I.

INTRODUCTION
Cerebrovascular accident: The sudden death of some brain cells due to
lack of oxygen when the blood flow to the brain is impaired by blockage or
rupture of an artery to the brain. A CVA is also referred to as a stroke.
Symptoms of a stroke depend on the area of the brain affected. The
most common symptom is weakness or paralysis of one side of the body with
partial or complete loss of voluntary movement or sensation in a leg or arm.
There can be speech problems and weak face muscles, causing drooling.
Numbness or tingling is very common. A stroke involving the base of the
brain can affect balance, vision, swallowing, breathing and even
unconsciousness.
A stroke is a medical emergency. Anyone suspected of having a stroke
should be taken immediately to a medical facility for diagnosis and
treatment.
The causes of stroke: An artery to the brain may be blocked by a clot
(thrombosis) which typically occurs in a blood vessel that has previously
been narrowed due to atherosclerosis ("hardening of the artery"). When a
blood clot or a piece of an atherosclerotic plaque (a cholesterol and calcium
deposit on the wall of the artery) breaks loose, it can travel through the
circulation and lodge in an artery of the brain, plugging it up and stopping
the flow of blood; this is referred to as an embolic stroke. A blood clot can
form in a chamber of the heart when the heart beats irregularly, as in atrial
fibrillation; such clots usually stay attached to the inner lining of the heart
but they may break off, travel through the blood stream, form a plug
(embolus) in a brain artery and cause a stroke. A cerebral hemorrhage
(bleeding in the brain), as from an aneurysm (a widening and weakening) of
a blood vessel in the brain, also causes stroke.
The diagnosis of stroke involves a medical history and a physical
examination. Tests are done to search for treatable causes of a stroke and
help prevent further brain damage. A CAT scan (a special X-ray study) of the
brain is often done to show bleeding into the brain; this is treated differently
than a stroke caused by lack of blood supply. A CAT scan also can rule out
some other conditions that may mimic a stroke. A soundwave of the heart
(echocardiogram) may be done to look for a source of blood clots in the
heart. Narrowing of the carotid artery (the main artery that supplies blood to
each side of the brain) in the neck can be seen with a soundwave test called
a carotid ultrasound. Blood tests are done to look for signs of inflammation
which can suggest inflamed arteries. Certain blood proteins are tested that
can increase the chance of stroke by thickening the blood.
Stroke look-alikes: Just because a person has slurred speech or
weakness on one side of the body does not necessarily mean that person has
had a stroke. There are many other nervous system disorders that can mimic
a stroke including a brain tumor, a subdural hematoma (a collection of blood
between the brain and the skull) or a brain abscess (a pool of pus in the brain
caused by bacteria or a fungus). Virus infection of the brain (viral

encephalitis) can cause symptoms similar to those of a stroke, as can an

overdose of certain medications. Dehydration or an imbalance of sodium,
calcium, or glucose can cause neurologic abnormalities similar to a stroke.
Treatment of a stroke: Early use of anticoagulants to minimize blood
clotting has value in some patients. Treatment of blood pressure that is too
high or too low may be necessary. (Lowering elevated blood pressure into the
normal range is no longer recommended during the first few days following a
stroke since this may further reduce blood flow through narrowed arteries
and make the stroke worse.) The blood sugar glucose in diabetics is often
quite high after a stroke; controlling the glucose level may minimize the size
of a stroke. Drugs that can dissolve blood clots may be useful in stroke
treatment. Oxygen is given as needed. New medications that can help
oxygen-starved brain cells survive while circulation is reestablished are being
developed.
Rehabilitation: When a patient is no longer acutely ill after a stroke, the
aim turns to maximizing the patient's functional abilities. This can be done in
an inpatient rehabilitation hospital or in a special area of a general hospital
and in a nursing facility. The rehabilitation process can involve speech
therapy to relearn talking and swallowing, occupational therapy for regaining
dexterity of the arms and hands, physical therapy for improving strength and
walking, etc. The goal is for the patient to resume as many of their pre-stroke
activities as possible.

