A.

INTRODUCTION

CVA or STROKE: THINK GLOBALLY, ACT LOCALLY (from the stroke society of
the Philippines). Stroke is a brain attack which needs emergency management,
including specific treatment and secondary and tertiary prevention. An emergency
where virtually no allowances for worsening is tolerated. It is treatable and
preventable in a manner that could be implemented across all levels of society.
According to the World Health Organization, 1 in ten in the 55 million deaths
that occurs every year worldwide is due to stroke and two-thirds of which occur in
people living among developing countries. Strokes are much more common among
older people than among younger adults, usually because the disorders that lead to
strokes progress over time. Over two thirds of all strokes occur in people older than
65. Slightly more than 50% of all strokes occur in men, but more than 60% of
deaths due to stroke occur in women, possibly because women are on average
older when the stroke occurs. (www.who.org)
In the Philippines, stroke remains to be the leading cause of disability,
afflicting 400,000 Filipinos yearly. (Manila Bulletin, 13 September 2008) making it
one of the leading causes of death together with vascular diseases. The former
Health Secretary Alberto G. Romualdez said in a press release that the cost of
treating uncomplicated stroke for 5-7 days ranges from Php 15,000-20,000 making
it not only a burden emotionally but also economically to the family and community.
(www.doh.gov.ph)
But before a stroke occurs, one needs to understand its risk factors so that
the medical intervention is administered early and aggressively. The non-modifiable
risk factors include age, sex, family history, race, and ethnicity – factors that we
cannot control. However there are modifiable risk factors for stroke which when
eliminated or controlled reduce the risk of stroke significantly. These are
hypertension, cardiac diseases (particularly atrial fibrillation), diabetes,
hyperlipidemia or elevated cholesterol, cigarette smoking, alcohol abuse, physical
inactivity, asymptomatic carotid stenosis, and transient ischemic attack.
There is a growing concern because of lifestyle and diet of Asians, particularly
Filipinos, cholesterol levels are rising, resulting in an increased risk for stroke (brain
attack). In addition to be a leading cause of heart attacks, high cholesterol is
emerging as a major risk factor that is known as ischemic stroke. In this type of

1
stroke, the blood supply to the part of the brain is cut off because either
atherosclerosis or a blood clot has blocked the vessel.

B. OBJECTIVES

General:

The main aim of this study is to present all the accumulated information about a patient
diagnosed with Cerebrovascular Accident Bleed, Hypertensive Cardiovascular Disease,
Coronary Artery Disease, Left Ventricular Hypertrophy, Myocardial Infarction, Community
Acquired Pneumonia Moderate Risk while at the same time improving our knowledge and skills
pertaining to caring of patients with this kind of disease.

Specific:

More particularly our case study aims to:

1. Determine the incidence of CVA Bleed, HCVD, CAD, LVH, MI, CAP MR
in global, national and local setting.

2. Present an inclusive assessment of the client involving biographical data,

chief complaint upon admission, past and present medical history; personal,
family, and socio-economic status as an apparent substantiation to the
condition.

3. Conduct review of systems through detailed and comprehensive physical

assessment.

4. Determine the significant diagnostic and laboratory examinations,

comparing abnormal results from normal values with its corresponding
interpretation in relation to the current status of the client.

5. Discuss the review of anatomy and physiology of the heart and brain in a
comprehensive and detailed manner.
2
6. Determine the presenting actual symptoms manifested by the client
based on the condition through its symptomatology.

7. Present the etiology of the disease process through the given

precipitating and predisposing factors.

8. Discuss the pathophysiology of CVA Bleed, HCVD, CAD, LVH, MI, CAP
MR, its symptomatology, complications and prognosis of the client.

9. Identify three (3) priority health needs and/or problems of the client and
be able to formulate nursing plans as frameworks of care.

10. Enumerate the pharmacological management of the said disease and its
nursing considerations.

11. Present the syntheses of client’s condition in the ward from the day of
admission until the student nurse’s assessment.

12. Discuss the appropriate discharge plan to the patient with CVA Bleed.

13. Evaluate all of the accumulated information about our client’s condition
duly diagnosed with CVA Bleed, HCVD, CAD, LVH, MI, CAP MR from his
past medical history, days of confinement to the day he was discharged in the
hospital.

3
C. ASSESSMENT

A. Biographic Data

Name: Efficascent

Birthday: July 23, 2009

Birthplace: Davao

Age: 68y/o

Sex: Female

Address: Prk. 14, Poblacion Nabunturan, C/P

Nationality: Filipino

Date/Time of Admission: December 7, 2009 – 8:00AM

Attending Physician: Dr. Llanos

B. Chief Complaint

Admitted due to cough and right sided weakness.

Vital signs:
Height: 5 feet 1 inch Weight: 50 kls BP – 180/120
Cardiac rate: 92 bpm RR – 24cpm T – 37.4

C. History of Present Illness

4
 Efficascent was admitted last December 7, 2009 in due to cough and right
sided weakness. She was diagnosed with LRTI CV. During that day, she had
undergone CT scan where findings suggest of Acute Intracerebral Hemorrhage
with mild vasogenic edema and mild mass effect, Left Capsulo-ganglionic
regions, Lacunar infarct, left caudate nucleus, Moderate Microvascular Disease
and Consider arachnoid cyst, left parietal convexity. Prior to admission, she had
onset of cough, non-productive. She is positive of slurring of speech, right sided
weakness with nasolabial swallowing. She has history of hypertension and
cardiovascular diseases, has no history of diabetes mellitus and is a tobacco
smoker but a non-alcoholic drinker.

D. Past Medical History

Efficascent had her first hospitalization way back 1982 wherein she had
undergone an operation of hysterectomy at Brokenshire hospital.
Second hospitalization was on 1995. This was due to nervous breakdown
because of the death of her husband. Four months later of the same year, she
was brought to Davao Mental Hospital for psychiatric consultation. It was found
out that she has severe depression. Medications given were Haloperidol and
other vitamin supplements.
Third hospitalization was way back year 2003 as an out-patient. This was
due to vaccination of anti-tetanus because she was accidentally punctured with
a nail. Efficascent was known hypertensive and maintaining a metoprolol and
aspirin with good compliance.

