A

Case Presentation
On
Cerebrovascular Accident

Group J
Marco Paul Velasco
Precious Jane Parungao
Rod Lambert de Leon
Carla Aleja Abijay
Mylene Narag
Jenalin Quilang
Krizzia Marie Palce
Jessica Datul
General Objective :

At the end of the case presentation ,

the presenters together with the audience
will enhance our understanding on the
disease process of CVA , its nursing
management and paves a way to us student -
nurses appreciate our roles of being health
care providers in the country ’ s guest for
health progress and development .
 
Specific Objectives :

•Define Cerebrovascular Accident

•Discuss and interpret data gathered through
theoretical analysis of Nursing History , Gordon ’ s 11
Functional Pattern , Physical Assessment and Laboratory
Results .
•Explain the anatomy and Physiology of Nervous System
•Discuss the Pathophysiology of Cerebrovascular
Accident
•Create effective and efficient nursing care plan
required by a patient with the above mentioned disease
process .
•Discuss the medications taken by the client , its
action , side effects and nursing responsibilities
erebrovascular Accident
 Cerebrovascular Accident is a sudden loss
of function resulting from disruption of the
blood supply to a part of the brain . Stroke ,
also called brain attack or ischemic stroke ,
happens when the arteries leading to the brain
are blocked or ruptured . When the brain does
not receive the needed oxygen supply , the brain
cells begin to die , a stroke can cause
paralysis , inability to talk , inability to
understand , and other conditions brought on by
brain damage .
 
Four types of stoke :
1 . Cerebral Thrombosis - caused by blood clots
2 . Cerebral Embolism - caused by blood clots
3 . Cerebral Hemorrhage - caused by bleeding
inside the brain
4 . Subarachnoid Hemorrhage - caused by bleeding
inside the brain .
Cerebral Thrombosis
•The most common type of brain attack
•Occurs when a blood clot (thrombus) forms and
blocks blood flow in an artery leading to the
brain arteries primarily affected by
atherosclerosis and more susceptible to blood
clots.
•Most often occurs at night or in the morning
when blood pressure in low.
•Often preceded by a transient ischemic
attack(TIA) or “mini-stroke”

•
Cerebral Embolism
•Occurs when a wondering clot ( embolus ) or
some other particle forms in a blood vessel
away from the brain , usually in the heart .
The clot then travels and lodges in an
artery leading on the brain .

Cerebral Hemorrhage
•Occurs when a defective artery in the brain
busts .
 
Subarachnoid Hemorrhage
•Occurs when a blood vessel on the surface of
the brain ruptures and bleeds into the space
between the brain and the skull .
•
 
 The World Health Organization ( WHO )
definition of stroke is “ rapidly developing
clinical signs of focal ( or global ) disturbance
of cerebral function , with symptoms lasting 24
hours or longer or leading to death , with no
apparent cause other than of (1) Non -
communicable disease . WHO Geneva ( 2 ) vascular
origin ” (3) By applying this definition
transient ischemic attack ( TIA ), which is
defined to less than 24 hours , and patients
with stroke symptoms caused by subdural
hemorrhage , tumors , poisoning , or trauma , are
excluded .
 
Based from the data gathered from TCGPH
records section , there were 10 reported cases
of CVA as of January 2009 until December 2009
comprises of 2 mortality cases and 8 morbidity
cases .
 
 
Why this case?
 
•We have chosen this case as our topic during
the case presentation because we would like
that we , student - nurses , to be aware about CVA
and also to broaden our knowledge about the
management and treatment of this disease .
•Having awareness and gaining more knowledge
about CVA would enhance our skills and
attitudes in handling patients suffering from
this disease .
•This case serves as a challenge for us
student - nurses to be committed and dedicated
health professionals for in the next days , we
will take care of the health of the citizens .
•
•
 PATIENT ’ S PROFILE
Name : I.M.
Age : 80 y / o
Gender : Female
Civil Status : Widower
Birth date : Dec . 24 , 1928
Nationality : Filipino
Religion : Roman Catholic
Address : Ugac Norte , Tuguegarao City
Educational Background : College Graduate
Occupation : Retired Teacher
Date of admission : November 19 , 2009
Time of admission : 6 : 45 pm
Chief complaint : Loss of consciousness
Admitting diagnosis : HPN t / c CVA
Final Diagnosis : CVA recurrent
Sepsis secondary to Pneumonia
NIDDM

 
 
 
 
Attending Physician : Dr . Valeriano Combate , Jr .
Dr . Marlene Cinco
Dr . Gerardo Pagaddu

Source of information : SO
Patient ’ s chart
Record ’ s section

Hospital : TCPGH - Pay ward

 
NURSING HISTORY
Past Health History
 
According to SO , when the patient
suffered from headache , fever , and
cough , patient takes over the counter
drugs like paracetamol , biogesic ,
alaxan and solmux . Patient was
diagnosed with Alzheimer ’ s disease on
2004 , and undergone mastectomy when
she was 42y / o .
 