OBJECTIVES:

General Objective: To be able to acquire knowledge on how to deal or

manage a patient with Cerebrovascular Accident.

Specific Objective:
1. To thoroughly assess the clinical manifestations of patient with CVA
based on the patients history.
2. To formulate comprehensive nursing diagnosis for a client with CVA.
3. To formulate a plan of care for patients with CVA.
4. To formulate appropriate nursing interventions that can be applied for
a patient with CVA.
5. To evaluate the plan of care for a patient with CVA.

NURSING HEALTH HISTORY

A.

BIOGRAPHIC DATA
Name: Mrs. Alen Santos
Address: Binalonan Pangasinan
Age: 52 yrs old
Sex: F
Race: Filipino
Marital Status: Married
Occupation: Tricycle Driver
Religious Orientation: Roman Catholic

B.

CHIEF COMPLAINT
Nanghina ang kaliwag bahagi ng akng katawan, as verbalizes
by the patient
C.

HISTORY OF PRESENT ILLNESS

One day prior to admission, the patient felt weak on the left side
of her body, she also has high blood pressure that day, so they
decided to go to the hospital for further management and
treatment

D.

PAST HISTORY
The client received 2 immunizations only (BCG and DPT) because
the family is not aware of its importance. The client commonly had
cough and fever. The childhood diseases that she acquired are mumps,
measles, and chicken pox and sore eyes .There were no known food or
medication allergy. Client has no history of accidents or injuries. She
does not smoke or drink alcohol

E.

FAMILY HISTORY OF ILLNESS

The clients father and mother has a history of hypertension.

F.

HEALTH PERCEPTION PATTERN

BEFORE HOSPITALIZATION
The client experienced weakness on the left side of her body
when she does some household task like gardening. She manages it by
having a period of rest in bed. She is still uncomfortable with her state

of health because it greatly affects her daily activities. She cannot

perform the things she likes and usually do. Client believed that proper
diet, exercises, and adequate financial support are the things needed
to maintain proper health diet and no vices are factors of having a
healthy body. She does not perform self-breast examination. When
signs and symptoms arise they sought medical consultation. The client
also believed in albularyo and use herbal medicines such as lagundi,
guava leaves, pito-pito (7 different kinds of leaves).
DURING HOSPITALIZATION
The client still feels left sided body weakness
G.

NUTRITIONAL AND METABOLIC PATTERN

PRIOR TO HOSPITALIZATION
The clients typical food intake is composed of rice, meat, and
fish. Occasionally she eats vegetables and fruits. Shes fond of eating
processed food like corned beef, anything with preservatives, tocino,
chicharon and fried dish (porkchop, chicken). She used a lot fish sauce,
MSG when cooking. Her appetite was good and drinks 6 glasses of
water daily. Client wound heals well and she wears complete upper and
lower dentures but this doesnt affect her food intake.

H.

ELIMINATION PATTERN
BEFORE HOSPITALIZATION
Client usually defecates at least 2-3 times of soft and watery
stool consisting of small amounts which is light brown color with
presence of blood (fresh blood), with discomfort or difficulties and
experienced excessive sweating. Client urinates 6x a day which is
yellowish- orange color w/out any discomfort.
Stool Characteristics
Color
Light brown
Consistency

Formed stool

Smell

Foul odor

Frequency and amount

Once a day

Urine Characteristics
Color
Smell
Frequency and Amount

Yellowish- orange
aromatic
6 times a day at least
1000ml/day

DURING HOSPITALIZATION
Client usually defecate at least 1-2x a day semi formed stool
with the presence of blood which is light brown to brown. She has
difficulty in defecation with excessive sweating.
Client urinates 4x a day which is yellow in color w/out any discomfort.
Stool Characteristics
Color
Light brown to brown

