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Presented to the Clinical Instructor ofThe Notre Dame of Tacurong College

College of Nursing

CEREBROVASCULAR ACCIDENT  _________________________________________________

Mr. Richard Deo Rox Alave, RNClinical Instructress

In Partial Fulfillment of the Course 

Requirements in

NURSING CARE MANAGEMENT 106 RLE 

Submitted by:

Aguilos, CristineArboleras, Erika

Calimbol, NorhataDilanggalen, AsrizahGentugaya, Shenette

Ghazi, Rashea

Gumisad, Richelle MaeLumenda, Farrah Jade

Mangudadatu, Marsha Mae

Date:August 27, 2013

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TABLE OF CONTENTS

I.  Introduction

II.  Objectives of the Study

III.  Vital information

IV.  Family Background

V.  History of Past Illness

VI.  History of Present Illness

VII.  Effects and Expectations

VIII.  Genogram

IX.  Developmental Data

X.  Physical Assessment

XI.  Textbook Discussion/ Anatomy & Physiology

XII.  Definition of Terms

XIII.  Etiology/ Symptomatology

XIV.  Pathophysiology

XV.  Doctor’s Order  

XVI.  Laboratory Results

XVII.  List of Drugs

XVIII.  Drugs Study

XIX.  List of Prioritized Problem

XX.   Nursing Care Plan

XXI.  Prognosis

XXII.  References 

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OBJECTIVES

General Objectives:

After 2 hours of presenting the case, the listeners will be able to gain adequate knowledge

on CVA and enhance knowledge and skills in dealing with patient’s having this kind of

condition , hence allowing listeners to apply their learning appropriately in clinical setting and

develop positive attitude in caring for patients with the same condition.

Specific Objectives:

After 1 hour and 30 minute of presenting the case, the listeners will be able to:

  Discuss the brief summary of the introduction about the deceases involved.

  Enumerate completely the general and specific objectives.

  Identify correctly with important information regarding patient’s data by presenting the

following:

  Vital Information

  History of present and past Illness

  Family Background

  Effects and Expectations of illness to self and family

  Genogram

  Growth and Development Data

  Discuss the result of Physical Assessment Cephaloucaudically.

  Identify completely with Review of System.

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  Discuss comprehensive with complete diagnosed of the patient based on textbook

discussion.

  Relate the Anatomy and Physiology of the systems involved in CVA Hemorrhagic

  Enumerate the predisposing and precipitating factors involved with the diagnosis clearly.

  Enumerate the etiology of CVA Hemorrhagic.

  Discuss the pathophysiology of CVA Hemorrhagic.

  Identify the laboratory test undergone by the patient and interpret the result accurately.

  Discuss the doctor’s order for patient wellness and rationalize properly. 

  Rationalize the drugs that the physicians ordered and discuss the mechanisms of action,

side and adverse effects, contraindication, special precaution and drug interaction

 precisely.

  Prioritized nursing diagnosis of patient and enumerate applicable nursing interventions

correctly.

  Enumerate the references/bibliography precisely.

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INTRODUCTION

This is a case of Mrs. Pet, a 69 years old female patient of South Cotabato Provincial

Hospital. She was admitted last July 23, 2013 at 4:35am with admitting diagnosis of

Cerebrovascular accident, under the service of Dr. Xoxo

Cerebrovascular accident (CVA) is the rapid loss of  brain function due to disturbance in

the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by

 blockage (thrombosis, arterial embolism), or a hemorrhage. As a result, the affected area of the

 brain cannot function, which might result in an inability to move one or more limbs on one side

of the body, inability to understand or  formulate speech, or an inability to see one side of the

visual field.

A stroke is a medical emergency and can cause permanent neurological damage and

death. Risk factors for stroke include old age, high blood pressure, previous stroke or  transient

ischemic attack (TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation.[2] High

 blood pressure is the most important modifiable risk factor of stroke. It is the second leading

cause of death worldwide.

Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemic

strokes are those that are caused by interruption of the blood supply, while hemorrhagic strokes

are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About

87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages

develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown how many

hemorrhages actually start as ischemic stroke.

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Each year in the United States, approximately 795,000 people experience new or

recurrent stroke. Of these, approximately 610,000 represent initial attacks, and 185,000 represent

recurrent strokes. Epidemiologic studies indicate that approximately 87% of strokes in the

United States are ischemic, 10% are secondary to intracerebral hemorrhage, and another 3% may

 be secondary to subarachnoid hemorrhage.

According to the World Health Organization (WHO), 15 million people suffer stroke

worldwide each year. Of these, 5 million die and another 5 million are left permanently disabled. 

The latest WHO data published in April 2011 stroke deaths in the Philippines reached 40,245 or

9.55% of total deaths. The age adjusted Death Rate is 82.22 per 100,000 of population rank

Philippines #106 in the world.

In a prospective, population-based registry study from Italy, the crude annual incidence

rate of intracerebral hemorrhage was 36.9 per 100,000 population. When standardized to the

2006 European population, the rate was 32.9 per 100,000 population; standardized to the world

 population, the rate was 15.9 per 100,000 population.

The global incidence of stroke has at least a modest variation from nation to nation,

suggesting the importance of genetics and environmental factors, such as disparities in access to

health care in developing countries. The age-adjusted incidence of total strokes per 1000 person-

years for people 55 years or older has been reported in the range of 4.2 to 6.5. The highest

incidences have been reported in Russia, Ukraine, and Japan.