E. Personal, Family History

Efficascent belongs to an extended family. She was the fourth child

among 9 siblings and was not the only one affected by the said disease but most
of them. Her father and mother have history of hypertension and cardiovascular
disease. Her father died due to cardiac arrest and most of her siblings died in the

5
 same manner and her 2 other siblings were suffering from paralyzed. She was
fun of tobacco smoking and most of her diet is high in cholesterol. According to
her daughter, Efficascent got easily depressed and nervous in handling
problems.

F. Socio-Economic Factor

Efficascent belongs to low class family. He used to have a simple and

typical way of living. She finished her study until high school. Presently, she was
a plain housewife and got support from the pension of her deceased husband
about P7, 000/month who was a retired teacher. Support was given also by her
children.

G. DEVELOPMENTAL TASK

6
 Psychosocial Positive Developmental
Central Task Ego Quality Definition
Crisis Outcome Task

Infancy Trust Receiving care Trust in Hope Enduring belief Social

vs. people and that one can attachment;
Birth-18 Mistrust the attain one’s deep
Months environment and essential Maturation of
wishes sensory,
perceptual, and
motor functions;

Primitive
causality

Younger Autonomy Imitation Pride in self; Will Determination to Locomotion;

Years vs. exercise free
Shame & Assertion of choice and self- Fantasy play;
18 Months-3 doubt will in the control
Years face of Language
danger development;

Self-control

Early Initiative Identification Able to Purpose Courage to Sex-role

Childhood vs. initiate imagine and identification;
Guilt activities and pursue valued
3-6 Years enjoy learning goals Early moral
development;

Self-esteem;

Group play;

Egocentrism

Middle Industry Education Acquire skills Competence Free exercise of Friendship;

Childhood vs. for and skill and
Inferiority develop intelligence in Skill learning;
6-12 Years competence completion of
in work; tasks Self-evaluation;

Enjoy Team play

achievement

Early Group Identity Peer group A strong Loyalty Ability to freely Physical
Adolescence vs. group pledge and maturation;
Alienation identity; sustain loyalty to
12-18 Years others Emotional
Ready to plan 7
development;
for the future
Membership in
peer group;
Wisdom: Ego Integrity vs. Despair (Seniors, 65 years onwards)

• Psychosocial Crisis: Ego Integrity vs. Despair

• Main Question: "Have I lived a full life?"
• Virtue: Wisdom

As we grow older and become senior citizens we tend to slow down our productivity
and explore life as a retired person. It is during this time that we contemplate our
accomplishments and are able to develop integrity if we see ourselves as leading a
successful life. If we see our life as unproductive, or feel that we did not accomplish our
life goals, we become dissatisfied with life and develop despair, often leading to
depression and hopelessness.

The final developmental task is retrospection: people look back on their lives and
accomplishments. They develop feelings of contentment and integrity if they believe that
they have led a happy, productive life. They may instead develop a sense of despair if
they look back on a life of disappointments and unachieved goals.

Value of the theory

One value of this theory is that it illuminated why individuals who had been
thwarted in the healthy resolution of early phases (such as in learning healthy levels of
trust and autonomy in toddlerhood) had such difficulty with the crises that came in
adulthood. More importantly, it did so in a way that provided answers for practical
application. It raised new potential for therapists and their patients to identify key issues
and skills that required addressing. But at the same time, it yielded a guide or yardstick
that could be used to assess teaching and child rearing practices in terms of their ability
to nurture and facilitate healthy emotional and cognitive development.

"Every adult, whether he is a follower or a leader, a member of a mass or of an

elite, was once a child. He was once small. A sense of smallness forms a substratum in
his mind, ineradicably. His triumphs will be measured against this smallness, his defeats
8
will substantiate it. The questions as to who is bigger and who can do or not do this or
that, and to whom—these questions fill the adult's inner life far beyond the necessities
and the desirabilities which he understands and for which he plans." - Erik H. Erikson
(1902–1994), U.S. psychoanalyst. Childhood and Society, ch. 11 (1950).

D. PATIENT NEED ASSESSMENT

Date: December 9, 2009

Name: Efficascent Age: 68 y.o. Sex: Female Status: Widow

Admission Date and Time: 12/07/09 - 8:00 aM

Admitting Medical Diagnosis: CVA, LRTI

Arrived on unit by: stretcher From: Emergency Room

Accompanied by: Children

Admitting weight:_50_kg*VS:BP- 180/120mmHg; PR-92bpm; RR- 24 cpm; T- 37.4ºC______

Client’s Perception of Reason for Admission: “ningkalit ra man to…gi-atake man gud sya sa
iyang highblood”

How was the problem been managed at home? “naa man sya’y ginatake na tambal pang.high
blood”

9
Allergies: No known allergies__________________________________________________

Medication (at home): Amlodipine, Captopril

PHYSIOLOGIC NEED

I. Oxygenation

*BP: 170/110mmHG*PR/CR: 94 BPM *RR: 24 CPM (Character) Tachypneic,

hypertensive

*Lungs (per auscultation: character, lung sound; symmetry of chest expansion; breathing
character and pattern) Use of accessory muscles noted upon breathing, with symmetrical__
chest expansion and use of intercostal retraction noted;crackles sound heard per auscultation
on both lung fields

*Cardiac status (per auscultation  sounds, character, chest pain?: Murmur sound heard per
auscultation, chest pain not noted, fast heart beat noted

*Capillary Refill: Blanch test performed, pail nail beds returned within 3 seconds ________

*Skin character and color: with fair complexion, dry and not warm to touch ___

*Life-supporting Apparatus: IVF of PNSS 1L @140cc/ º - left cephalic vein ___

*Other observations related: patient experienced deep and quick breaths ___

II. Temperature Maintenance

*Temperature: 37.2 ºC

*Skin character: with dry, wrinkled, cold and clammy skin

*Other observations related: not noted

III. Nutritional Fluids

10
*Height/Weight:5’1/50 klsAmount of food consumed: with good appetite; able to consumed the
diet served

*Prescribed diet:Low salt low fat; OF 1.8/3 Problem (nausea, vomiting, no. of times, frequency,
amount, character): not noted *Eating Pattern: Thrice a day

*Skin character: with dry skin but with fair skin turgor

*Intake (IVF; Fluid/Water): IVF  350cc; H20  200 cc; _____

IV. Elimination

*Last Bowel Movement (Frequency, Amount, Character): Defecated last December 9, 2009, on
moderate amount, soft, yellowish stool as described by the daughter of the patient_____

