilar artery. The basilar artery joins the blood supply from the internal carotids in an arterial
ring at the base of the brain (in the vicinity of the hypothalamus and cerebral peduncles) called the circle of
Willis. The posterior cerebral arteries arise at this confluence, as do two small bridging arteries,
the anterior and posterior communicating arteries. Conjoining the two major sources of cerebral vascular
supply via the circle of Willis presumably improves the chances of any region of the brain continuing to
receive blood if one of the major arteries becomes occluded.
PHYSIOLOGY OF BRAIN
 The brain controls many of the body's functions, including movement, senses,
emotions, language, communication, thinking, and memory.
 The brain also controls body processes that happen automatically, like breathing, heart
rate, and body temperature.
 The brain receives chemical and electrical signals from the body, and interprets them
to control different processes.

INCIDENCE
The incidence of Moyamoya disease exhibits significant regional differences, with a high
incidence in East Asia and a low incidence in other regions. According to previous studies,
the prevalence of Moyamoya disease is 10.5/100,000 individuals and the incidence rate is
0.94/100,000 individuals in Japan; in South Korea, the prevalence rate is 16.1/100,000 and
the incidence rate is 2.3/100,000 individuals. The incidence of Moyamoya disease was as low
as 0.09/100,000 individuals in other regions, including North America, but it has exhibited an
upward trend in the US. In Nanjing (China), the prevalence of MMD in the time frame of
2000–2007 was 3.92/100,000. According to the most recent study, 2,430 cases of MMD have
been reported in China since 1976.
Worldwide, the age of onset of MMD is significantly bimodal in distribution, with a bimodal
peak consisting of a major peak in the first decade of life and a moderate peak in the late 20
to 30s. Of note, geographic differences in sex distribution have been observed. In foreign
populations, the incidence of MMD in females was reported to be higher than that in males
with the male-to-female ratio ranging from 1:1.8 to 1:2.2; however, the sex ratio is 1:1 in
China.
Moyamoya disease is more common in people of Asian origin, including those in India. In
India, Moyamoya disease has a bimodal age distribution, with peaks at 3–8 years and 41–47
years.
ETIOLOGY AND RISK FACTORS:
BOOK PICTURE PATIENT’S PICTURE

RISK FACTORS
 Asian origin: Although the disease is  Present. Patient is from Assam
found all throughout the world, East
Asian countries like China, Japan,
and Korea have higher rates of
moyamoya infection. This may be
the result of some genetic factors
present in those populations. It has
been discovered that Asians living in
Western countries exhibit the same
elevated frequency.
 Health problems: Sometimes, a  Absent
number of diseases,
including neurofibromatosis type 1,
sickle cell disease, and Down
syndrome, coexist with moyamoya
syndrome.
 Sex: Moyamoya is a condition that  Absent
affects women significantly more
frequently.
 Age: Although it can occasionally  Present. Patient was diagnosed at the
affect adults, age of 12.
moyamoya sickness primarily
affects children under the age of
fifteen.  Absent
 Smoking: causes constant
inflammation and weaken the
immune system.
 Alcohol use: affects a wide range of  Absent
structures and processes in the
central nervous system.
 Oral contraceptives in adult female:  Absent
can increase the risk of blood clot
forming.

ETIOLOGY

The exact cause is unknown. Other causes


include:
 Genetic factors: Inherited defective
blood vessels may cause moyamoya  Absent
disease. About 7% of children with
moyamoya may have an inherited
gene defect. The risk of developing
moyamoya disease is 30–40 times
higher for people with a family
history of the disease.
 Traumatic injury may trigger  Absent.
moyamoya disease
 Atherosclerosis of skull base
arteries: due to proliferation and
enlargement of the lenticulostriate
arteries in the basal ganglia.
 Absent
 Arteriosclerosis: Moyamoya
collaterals form in response to
progressive narrowing or occlusion
of the distal internal carotid artery
(ICA) or its proximal branches.  Absent
 Cerebral vasculitis: Moyamoya
disease is a progressive occlusive
disease of the cerebral vasculature
with particular involvement of the
circle of Willis.