History of Present Illness
 
According to SO , at the evening of
November 19 , 2009 , 45 minutes PTC , SO noticed
that patient was still sleeping at around
6 : 00pm . She then tried many times to wake up
the patient and called her to eat but she
did not receive any response . The SO was
alarmed and decided to rush the patient to
People ’ s Emergency Hospital and was admitted
around 6 : 45pm . . At the age of 52 patient was
hospitalized and diagnosed of HPN and
manages it by taking maintenance drugs such
as amlodipine , simvastatin & aspirin taken
twice a day .
 
Family Health History
 
The patient has a history of Asthma on her
paternal side . Her father died of Asthma and
her mother died due to hypertension .
 
Social Health History
 
Patient is a retired teacher ; she lives
with her daughter and grand children .
According to the SO before the patient was
diagnosed of Alzheimer ’ s disease , the patient
loves to mingle with her neighbors and loves
to take care of her grand children . SO also
verbalized that patient does not drink
alcohol nor smoke cigarettes .

 
Gordon’s 11 Functional
Pattern
Health Perception - Health Management
Pattern
Before
• Hospitalization During Hospitalization
  According to the SO, According to the SO, she
her mother has been stated that her mother is
pampered starting when she not in good condition. She
was diagnosed with believes that doctors,
Alzheimer’s disease 5 years nurses and other medical
ago. When she suffered from members will help her
the sickness, they treated mother to recover. SO also
her immediately by taking added that they obediently
OTC drugs for cough, colds follow all the orders of
and fever. With regards to the doctors.
her maintenance drugs to
her hypertension, they give
it at right time as
prescribed.
Nutritional - Metabolic Pattern
•
 Before Hospitalization During Hospitalization
According to the SO, Upon admission, the
her mother eats everything patient was inserted NGT
she wants and sees. She has and was ordered with PNSS
no preference diet. She 1liter to run for 8 hours.
eats 3 times a day with mid The diet was osteorized
afternoon snacks. She feeding with SAP.
drinks 6-8 glasses of water
a day. She has no
difficulty in swallowing
and has no allergy with any
type of food.
Elimination Pattern
Before Hospitalization During Hospitalization
According to the SO, Upon admission, the
•her mother eats everything patient was inserted NGT
she wants and sees. She has and was ordered with PNSS
 no preference diet. She 1liter to run for 8 hours.
 eats 3 times a day with The diet was osteorized
mid afternoon snacks. She feeding with SAP.
drinks 6-8 glasses of water
a day. She has no
difficulty in swallowing
and has no allergy with
any type of food.
Activity Exercise Pattern
•
Before During
Hospitalization
According to the SO, Hospitalization
The patient is in
the patient is like a comatose state.
child. She plays with Student-nurses and SO
her neighborhood. initiated passive range
Sometimes walking of motion for her to
around their house. exercise.
About her hygiene, they
see to it that
cleanliness must
maintain to her.
Sleep - Rest Pattern
Before During
Hospitalization
According to the SO, Hospitalization
Patient is comatose
her mother sleeps at but can respond to
around 8 in the evening physical stimuli.
and wakes up at around
5 in the morning. She
takes naps at
afternoon. She has no
rituals before sleeping
she added.
Cognitive Perceptual Pattern
Before During
Hospitalization
According to the Hospitalization
The patient responds
SO, her mother is a to stimuli by means of
retired teacher, she rubbing her sternum for
uses eyeglasses. She her to wake up.
speaks dialects such as
Ilocano, Tagalog and
English.
lf - Perceptual Pattern
Before During
The patient suffers
Hospitalization Hospitalization
The patient is
from Alzheimer’s comatose.
disease.
Role - Relationship Pattern
•Before Hospitalization During Hospitalization
  According to the SO, Due to her condition,
before her mother was her daughter stated that
diagnosed with Alzheimer’s, they will do all their best
she was a loving mother and to take care of their
responsible to her mother. They will make sure
children. She provides to give back the care they
their needs and sees to it have received from her.
that they are comfortable
in their way of life.
 Coping - Stress Pattern
•
Before During
Hospitalization
When her mother is Hospitalization
During her present
tired, she sleeps for condition, she is in a
her to rest. stressful state. Her
family is there to
comfort and give her
necessary needs just to
show their love.
 Sexual - Reproduction Pattern
  The patient has five children and
had her menopause at the age of 50 .