Asking the question of how this condition occurs, this case study will provide

information that may help the readers/listeners understand the cause of condition. This case study

will enhance the knowledge and skills in dealing with patient who suffers from this condition

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Further complications will be prevented if immediate proper action is provided and

intervention is rendered. Therefore it is important that the health care provider develop skills in

 proper management of the client having this condition.

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PATIENT’S DATA 

Vital Information

Patients Name: Mrs. Pet

Age: 69 years old

Sex: Female

Birth Date: November 13, 1943

Birth Place: Dumalag, Capiz

Address: Prk. San Vicente, Bai Sarifirang, Bagumbayan, Sultan Kudarat

Occupation: House keeper

Tribe: Ilonggo

Citizenship: Filipino

Religion: Roman Catholic

Civil Status: Widowed

Educational Attainment: None

 Name of Institution: South Cotabato Provincial Hospital

Date and Time of Admission: July 23, 2013 @ 4:35 am

Chief Compliant: Not assessed from patient (Coma)

Admitting Diagnosis: Cerebro Vascular Accident 

Attending Physician: Dr. Xoxo

Spouse Name: Mr. Dedo

Age: Deceased

Educational Attainment: Deceased

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Occupation: Deceased

Siblings: (The informant was not familiar with the patient’s siblings) 

Children:

 Name Age Educational Attainment Occupation

1. F 48 None Farmer

2. M 46 None Farmer

3. M 45 None Farmer

4. M 44 None Farmer

5. M 43 None Farmer

6. F 40 None Delivery Boy

7. M 37 Highschool Graduate OFW

8. F 28 College Graduate Teacher

Source of Information:

Patient’s Chart 

Patient’s relative 

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FAMILY BACKGROUND

Mrs. Pet was born on August 27, 1962 at Dumalag, Capiz. She is an ilonggo and an

affiliate of Roman Catholic. She does not know how to read and write (according to the patient’s

son, Emo) because she was not given the chance to attend school. As far as Mr. Emo can

remember about the story that their mother have shared to them, she and her siblings help their

 parents in farming to have enough money for their basic needs particularly with food.

Mrs. Pet was married to Mr. Pot and had eight children. The eldest daughter is Mrs. Abie,

a farmer who has diabetes mellitus and hypertension, while Mr. Boyet, Mr. Carl, Mr. Dante, Mr.

Earl, Mr. Fifito are all farmers and has no known disease. Mrs. Gale, an OFW in Saudi Arabia

with no known disease, and the youngest Mrs. Hazel, a public teacher with no known disease.

Their house was made of “kugon” and “kalakat”; they have vegeta ble plants such as eggplant,

squash, kangkong, beans, okra and alugbati. Mrs. Pet is fond of eating dried fish like bulad and

she uses “bagoong pang saw-saw sa talong”. The family income ranges from 3,000-6,000 pesos

every month. In 2001, Mr. Dedo died due to kidney failure.The family usually used herbal meds

like sambong, lagundi and guava leaves and they sometimes utilize Over-The-Counter drugs

such as paracetamol, Bioflu, and salbutamol for their coughs and colds. The family experienced

common illnesses such as fever, cough, cold & flu and headache.

Presently, Mrs. Pet is living with her two grandchildren; she took care of Mrs. Gale’s

children because she works in abroad. According to Mr. Emo she loves to use “mama” as what

he verbalized “gamama na siya”.

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HISTORY OF PAST ILLNESS

The patient experienced stroke for three times as verbalized by her son. For the first and

second stroke, she was admitted to the same hospital which is Sto. Nino Hospital with the same

 physician. After her first and second stroke, she was feeling well as verbalized by the son but her

condition became worse on her third stroke and the doctor Blabla refer her to South Cotabato

Provincial Hospital for further observation and management.

Six months prior to his 1st admission, she experienced dizziness and blurred vision but

she didn’t take any OTC drugs or seek medical advice; he was rushed into the South Cotabato

Provincial Hospital with a diagnosis of Cerebrovascular Accident, Hemorrhagic. Mr. Talky

returned to his home and does his usual work as a farmer after being discharged in the hospital.

HISTORY OF PRESENT ILLNESS

One week prior the 3rd admission, the patient once again experienced dizziness and

 blurring vision as verbalized by her son (Mr. Emo). She was rushed to the Sto. Nino hospital but

the Dr. Blabla says that she needs to be refer at South Cotabato Provincial Hospital for further

observation and proper treatment. So the patient admitted to South Cotabato Provincial Hospital

last July 23, 2013 at around past four in early morning with the admitting diagnosis of

Cerobrovascular Vascular Accdent, hemorrhagic under the service of Dr. Soso.

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EFFECTS AND EXPECTATION OF ILLNESS

TO SELF AND FAMILY

To self:

(no verbal cues)

To family:

Family verbalized that they worried about the patient’s condition and expect that the

 patient will recovered soon so that the expenses will be lessen. According to Mr. Emo, his

mother can’t perform her activity of daily living; he is worried about their expenses in the

hospital. The family expects that the patient will recover soon.

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DEVELOPMENTAL DATA

DEVELOPMENTAL TASK THEORY

 Robert Havighurst

He believes that learning is basic to life and that people continue to learn throughout life.

He describes growth and development as occurring during six stages each associated with from

six to ten tasks to be learned. Havighurst developmental task provide a framework that the nurse

can use to evaluate a person’s general accomplishments. 

THEORY TASK JUSTIFICATION REMARKS

Robert

Havighurst

(Later Maturity)

  Adjusting to

decreasing

 physical strength

and health.

  Adjusting to death

of a spouse.