STAGES/GRADES/SUZUKI OF MOYAMOYA DISEASE


BOOK PICTURE PATIENT PICTURE
 Stage 1 — Narrowing of carotid  Absent
fork: The narrowing or blockage is
only affecting the internal part of
your carotid artery.
 Stage 2 — Initiation and
appearance of basal moyamoya  Absent
vessels: The narrowing is affecting
all the terminal branches of your
internal carotid artery, and deep
moyamoya blood vessels are starting
to become visible on the angiogram.
 Stage 3 — Intensification of basal
moyamoya vessels: The deep  Present
moyamoya blood vessels are
intensified on the angiogram, and
the “puff of smoke” appearance can
be seen.
 Stage 4 — Minimization of basal
moyamoya vessels: On the
angiogram, the deep moyamoya  Absent
blood vessels start to regress. Other
blood vessels called transdural
collateral vessels start to appear.
 Stage 5 — Reduction of
moyamoya vessels: On the
angiogram, the deep moyamoya
blood vessels continue to regress,  Absent
and more transdural collateral
vessels begin to appear.
 Stage 6 — Disappearance of
moyamoya vessels: All the deep
moyamoya blood vessels have  Absent
vanished, and there’s a complete
narrowing or blockage of the
internal carotid artery.

PATHOPHYSIOLOGY

Due to genetic predisposition and unknown factors

Progressive stenosis of the internal carotid artery (ICA) at the base of the
brainabsorbed.

The narrowing of the ICA leads to decreased blood supply to the brain regions

Brain tissue experiences ischemia due to inadequate blood flow

The inner lining of the ICA develops abnormal thickening causing narrowing of the
vessel lumen.
In response to ischemia, the brain attempts to develop new, abnormal blood vessels
(collateral vessels) around the stenotic area, appearing as a "puff of smoke"

Ischemic stroke/Hemorrhagic stroke/ Moyamoya disease

There is growing evidence that MMD is primarily a proliferative disease of the intima. The
smooth muscle proliferation that is associated with an ACTA2 mutation has been postulated to
be the key mechanism of the vascular occlusion in familial MMD. The histopathological
findings in the distal ICA have shown a proliferation of the smooth muscle cells or
endothelium and a stenosis or occlusion associated with the fibrocellular thickening of the
intima. An enhancement of the stenotic segments may represent either a neo-vascularization
or an intimal hyperplasia.
The moyamoya vessels are the dilated perforating arteries that have various histopathological
changes, including fibrin deposits in the wall, fragmented elastic laminae, attenuated media,
and the formation of microaneurysms. In addition to the moyamoya vessels, cortical
microvascularization, which is characterized by a substantially increased microvascular
density and diameter, is suggested as a specific finding in MMD. These basal and cortical
vessels may represent compensatory mechanisms for the reduced cerebral blood flow or the
aberrant active neo-vascularization before the vascular occlusion

CLINICAL MANIFESTATIONS
BOOK PICTURE PATIENT’S PICTURE
 Stroke: Ischemic strokes  Absent
(blockages) or hemorrhagic strokes
(bleeding) as it causes a narrowing
of the major arteries supplying blood
to the brain, significantly reducing
blood flow and oxygen delivery to
the brain tissue
 Hemiparesis: Weakness or paralysis  Present
on one side of the body as it causes a
narrowing of the major arteries
supplying blood to the brain, which
results in reduced blood flow to one
side of the brain, leading to
weakness or paralysis on the
opposite side of the body
 Headaches: Severe headaches, or  Absent
migraine-like headaches due to the
narrowed blood vessels in the brain
causing reduced blood flow, which
triggers the activation of pain
receptors
 Vision changes: Blurred vision or  Absent
vision loss as it causes a narrowing
of the major blood vessels supplying
the brain, including those that feed
the retina, resulting in reduced blood
flow to the eyes
 Cognitive problems: Difficulty  Present
learning, focusing, or remembering
as it causes chronic cerebral
hypoperfusion, meaning the brain
doesn't receive enough blood flow
due to narrowed arteries at the base
of the brain, which results in
impaired brain function
 Seizures: Epilepsy or seizures as it  Absent
causes a significant reduction in
blood flow to the brain due to the
narrowing of the major arteries
supplying it, leading to areas of
brain tissue becoming ischemic
 Involuntary movements: Jerky  Absent
movements due to the reduced blood
flow to the brain caused by the
narrowing of major arteries
 Sensory problems: Loss of hearing,  Absent
sight, smell, taste, or touch as it
affects the blood supply to the brain,
specifically the areas responsible for
auditory processing
 Slurred speech: Difficulty speaking  Present
or understanding words as it causes
a reduced blood flow to the brain
 Facial asymmetry: Asymmetry of  Present
the face.
 Dizziness as the narrowed blood  Present
vessels in the brain, known as
"moyamoya vessels," significantly
reduce blood flow to the brain,
causing oxygen deprivation which
can manifest as dizziness
 Vomiting is when the blood flow to  Present
the brain is significantly reduced due
to narrowed arteries