*Normal Pattern: once a day __

*Urination ( Frequency, Amount, Character, Sensation) December 9, 2009 - With foley catheter
to urobag, draining a yellowish urine about 550 cc within the shift

*Other observations related: Distended abdomen noted per palpation

V. Rest- Sleep

*Bedtime: 10- 11PM(with some alterations) Waking up: 4:00-6:00AM_

*Sleep (Pattern, Amount of Sleep): 6 – 7 hours

*Problems (as verbalized): “Maglisod jud og tulog ni akong mama kay gnabantayan man gud
niya nang mga nars na nagahatag sa iyag tambal, mahadlok man gud siyag nakaputi

*Other Observations related: Dark circles under eyes and frequent yawning noted

VI. Pain Avoidance

*Rate Pain: not noted Time started: not noted

11
*Bedtime: 10- 11PM(with some alterations) Location: not noted

*Frequency: not noted Behavior (Restless, Facial expression,

*Character: not noted Irritable, Diaphoretic: not noted

*Other observations related: not noted

VII. Sexuality-Reproductive

*LMP: N/A AOG: N/A

*Gravida/Parity: N/A Prenatal: N/A

*Menstrual Cycle: N/A Gynecologic Problems: N/A

*EDC: N/A

*Family Planning Method Used: N/A

*Children: 10

VIII. Stimulation-Activity

*Work: Patient is a plain housewife. During hospitalization, she

can’t able to sit, can’t be able to feed herself, can’t able to

*Recreation / Pastime: perform ADL without the assistance from the children, she

*Hobbies / Vices: was totally on complete bed rest. Patient has history of tobacco

smoking

SAFETY – SECURITY NEED

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*Neuro V/S: GCS of 10/15, eye opening – per stimulation, motor response - difficulty of
performing gross motor & some fine motor activities, verbal response – makes
incomprehensible sounds, slurred speech noted

*Mental Status (Coherent, Responsive, Conscious, Unconscious): Patient is conscious, makes

incomprehensible sounds when responded, right sided weakness noted.

*Emotional Problem (Diaphoretic, Trembling, Restless): Patient got easily nervous and depress
in handling big problems especially in terms of financial matters;

LOVE-BELONGING NEED

*Children (Living with) Client is presently living with her children. She has 9 siblings.

*Husband (Living with) She is being loved by her children, due respect was given to her and
all efforts for her hospitalization was given

SELF-ESTEEM NEED

* I observed that patient has developed low self esteem since according to her daughter, patient
is not cooperative in terms of her hospitalization. She got easily depress when problems and
challenges came and poor coping mechanism are then evidently present Restlessness and
nervousness noted during the interview; although she was cooperative, nervousness still noted.

SELF-ACTUALIZATION

* I can assess that patient is not that a self-actualized person because although she was well
provided with basic needs such as food, clothing, shelter and proper education, poor coping
mechanism is still evident in handling problems and fears on hospitalization. Some of her
children are professional and some are not.

13
Date of Assessment: December 9, 2009

A. General Survey
On bed, awake, on moderate high back rest, and responsive – slurred speech
noted. With isocoric pupil of 2mm in diameter, less briskly reactive to light and
accommodation. (+)nasolabial swallowing. With NGT attached to right nostril, patent
and intact, with distal end close. Dry lips noted. Breathing through the mouth, with
crackle sound heard per auscultation on both lung fields. With symmetrical chest
expansion; (+) use of accessory muscle; (+) substernal retraction. Productive cough
noted; able to expectorate a scanty amount of yellowish phlegm, about 5 cc. With flaky,
wrinkled and dry skin. With ongoing IVF of # 3 PNSS 1 L @ 140 cc/hr at 700 cc level
infusing well at left cephalic vein, infiltrations not noted. Distended abdomen noted. With
foley catheter intact and attached to urobag, draining a yellowish urine at 550 cc level.
With diaper clean, dry and intact. Non-edematous lower extremeties noted. Slurred
speech and hemiplegia on right side noted. Glasgow coma scale of 10/15. Eye opening

14
– to verbal command (3), motor response – to localized pain (5) and verbal response –
makes incomprehensible sounds (2).

B. Vital Signs
DATE/TIME TEMP. BP PR RR I&O
12-7-09 H2O-150cc u-c diaper

12:00 36.7 160/90 80 20 IVF-90cc s-0

OF-210cc
4:00 38 160/100 86 24
8:00 37.2 130/80 84 20
12-08-09
36.5 130/80 93 20
12:00
4:00 36.2 130/90 90 20 H20-50cc u-500cc

IVF-120cc s- 0

OF-600cc
8:00 37.2 170/110 87 20
12:00 37 160/90 92 20 H2O-50cc u-1000cc

IVF-400cc s-0

OF-600cc
4:00 37.9 170/110 95 23
8:00 38.5 220/110 93 21 H20-60cc u-1150cc

IVF-110cc s- 0

Mannitol-100cc
12-09-09
37 140/90 90 20
12:00
4:00 36.5 140/90 88 20 H2O-50cc u-500cc

IVF-150cc s-0

OF-400cc

Mannitol-200cc
8:00 37.9 160/100 98 25
12:00 37.4 160/100 96 23 H2O-60cc u-750cc

IVF-510cc s-0

15
C. Nutritional Status
Efficascent has a small body built, stands 5’1” and weighs 50 kilos.
On osteorized feeding of 1,800 kcal divided into 3 feedings.. With ongoing IVF of #3
PNSS 1 liter @ 140cc/ hr. With flaky, wrinkled and dry skin With fair skin turgor.
Able to consumed the diet served. Without food allergies and is able to eat different
kinds of food. Denies malnutrition during childhood.

D. Neurologic Status
Glasgow coma scale of 10/15. Eye opening – to verbal command (3), motor
response – to localized pain (5) and verbal response – makes incomprehensible
sounds (2). Slurred speech and hemiplegia on right side noted. Change in
coordination noted. Reduced of speed fine finger movements. She knew that she
admitted and in the hospital according to her daughter. Language and vocabulary
suitable to educational level. CT scan findings suggest of Acute Intracerebral
Hemorrhage with mild vasogenic edema and mild mass effect, Left Capsulo-
ganglionic regions, Lacunar infarct, left caudate nucleus, Moderate Microvascular
Disease and Consider arachnoid cyst, left parietal convexity.