  Establishing an

explicit affiliation

with one’s age

group.

  Meeting social and

civil obligations.

  SO says that decreasing physical

strength and health in older people is a

normal process of life and that he

assumed that his mother already

accepted it.

  “napatay naman si papa kag nadawat

naman to ni mama” as verbalized by the

 patient`s son.

  According to the SO that patient is used

to attend meeting in their barangay

concerning their groups but now she is

unable to do it because of her condition.

Achieved

Achieved

Partially

Achieved

 Not achieved

 Not achieved

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  Establishing

satisfactory

 physical living

arrangements.

  The SO says that her mother has

difficulty of living right now because of

her present condition and that she is

unable to do things she wants.

  The SO says that her mother is having

difficulty of doing her physical living

arrangement due to her present

condition.

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PSYCHOSOCIAL THEORY

 Erik Erikson

He envisions life as a sequence of level of achievement. Each stage signals a task that must

 be achieved. The resolution of the task can be complete, partial or unsuccessfully.

Erikson believes that the greater the task achievement, the healthier the personality of the

 person failure to achieve the task influences the ability of the person to achieve the next task.

This developmental task can be viewed as a series of crisis and unsuccessful resolution of this

crisis is damaging to the ego. After attaining ones stage, the person may fall back and need to

approach it again.

THEORIST Positive

Resolution

 Negative

Resolution

JUSTIFICATION REMARKS

Erik

Erikson’s 

Psychosocial

Theory

(Maturity 65

yrs-death)

Integrity vs. Despair

  Acceptance

of worth and

uniqueness

of one’s own

life

  Acceptance

of death

Sense of loss,

contempt for others

Patient`s son says that

even though they have

difficulties in their

daily living, they are

living their lives

happily as long as they

are safe even though

some of his siblings are

living in far places. He

stated that the patient is

contented with their life

achieved

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and never felt

insecurities with other

 people.

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Westerhoff’s Four Stages of Faith 

Westerhoff describes faith away of being and behaving that evolves from an experienced

faith guided by parents and others during a  person’s infancy and childhood to an owned-faith

that is internalized in adulthood and serves as directive for personal action. For the client who is

ill faith-whether in a higher authority(e.g. Allah, GOD, Jehovah), in the client’s own self, in the

health care team or in a combination of all provides strength and trust.

Theorist Behavior Justification Remarks

Westerhoff’s four

stages of faith owned

faith.

Middle adulthood/old

age

Puts faith into

 personal and social

action and is for what

he believes even

against the nurturing

communication

Our patient is a

catholic in religion

her son says that her

mother used to go to

church when she was

strong she said that

 being a Christian is

her will and she does

what other do like

following the rule of

God.

Achieved

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Diagnosis: Cerebrovascular Accident

PHYSICAL ASSESSMENT

Date and time:

August 6, 2013

11:30 AM

General Appearance:

The patient is an older female, with IVF D5LR 1L @ 20 gtts/min hooked at right basillic vein,

 patent and infusing well. Patient is unconscious, hair is not well-fixed, with Nasogastric tube

inserted on her right nostril and her right hand is tied on the side of the bed. The patient wears

striped sando and lavender shorts. The patient also wears a diaper.

Vital signs:

BP: 110/70 mmHg

T- 37 C

RR- 20 cpm

PR-72 bpm

GCS- 8

Head/Hair/Scalp:

Inspection: Head is proportional to the body and skull is rounded and symmetrical, no dandruff

and lice noted, hair is evenly distributed, gray in color with dry texture.

Palpation: No tenderness and masses noted.

Face:

The face is symmetrical, skin is brown in complexion and has poor skin turgor.

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Eyes:

Eyes are symmetrical, eyebrows are black in color. Yellowish discharges noted. Pupils are equal

in size and reacts to light. Eye opening is poor.Conjunctiva is yellowish in color and sclera is

well lubricated.

Nose:

Inspection: The external nose is symmetrical, align at the midline, nasogastric tube noted

inserted through the right nostril, mucosa is moist, nasal septum is intact, no lesions and nose

deformities noted.

Palpation: There is no tenderness noted.

Ears:

Inspection: Ears are symmetrical, normal in size with equal color to the body complexion, no

lesions noted, small amount of dirt accumulates at the external ear, earwax noted, auricle has no

deformities, pinna recoils when folded.

Palpation: No tenderness and nodules noted.

Mouth and Lips:

Inspection: Lips are pale in with dry and flaky texture, no presence of stomatitis, no lesions

noted, the tongue is pinkish in color with white spots. Incomplete set of teeth and yellow-orange

color of the teeth is noted. Gums and mucosa is light pink and no lesion noted. Tonsils are not

inflamed; uvula is bell in shape, pinkish in color, and at the midline.

Neck: 

Inspection: Jugular veins are not inflamed and no stiffness noted.

Palpation: Lymph nodes at the neck are not palpable.

Breast: 

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Inspection: Brown areola and nipple noted, areola are equal in size.

Palpation: No tenderness and masses noted.

Lungs: 

Auscultation: Breathing pattern is normal and no irregular rhythm noted. Crackles noted on the

left lung.

Heart: 

Auscultation: No abnormal sound noted.

Abdomen: 

Inspection: No scars noted upon inspection. No lesion noted.

Auscultation: Gurgling sound noted. 7 gurgling sound/min.

Palpation: No tenderness noted, no masses noted.

Extremities: 

Inspection: Extremities are proportionate to the trunk; skin is brown in complexion, symmetrical

on both upper and lower extremities. Immobility noted on the right leg and arms. No withdrawal

even on evoked pain stimulus.