DIAGNOSTIC EVALUATION
BOOK PICTURE PATIENT’S PICTURE
 History and Physical Examination.  Done.
 Magnetic resonance imaging
(MRI). An MRI uses powerful  Not done.
magnets and radio waves to create
detailed images of the brain. A
health care provider may inject a dye
into a blood vessel to view the
arteries and veins and highlight
blood circulation. This type of test is
called a magnetic resonance
angiogram.
 Computerized tomography (CT)  Done
scan. A CT scan uses a series of X- Result shows significant luminal
rays to create a detailed image of narrowing with multiple stenotic
your brain. A health care provider segments in bilateral supraclinoid ICAS
may inject a dye into a blood vessel and proximal MACS and ACAS with
to highlight blood flow in your multiple surrounding collaterals
arteries and veins. This is called a formation-Suggestive of residual
(CT angiogram) disease.
 Cerebral angiogram. In a cerebral
angiogram, a health care provider  Done
inserts a long, thin tube called a Present DSA features are consistent
catheter into a blood vessel in the with Grade 3 Moyamoya disease
groin. The provider then guides it to (Extensive involvement of the left
the brain using X-ray imaging. The side noted). Bilateral distal MCA
provider injects dye through the branches seen filling from collaterals
catheter into the blood vessels of the and STA-MCA bypass.
brain.
 Positron emission tomography  Not done
(PET) scan or single-photon
emission computerized
tomography (SPECT): In these
tests, you're injected with a small
amount of a safe radioactive
material. PET provides visual
images of brain
activity. SPECT measures blood
flow to regions of the brain.
 Electroencephalogram  Not done
(EEG). An EEG monitors the
electrical activity in your brain using
small metal discs called electrodes
attached to your scalp.
 Transcranial Doppler  Not done
ultrasound. In surgical transcranial
Doppler ultrasound, sound waves are
used to obtain images of your head
and sometimes your neck.
Specialists may use this test to
evaluate blood flow in blood vessels
in your neck.

MANAGEMENT
BOOK PICTURE PATIENT’S PICTURE
Medical Management

 Blood thinners: Prevent blood clots  Not received.


from forming, but can increase the
risk of bleeding.
Example: Aspirin, Warfarin

 Calcium channel blockers: Dilate  Not received.


blood vessels, which can help lower
blood pressure and reduce the risk of
headaches and strokes.
Example: Nicardipine and Verapamil

 Anti-seizure medicines. These  Patient received Inj. Valprol 300 mg


medicines could be helpful for those TDS IV
who have had seizures.
Example: Clonazepam,
Levetiracetam

Surgical Management
 Revascularization surgery:
surgeons bypass blocked arteries.
They do this by connecting blood
vessels on the outside and inside of
the skull to help restore blood flow
to your brain. This may include
direct or indirect revascularization
procedures. Or it may include a
combination of both.

a) Direct revascularization
procedures. In direct
revascularization surgery, surgeons
stitch the scalp artery directly to a  Not done.
brain artery. This is also known as
superficial temporal artery to middle
cerebral artery bypass surgery. This
procedure increases blood flow to
your brain immediately.
Direct bypass surgery may be
difficult to perform in children due
to the size of the blood vessels to be
attached. But it's the preferred option
in adults. This intervention can be
performed safely and effectively by
an experienced surgical team that
treat moyamoya patient
on a daily basis.

b) Indirect revascularization: The


goal is to lay over the brain surface
blood-rich tissues to increase blood
flow to your brain gradually over
time. In high-volume surgical
centers, indirect revascularization is  Done
almost always combined with direct
revascularization in adult patients.
Types of indirect revascularization
procedures include
Encephaloduroarteriosynangiosis
(EDAS) or
Encephalomyosynangiosis (EMS),
or a combination of both.