E. Integumentary System
Skin is fairly complexion and dry to touch. Skin hair is not prominent. The skin
appears thin and translucent. Flat to tan macules or senile lentigines appeared on
most exposed body parts such as face, neck, hands and legs. Hair is grayish in
color, straight, tangled, long and evenly distributed. No evidence of hair application.
Presence of parasites not noted. Fingernails and toenails untrimmed and appear
thick.

F. HEEN

16
 Head. Symmetrically rounded, neck non tender, lymph nodes non-palpable. No
deviation of the trachea. Carotid pulse at both sides equally slightly strong. Able to
identify light and deep touch to various parts of the face.
Eyes. Sunken eyeballs noted. The skin around the orbit of the eye is darken. Skin
folds of the upper lids is prominent and sag lower lids noted. Decrease visual acuity
noted. Eyebrows appear bristle –like and coarse. Sclera is white without lesions.
With isocoric pupil of 2mm in diameter less briskly reactive to light and
accommodation.
Ears. The skin appears dry and less resilient. Equal size and similar appearance
noted. Dry earwax noted. Earlobe is elongated and pinna is increased in both width
and length.
Nose. Symmetrical and straight, uniform in color without discharges, not tender and
without lesions. Frontal and maxillary sinuses non-tender with poor olfactory sense,
sense of smell markedly diminish; unable to identify different scents. With NGT
attached to right nostril, patent and intact, with distal end close.
G. Pulmonary System
Respiratory rate is above normal range – 24 cpm. Nasal flaring noted. Shallow
and fast breathing noted. The use of accessory muscles can be observed during
expiration, crackles sound heard per auscultation. With substernal retraction noted.
Breathing rate and rhythm are unchanged at rest. Productive cough: able to expectorate
a scanty amount of yellowish phlegm, about 5 cc.

H. Cardiovascular System
Cardiac rate plays around 80-95 bpm, above and within normal range. “ Lub-dub”
with a gallop-like sound heard per auscultation on apical area. Strong and fast
pulsations noted per palpation. Blood pressure changes, ranging from 130/90 –
170/100, within and above normal range. Clubbing of fingers not noted.

I. Gastrointestinal System
Distended abdomen noted. Abdominal wall is slack and thinner upon palpation.
Skin is dry and wrinkled without varying amounts of hair. Discoloration, stride, rashes,

17
 lesions and dilated veins not noted. Everted unclean navel noted. During auscultation,
gurgling noises noted. Doesn’t able to defecate for 2 days since she was admitted.

J. Musculoskeletal System
Muscle mass decreased. Unable to perform activities of daily living, thus, needs
assistance from watcher. Decrease in speed, strength, resistance to fatigue and
reaction time and coordination noted. Hemiplegia noted on right side of the body.

K. Genito-Urinary System
Labia are atrophied and flatter. No bulging or masses on inguinal area.
Claimed menopausal period at the age of 41 y/o . Prominent hair observed in mons
pubic area. Unable throughout the 8 hour shift. Denies history of hemorrhoids.

F. COURSE IN THE WARD

DATE &
NURSES NOTES DOCTORS ORDER RATIONALE
SHIFT

12-07-09 D- Admitted this 68y.o. @8:00am LSLF diet-Low Salt

female, in due to cough and Low Fat diet in order to
8am right sided weakness. BP -Please admit prevent further
160/80
-LSLF complications brought
8:10am A- CBC, ECG 12L, FBS, by sodium and fat.
serum crea, serum uric acid- - IV: PNSS IL KVO
request forwarded, CXR-PA - Labs:
done, UA request attached, CBC, FBS, SUA
cranial CT scan given to CBC- help
watcher for approval S. Crea determine their
8:15am general health
Lipid Profile status. If they are
8:15am A- Captopril 50mg 1tab SL healthy and they
given ECG,CT Scan Cranial, have cell
CXR PA, UA populations that
8:30am A- Venoclysis of PNSS 1L are within normal
regulated @ KVO rate - Meds:
Citicholine 1gm IVTT q8 limits, then they
may not require
A- Transported to room,
8:35am Cefuroxime 750 mg another CBC until
endorsed to NOD
IVTT q8 ANST ( ) their health status
18
 R- BP-140/80, cranial CT changes or until
scan still for approval. Captopril 50mg now, their doctor feels
then q6 PRN BP > that it is
ADDENDUM to care 160/100 necessary.
>Seen and examined by Dr
Llanos Losartan + HCTZ
50/12.5 1 tab OD
FBS- is ordered in
>Inserted NGT and closed
distal end -VS q4 order to determine the
-I&O q4 serum glucose level of
>CXR-PA and cranial CT -Inform AP the patient.
scan done. -Refer

-Pls insert NGT

-Cranial CT Scan Plain SUA- done to
-Give oral meds/NGT measure the levels of
-Star OF 1,800 kcal/day
uric acid in blood
in three divided feedings
-Paracetamol 500mg 1 serum or in urine
tab q4 PRN

5:05pm
-IVF TF c PNSS 1L @ S. Creatinine- is
SR ordered to determine
whether the kidneys/
10:20pm renal system of the
-Start Mannitol 100 cc patient are functioning
q6 well.
-Amlodipine 5g OD/NGT
-Insert Foley catheter
-I & O q shift
Lipid Profile- to
determine whether high
or low concentration of
a specific lipid is
present

ECG- To detect heart

problems or
blockages in the
coronary arteries. To
draw a graph of the
electrical impulses
moving through the
heart. To record
heart rate and the
regularity of
heartbeats. To

19
diagnose a possible
heart attack or other
heart disorders.

Cranial CT Scan- A
cranial computed
tomography (CT) scan
is an imaging method
that uses x-rays to
create cross-sectional
pictures of the head,
including the skull,
brain, eye sockets, and
sinuses.

CXR PA- makes

images of the heart,
lungs, airways,
blood vessels and
the bones of the
spine and chest.

UA- urinalysis is a
microscopic
examination of the
urine that detects red
blood cells, WBC &
bacteria in urine.

PNSS- isotonic solution

to compensate for
blood loss or any fluid
deficits.

Vital signs are the

basis for the general
20
 physiologic function of
an individual.