Skin: 

Inspection: Skin is dry and flaky, no lesions noted. Skin has poor skin turgor.

Palpation: No masses and tenderness noted. Cool to touch.

Nails: 

Inspection: Nails are dirty, and pinkish in color. Capillary refills after 3 seconds. Clubbed nails

noted.

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Anatomy and Physiology

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Forebrain - is responsible for a variety of functions including receiving and processing

sensory information, thinking, perceiving, producing and understanding language, and

controlling motor function. There are two major divisions of forebrain: the diencephalon and the

telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus

which are responsible for such functions as motor control, relaying sensory information, and

controlling autonomic functions. The telencephalon contains the largest part of the brain, the

cerebral cortex. Most of the actual information processing in the brain takes place in the cerebral

cortex.

Midbrain- and the hindbrain together make up the brainstem. The midbrain is the portion

of the brainstem that connects the hindbrain and the forebrain. This region of the brain is

involved in auditory and visual responses as well as motor function.

Hindbrain- extends from the spinal cord and is composed of the metencephalon and

myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These

regions assists in maintaining balance and equilibrium, movement coordination, and the

conduction of sensory information. The myelencephalon is composed of the medulla oblongata

which is responsible for controlling such autonomic functions as breathing, heart rate, and

digestion.

Basal Ganglia 

  Involved in cognition and voluntary movement

Brainstem 

  Relays information between the peripheral nerves and spinal cord to the upper parts of the

brain

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  Consists of the midbrain, medulla oblongata, and the pons

Broca's Area 

  Speech production

  Understanding language

Central Sulcus (Fissure of Rolando) 

  Deep grove that separates the parietal and frontal lobes

Cerebellum 

  Controls movement coordination

  Maintains balance and equilibrium

Cerebral Cortex 

  Outer portion (1.5mm to 5mm) of the cerebrum

  Receives and processes sensory information

  Divided into cerebral cortex lobes

Cerebral Cortex Lobes 

  Frontal Lobes -involved with decision-making, problem solving, and planning

  Occipital Lobes -involved with vision and color recognition

  Parietal Lobes - receives and processes sensory information

  Temporal Lobes - involved with emotional responses, memory, and speech

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Cerebrum 

  Largest portion of the brain

  Consists of folded bulges called gyri that create deep furrows

Corpus Callosum 

  Thick band of fibers that connects the left and right brain hemispheres

Cranial Nerves 

  Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck and

torso

Fissure of Sylvius (Lateral Sulcus) 

  Deep grove that separates the parietal and temporal lobes

Hypothalamus 

  directs a multitude of important functions such as body temperature, hunger, and homeostasis

Olfactory Cortex 

  receives sensory information from the olfactory bulb and is involved in the identification of

odors

Thalamus

  mass of grey matter cells that relay sensory signals to and from the spinal cord and the

cerebrum

Medulla Oblongata 

  Lower part of the brainstem that helps to control autonomic functions Meninges

  Bulb-shaped end of the olfactory lobe

  Involved in the sense of smell

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Pineal Gland 

  Endocrine gland involved in biological rhythms

  Secretes the hormone melatonin

Pituitary Gland 

  Endocrine gland involved in homeostasis

  Regulates other endocrine glands

Pons 

  Relays sensory information between the cerebrum and cerebellum Reticular Formation

  Nerve fibers located inside the brainstem

  Regulates awareness and sleep

Substantia Nigra 

  Helps to control voluntary movement and regulates mood

Wernicke's Area 

  Region of the brain where spoken language is understood

Source: http://biology.about.com/od/humananatomybiology/a/anatomybrain.htm

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Textbook Discussion

  A Stroke occurs when an infarct (damage) to the brain occurs, either because there

is not enough blood or oxygen (nonhemorrhagic Stroke) going to the brain, or due to

 bleeding into the brain (hemorrhagic Stroke). A Non-hemorrhagic Stroke is more

common than a hemorrhagic Stroke.  Strokes because symptoms and physical findings

depending on the area injured in the injured brain.

Source: http://www.ecureme.com/emyhealth/data/Cerebrovascular_Accident.asp

  Cerebrovascular accident (CVA) prevention: In many cases, a person may have a

transient ischemic attack (TIA), a neurological event with the symptoms of a stroke, but

the symptoms go away within a short period of time. This is often caused by the

narrowing or ulceration of the carotid arteries (the major arteries in the neck that supply

 blood to the brain). If not treated, there is a high risk of having a major stroke in the

future. If you suspect a TIA, you should seek medical attention right away. An operation

to clean out the carotid artery and restore normal blood flow through the artery (a carotid

endarterectomy) markedly reduces the incidence of a subsequent stroke. In other cases,

when a person has a narrowed carotid artery, but no symptoms, the risk of having a

stroke can be reduced with medications such as aspirin and ticlopidine (TICLID). These

medications act by partially blocking the function of blood elements, called platelets,

which assist blood clotting

Source: http://www.medterms.com/script/main/art.asp?articlekey=2677

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  Cerebrovascular accident (CVA) is the medical term for what is commonly

termed a stroke. It refers to the injury to the brain that occurs when flow of blood to

 brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die

 because of lack of nutrients and oxygen.

Source: http://www.healthline.com/galecontent/cerebrovascular-accident

The severity associated with cerebrovascular accident can best be demonstrated by the following

facts:

  CVA is the leading cause of adult disability in the world.

  Worldwide, one-quarter of all strokes are fatal.