 In EDAS, a surgeon separates a


scalp artery over several inches.
The surgeon makes a small  Done.
temporary opening on the skin to
expose the artery. Then the surgeon
makes an opening in your skull
directly beneath the artery. The
surgeon lays the intact scalp artery to
the surface of your brain, which
allows blood vessels from the artery
to grow into your brain over time.
The surgeon then replaces the bone
and closes the opening in your skull.
 In EMS, the surgeon separates a
muscle in the temple region of the
forehead and places it onto the
surface of the brain through an
opening in the skull. This helps  Not done.
restore blood flow. The surgeon may
perform EMS with EDAS. In this
procedure, your surgeon separates a
muscle in the temple region of your
forehead. The surgeon places it onto
the surface of your brain after
attaching the scalp artery to the
surface of your brain. The muscle
helps to hold the artery in place as
blood vessels grow into your brain
over time.
 Pial synangiosis: It is a surgical
procedure used to treat moyamoya
disease, a condition where the major
blood vessels supplying the brain
become narrowed, by rerouting
healthy blood vessels from the scalp
to the brain surface, essentially  Not done.
creating new pathways for blood
flow to reach the brain tissue

COMPLICATIONS
BOOK PICTURE PATIENT’S PICTURE
 Ischemic stroke  Absent.
Can be life-threatening, and
symptoms include weakness,
numbness, balance problems, and
headaches
 Hemorrhagic stroke  Absent.
More common in adults, and
symptoms include severe bleeding
and brain damage

 Brain damage  Absent.


Moyamoya disease can cause serious
and permanent brain damage

 Paralysis.  Absent.
 Vision problems.  Absent.
 Speech problems.
 Movement disorders.  Present.
 Present.
 developmental delays
 Seizure  Absent.
 Absent.

DIETARY ASSESSMENT
Good nutrition is a vital part of staying healthy. Diet plan for Moyamoya disease include low
potassium diet, moderate calorie, low sodium diet, high protein diet, high vitamin and
mineral diet.
1.Patient clinical history taken: Yes
2.Anthropometric measurement:
-Weight: 50 kg
-Height: 175 cm
BMI: 16.33 kg/m2
3.Dietary Habit: On hospitalization, patient is advised to take low sodium diet, low potassium
diet, moderate calorie, high protein diet. Patient is both vegetarian and non-vegetarian.
4.Food allergies: No significant of food allergies.
5.Nutritional requirement: Diet for patient with Moyamoya disease should include the
following: -

i. Fruits and vegetables : Abundant in vitamins, minerals, antioxidants, and fiber,


which promote overall vascular health.
ii. Whole grains: Provide complex carbohydrates and fiber for sustained energy.
iii. Lean protein sources: Fish, poultry, beans, lentils, tofu
iv. Healthy fats: Avocados, nuts, seeds, olive oil
v. Drink more liquids: Drink plenty of water throughout the day to maintain proper
blood volume and viscosity, which is especially important for optimal brain blood
flow. Aim for 2-3 litres of non-caffeinated fluids daily.
vi. Avoid caffeinated drinks: Avoid caffeinated drinks like tea and coffee.
TIME FOOD ITEM QUANTITY CALORIE/Kcal/day CHO FAT PROTEIN CALCIUM IRON
gm/dl gm/dl g/dl g/dl mg/dl
6:30 am Morning Tea:
Black tea 1cup 2 0.2 0.08 0.05 0.06 0
150 ml
Biscuit (cream cracker/Nutri 2 pcs 25 2.2 0.1 2 0.2 0.01
choice)
Nuts 5-6 nos 30 0.5 0.5 3 0.5 1.3
8:30 am Breakfast:
Roti 2 slices 224.08 40.8 1.0 7.4 21.65 1.6
Dahi or Khichdi 1 cup 80 7 0.2 5 164 0.3
(150 ml)
Egg 1 whole egg 84.85 0 4.8 8.27 26.63 1.08

Veg curry (mixed potato+ beans) 1 serve 90.87 16.67 1.94 2.0 30.5 0.6

11:00am Mid-Morning 13.4 0.5 0.2 10 0.66


Fruit (guava/ apple) 1 pc apple 5
1:30 pm Lunch:
Rice/Khichdi 1 ½ bowl 402 80.34 0.59 8.96 8.46 0.73

Lentil dal (cooked) 1 bowl 170.5 20.8 6.8 10.1 29.6 3.2

Veg Steamed (mixed potato+ 1 serve 85.5 12.4 0.8 0.8 1.6 0.1
bean+ cabbage + carrot)

Fish curry/Chicken/Egg white 1 medium size 89 0.8 1.6 1.6 0.32 5.2
fish
4:30 pm Evening Tea:
Red Tea 1cup 15 2 0 1 38.7 0
(100 ml)
Biscuit 2 pcs 30 2.2 0.1 2 0.2 0.01