Consistency

Semi formed

Smell

Foul odor

Frequency and Amount

1-2 times a day in small

amounts

Urine Characteristics
Color

I.

yellow

Smell

aromatic

Frequency and Amount

6 times a day at least

1000ml/day

ACTIVITY-EXERCISE PATTERN
BEFORE HOSPITALIZATION
The client said that her activities at home were limited because
she has experience high blood pressure. She spends her days with
minimal cleaning like gardening and watching TV. She also played with
her grand daughter and grandsons. She walks short distances as form
of her exercise.
DURING HOSPITALIZATION
Client shows tiredness and limited movement. A client doesnt
perform any routine exercise. In the hospital the client instructed to
Perform ROM by the health care provider.
3-FEEDING
3-GROOMING
3-TOILETTING
3-GENERAL MOBILITY
4-COOKING
3-BED MOBILITY
4-BATHING
3-DRESSING
4-HOME MAINTENANCE
Level 0 - Full self care
Level 1 - Requires use of equipment or device
Level 2 - Requires assistance or supervision from another person
Level 3 - Requires assistance or supervision from another person or
device
Level 4 - Is dependent and does not participate

J.

SLEEP-REST PATTERN
BEFORE HOSPITALIZATION
The client sleeps for 8-9 hours usually from 8pm-5am but not
continuous because of prompt abdominal pain. She doesnt take any
sleep medications. She also does take naps during afternoon. The
client sleeps inadequately at night. Clients usually watch TV shows and
played with her grand daughter and grandsons.
DURING HOSPITALIZATION
The client sleeps is lessen to 6 hours due to abdominal pain and
interrupted when the health care provider give medication and monitor
her vital signs during the night. She takes naps in the afternoon for
about 1 hour.

K.

COGNITIVE-PERCEPTUAL PATTERN
The client does not have any hearing difficulty and cant
remember past events She has a visual problem far-sightedness.
Through demonstration she could easily learn things. Abdominal pain is
the one which alters her comfort and she manages it with taking
prescribed medications.

L.

SELF PERCEPTION AND SELF CONCEPT PATTERN

The client said that her condition was not improve, she still
experience left sided body weakness and high blood pressure. Client feels
that she lose some weight. Financial problems and health condition usually
makes her worried. When this things are encountered the client diverts her
attention through talking to a family member and praying.
M.

ROLE-RELATIONSHIP PATTERN
The client lives in extended family. They live peacefully even
there are hardship and difficulties that arrives to their lives. By means
of good conversation they can easily fixed family problems. When
family experienced difficulty of caring for the client they just take it as
trials given by god. They have harmonious relationships with the family
and their neighbors.

N.

SEXUALITY-REPRODUCTIVE PATTERN
The client is done in stage of menopausal. There is no sexual
activity. According to the client, decreased sexual activity is not a
problem because they were already old. They spent most of their time
by taking care of each other and with that they are showing their love
for one another.

O.

COPING STRESS TOLERANCE PATTERN

The client was observed to be withdrawn but the behavior
improved as evidenced by her socialization with other people. When
things are not so well, she finds her husband to be the most helpful
person in talking things over. When big problems encountered, she
always prays and ask assistance with the Lord. Some of the time they
failed to attain what they want and try other alternatives in solving it.

P.

VALUE-BELIEF PATTERN
The client is a Roman Catholics usually go to the church to
attend mass every Sundays, first Friday of the month and novena. She
is very active in participating religious activities. She helps spread the
word of god through catechism.

The Brain
Three cavities, called the primary brain vesicles, form during the early
embryonic development of the brain. These are the forebrain
(prosencephalon), the midbrain (mesencephalon), and the hindbrain
(rhombencephalon).
During subsequent development, the three primary brain vesicles develop
into five secondary brain vesicles. The names of these vesicles and the
major adult structures that develop from the vesicles follow (see Table 1 ):

The telencephalon generates the cerebrum (which contains the

cerebral cortex, white matter, and basal ganglia).