  Stroke is the third leading cause of death in the United States and the leading cause of

disability.

  It is estimated that four of every five families in the United States will be affected by

stroke in their lifetime,

  More than half a million people in the United States experience a new or recurrent stroke

each year.

  Stroke kills about 150,000 Americans each year, or almost one out of three stroke

victims.

  Three million Americans are currently permanently disabled from stroke.

  In the United States, stroke costs about $43 billion per year in direct costs and loss of

 productivity.

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  Two-thirds of strokes occur in people over the age of 65.

  Strokes affect men more often than women, although women are more likely to die from

a stroke.

  Strokes affect African Americans more often than Caucasians, and are more likely to be

fatal among African Americans.

  The incidence of strokes among people ages 30 to 60 is less than 1%. This figure triples

 by the age of 80.

  The rate of occurrence for strokes in the United States fell by 15.52% between 1988 and

1998. But the number of deaths from stroke actually rose by 5%.

Causes and symptoms

Arterial blood carries oxygen and nutrients to the cells of the body. When arteries are

unable to carry out this function due to rupture, constriction, or obstruction, the cells nourished

 by these arteries die. There are two forms of stroke, ischemic, which is caused by a blocked

 blood vessel that supplies blood to the brain, and hemorrhagic, which is bleeding into or around

the brain.

The most common type of stroke is ischemic, which refers to the loss of oxygen and

nutrients for brain cells that occurs because the blood supply to a portion of the brain has been

cut off. Ischemic strokes account for approximately 80% of all strokes, and can be further broken

down into two subtypes: thrombotic, also called cerebral thrombosis, and embolic, also termed

cerebral embolism.

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Thrombotic strokes are by far the more prevalent of ischemic strokes, and can be seen in

nearly all aging populations worldwide. As people grow older, atherosclerosis, or hardening of

the arteries, occurs. This results in a buildup of a waxy, cholesterol-laden substance in the

arteries, which eventually narrows the interior space, or lumen, of the artery. This arterial

narrowing occurs in all parts of the body, including the brain. As the process continues, the

occlusion, or shutting off, of the artery eventually becomes complete so that no blood supply can

 pass through. Usually the occurrence of the symptoms of a thrombotic stroke are much more

gradual and less dramatic than other strokes due to the slow, ongoing process that produces it.

Embolic strokes are usually a more spectacular, emergency event. They take place when

the heart's rhythm is changed for a number of reasons, and blood clot formation takes place.

Such a blood clot can move through the circulatory system until it blocks a blood vessel and

stops the blood supply to cells in a specific portion of the body. If the blood clot occludes an

artery that nourishes heart muscle, it causes myocardial infarction, or heart attack. If it blocks off

a vessel that feeds brain tissue, it is termed an embolic stroke. Normally, these blockages occur

in the brain itself, as when arteries directly feeding portions of brain tissue are blocked by a clot.

But occasionally, the obstruction is found in the arteries of the neck, especially the carotid artery.

Approximately 20% of cerebrovascular accidents are termed hemorrhagic strokes, and

are generally classified as subarachnoid hemorrhage or intracerebral hemorrhage,  depending

upon the location of the hemorrhage. Hemorrhagic strokes occur when an artery to the brain has

a weakness and balloons outward, producing an aneurysm. Such an aneurysm often ruptures due

to this inflation and thinning of the arterial wall, causing a hemorrhage in the affected portion of

the brain.

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Both ischemic and hemorrhagic strokes display similar symptoms. However, which

symptoms appear depends upon which portion of the brain is cut off from its supply of oxygen

and nourishment. The brain is divided into left and right hemispheres, which control bodily

movement on opposing sides of the body. For example, the left hemisphere of the brain is

responsible for both motor control of the right side of the body, and its sensory discrimination,

 just as the right hemisphere is responsible for body movements and feeling on the left side.

Deeper brain tissue in the left hemisphere of the brain directs muscle tone and coordination for

 both the right arm and leg. As the communication and speech centers for the brain are also

located in the left hemisphere of the brain, interruption of blood supply to that area can also

affect the person's ability to speak.

Besides age, high blood pressure (hypertension) is one of the foremost causes of

thrombotic stroke. Heart disease,  obesity, diabetes,  smoking, oral contraceptives in women,

 polycythemia (an increased number of red blood cells), and sleep apnea are also risk factors for

thrombotic stroke, as is a diet high in cholesterol-producing, or fatty, foods.

The risk factors for hemorrhagic stroke include high blood pressure that can, over a

 period of time, cause the ballooning out of arteries known as aneurysm, and also causes the

hereditary malformation that produces defective and weakened veins and arteries. Substance

abuse is another major cause of hemorrhagic stroke. Cocaine, stimulants such as amphetamine

drugs, and chronic alcoholism can cause a weakening of blood vessels that can result in

hemorrhagic stroke.

The symptoms of stroke depend upon the part of the brain that is affected, and how large

a portion of brain tissue has been damaged by the CVA. Unconsciousness and even seizures can

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 be initial components of a stroke. Other effects materialize over a time period ranging from

minutes to hours, and even, in some rare instances, over several days. Headache, mental

confusion, vertigo, vision problems, difficulty speaking and communicating, including slurring

of words (aphasia), and weakness or paralysis of one side of the body (hemiplegia) are all

symptoms of stroke that are frequently observed. Stroke victims often have facial drooping, or

slackness of the facial muscles, on the affected side, as well as difficulty swallowing.  The

severity of these symptoms will depend upon the amount of brain tissue that has been damaged

and its location in the brain.