Citicholine- a CNS
stimulant

Mannitol- an osmotic
diuretic

Cefuroxime- an
antibiotic for the client’s
cough for she was been
also diagnosed with CAP

12-08-09 D- Received from ER per @11am

7am stretcher upon admission
awake, with IVF #1 -Refer to PT
PNSS 1L @ KVO rate -Continue meds
with NGT distal end
closed. CT scan and
CXR-done as ordered.
CBC taken, lipoid profile,
ECG, serum creatinine,
Serum uric acid
forwarded as endorsed.
Still for U/A
A- Placed on bed
comfortably, provided
with SB
D- On OF 1,800 KCAL/day
in 3 divided feeding
R- OF and meds per NGT
given

12-08-09 S-“Huyang gayud kayo siya 5:45pm Nicardipine- for

3pm kinahanglan alalayan”-as
verbalized by watcher.
O- Unable to raise or move
both right upper and lower
extremities, difficulty in
turning, requires assistant
_________ of speech
noted, with #1 PNSS 1L
@ KVO rate, with NGT @
right nostril closed at distal
end, patent and intact
A- Impaired physical mobility
related to decreased
-IVF TF PNSS 1L @ SR hypertension; a calcium
channel blocker
8:18 pm
-Start Nicardipine drip:
Nicarl 10 g + 90 cc
D5W to run @ 10
mgtts/min, titrate by 5
mgtts/min until BP-
140/90
8:40 pm
-D/C temporarily
nicardipine drip and
21
 muscle strength resume once BP is
elevated
P- After 6 hours of care, will
at least turn to side
independently

I- >Determined degree of
immobility or weakness
to assess function
mobility,
>Assisted in repositioning
to prevent and relieved
pressure
>placed on moderate
high back rest to
enhance circulation
>provided ROM activities
to maintain joint mobility,
regain motor control,
prevent further
deterioration.
>provided skin care to
include pressure area
management
>provided safety
measures such as
placing pillow on both
sides of back and
instructed watcher not to
leave patient unattended.

6pm >NGT checked, patent:

PRN paracetamol given
per NGT
E- After 6 hours of
nursing care, goal unmet as
evidenced by:

10pm- still needs

assistance in turning to
sides.

22
12-09-09 D-Received on bed awake
and responsive with IVF #2
73 PNSS 1L at KVO infusing
well. With NGT, with Foley
catheter attached to urobag
A- Provided with lab request.
Needs attented to.
Medicated. VS checked
and recorded.
D- Seen and examined by
Dr Llanos with orders
made and carried out
A- Increase IVF rate to
140cc/hr
R- On bed resting with IVF
on. Endorsed to NOD.
↑ IVF rate to 140 Captopril- ordered for
cc/hour hypertension
-Start Cefuxime 1.5 g IV
q 8hours (ANST) Losartan + HCTZ-
ordered for
-Captopril 20g TID/NGT
hypertension
-Losartan 500g 1 tab
OD/NGT
-Paracetamol 500mg 1
tab q4 / NGT RTC x 4
23
G. LABORATORIES AND DIAGNOSTIC EXAMINATIONS

HEMATOLOGY

NORMAL
TESTS RESULTS INTERPRETATION ANALYSIS
VALUES

Hemoglobin 147 g/L M: 140-160 Normal

Mass
Concentration F: 120-140

Hematocrit 0.44 0.36-0.48 Normal

Leukocytes No. 15.06 x 10 5.0-10.0 Increase Increased due to

Concentration g/L Pneumonia.
x 10^3/uL Leukocytes will
normally increase
to fight against
infection.

Lymphocytes 0.06 0.24-0.40 Decrease Decrease due to

infection.

24
 Eosinophils 0.04 0.01-0.05 Normal

Basophils 0.01 0-1 Normal

Monocytes 0.02 0.02-0.06 Normal

Thrombocytes 246.6 150-400 Normal

x 10^3/uL

Segmenters 0.90 0.40-0.60 Increase

Exam: URINALYSIS

Color: Yellow Epithelial Cells: Few

Sugar: Negative Pus Cells: 1-2/HPF

Albumin: TRACE M. threads: FEW

Platelet: 6.0 RBC: 2-4 HPF

Specific Gravity: 1.015

BLOOD CHEMISTRY

Test Result Unit Reference Range

FBS 5.51 mmo/l mmol/L 4.56-6.38 mmol/L

Creatinine 74.26 umol/L 45-84 umol/L

Uric acid 376 mmo/L mmo/L

140 340 mmo/L

Total Cholesterol 142 mg/dL mg/dL 150- 200 mg/dL

Triglycerides 110 mg/dL mg/dL 325 mg/dL

25
 HDL 37 mg/dL mg/dL 48-65 mg/dL

LDL 83 mg/dL 66 -178 mg/dL

X-RAY REPORT DATE: 12/07/09

Clinical diagnosis: Cough EXAMINED: CHEST PA (X-Ray)

Refered By: Llanos Department: In-patient

FINDINGS

Chest supine: Heart size cannot be properly evaluated due to the supine position and left
obliquity. Both lung fields are clear. An atherosclerotic aorta is noted.

CT-SCAN REPORT DATE: 12/07/09

CLINICAL DIAGNOSIS: CVA EXAMINED: CRANIAL ( CT-SCAN)

Refered By: Llanos Department: In-patient

CT-SCAN of the Brain

Multiple contiguous axial images of the brain were obtained. No intravenous contrast
was given. There is an intraaxial hyperdense collection in the left capsulo-ganglionic regions,
measuring 3.2 x 2.3 cm ( approximate volume : 12.1 cc) with minimal vasogenic edema.There is
mild compression of the left lateral ventricle. Small fairly-defined hypodensity is seen in the left
caudate nucleus. Periventricular and subcortical hypodensities are also appreciated. There is a
CSF- filled focus in the left parietal convexity, measuring 3.2 x 1.6 cm (APxW).bothe temporal
26
lobes are slightly prominent. Small calcific density is seen in the posterior falx cerebri. There is
no midline shift.

The cistems, sella and CP angles are normal for the patient’s stated age. The visualized
paranasal sinuses and mastoid air cells are pneumatized. The visualized cranium is intact.

Calcific densities are seen along the walls of the supraclinoid segment of both ICA and both
vertebral arteries.

IMPRESSION:

Acute intracerebral hemorrhage with mild vasogenic edema and mild mass effect, left
capsulogenic regions.