6:30 pm Dal/Chicken soup/Oat/Suji 1 bowl 172.3 22.2 7.4 12.2 32.7 3.5

9:00 pm Dinner:
2Rice (cooked) 1bowl 287.3 63.1 0.42 6.4 6.4 0.52
Dal (lentil) 1 bowl 170.5 20.1 6.8 10.1 29.6 3.2
Veg curry (potatoes+ beans) 1 serve 124 8.4 1.32 5.37 50.72 0.82

Total 2087.9 313.11 34.95 86.47 451.84 22.833s


THEORY APPLICATION – OREM’S THEORY OF SELFCARE NURSING
BIOGRAPHIC DATA: -
Dorothea Elizabeth Orem was born and brought up in Baltimore, Maryland. Orem
attended Seton High School in Baltimore, and graduated in 1931. She received a diploma
from the Providence Hospital School of Nursing in Washington, D.C. in 1934 and went on to
the Catholic University of America to earn a B.S. in Nursing Education in 1939, and an M.S.
in Nursing Education in 1945. Her earliest years in nursing were spent in practice at
Providence Hospital, Washington, D.C. (1934-1936, 1942) and St. John’s Hospital, Lowell,
Massachusetts (1936-1937). After receiving advanced degrees, Orem focused primarily on
teaching, research, and administration. She served as director of the Providence Hospital
School of Nursing in Detroit, Michigan from 1945 to 1948, where she also taught biological
sciences and nursing (1939-1941). At the Catholic University of America, Orem served as
Assistant Professor (1959-1964), Associate Professor (1964-1970), and Dean of the School of
Nursing (1965-1966). In 1971 Orem published Nursing: Concepts of Practice, the work in
which she outlines her theory of nursing, the Self-care Deficit Theory of Nursing.

THEORY OF SELF CARE DEFICIT


Self-care deficit is a relation between the human properties of therapeutic self-care demand
and self-care agency in which constituents developed self-care capabilities within the self-
care agency are not operable or not adequate for knowing and meeting some or all
components of the existent or projected therapeutic self-care demand.
Orem (1991) identifies the following five methods of helping in Theory of Self-Care
Deficit:
 Acting for or doing for another.
 Guiding and directing.
 Providing physical or psychological support.
 Providing and maintaining an environment that supports personal development.
 Teaching.
OREM’S SELF-CARE THEORY CONCEPTUAL FRAMEWORK

Self-Care

-Grooming

-Food

-Exercise

-Medications

-Sleep pattern

Self Care Agency


Self Care
-Grooming (Oral DEFICIT
care, personal Demand
hygiene)
-Grooming
-Food and dietary
-Food
habits
-Exercise
-Exercise
-Medications
-Sleep pattern
-Sleep pattern
-My patient Mr.
Madhurjya Kishor -My patient
Das is able to Nursing requires self-care
perform activities demands partially.
of daily living Agency
partially. -Patient can
perform his self -
care activities
partially.

-Ambulation and
support was
provided to meet
his self-care needs
Orem (1991) has identified five areas of activity for nursing practices as given below:
 Entering into and maintaining nurse patient relationship with individuals, families or
groups until patients can legitimately be discharged from nursing.
 Determining if and how patients can be helped through nursing.
 Responding to patient’s requests, desires and needs for nurse contacts and assistance.
 Prescribing, providing and regulating direct help to patients in the form of nursing.
 Coordinating and integrating nursing with the patients daily living, other health care
needed or being received, and social and educational services needed or being
received.

METAPARADIGM OF OREM’S THEORY

Metaparadigm is the concepts which define the nursing practice. Person, health,
nursing, and environment are considered as the metaparadigm of nursing theories by
many nursing theorists.

1) Person: Orem views a person as a physical, social, and psychological character


with inconsistent degrees of self-care abilities. Person is the recipient of care
needed, and has potentials for learning and development, and also has the
abilities to learn how to meet self-care needs.

2) Health: Health is the major metaparadigm, which Orem views as physical,


mental, and social well-being. It is the integrity of human structure and the
crucial goal of Orem’s theory. Her theory discusses the limitations concerned
in meeting the requirements for self-care and the effects on health. The basic
principle of the theory is to create such plan to enhance and maintain the
health of the patient.
3) Environment: Environment is the major concept in both models. Orem’s
describe it as a stat that a person exists in an environment. Orem asserted that
person and environment are separate entities in our minds which required
sophistication to conceptualize them as a single unit.