Value Belief Pattern

She is a Roman Catholic . When she
was diagnosed with Alzheimer ’ s disease ,
her family never allowed her to go to
mass , preventing her to lose her way
home .
PHYSICAL
ASSESSMENT
•
•Date Assessed: December 03, 2009, 5:15 PM
•Vital Signs:
•BP: 140/90 mmHg
•PR: 92 bpm
•RR: 23 cpm
•T: 36.8°C
General Appearance:
ØPatient is lying on bed, comatose with ongoing
IVF of PNSS 1L x 20 gtts/minute at 500 cc level
hooked at left metacarpal vein patent and
infusing well.
ØWith NGT patent.
ØWith IFC connected to urine bag draining
yellow amber.
AREA METHOD USEDNORMAL ACTUAL
ASSESSED FINDINGS FINDINGS ANALYSIS
SKIN Inspection Fair complexion Pale d/t decreased tissue
Color perfusion and
peripheral
vasoconstriction

Inspection/ Smooth Wrinkled d/t loss of elastic

Texture Palpation fiber and decreased
subcutaneous fat
from hypodermis
secondary to aging

d/t poor hygiene

Inspection Presence of rashes

d/t peripheral
Normally warm Cold and clammy vasoconstriction
Temperature Palpation
Moisture Palpation Moist to dry Dry d/t decreased activity of
sebaceous and sweat
glands secondary to
aging

d/t loss of elastic fiber

Turgor Palpation Snaps back to Sagged and decreased
previous subcutaneous fat from
hypodermis secondary
to aging
HAIR Inspection/ Evenly Evenly Normal
Distribution Palpation distributed distributed

Texture Inspection Silky, resilient Resilient Normal

Black
Color Inspection Black w/ white d/t decreased
hairs melanocyte
production
secondary to
aging
NAILS
Color of the nail Inspection Pink transparent Pallor d/t poor arterial
bed circulation

Delayed 1-2 sec. d/t poor arterial

Capillary refill Palpation Delayed 4 sec. circulation
time
Convex Normal

Shape Palpation Convex

EYES/ Normal
Round
EYEBROWS
Shape Inspection Round Normal
Equal in size
Symmetry Equal in size Normal
Inspection Symmetrical in
movement Symmetrical in
Movement Inspection
movement
Blinks involuntarily d/t decrease activity
& bilaterally of CN V
Ability to blink Inspection Absence of blink
CONJUNCTIVA
Color Inspection Pink - red Pale d / t poor
        arterial
        circulation
       
PUPILS
PERRLA Inspection Response to Very slow to d/t
    penlight react to compression
    ( dilates and light of CN III
    constricts )    
     
Size of the Inspection    
pupil     2mm  
         
EXTERNAL      
AUDITORY
CANAL
 
Hearing Inspection Hears equally   Normal
in both ears Hears equally
in both ears
NOSE  
Symmetry Inspection Symmetrical Symmetrical Normal
         
Color Inspection Same color as Same color as   Normal
    the face and the face and  
    neck neck
     
LIPS & MOUTH  
Symmetry Inspection Symmetrical Symmetrical Normal
          
Color ( lips ) Inspection Pink Pale d / t decrease
        oxygenation
         
Moisture Inspection Moist Dry d / t decreased
  salivary
production
r / t loss of
vagal
stimulation
NECK
Symmetry Palpation Symmetrical Symmetrical Normal
         
Appearance Inspection No No Normal
    distentions distentions  
THORAX        
Chest Inspection     Normal
contour   Symmetrical Symmetrical  
  Inspection     Normal
Clavicle   Prominent Prominent  
  Inspection     Normal
Chest wall   Full chest Full chest  
  expansion expansion  
  Inspection     d / t decreased
Breathing   Regular Irregular function of
pattern     the medulla

ABDOMEN Inspection Normal

General Auscultation Non - tender Non - tender
contour Percussion
Palpation
UPPER
EXTREMITIES

Symmetry Inspection Symmetrical Symmetrical Normal

         
ROM Inspection / (+) ROM upon (+) ROM upon Normal
  Palpation movement movement  
         
         
LOWER    
EXTREMITIES
   
Size Inspection Equal in size Equal in size Normal
         
Symmetry Inspection Symmetrical Symmetrical Normal
         
ROM Inspection (+) ROM upon (+) ROM upon Normal
  movement movement
 
LABORATORY RESULTS
 Hgt
Date Result Normal Range Analysis
11 - 21 - 09 6am 284 mg / dl 80 - 120 mg / dl
11 - 21 - 09 6pm 155 mg / dl 80 - 120 mg / dl
11 - 22 - 09 6am 186 mg / dl 80 - 120 mg / dl
11 - 22 - 09 153 mg / dl 80 - 120 mg / dl
11 - 23 - 09 170 mg / dl 80 - 120 mg / dl
11 - 24 - 09 215 mg / dl 80 - 120 mg / dl
11 - 27 - 09 172 mg / dl 80 - 120 mg / dl
11 - 28 - 09 152 mg / dl 80 - 120 mg / dl
11 - 30 - 09 120 mg / dl 80 - 120 mg / dl
12 - 01 - 09 133 mg / dl 80 - 120 mg / dl
 Na
Date Result Normal Range Analysis
11 - 24 - 09 131 mmOl / L 135 - 145 Normal
11 - 29 - 09 132 mmOl / L mmOl /L
135 - 145 Normal
mmOl / L