The diencephalon generates the thalamus, hypothalamus, and

pineal gland.

The mesencephalon generates the midbrain portion of the brain

stem.

The metencephalon generates the pons portion of the brain stem

and the cerebellum.

The myelencephalon generates the medulla oblongata portion of the

brain stem

A second method for classifying brain regions is by their organization in

the adult brain. The following four divisions are recognized (see Figure 1 ).

The cerebrum consists of two cerebral hemispheres connected by a

bundle of nerve fibers, the corpus callosum. The largest and most
visible part of the brain, the cerebrum, appears as folded ridges

and grooves, called convolutions. The following terms are used to

describe the convolutions:

A gyrus (plural, gyri) is an elevated ridge among the

convolutions.

A sulcus (plural, sulci) is a shallow groove among the

convolutions.

A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most
named after bordering skull bones)the frontal lobe, the parietal
love, the temporal lobe, the occipital lobe, and the insula. All but
the insula are visible from the outside surface of the brain.
A cross section of the cerebrum shows three distinct layers of
nervous tissue:

The cerebral cortex is a thin outer layer of gray matter. Such

activities as speech, evaluation of stimuli, conscious thinking,
and control of skeletal muscles occur here. These activities
are grouped into motor areas, sensory areas, and association
areas.

The cerebral white matter underlies the cerebral cortex. It

contains mostly myelinated axons that connect cerebral
hemispheres (association fibers), connect gyri within
hemispheres (commissural fibers), or connect the cerebrum
to the spinal cord (projection fibers). The corpus callosum is a
major assemblage of association fibers that forms a nerve
tract that connects the two cerebral hemispheres.

Basal ganglia (basal nuclei) are several pockets of gray

matter located deep inside the cerebral white matter. The
major regions in the basal gangliathe caudate nuclei, the
putamen, and the globus pallidusare involved in relaying
and modifying nerve impulses passing from the cerebral
cortex to the spinal cord. Arm swinging while walking, for
example, is controlled here.

The diencephalon connects the cerebrum to the brain stem. It

consists of the following major regions:

The thalamus is a relay station for sensory nerve impulses

traveling from the spinal cord to the cerebrum. Some nerve
impulses are sorted and grouped here before being
transmitted to the cerebrum. Certain sensations, such as
pain, pressure, and temperature, are evaluated here also.

The epithalamus contains the pineal gland. The pineal gland

secretes melatonin, a hormone that helps regulate the
biological clock (sleep-wake cycles).

The hypothalamus regulates numerous important body

activities. It controls the autonomic nervous system and
regulates emotion, behavior, hunger, thirst, body
temperature, and the biological clock. It also produces two
hormones (ADH and oxytocin) and various releasing
hormones that control hormone production in the anterior
pituitary gland.

The following structures are either included or associated with the

hypothalamus.

The mammillary bodies relay sensations of smell.

The infundibulum connects the pituitary gland to the

hypothalamus.

The optic chiasma passes between the hypothalamus and the

pituitary gland. Here, portions of the optic nerve from each
eye cross over to the cerebral hemisphere on the opposite
side of the brain.

The brain stem connects the diencephalon to the spinal cord. The
brain stem resembles the spinal cord in that both consist of white
matter fiber tracts surrounding a core of gray matter. The brain
stem consists of the following four regions, all of which provide
connections between various parts of the brain and between the

brain and the spinal cord. (Some prominent structures are

illustrated in Figure 2 ).

Figur
e2

Prominent structures of the brain

stem.

The midbrain is the uppermost part of the brain stem.

The pons is the bulging region in the middle of the brain

stem.

The medulla oblongata (medulla) is the lower portion of the

brain stem that merges with the spinal cord at the foramen
magnum.