4) Nursing: Orem have distinct approaches towards the concept of nursing. Orem
presented nursing as a unique field of knowledge and an action system, which
is professional practice. According to her nursing is the intervention to meet
the required need for self-care and need for medical care of patients.

THEORY OF NURSING SYSTEM


Nursing system is a “continuing series of actions produced when nurses link one way
or a number of ways of helping to their own to their own actions or the actions of
persons under care that are directed to meet these person’s therapeutic self-care
demands or to regulate their self-care agency”.
Orem (1991) has identified three classifications of nursing system to meet self-
care requisites of the patient. These systems are:
1) The Wholly compensatory system.
2) The Partial compensatory system.
3) The Supportive educative system.

Wholly Compensatory Nursing System


Wholly Compensatory nursing system is needed when the “nurse should be compensating for
a patient’s total inability for engaging in self-care activities that require ambulation and
manipulation movements.”
This system is represented by a situation in which the individual is
unable to engage in those self-care actions requiring self-directed and controlled ambulation
and manipulative movement or the medical prescription to refrain from such activity. Persons
with these limitations are socially dependent on others for their continued existence and well-
being.
Subtypes of the wholly compensatory are nursing systems for people who are:
 Unable to engage in any form of deliberate action. Example in coma.
 Aware and who may be able to make observations, judgements and decisions about
self-care and other matters but cannot or should not perform actions requiring
ambulation and manipulative movements.
 Unable to attend to themselves and make reasoned judgements and decisions about
self-care and other matters but who can be ambulatory and may be able to perform
some measures of self-care with continuous guidance and supervision.

Partly Compensatory Nursing System


This system exists when both nurse and perform care measures or other
actions involving manipulative tasks or ambulation. It is represented by a situation in
which the patient or the nurse may have the major role in the performance of care
measures. For example, patients who have undergone abdominal surgery might be
able to wash his or her face and brush his or her teeth but needs the nurse for help in
ambulating and in changing the surgical dressing.

Supportive-educative Nursing System


Supportive-educative systems are “for situations where the patient is able to
perform or can and should learn to perform required measures of externally or
internally oriented therapeutic self-care, but cannot do so without assistance”. This is
also known as supportive-developmental system. Here, the patient is doing all the
self-care. The patient’s requirements for help are confined to decision making,
behavior control, and acquiring, knowledge and skills.

So, my patient Mr. Madhurjya Kishor Das complaining of dizziness,


weakness of the left side of the body, deviation of the angle of mouth falls under
Wholly Compensatory Nursing System as he needs help and depends on the nurses
for all his daily activities.

NURSING PROCESS
NURSING ASSESSMENT
 To obtain detail history and physical examination.
 Obtain a thorough medical history to identify potential risk factors and current
symptoms like headaches, dizziness, seizures, or transient ischemic attacks (TIAs)
 Assess for other illness like diabetes, hypertension, sleeping disorder and drug
therapy.
 Obtain lifestyle history related to dietary and habits, type of food he usually consume.
 To obtain history related to allergic reaction regarding to food and drugs.
 Obtain family history related to Moyamoya disease, heart problem and diabetes,
hypertension, Tuberculosis or any other chronic illness.
 Assess patient and family knowledge about the diseases.
 To perform head to toe examination and note any abnormalities.
 To focus on detailed neurological evaluation, including mental status, motor function,
sensory perception, speech, and cranial nerve function.
 To obtain investigation and identify any abnormalities.
NURSING DIAGNOSIS
1) Ineffective cerebral perfusion related to decreased cerebral blood flow secondary to
occlusion in the cerebral artery as evidenced by dizziness and weakness on the left
side of the body.
2) Disturbed sensory perception related to motor disturbances as evidenced by patient is
having weakness on the left side if the body and deviation of the mouth.
3) Decreased activity intolerance related to motor disturbances as evidenced by patient is
having weakness on the left side of the body.
4) Imbalanced nutrition less than body requirements as evidenced by patient is having
loss of appetite and patient’s BMI is 16.33 kg/m2.
5) Self-care deficit related to weakness as evidenced by patient needs help in meeting his
daily activities.
6) Risk for ineffective airway clearance related to neurological complications that can
affect their ability to cough effectively, including facial weakness secondary to
Moyamoya as evidenced by patient is having deviation of mouth.
7) Risk for injury related to seizure activity secondary to cerebral irritation.