Diagnosis

 Normally, initial diagnosis will be made based upon observation by health care

 professionals, and usually a complete neurological examination.  Once stroke is suspected, a

computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is performed to

distinguish a stroke caused by blood clot from one caused by hemorrhage, a critical distinction

that guides therapy. Blood and urine tests are done routinely to look for possible abnormalities

associated with ischemic activity within the body. Electrocardiogram (EKG), angiography, and

lumbar puncture are all used to rule out any other possible causes of the symptoms

A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the

 brain is disrupted, causing brain cells to die. When blood flow to the brain is impaired, oxygen

and glucose cannot be delivered to the brain. Blood flow can be compromised by a variety of

mechanisms.

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Definition of Terms

Brain

  The brain is the most important organ in your body because it controls everything in

your body.

It can be seen as supersense or sensory motor. The brain controls the functioning of the

 body electrical impulses. 

Cerebrovascular accident (CVA),

  is the rapid loss of  brain function due to disturbance in the blood supply to the brain.

Hemiplegia

  The inability to move a group of muscles in one side of the body. When hemiplegia is

caused by a stroke, it often involves muscles in the face, arms and legs. 

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ETIOLOGY

Predisposing Factor

FACTOR RATIOANLE REMARKS

Age (69)

The chances of having strokeapproximately for each decadeof life after age 55 due tochanges in the vascularity ofthe Blood Vessel anddecreased of body functions.

Present

Heredity(HTN)

Those whose blood pressurerelatively with cerebrovascularAccident has a great risk ofdeveloping CVA in later yearsdue to its complication if leftuntreated.

Present

Sex (Female)

A stroke is more common in

men than in women about 46%of men develop stroke and24% are women. So it is mostcommon on men.

 NotPresent

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Precipitating Factor

FACTOR RATIOANLE REMARKS

DM

This condition bringhyperviscosity in the blooddue to increase glucose leveland increase risk ofhypertension and may progressto CVA

 NotPresent

Lifestyle (Alcohol Intake and

Smoking)

Theses substance cause alsochanges in the normal shape of

the blood vessel thusrestriction of blood flow occuralso triggers HTN

 Not Present

Diet

It was clinically proven thattoo much take of fatty foodsand high in sodium (salt) canincrease BP and casuedeposition of thrombus in the blood vessel which can restrict blood flow.

Present

Trauma

It is also believed that thisetiology can cause bloodvessel to weaken thus whenhypertension occur theweakened area to protrudesresulting to

 NotPresent

Previous Stroke attack35% of those people who havealready a previous strokeattacks will have a

cerebrovascular accidentreccurence within five years oftheir life.

Present

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SYMPTOMATOLOGY

FACTOR RATIOANLE REMARKS

DecreaseLOC

Due to deprivation of the exactoxygen needed by the brain. Ittends also to altered itsfunction thus consciousnessdecreased

Present

Headache, Nausea andvomiting

Due to the occurrence of theincrease intracranial pressurewhich results to this symptoms

 Not Present

Atrophy

Due to irreversible damage to

the right hemisphere of the brain, normalneurotransmissions impairedresulting in ability of the leftarm to make normally and inlonger time is physicalappearance deteriorate as wellas its function resulting toatrophy

 Not Present

Slurring SpeechThis is also due to theirreversible damage to a

certain part of the brain which primarily involved for thespeech

 Not Present

Left HemiplegiaThis is the damage to the brainin the right hemispheres of the brain its effects is that paralysis on one side of body

 Not Assessed

ParalysisIt’s because of the defect in the

neurotransmission cause by thedamage to the brain with motoraction is altered

Present

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DATE/TIME ORDER RATIONALE REMARKS

7-23-134:35 am

-Admit pt.

-NPO

-TPR q4 shift

-Lab Test: CBC,urinalysis,Fecalysis, ECG,ChestBrain scan

-PLR 1L @3Ogtts/min

-Mannitol 20%-100ml IV now q6

-Ranitidine 50mg q6IVTT

-Citicholine 1ampIVTT q6

-For furtherobservation andmanagement

-For baseline data

-To monitor anycomplications andabnormalities

-Used to replace fluidlost by the body. It iscommonly used for

fluid resuscitation,meaning that the patient needsaggressive fluidreplacement for theirinjury or illness.

-Increase osmotic pressure of plasma inglomerular filtrate,inhibiting tubular

reabsorption of waterand electrolytes.

-Competitivelyinhibits acion ofhistamine on the H2 atreceptors sites of parietal cells,decresing gastric acidsecretion.

-Citicholine seems toincrease brainchemical phosphatidychloline.The brain chemical isimportant for brainfunction.It might alsodecrease brain

-Done

-Done

-Done and monitored

-Done, patient had alab test.

-Done, patient’s IVFwas hooked ,andregulated to desired

rate

-Given and recorded.

-Given and recorded.

-Done, carried out.

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-Clonidine 75mgIVTT q6

-Metochlopromide1amp IVTT PRN

-Cefuroxime750mg IVTT q6

-Paracetamol500mg PRN

Aspirin80mg/tab (NGT)BID

damage when the brain is injured.

-Stimulates alphaandrenergic receptors

in CNS decreasingsymphatetic out flow,inhibitingvasoconstriction andultimately reducing blood pressure

-Blocks dopaminereceptors inchemoreceptor triggerzone of the CNS.

Stimulates motility ofthe upper GI tract andaccelerates gastricemptying

-Second generationcephalosporin thatinhibits cell-wallsynthesis, promotingosmotic instabilityusually bactericidal

-Inhibits the synthesisof prostaglandins thatmay serve asmediators of pain andfever primarily in theCNS.