Lacunar infarct, left caudate nucleus.

Moderate microvascular disease. Consider arachnoid cyst, left parietal convexity.

CT-SCAN REPORT DATE: 12/07/09

CLINICAL DIAGNOSIS: CVA EXAMINED: CRANIAL ( CT-SCAN)

Refered By: Llanos Department: In-patient

Mild temporal lobe atrophy.

Posterior falx cerebri calcification.

Atherosclerotic disease, supraclinoid segment of both ICA and both vertebral arteries.

27
H. ANATOMY AND PHYSIOLOGY

Basic Anatomy and Physiology of the

Human Brain

This chapter contains some basic background on the anatomy and physiology of the human
brain relevant to this project. The final section focuses on the neonatal brain and some common
pathologies.

28
Figure 2–4 Cerebrospinal Fluid. (Reproduced from [Marieb 1991]).

Cerebrospinal fluid
Cerebrospinal fluid (CSF) is a watery liquid similar in composition to blood plasma. It is formed
in the choroid plexuses and circulates through the ventricles into the subarachnoid space,
where it is returned to the dural venous sinuses by the arachnoid villi. The prime purpose of the
CSF is to support and cushion the brain and help nourish it. Figure 2–4 illustrates the flow of
CSF through the central nervous system.

Major regions of the brain and their functions

29
The major regions of the brain (Figure 2–5) are the cerebral hemispheres, diencephalon,
brain stem and cerebellum.

Figure 2–5 Major Regions of the Brain. (Reproduced from [Marieb 1991]).

Cerebral hemispheres

The cerebral hemispheres (Figure 2–6), located on the most superior part of the brain, are
separated by the longitudinal fissure. They make up approximately 83% of total brain mass, and
are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4 mm thick grey
matter surface layer and, because of its many convolutions, accounts for about 40% of total
brain mass. It is responsible for conscious behaviour and contains three different functional
areas: the motor areas, sensory areas and association areas. Located internally are the white
matter, responsible for communication between cerebral areas and between the cerebral cortex
and lower regions of the CNS, as well as the basal nuclei (or
basal ganglia), involved in controlling muscular movement.
30
Cerebral Cortex

Ventral View ( From bottom)

The outermost layer of the cerebral hemisphere which is composed of gray matter.
Cortices are asymmetrical. Both hemispheres are able to analyze sensory data, perform
memory functions, learn new information, form thoughts and make decisions. Left
Hemisphere Sequential Analysis: systematic, logical interpretation of information.
Interpretation and production of symbolic information:language, mathematics,
abstraction and reasoning. Memory stored in a language format. Right Hemisphere
Holistic Functioning: processing multi-sensory input simultaneously to provide "holistic"
picture of one's environment. Visual spatial skills. Holistic functions such as dancing and
gymnastics are coordinated by the right hemisphere. Memory is stored in auditory,
visual and spatial modalities.
Diencephalon

The diencephalon is located centrally within the forebrain. It consists of the thalamus,
hypothalamus and epithalamus, which together enclose the third ventricle. The
thalamus acts as a grouping and relay station for sensory inputs ascending to the
sensory cortex and association areas. It also mediates motor activities, cortical arousal
and memories. The hypothalamus, by controlling the autonomic (involuntary) nervous
system, is responsible for maintaining the body’s homeostatic balance. Moreover it
forms a part of the limbic system, the ‘emotional’ brain. The epithalamus consists of the
pineal gland and the CSF-producing choroid plexus.

31
Figure 2–6 Major Regions of the cerebral hemispheres. (Reproduced from [Marieb 1991]).

Brain stem

The brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded by
white matter fibre tracts. Its major regions are the midbrain, pons and medulla oblongata. The
midbrain, which surrounds the cerebral aqueduct, provides fibre pathways between higher and
lower brain centres, contains visual and auditory reflex and subcortical motor centres. The pons
is mainly a conduction region, but its nuclei also contribute to the regulation of respiration and
cranial nerves. The medulla oblongata takes an important role as an autonomic reflex centre
involved in maintaining body homeostasis. In particular, nuclei in the medulla regulate
respiratory rhythm, heart rate, blood pressure and several cranial nerves. Moreover, it provides
conduction pathways between the inferior spinal cord and higher brain centres.

32
Cerebellum

The cerebellum, which is located dorsal to the pons and medulla, accounts for about 11% of
total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal white
matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum
processes impulses received from the cerebral motor cortex, various brain stem nuclei and
sensory receptors in order to appropriately control skeletal muscle contraction, thus giving
smooth, coordinated movements.

The cerebral circulatory system

Blood is transported through the body via a continuous system of blood vessels. Arteries carry
oxygenated blood away from the heart into capillaries supplying tissue cells. Veins collect the
blood from the capillary bed and carry it back to the heart. The main purpose of blood flow
through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange
gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys.
All the circulation besides the heart and the pulmonary circulation is called the systemic
circulation. Since it is the ultimate aim of this research project to image cerebral oxygenation
and haemodynamics some aspects of the cerebral circulatory system are described below.

33
Figure 2–7 Major cerebral arteries and the circle of Willis. (Reproduced
from [Marieb 1991]).

Blood supply to the brain

Figure 2–7 shows an overview of the arterial system supplying the brain. The major arteries are
the vertebral and internal carotid arteries. The two posterior and single anterior communicating
arteries form the circle of Willis, which equalises blood pressures in the brain’s anterior and
posterior regions, and protects the brain from damage should one of the arteries become
occluded. However, there is little communication between smaller arteries on the brain’s
surface. Hence occlusion of these arteries usually results in localised tissue damage.

I. SYMPTOMATOLOGY

CLINICAL MANIFESTATIONS PRESENT IN THE PATIENT RATIONALE

 Difficulty speaking
understanding
speech(aphasia)
 Difficulty walking
 Dizziness (Vertigo)
 Numbness or paralysis or
weakness on one side of
the body(HEMIPLEGIA;
right side of the body)
 Severe headache
or  Possibly the cerebral cortex is
affected which is a part of the
brain where language ,awareness
and others were regulated.
 Because part of the brain is
affected particularly the basal
ganglia where all motor control
and activities were also
regulated.