NURSING CARE PLAN


SL ASSESSMENT NURSING GOAL NURSING RATIONALE NURSING EVALUATION
NO DIAGNOSIS INTERVENTION IMPLEMENTATION
1 Subjective Data: Ineffective To - Assess the - To provide - The Cerebral
The patient says, “I cerebral maintain neurological baseline neurological perfusion and
am having dizziness perfusion related normal status of the data. status of the blood flow of
and weakness on to decreased cerebral patient every patient was the patient has
left side of my cerebral blood perfusion two hours. assessed. improved to
body.” flow secondary and blood GCS score – some extent.
to occlusion in flow. E4V5M5
Objective Data: the cerebral
On examination, the artery as - Monitor the - To provide - Vital signs of
patient cannot move evidenced by vital signs of baseline the patient was
his extremities on dizziness and the patient. data. assessed
the left side. weakness on the BP – 130/70
left side of the PR – 105 b/m
body. RR – 20 b/m
SPO2 – 99%
- Provide - To avoid - Slightly
comfortable obstruction elevated head
position to the of blood position was
patient. flow. provided.

- Administer - To maintain - Medications


medications as blood flow like Inj.
prescribed by and improve Mannitol was
the physician. cerebral administered as
perfusion. prescribed by
the physician.
SL ASSESSMENT NURSING GOAL NURSING RATIONALE NURSING EVALUATION
NO DIAGNOSIS INTERVENTION IMPLEMENTATION
2 Subjective Data: Disturbed To - Assess - To provide - Neurological Patient’s
The patient says, “I sensory maintain neurological baseline status was sensory
am having perception sensory status of the data. assessed. perception has
weakness on the left related to motor perception. patient GCS – 14/15. been
side of my body and disturbances as including facial maintained to
my mouth is evidenced by muscle some extent.
deviated towards patient is having strength.
right” weakness on the - To monitor - Vital signs
left side if the - Monitor the effectiveness were
Objective Data: body and vital signs of of monitored.
On observation, deviation of the the patient. management BP – 130/70 mmHg
patient’s angle of mouth. and P – 105 b/m
the mouth is treatment. R – 20 b/m
deviated towards SPO2 – 99%
the right side.

- To improve - The patient was


- Encourage the facial advised to take
patient to muscle lots of fluids.
communicate strength.

- Teach the - To - Gentle facial


patient gentle strengthen exercises were
facial exercises the taught to the
weakened patient.
muscle.
SL ASSESSMENT NURSING GOAL NURSING RATIONALE NURSING EVALUATION
NO DIAGNOSIS INTERVENTION IMPLEMENTATION
3 Subjective Data: Decreased To - Monitor the - To provide - Vital signs Patient is able
The patient says, “I activity improve vital signs of baseline were to move his
feel weak and tired.” intolerance physical the patient. data. monitored. upper and lower
related to motor activity of BP – 130/70 mmHg extremities on
Objective Data: disturbances as the P – 105 b/m the left side
On examination, evidenced by patient. R – 20 b/m slowly.
patient is having patient is having SPO2 – 99%
weakness on the left weakness on the
side of his body. left side of the - Assess the - To provide - The condition
body. condition of baseline of the patient
the patient. data. was assessed.

- Encourage - To gain - The patient was


the patient to strength. encouraged to
take take complete
complete rest.
rest.

- Advice the - To gain - The patient was


patient to bodily advised to take
take strength. nutritious
nutritious foods.
foods.
SL ASSESSMENT NURSING GOAL NURSING RATIONALE NURSING EVALUATION
NO DIAGNOSIS INTERVENTION IMPLEMENTATION
4 Subjective Data: Imbalanced To - Assess the - To provide - Nutritional The nutritional
The patient says, “I nutrition less maintain a nutritional baseline status of the status of the
don’t have an than body nutritional status of the data. patient was patient has been
appetite.” requirements as balance. patient assessed. improved to
evidenced by BMI – 16.33 some extent.
Objective Data: patient is having kg/m2.
On observation, loss of appetite
patient looks weak and patient’s - Advice the - To improve - The patient was
and BMI is BMI is 16.33 patient to appetite. advised to take
16.33kg/m2. kg/m2. take small small meal at
meals at frequent
frequent interval.
intervals.