-Produce analgesiaand reduceinflammation and

fever by inhibiting the production of prostaglandins.

-Done and carried out.

-Done and carried out.

-Done and carried out.

-Done and carried out

-Done and carried out

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27-24-13 -Follow up CT scanRBS now

-To follow D5LR 1L@20gtts/minregulated @prese

-Vital signs q4

-Monitor the status ofthe patient

-For fluid replacement

-For patient vitalinformation

-Done and recorded

-Done and regulatedto desired rate

-Done and monitored

7-25-13 -Liquid diet withaspiration percaution

-Decrease mannitol q8

-Referral to Dr,Xoxoa neurologist forfurther information-Pls.xerox theLab.result for Pt. file

To prevent aspirationand easy swallowing

-Given and recorded.

7-26-13

7-27-13

-follow up check up

GCS7( glasgow comascale)

-RBS now and O2inhalation 2-3 litters

- To follow Plain NSS

-To monitor thecondition of the patient.

-Patient conditions

-Instruct

-Done and monitored

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07-28-138:45am

07-29-1310:35am

07-30-138:35am

07-31-131:00pm

08-01-1311:30amBP: 160/100

08-02-138:20amBP:150/90

-Decrease Mannitolfor tomorrow q12

-Instruct the relativesto try dropper for H2oif tongue tolerate

-For NGT insertion tosecure consent

-NGT @ 1,200Kcal/day to be given

in 4 divided dose(200every 6hrs)

-NGT removed by the patient-Patient is lethargic but understand-Resume citicoline asordered-Decrease mannitolOD

-Pt. still lethargic

-IVF to follow D5LR1L @20gtts/min

-IVF to follow PNSS1L Lx KVO-Reinsertion of NGT

and resume feedingonce inserted

IVF to follow PNSS1L Lx@ KVO

Increase osmotic pressure of plasma inglomerular filtrate,inhibiting tubular

reabsorption of waterand electrolytes-For prevent dry lipsand to monitored patient followinginstruction

-Patient nourishment

-Patients comfort withher condition

-Fluid replacement ofthe patient

-Fluid replacement ofthe patient

-Fluid replacement ofthe patient

-Done and recorded

-Done and recorded

-Done and monitored

-Given and recorded

-Done and monitored

-Done and recorded

-Done and regulatedto desired rate

-Done and regulatedto desired rate-Done and recorded

-Done and regulatedto desired rate

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08-03-139;30am

08-04-1311:15am

08-05-139:45amBP:100/60

08-06-138:am

BP:110/80

-RBS-152-RBS now-may use ENSUREIf no oral feeding

-IVF to follow PNSS1L @ KVO

-Nebulized withPNSS(3ml)TID

-IVF to follow PNSS1L @KVO

-D/C Ranitidine-Decrease MannitolOD-Simvastatin 40mg1tab/NGT in pulvorizedRBS now>Repeat ECG

>MGH once withwatcher able to feed

 NGT

-Patient nourishment

-Fluid replacement ofthe patient

-To lossen secretionand patient comfort

-Fluid replacement ofthe patient

-Net effects of totalcholesterol and serumtriglyceridereductions.

-Done and recorded

-Instruct the SO

-Given and regulatedto desired rate

-Given and recorded

-Done and regulatedto desired rate

-Done and carried out

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LABORATORY RESULTS

HEMATOLOGY- The branch of science concerned with the study of blood and blood forming

tissue and disorder associated with them.

DATE:07-24-13

COMPONENT NORMALVALUE

RESULT INTERPRETATION NURSINGRESPONSIBILITIES

HGB MASSCONCENTRATION

WBC

HCT

SEGMENTERS

EOSINOPHILS

MONOCYTE

PLATELET

140-170g/dl

5.1X10g/l

0.37-0.43

0.55-0.65

0.02-0.04

0.02

268

131

14.2

0.41

0.93

0.02

0.03-0.04

150-450 x10 cu/ml

Decreased

Increased

 Normal

Increased

 Normal

Decreased

 Normal

Inform patient to takefood rich in iron suchas animal liver.

Give antibiotic asordered

Always check IV patency

Inform patient that anantibacterialmedication is neededto prevent bacterialinfection.

Instruct patient to eat

vegetables that is richin iron and increaseoral fluid intake.Instruct patient to eatvegetables that is richin iron and increaseoral fluid intake.Increase oral fluidintake.

BLOOD TYPERESULT: “O+” 

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SODIUM POTASSIUM DETERMINATION 

COMPONENT NORMALVALUE

RESULT INTERPRETATION

Potassium (K+)

Sodium (Na+)

3.5-5.3

mmol/L135-148mmol/L

3.86

141

 Normal

 Normal

Troponine Test: NEGATIVE

Arterial Blood Gas- is a blood test that is performed using blood from an artery. It involves

 puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The

most common puncture site is the radial artery at the wrist, but sometimes the femoral artery in

the groin or other sites are used. The blood can also be drawn from an arterial catheter. 

COMPONENT NORMALVALUE

RESULT INTERPRETATION

 pH

PCO2

PO2

HCO3

B.E

O2 sat

7.35-7.45

35-45 mmHG

80-100 mmhg

22-26 mEq/L

(-1 + 2 mEq/L)

90-100%

7.415

30.7

110

19.3

-5.3

98.1%

 Normal

Decrease

Increase

Decrease

 Normal

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Urinalisys- an analysis of the volume and physical, chemical and microscopic properties ofurine.