34
  Sudden confusion
 Sudden loss of balance or
coordination.
 Sudden Vision
problems(blurry,
blindness of one eye).
 Vomiting
 Productive cough  This was due to her Pneumonia
which is a common symptom
where there is infection of lung
paranchyma and causes
production of mucus secretions.
 Difficulty swallowing  Hypoglossal nerve(Cranial nerve
XII) is affected which is
responsible for speaking,
chewing and swallowing.

J. ETIOLOGY

Intracerebral hemorrhage usually results from rupture of an arteriosclerotic small

artery that has been weakened, primarily by chronic arterial hypertension. Such
hemorrhages are usually large, single, and catastrophic. Use of cocaine or,
occasionally, other sympathomimetic drugs can cause transient severe hypertension
leading to hemorrhage. Less often, intracerebral hemorrhage results from congenital
aneurysm, arteriovenous or other vascular malformation , trauma, mycotic aneurysm,
brain infarct (hemorrhagic infarction), primary or metastatic brain tumor, excessive
anticoagulation, blood dyscrasia, or a bleeding or vasculitic disorder.

Lobar intracerebral hemorrhages (hematomas in the cerebral lobes, outside the

basal ganglia) usually result from angiopathy due to amyloid deposition in cerebral

35
arteries (cerebral amyloid angiopathy), which affects primarily the elderly. Lobar
hemorrhages may be multiple and recurrent.

Blood from an intracerebral hemorrhage accumulates as a mass that can dissect

through and compress adjacent brain tissues, causing neuronal dysfunction. Large
hematomas increase intracranial pressure. Pressure from supratentorial hematomas
and the accompanying edema may cause transtentorial brain herniation, compressing
the brain stem and often causing secondary hemorrhages in the midbrain and pons If
the hemorrhage ruptures into the ventricular system (intraventricular hemorrhage),
blood may cause acute hydrocephalus. Cerebellar hematomas can expand to block the
4th ventricle, also causing acute hydrocephalus, or they can dissect into the brain stem.
Cerebellar hematomas that are > 3 cm in diameter may cause midline shift or
herniation. Herniation, midbrain or pontine hemorrhage, intraventricular hemorrhage,
acute hydrocephalus, or dissection into the brain stem can impair consciousness and
cause coma and death.

K. PATHOPHYSIOLOGY

A. WRITTEN

Stroke, or cerebral vascular accident (CVA), is a condition that is caused by a

lack of oxygen to the brain leading to reversible or irreversible paralysis (“Stroke,”
2007). A CVA is induced by an obstruction in blood flow to the brain causing hypoxia to
the effected brain tissue which quickly leads to neuronal cell death if left untreated
(Corwin, 2008). Due to cell death there is a great deal of inflammation, production of
oxygen free radicals and oedema which worsens the condition (Corwin, 2008). Acidosis
is a side effect of hypoxia which causes further injury by activating the acid-sensing
neuronal ion channels (Corwin, 2008). Brain damage ensues and usually peaks 24-72
hours after onset (Corwin, 2008). When classifying a cerebrovascular accident there are
two main categories: ischemic and haemorrhagic (Corwin, 2008).
36
 Transient ischemic attacks are also thought to be caused by thrombi, however,
the difference is that these strokes resolve within 24 hours of onset (McCance &
Huether, 2006). There is a very high probability of reoccurrence in these patients if left
untreated (McCance & Huether, 2006). Like thrombotic strokes TIA’s are usually
caused by atherosclerosis (Corwin, 2008). It has been hypothesized that TIA’s occur
when the atherosclerotic vessel spasms cutting off oxygen supply to the distal tissue, or
there is an increased demand for oxygen which can not be met due to the partially
occluded vessel (Corwin, 2008).

Haemorrhagic stroke accounts for roughly 15% of all strokes (Brown & Edwards,
2005). The stroke occurs when there is a larges accumulation of blood causing the
surrounding brain tissue to be displaced and compressed, often causing blood to leak
into the ventricles (McCance & Huether, 2006). There are large haemorrhages, which
may be several centimeters, or small haemorrhages that may only be one to two
centimeters in diameter (McCance & Huether, 2006). There may only be a slit, referred
to as a petechial haemorrhage which is a very small pinhead size bleed (McCance &
Huether, 2006). The main contributing factor to this type of stroke is hypertention
(McCance & Huether, 2006).
B. DIAGRAM

Predisposing Factors: Precipitating Factors:

• Gender • Lifestyle

• Age • Uncontrolled HTN

Hypertension Hyperlipidemia

37
 ↑Shearing force Fatty disposition into arterial wall

Damage of arterial endothelial layer

Inflammatory response & intramuscular clotting

Atheromatous aorta Thrombus Formation

S: Sx

↑BP, dyspnea,
LVH Narrowing of the lumen
Angina, edema,

Dizziness,
swollen Embolic occlusion in myocardial artery

Neck vein, Disrupted brain cell metabolism

S: Sx
Accumulation of H2O, Ca, NA CAD
Chest pain,

Dyspnea,
dizziness,
unusual fatigue,
↑ ICP
ECG changes,

Localized acidosis and free radical

Formation

Cell injury

38
 CVA

Prognosis

If Treated If untreated

Return of normal Coma

perfusion

Cerebral death
Decreased Edema

Loss of neural feedback

mechanism

Cessation of physiologic
functions

39
L. SYNTHESIS OF THE CLIENT’S CONDITION/STATUS FROM ADMISSION
TO PRESENT

A. Conclusion
We were able to conclude that the study portrayed its value and helped us know
all about Cerebrovascular Accident. This study made us aware of the right picture and
characteristics of the disease. It also made us understood the cause and effects of the
ailment that enabled us to find out the predisposing and precipitating factors how the
disorder was developed. This also had given us the knowledge to identify where and

40
when it had started and how the disease progressed, we were able to trace the
pathophysiology of the disease and we had also interpreted the laboratory and
diagnostic exam results of the client and known the implications of the different
procedures. We also had formulated Nursing Care Plans and identified our appropriate
and therapeutic nursing interventions that would help us arrive on our goal of care for
our patient with this kind of disease.

B. Patient’s Prognosis
After the continuous treatment which consists of the medical and the nursing
management of the patient, a development of her present health status is projected.
Continuous administration of therapy had partially alleviated the clients suffering from
the disease. Although disease process is incurable and has the tendency to attack
again one’s life, if the client will undergo treatment, by some means this will help reduce
the sufferings of the client brought by the disease. But if the client will not subject herself
to any medical management, this could lead to further complications; signs and
symptoms of the disease will progress and will evidently manifested by the client.
Furthermore, this would worsen the condition and eventually leads to death.