The reticular formation consists of small clusters of gray

matter interspersed within the white matter of the brain stem
and certain regions of the spinal cord, diencephalon, and
cerebellum. The reticular activation system (RAS), one
component of the reticular formation, is responsible for
maintaining wakefulness and alertness and for filtering out
unimportant sensory information. Other components of the
reticular formation are responsible for maintaining muscle
tone and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two

winglike lobes, the cerebellar hemispheres. Like that of the
cerebrum, the surface of the cerebellum is convoluted, but the gyri,
called folia, are parallel and give a pleated appearance. The
cerebellum evaluates and coordinates motor movements by
comparing actual skeletal movements to the movement that was
intended.

The limbic system is a network of neurons that extends over a wide

range of areas of the brain. The limbic system imposes an emotional
aspect to behaviors, experiences, and memories. Emotions such as
pleasure, fear, anger, sorrow, and affection are imparted to events and
experiences. The limbic system accomplishes this by a system of fiber
tracts (white matter) and gray matter that pervades the diencephalon and
encircles the inside border of the cerebrum. The following components are
included:

The hippocampus (located in the cerebral hemisphere)

The denate gyrus (located in cerebral hemisphere)

The amygdala (amygdaloid body) (an almond-shaped body

associated with the caudate nucleus of the basal ganglia)

The mammillary bodies (in the hypothalamus)

The anterior thalamic nuclei (in the thalamus)

The fornix (a bundle of fiber tracts that links components of the

limbic system)

PATHOPHYSIOLOGY

Cerebrovascular accident or stroke (also called brain attack) results from

sudden interruption of blood supply to the brain, which precipitates
neurologic dysfunction lasting longer than 24 hours. Stroke are either
ischemic, caused by partial or complete occlusions of a cerebral blood vessel
by cerebral thrombosis or embolism or hemorrhage (leakage of blood from a
vessel causes compression of brain tissue and spasm of adjacent vessels).
Hemorrhage may occur outside the dura (extradural), beneath the dura
mater (subdural), in the subarachnoid space (subarachnoid), or within the
brain substance itself (intracerebral).
Risk factors for stroke include transient ischemic attacks (TIAs) warning
sign of impending stroke hypertension, arteriosclerosis, heart disease,
elevated

cholesterol,

diabetes

mellitus,

obesity,

carotid

stenosis,

polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarette

smoking. Complications of stroke include aspiration pneumonia, dysphagia,
constractures, deep vein thrombosis, pulmonary embolism, depression and
brain stem herniation.

Labaoratory Result
Blood Chemistry

RESULT
Glucose

110mg/dl (high)

Uric acid

5.9 mg/dl

CHL

269 mg/dl (high)

Tryglycerides

169mg/dl ( high)

Directhol

63 mg/dl (high)

LL

173 mg/dl (high)

VLDL

34

Alanine Amino Transferase

115 U/L (high)

Fasting Blood Glucose

Result
Crea
Alanine Transferase
Na
K

113 mg/dl
0.9mg/dl
151mg/dl
4.2mmol/L

DRUG STUDY
Name of
Drug,
Generic,B
rand
name

Dosage
,
Route,
Freque
ncy

Generic
Name:
Mannitol

75
q6

Brand
Name:
Osmitrol
Drug
Classificat
ion:
Diuretics

Action

ml, Increase
osmotic
pressure of
glomerular
filtrate,
inhibiting
tubular
reabsorbpti
on of water
and
electrolyte
s,
drug
elevates

Indicati
on

Contraindic
ation

to
reduce
intraocul
ar
or
intracran
ial
pressure

contraindicat
ed to patient
hypersensitiv
e to drugs

Adver
se
Reacti
on

Nursing
Responsib
ility

Seizure
Edema
-Heart
Failure
-Urine
retenti
on
Blurred
Vision
-chills

-monitor
vital sign
-to relieve
thirst give
frequent
mouth care
-dont give
electrolyte
free
solution
with blood

plasma
osmolality,
increasing
water flow
into
exracellula
r fluid