COMPONENT NORMALVALUE

RESULT INTERPRETATION NURSINGRESPONSIBILITIES

Color

Appearance

Reaction

Sugar

Protein

Ketone

Specific Gravity

PUS Cells

LightStraw/amber

Clear

4.5-8.0

(-)

(-)

(-)

1.005-1.030

1-2/hpf

LightYellow

Clear

7.0

(-)

(-)

(-)

1.015

20-25/hpf

 Normal

 Normal

 Normal

 Normal

 Normal

 Normal

 Normal

Increase

> Maintain hydrationstatus of the pt.continuation of the pt.IVF therapy help to thiscondition.> Maintain hydrationstatus of the pt.continuation of the pt.IVF therapy help to thiscondition.> Maintain hydration

status of the pt.continuation of the pt.IVF therapy help to thiscondition.> Maintain hydrationstatus of the pt.continuation of the pt.IVF therapy help to thiscondition.

>M the status of the patient maintain

> Maintain HydrationStatus; Monitor V/S andregulate IV well asordered rate.

> Maintain HydrationStatus; Monitor V/S andregulate IV well asordered rate.> Indicates that the pt.has infection and thusshould administer/managed with

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RBC

Amorphousurates

0-1/hpf

Occasional/few

8-10/hpf

Few

Increase

 Normal

antiinfectives andincrease fluid intake.> Bleeding is present.Monitor the Laboratory;CBC and be prepare for

BT if Problem persist.

> Maintain Hydration

Oxygen Supplement of 80% FiO2

COMPONENT RESULT NORMALVALUES

INDICATION NURSINGRESPONSIBILITIES

Creatinine

Uric Acid

Sodium

Potassium

1.70g/dl

9.32mg/dl

138mmoL/L

2.46mmoL/L

0.6-1.3

2.6-7.2mg/dl

135-148mmoL/L3.5-5.3

mmoL/L

Increase

Increase

 Normal

Decrease

- Possible for MI;Administer

antiangina drugs asordered.- Pt. has possiblegout; protect joints by putting pillow under.-avoid high sodiumdiet-Potassium Loss;Administer KCL toreplace K+ Loss.Provide adequate

hydration.

Blood Glucose Examination- used to measure glucose level in the blood.

COMPONENT RESULT NORMALVALUES

INDICATION NURSINGRESPONSIBILITIES

Glucose

Cholesterol

Triglyceride

124mg/dl

231.00g/dl

137g/dl

70-105mg/ dl

0-200

0-150

Increase

Increase

Increase

> Diabetes is noted.Decrease sugar intakeand give & give theCalculated KCAL.

> Pt. is at risk forObstruction of anyartery leads to prone/risk to stroke.Administeranticoagulant asordered.> Pt. is at risk for

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HDL

LDL

42g/dl

161.6g/dl

Greaterthan 60

0.150

Low

Increase

Obstruction of anyartery leads to prone/risk to stroke.Administeranticoagulant as

ordered.> Pt. is at risk forObstruction of anyartery leads to prone/risk to stroke.Administeranticoagulant asordered.> Pt. is at risk forObstruction of anyartery leads to

 prone/risk to stroke.Administeranticoagulant asordered.

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Criteria Good Fair Poor Justification

Onset of

Illness

Mrs. Pet had

already

Cerebrovascular

attack for three

times. It is

already Mrs.

Pet’s 3rd attack.

Duration of

Illness

Mrs. Pet’s

duration of

Cerebrovascular

attack is already

3 years.

Hygiene

the patient has

 poor hygiene.

She is

dependent to

her watcher, but

the watcher is

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not maintaining

good gygiene to

Mrs. Pet. It is

visible that her

clothes are

soiled and her

mouth is not

clean.

. 

Diet - Pt. has a poor

diet because he

is only fed

through NGT.

And Mrs. Pet

also tries to

remove the

 NGT with her

left hand. 

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Age -The patient is

69 years old.

The patient is

not strong

enough to take

care of herself

 because she is

 physically

weak. 

Performance

Level

- Upon

assessment

 patient is

unconscious.

Willingness to

undergone the

treatment

- The pt. is

admitted to

SCPH and her

relatives are

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willing to

undergo the

treatment that

the physician

has ordered. 

Family

Support

- The patient’s

family is not

supportive

 because the

 pt.’s watcher is

her

goddaughter.

Mrs. Pet’s son

only visits her

when he is

 badly needed.

Computations:

Good: 0/8 x 100 = 0%

Fair: 1/8 x 100 = 12.5% 

Poor: 1/8 x 100 = 87.5% 

100%

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Interpretation:

Based on the patients prognosis the result is poor because the patient illness is

chronic because it is present for more than 3 years and the patient is unconscious and poor in

hygiene. The family also lacks in family support.

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BIBLIOGRAPHY

1.  CerebrovascularAccident.Retrieved last August 19, 2013 from

http://www.ecureme.com/emyhealth/data/Cerebrovascular_Accident.asp

2.  Definition of Cerebrovascular accident (CVA) prevention. Retrieved last August

19, 2013 from  http://www.medterms.com/script/main/art.asp?articlekey=2677 

3.  Mary Ellen Ellis (2013). Cerebrovascular Accident. Retrieved las August 19, 2013 from

http://www.healthline.com/galecontent/cerebrovascular-accident  

4.  Regina Bailey. Anatomy of the Brain. Retrieved las August 19, 2013 from

http://biology.about.com/od/humananatomybiology/a/anatomybrain.htm