INTRODUCTION 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.

LEARNING OBJECTIVES This study aims to help the readers to be able to: Define Cerebrovascular Accident. Discuss and interpret data gathered through theoretical analysis of Nursing History, Gordons 11 Functional Pattern, Physical Assessment and Laboratory Results. Explain the Anatomy and Physiology of Nervous System. Trace 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.

PROFILE Name: Mr. X Birthday: May 20, 1935 Address: Valenzuela City Religion: Roman Catholic Sex: Male Civil Status: Married

PAST PRESENT HISTORY The son of the patient reported that the patient already has diabetes and hypertension during her 40s and has no other sickness other than those.

HISTORY OF PRESENT ILLNESS Prior to admission, patient is having a slurred speech and an elevated blood pressure. According to his son, the patient suddenly fell from his seat and speech became incomprehensive, hand and feet movements became imprecise. Patient was then admitted in Valenzuela Medical Center by his attending physician, Dr. Salvador, at exactly 9:15pm of January 9, 2014. He was admitted with the admitting diagnosis of CVA probable infarct vs. hemorrhage.

GORDONS 11 FUNCTIONAL HEALTH PATTERNS ASSESSMENT Health Perception/Health Management 78 year old Mr. X has a poor general overall health. Ever since he was diagnosed with diabetes and hypertensive, his overall health worsened and he experiences a lot of complications with his condition. His general appearance includes pale, cold clammy skin, dry-chapped lips, weak and a gcs score of 9. Nutritional-Metabolic Before admission, Mr. X usually eats what he wants to eat. He is an avid coffee drinker. The doctor has prescribed a low salt, low cholesterol diet for the patient. During hospitalization, Mr. X has been taking Osteurized feeding via NGT.

Elimination Pattern Patient Mr. X has a regular elimination pattern, and defecates at least once a day. However, his urinary pattern and frequency has decreased. He does not seem to have any excessive perspiration or body odor.

Activity-Exercise Plan Over the years, He has no exercise pattern. His current functional level is 4, which means he is fully dependent for feeding, dressing, grooming, bathing, toileting, and mobility.

Sleep-Rest Pattern Mr. X has a regular sleep pattern and is said to feel well rested after sleep. He does not have sleep onset problems or rest-relax problems.

Cognitive-Perceptual According to relatives, J.E.s health has declined over the years due to complications of his diabetes and being hypertensive. Mr. X is also known to have blurry vision, and according to his son, his memory has declined over the years, and it is hard for him to learn new things.

Self-Perception/Self-Concept Since the patient has an NGT tube and an altered level of consciousness, I was only able to get information from the relatives. I was not able to properly assess Mr. Xs self-perception and self-concept.

Roles and Relationships According to his son, before her father was diagnosed with his illness he was a loving father and responsible to his children. He provides their needs and sees to it that they are comfortable in their way of life. Sexuality-Reproductive Pattern Mr. X is married and has 4 children.

Coping-Stress Tolerance According to his son, When his father is tired or stressed, he sometimes drink alcohol. During his present condition, he is in a stressful state. His family is there to comfort and give his necessary needs just to show their love.

Values-Beliefs According to Mr. Xs son, he usually gets what he wants in life. Anything that Mr. X wants to eat, he usually gets. As for religion, Mr. X is a Roman Catholic. However, because of his condition he is not able to attend mass, so instead his son will just read some bible verses for him.

ANATOMY AND PHYSIOLOGY

THE CENTRAL NERVOUS SYSTEM THE BRAIN

The brain accounts for approximately 2% of the total body weight; in an average young adult, the brain weighs approximately 1400g, whereas in an average elderly person, the brain weighs approximately 1200g. The brain is divided into three major areas: cerebrum, cerebellum and the brain stem. The cerebrum is composed of two hemispheres; the thalamus, the hypothalamus and the basal ganglia. The brain stem includes the midbrain, medulla and pons. The cerebellum is located under cerebrum and behind the brain stem. CEREBRUM The cerebrum of cerebral hemispheres makes up the largest portion of the human brain. Various structures combine forming the cerebral hemispheres, among others, the cortex, basal ganglia, amygdala and hippocampus. The hemispheres together control a large portion of the functions of the human brain such as emotion, memory, perception and motor functions. Apart from this the cerebral hemispheres stand for the cognitive capabilities of the brain. Connecting each of the hemispheres of is the corpus the most callosum as parts well of as the several cerebral

additional commissures. One

important

hemispheres is the cortex, which is made up of gray matter covering the surface of the brain. Functionally the cerebral cortex is involved in planning and carrying out of everyday tasks. DIENCEPHALON The two structures of the diencephalon are the thalamus and the hypothalamus. The thalamus acts primarily as a relay station for all sensation except smell. All memory, sensation and pain impulses pass through this section of the brain. The hypothalamus engages in functions of a number of primitive

emotions or feelings such as hunger, thirst and maternal bonding. This is regulated partly through control of secretion of hormones from the pituitary gland.

Additionally the hypothalamus plays a role in motivation and many other behaviors of the individual.