- Advice the - To gain - The patient was


patient to bodily advised to take
take strength. nutritious food.
nutritious
foods.

- Encourage - To maintain - The patient was


the patient to hydration. encouraged to
take lots of take lots of
fluid and fluid and fruits.
fruits.
SL ASSESSMENT NURSING GOAL NURSING RATIONALE NURSING EVALUATION
NO DIAGNOSIS INTERVENTION IMPLEMENTATION
5 Subjective Data: Self-care deficit To - Assess the - To provide - Vital signs of Self-care needs
The patient says, “I related to improve vital signs of baseline the patient was of the patient
cannot perform my weakness as self-care the patient. data. assessed. has been
daily activities.” evidenced by of the BP – 130/70 improved to
patient needs patient. PR – 105 b/m some extent.
Objective Data: help in meeting RR – 20 b/m
On observation, his daily SPO2 – 99%
patient looks weak activities.
and tired. - Assist the - To - The patient was
patient in promote assisted in
performing his well-being performing his
daily activities. of the daily activities
patient. like bathing,
eating.

- Teach the - To - The patient was


patient promote taught on how
regarding bodily to perform
ROM exercise. strength ROM exercise.

- Encourage - The patient was


independence - To encouraged to
but assist when promote perform
patient cannot self-care. independently.
perform
HEALTH EDUCATION
ON HOSPITAL STAY ON DISCHARGE
 Disease Condition  Disease Condition
- Provide relevant information - Provide proper information about
related to disease, treatment, the disease, treatment, prevention
management and prognosis. and management as well as the
- Encourage the patient to inform if family members.
any complications occur. - Advice the patient to inform if any
complications.
 Medication  Medication
- Provide medication regularly - Provide medication list to the
according to physician’s order and patient. Explain in clear and
time. understanding language.
- Check for the name, dose, time and - Advice not to skip the dose of
route. medication.
- Administer medication on time and - Advice to inform if any side effects
take medication on time and take present.
medication as prescribed by the
physician.
 Exercise  Exercise
- Advice the patient to do active and - Encourage the patient to do self-
passive exercise on bed. Advice to care activity with light weight.
do light exercise.
 Nutrition and Fluids  Nutrition and Fluids
- Encourage the patient to eat high - Encourage patient to eat high
protein and low sodium diet. protein and low sodium diet.
- Provide fluid according to - Encourage the patient to take
physician’s order. complete rest.
- Provide pleasant environment. - Advice the patient to take lots of
fluid and fruits.
 Hygiene  Hygiene
- Provide sponging daily. - Encourage patient to keep himself
- Assist the patient in performing clean.
daily activities. - Encourage the patient to take bath
- Encourage the patient to perform and brush teeth daily with the help
self-care activities independently. of family members.
 Follow up
- Advice the patient to visit the
hospital after 7/10 days after
discharge to see the progress.
- Call for emergency in the hospital
number.
PROGNOSIS
Day 1: - Patient complaint of dizziness and weakness on the left side of the body and
deviation of angle of mouth towards the right.
BP – 130/70 mmHg
P – 105 b/m
R – 22 b/m
T – 98.8 F
SPO2 – 99 % RA
Day 2: - Patient was able to move the left side of his body to some extent.
BP – 110/70 mmHg
P – 98 b/m
R – 20 b/m
T – 98.7 F
SPO2 – 98 % RA
Day 3: - Patient was able to communicate properly.
BP – 110/70 mmHg
P – 96 b/m
R – 20 b/m
T – 98.7 F
SPO2 – 99 % RA
Prognosis is good and proper treatment was taken.
CONCLUSION
After studying about Moyamoya disease, I gathered more information about the disease
process and management. So, I hopefully in future, if I will get a patient with the same
diagnosis, I will gain more confident and have more knowledge to provide better nursing care
for the patient.
From the first day I met the patient till the day he was discharged, the patient
condition is improving.

BIBLIOGRAPHY
BOOK REFERENCES
1. Sharma S, “Lippincott Manual of Medical Surgical Nursing”, 2nd edition, published
by Wolter Kluwer (India) Pvt Ltd, pages number: 840-841.
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2) Rushiter S, Available from Cleveland Clinic, 2024
https://my.clevelandclinic.org/health/diseases/17244-moyamoya-disease
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https://journals.lww.com/ijcn/fulltext/2015/16020/
caring_for_a_patient_with_moyamoya_disease__a_case.3.aspx

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