C. Discharge Plan
Medicine – Comply with the treatment regimen. Keep a written list of the medicines you
take, the amounts, and when and why you take them. Bring the list of your medicines or
the pill bottles when you see your caregivers. Learn why you take each medicine. Ask
your caregiver for information about your medicine. Do not use any medicines, over-the-
counter drugs, vitamins, herbs, or food supplements without first talking to caregivers or
physician. Always take your medicine as directed by caregivers. Call your caregiver if
you think your medicines are not helping or if you feel you are having side effects. Do
not quit taking your medicines until you discuss it with your caregiver. If you are taking
medicine that makes you drowsy, do not drive or use heavy equipment.

41
Exercise – Everyone needs regular physical activity that strengthens body structures.
Regular exercises are good for the heart and lungs and could stimulate proper
circulation and oxygenation in the body. Exercise has consistently been shown to
improve cardiovascular health. Importantly, the first step in starting to exercise is to
determine the potential risk of heart and/or blood vessel complications from exercise. It
is important to gradually increase your level of activity, to increase blood flow and
improve muscle strength. Regular exercise should be minimal and basic in order not to
increase the workload of the heart. Follow your doctor’s recommendations for physical
activity. Choose exercises you enjoy and will make a regular part of your day.
Mobilization helps prevent activity intolerance and constipation. Everyone can exercise
safely after discharge, the intensity and duration of exercise should be adjusted
according to the severity of a person's heart disease. For most people, this could
include walking briskly or participating in another aerobic activity for at least 30 minutes
per day. Your primary care physician or cardiologist may recommend an outpatient
cardiac rehabilitation program, which can help you resume a healthy, active lifestyle
through exercise and education. The rate of recovery will depend upon your age,
general health and your heart function. Passive range of motion is necessary in her
condition since she cannot tolerate to do some exercises.

Treatment - You may be given medicine to take at home for controlling blood glucose.
Your caregiver will tell you how much to take and how often to take it. Take the
medicine exactly as directed by your caregiver. Treatment goals are related to effective
blood glucose, blood pressure and lipids to minimize the risk of long term consequences
associated with diabetes. Medications are prescribed to prevent complications that may
result. Control measures for this disease are administration of ACE inhibitors, HMG-
CoA inhibitors, and Anti-infective. The purpose of the treatment is to lessen etiologic
and contributing factors. Instructed client for strict compliance of treatment regimen.

Hygiene - Good oral hygiene and proper dental care apply to all age groups but the
needs of the elderly population can be slightly different than the needs of the younger
people. Client should also observe regular hand and body hygiene to decrease the risk

42
of acquiring infection. Daily bath is recommended as well as frequent hand hygiene, not
only for the client but also for the client’s significant others.

Diet – Limiting the amount of fat to no more than 25 to 35% of daily calories is
recommended to promote good health. However, some experts believe that fat must be
limited to 10% of daily calories to reduce the risk of coronary artery disease. A low-fat
diet also helps lower high total and LDL (the bad) cholesterol levels, another risk factor
for coronary artery disease. Eating at least five servings of fruits and vegetables daily
can decrease the risk of coronary artery disease. Such foods contain many
phytochemicals. One group of phytochemicals called flavonoids (found in red and
purple grapes, red wine, and black teas) appears to be particularly protective. A high-
fiber diet is also recommended. There are two kinds of fiber. Soluble fiber (which
dissolves in liquid) is found in oat bran, oatmeal, beans, peas, rice bran, barley, citrus
fruits, strawberries, and apple pulp. It helps lower high cholesterol levels, decrease or
stabilize high blood sugar (glucose) levels, increase low insulin levels and help people
with diabetes reduce their risk of coronary artery disease. Insoluble fiber (which does
not dissolve in liquid) is found in most grains and grain products and in fruits and
vegetables such as apple skin, cabbage, beets, carrots, brussels sprouts, turnips, and
cauliflower. It helps with digestive function. However, eating too much fiber can interfere
with the absorption of certain vitamins and minerals.

The diet should contain the recommended daily requirements of vitamins and
minerals. Vitamin supplements are not considered an acceptable substitute for a
healthy diet. People should maintain a healthy weight and eat a variety of foods. The
Mediterranean diet, which consists of large portions of fruits, vegetables, nuts, and olive
oil, appears to reduce the risk of coronary artery disease.

43
M. EVALUATION

After our thorough assessment, comprehensive observation,

44
interpretation of the patient’s laboratory results, the nursing responsibilities of the
prescribed medication, knowing the factors that affect the disease process and the
nursing interventions rendered to our patient, we came up with the following
evaluations:

General:

The group was able to present all the accumulated information

about our patient’s case, duly diagnosed with Cerebrovascular Accident Bleed,
Hypertensive Cardiovascular Disease, Coronary Artery Disease, Left Ventricular
Hypertrophy, Myocardial Infarction, Community Acquired Pneumonia Moderate Risk
and has improved our skills and knowledge pertaining on caring patients with the above
mentioned disease.

Specific:

1.) The incidence of CVA Bleed, HCVD, CAD, LVH, MI, CAP MR in
global, national, and local setting was determined.

2.) The inclusive assessment of the patient involving biographical

data, chief complaint upon admission, past and present medical
history, personal, family and socio-economic status as an apparent
substantiation to the condition were present.

3.) Review of systems through detailed but comprehensive physical

assessment was conducted.

4.) The significant diagnostic test and laboratory examinations,

comparing abnormal results from normal values with its corresponding
interpretation in relation to the current status of the client was
determined.

45
5.) The predisposing and precipitating factors that contributed to the
disease process and present comprehensively in a written and
diagrammatic illustration were identified.

6.) The pathophysiology of CVA Bleed, HCVD, CAD, LVH, MI, CAP
MR, its symptomatology and complications of the client was discussed.

7.) The client’s condition in the ward from the day of admission until
the student nurses’ assessment was determined.

8.) The pharmacological management of CVA Bleed, HCVD, CAD,

LVH, MI, CAP MR and its nursing considerations were enumerated.

9.) Three (3) prioritized health needs/ problems of the client and
formulate nursing plan as a framework of care identified and applied.

46
47