BRAIN STEM The brain stem consists of the midbrain, the pons and the medulla

oblongata. The midbrain (or mesencephalon) connects the pons and the cerebellum with the cerebral hemispheres; it contains sensory and motor pathways and serves as the center for auditory and visual reflexes. The pons is situated infront of the cerebellum between the midbrain and the medulla and is a bridge between the two halves of the cerebellum and between the medulla and the midbrain. The pons also contains motor and sensory pathways. Portion of the pons help regulate respiration. Motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain are located in the medulla. Most of these fibers cross or decussate at this level. Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing and sneezing are located at the medulla as well. The reticular formation, responsible for arousal and the sleep-wake cycle, begins in the medulla and connects with numerous higher structures. CEREBELLUM The cerebellum lies posterior to the midbrain and pons and below the occipital lobe. The cerebellum integrates sensory information to provide smooth

coordinated movement. It controls fine movement, balance and position (postural) sense or proprioception (awareness of where each part of the body is).

SPINAL CORD From and to the spinal cord are projections of the peripheral nervous system in the form of spinal nerves (sometimes segmental nerves). The nerves connect the spinal cord with skin, joints, muscles etc. and allow for the transmission of efferent motor as well as afferent sensory signals and stimuli. This allows for voluntary and involuntary motions of muscles, as well as the perception of senses. All in all 31 spinal nerves project from the brain stem, some forming plexa as they branch out, such as the; brachial plexa, sacral plexa etc. Each spinal nerve will carry both sensory and motor signals, but the nerves synapse at different regions of the spinal cord, either from the periphery to sensory relay neurons which relay the information to the CNS or from the CNS to motor neurons, which relay the information out. The spinal cord relays information up to the brain through spinal tracts through the "final common pathway" to the thalamus and ultimately to the cortex. Not all information is relayed to the cortex, and does not reach our immediate consciousness, but is instead transmitted only to the thalamus which sorts and adapts accordingly. This in turn may explain why we are not constantly aware of all aspects of our surroundings.

PATHOPHYSIOLOGY ETIOLOGY Subacute Infarct, righ basal ganglia and right perventricular white matter region Lacunar Infarct, left basal ganglia Sclerotic Mastiod, right Deposition of atherosclerotic Plaque in intima of arteries Elastic lamina become thin and frayed Platelet adhere to rough surface Release of adenosine diphosphate enzyme Thrombus form Enlargement of thrombus Occlusion of affected blood vessels Narrowed lumen Break off Emboli RISK FACTOR Age Hypertension Diet (LDL) DIC

Vertebral arteries Dysphagia Numbness Weakness

Vertebrobasilar arteries Vertigo Ataxia Hemiparesis Headache Syncope

Internalcarotid arteries Paralysis Lower facial Sensory loss weakness Numbness

Dysarthria Gait problem

DIAGNOSTIC TEST January 10, 2014

TEST Glucose FBS BUN Creatinine UA Total cholesterol Triglyceride HDL-C LDL V LDL ALT/SGPT Na KCl Chloride

RESULT 6.37 mmol/L 4.68 mmo/L 82.9 umol/L 0.470 mmol/L 4.30 mmol/L 1.15 mmol/L 0.99 mmol/L 2.79 mmol/L 1 mmol/L 22.6 u/L 138.20 mmol/L 4.21 mmol/L 107.20 mmol/L

NORMAL RANGE 3.85-6.40 2.50-6.50 58.0-127.0 0.100-0.400 0.00-5.20 0.40-2.30 0.90-1.56 1.70-4.00

0.0-45.0 135.0-148.00 3.50-5.30 98.00-107.00

January 11, 2011

TEST PT (prothrombin time) % Activity INR APTT

RESULT 13.7 SECS 100.0 % 0.98 53.1 SECS

NORMAL RANGE 11-14 SECS

24-35 SECS

TEST

RESULT

NORMAL RANGE

ANALYSIS

WBC

12.4x103 /mm3

3.5-10

d/t increase pyrogens Normal Normal Normal Normal

RBC Hgb Hct PLT

3.83x106 /mm3 11.4 g/dl 37.0% 188x103/mm3

3.8-5.8 11.0-16.5 35-50 150-390

CRANIAL CT-SCAN Plain and contrast-enhanced axial tomographic sections of the head shows hypoattenvation in the both fronto-parietal periventrical and both occipital periventricular areas. The ventricles are unenlarged 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 do not 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: Cerebral infarcts, both fronto-parietal periventricular and both occipital periventricular areas. Cerebral Atrophy Atherosclerotic Internal Carotid, basilar and vertebral arteries Sinusitis vs polyp, right maxillary sinus

Discharge Plan M- Medication Explain to the client and clients family of how important it is to comply with the medication regimen that the doctor has prescribed and to note the duration of how long to take the doctor prescribed medication and proper administration. E- Exercise/Environment Maintain a quiet and calm environment to promote relaxation and rest. Encourage the client to do deep breathing exercises to promote circulation. Teach the clients family on how to do passive ROM exercises with J.E. T- Treatments Advise the client and clients family to maintain the medication prescribed and to maintain the patients blood pressure at a normal level. H- Health Teaching Teach the client and family about the disease of Intracerebral Hemorrhage and how to prevent it from reoccurring. Instruct the family about a proper diet. O- Outpatient Referral Patient should come back for a follow-up check up if symptoms come back or if any problems or complications occur. Patient should be advised to see a physical, occupational, and speech therapist to help improve function and daily living as well as help the patient with rehabilitation. D- Diet

Low salt, low cholesterol diet and increase oral fluid intake to decrease blood pressure and reduce the risk of getting a stroke. Eat at least 5 servings of fruits and vegetables each day. Include foods that are high in potassium, such as potatoes and bananas. Limit alcohol intake. S- Spiritual Client can be referred to spiritual counseling by a chaplain if necessary.