K
Date Result Normal Range Analysis
11 - 24 - 09 3 . 0 mmOl / L 3.5-5.5
11 - 29 - 09 4 . 0 mmOl / L mmOl
3 . 5 - 5/.L5 Normal
mmOl / L
CBC
11 - 20 - 09
Parameters Result Normal Analysis
WBC 12 . 4x10 3 /mm 3 Range
3 . 5 - 10 d / t increase
RBC 3 . 83x10 6 /mm 3 3.8-5.8 pyrogens
Normal
Hgb 11 . 4 g / dl 11 . 0 - 16 . 5 Normal
Hct 37 . 0 % 35 - 50 Normal
PLT 188x10 3 /mm 3 150 - 390 Normal
 INTAKE AND OUTPUT MONITORING SHEET

12 - 05 - 09
Intake Output
Time Oral Parent Others Total Urine Drainag Others Total
7-3 500 erral
100 600 600 e 600
3-11 1000 430 700 700 700
11-7 660 200 800 800 800
Total : 2890
Total : 2100
12 - 04 - 09
Intake Output
Time Oral Parenterra Othe Total Urine Drainage Othe Total
7-3 720 l100 rs
75 895 200 rs 250
3-11 1000 250 1250 500 500
11-7 600 250 850 200 200

Total :
2995 Total : 950
12-03-09
Intake Output

Time Oral Parent Others Total Urine Draina Others Total

7-3 750 erral
350 75 1175 290 ge 290
3-11 1000 200 4 1204 350 350
Total : 2379
Total : 640
12-02-09
Intake Output
Time Oral Parenterra Others Total Urine Drainage Others Total
l
7-3 900 550 75 1525 790 790
3-11 832 120 75 1027 660 660
11-7 600 200 75 875 550 550
Total: 3427
Total: 2000

11-30-09
Intake Output
Time Oral Parenterra Others Total Urine Drainage Others Total
7- 3 600 l340 940 1000 1000
3-11 890 475 1365 1100 1100
11-7 550 200 750 900 900
Total: 2055
Total: 3000
11-29-09
Intake Output

Time Oral Parenterra Others Total Urine Drainage Others Total

l
3-11 800 300 1100 400 400
Total: 1100
Total: 400

11-28-09
Intake Output

Time Oral Parente Others Total Urine Drainag Others Total

rral e
7- 3 830 550 1380 1350 1350
3-11 1030 700 1730 600 600
11-7 700 700 1400 1650 1650

Total: 4510
Total: 3600
11-27-09
Intake Output

Time Oral Parenterra Others Total Urine Drainage Others Total

l
7- 3 1030 600 1630 1630 1630
3-11 600 450 1050 1050 1050
Total: 2680
Total: 2680

11-26-09
Intake Output

Time Oral Parenterra Others Total Urine Drainage Others Total

l
7-3 860 475 1335 600 600
3-11 1250 400 1650 1250 1250
Total: 2985
Total: 1850
11-25-09
Intake Output
Time Oral Parenterra Others Total Urine Drainage Others Total
l
7-3 770 350 1120 500 500
3-11 810 200 1010 800 800
11-7 800 200 1000 1250 1250
Total: 3130
Total: 2550
11-24-09
Intake Output
Time OralParenterral Others Total Urine Drainag Others Total
7-3 715 400 1115 350 e 350
3-11 850 200 1050 1400 1400

Total: 2165
Total: 1750
11-23-09
Intake Output

Time Oral Parenterra Others Total Urine Drainage Others Total

7- 3 1030 l200 1230 300 300
3-11 700 500 1200 600 600
11-7 600 750 1350 700 700
Total: 3780
Total: 1600
 Cranial CT Scan
Plain and contrast-enhanced axial tomographic sections
of the head shows ill defined hypoattenvation in the
both fronto-parietal periventrical and both occipital
periventricular areas.
The ventricles are un enlarged
The midline structures are undisplaced
The sulci and cisterns are prominent
No abnormal extra-axial fluid collection detected
The brain stem, pineal region and posterior fossa
donot appear unusual
The internal carotid basilar and vertebral
arteries are calcified
The sella turcica is not enlarged
Soft tissue attenvation is noted in the right
maxillary sinus
IMPRESSION :
Acute infarcts, both fronto-parietal
periventricular and both occipital
periventricular areas.
Cerebral Atrophy
Atherosclerotic Internal Carotid,
basilar and vertebral arteries
Sinusitis and polyp, right maxillary
sinus
Anatomy of the Brain