INTRODUCTION

A Stroke, cerebrovascular accident, or what is now being termed as brain attack, is a sudden loss of brain functions resulting from is disruption of blood supply to a part of the brain resulting from pathologic blood vessels. It denotes an abnormality of the brain. Stroke can be classified into ischemic and hemorrhagic strokes. Ischemic stroke can be divided into thrombotic and embolic stroke. Thrombotic stroke can be divided into thrombotic and embolic stroke. Thrombotic stroke results from the narrowing or occlusion of blood vessels due to fat deposits while embolic strokes result from the occlusion of a blood clot originating from the other parts of the body, most commonly from the heart. Hemorrhagic stroke is further classified into intracerebral hemorrhage and

subarachnoid hemorrhage. It results from the rupture of blood vessels in the brain. Rupture of arterioles result in bleeding into the parenchyma of the brain, while rupture of larger arteries or its tributaries result in bleeding in the subarachnoid space. Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP. Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage. Risk factors for hemorrhagic stroke include age, gender, race hypertension, smoking and use of illicit drug. A stroke causes a wide variety of neurologic deficit,

depending on the location of the lesion, the size of the area of inadequate perfusion and the amount of severity of blood flow. It may include vomiting, headache, seizures, hemiplegia and loss of consciousness. Pressure on the brain tissue from increase intracranial pressure may cause coma and death.

Latest Trend (Medication for Cerebrovascular Accident) Anti-platelet medicines like aspirin, clopidogrel, extended release dipyridamole and aspirin in combination, and ticlopidine help prevent stroke because they keep the blood from clotting. Like aspirin, these medicines keep your blood from clotting. They are available only prescription. dipyridamole and aspirin combination (Aggrenoxl),

clopidogrel (Plavixl), ticlopidine (Ticlidl). Anti-coagulant medicines keep you from getting blood clots. You may hear people call these medicines "blood thinners." Warfarin (Coumadinl) is often used in patients who have heart problems or artificial heart valves. Tissue plasminogen activator (t- PA or thrombolytic therapy) dissolves blood clots, but it may cause bleeding (including bleeding into the brain).This medicine must be given within 3 hours of the start of stroke symptoms. You will not be given t-PA if your blood pressure is too high, if changes on a CT scan show it should not be given, or if the risk of bleeding is too great. Heparin / heparinoid medicines slow the creating of blood clots. But there is little, if any, benefit in treating stroke. The medicines also can cause bleeding.

GENERAL OBJECTIVES: The primary concern of this study is to further enhance the understanding of Cerebrovascular Accident in congruence with the learned concepts of the Nursing students.

Objectives of study: Study: This case presentation seeks to provide different information about the disease to be presented about the client being considered with the ff. specific objectives: 1. A brief introduction about Cerebrovascular Accident together with its clinical manifestations. 2. Present a theoretical framework for the study in relation to a nursing approach applied to a patient with hemorrhagic stroke. 3. Discuss the normal Anatomy and Physiology of Circulatory and Central Nervous System. 4. Explain the patient-based Pathophysiology of Hemorrhagic stroke. 5. Identify Nursing Problems related to the situation and case of the client 6. Present a Nursing Care Plan for the problems of the client.

Anatomy and Physiology Cerebellum The cerebellum is involved in the coordination of voluntary motor movement, balance and equilibrium and muscle tone. It is located just above the brain stem and toward the back of the brain. It is relatively well protected from trauma compared to the frontal and temporal lobes and brain stem. Cerebellar injury results in movements that are slow and uncoordinated. Individuals with cerebellar lesions tend to sway and stagger when walking. Damage to the cerebellum can lead to: 1) loss of coordination of motor movement (asynergia), 2) the inability to judge distance and when to stop (dysmetria), 3) the inability to perform rapid alternating movements (adiadochokinesia), 4) movement tremors (intention tremor), 5) staggering, wide based walking (ataxic gait), 6) tendency toward falling, 7) weak muscles (hypotonia), 8) slurred speech (ataxic dysarthria), and 9) abnormal eye movements (nystagmus).

Cerebrum The cerebrum is the part of the brain that occupies the top and front portions of the skull. It is responsible for control of such abilities as movement and sensation, speech, thinking, reasoning, memory, sexual function, and regulation of emotions. The cerebrum is divided into the right and left sides, or hemispheres. Depending on the area and side of the cerebrum affected by the stroke, any, or all, of the following body functions may be impaired: movement and sensation speech and language eating and swallowing vision cognitive (thinking, reasoning, judgment and memory) ability perception and orientation to surroundings self-care ability bowel and bladder control emotional control sexual ability

Limbic System The limbic system is a set of evolutionarily primitive brain structures located on top of the brainstem and buried under the cortex. Limbic system structures are involved in many of our emotions and motivations, particularly those that are related to survival. Such emotions include fear, anger, and emotions related to sexual behavior. The limbic system is also involved in feelings of pleasure that are related to our survival, such as those experienced from eating and sex. Broca's Area An area located in the frontal lobe usually of the left cerebral hemisphere and associated with the motor control of speech, also called Broca's center. Temporal Lobe The temporal lobes are involved in the primary organization of sensory input (Read, 1981). Individuals with temporal lobes lesions have difficulty placing words or pictures into categories. Language can be affected by temporal lobe damage. Left temporal lesions disturb recognition of words. Right temporal damage can cause a loss of inhibition of talking. The temporal lobes are highly associated with memory skills. Left temporal lesions

result in impaired memory for verbal material. Right side lesions result in recall of nonverbal material, such as music and drawings. Parietal Lobe Damage to the left parietal lobe can result in what is called "Gerstmann's Syndrome." It includes right-left confusion, difficulty with writing (agraphia) and difficulty with mathematics (acalculia). It can also produce disorders of language (aphasia) and the inability to perceive objects normally (agnosia). Damage to the right parietal lobe can result in neglecting part of the body or space (contralateral neglect), which can impair many self-care skills such as dressing and washing. Right side damage can also cause difficulty in making things (constructional apraxia), denial of deficits (anosagnosia) and drawing ability.

Occipital Lobe The occipital lobes are the center of our visual perception system. They are not particularly vulnerable to injury because of their location at the back of the brain, although any significant trauma to the brain could produce subtle changes to our visual-perceptual system, such as visual field defects and scotomas. The Peristriate region of the occipital lobe is involved in visuospatial processing, discrimination of movement and color discrimination (Westmoreland et al., 1994). Damage to one side of the occipital lobe causes homonomous loss of vision with exactly the same "field cut" in both eyes.

Frontal Lobe The frontal lobes are considered our emotional control center and home to our personality. There is no other part of the brain where lesions can cause such a wide variety of symptoms. The frontal lobes are involved in motor function, problem solving, spontaneity, memory, language, initiation, judgement, impulse control, and social and sexual behavior. The frontal lobes are extremely vulnerable to injury due to their location at the front of the cranium, proximity to the sphenoid wing and their large size

PATHOPHYSIOLOGY

MODIFIABLE HYPERTENSION (BP 182/98 mmHg)

NON-MODIFIABLE AGE (76 Y.O.) SEX (male)

Changes within arterial wall

Rupture of vessels

Ineffective cerebral Tissue perfusion related to interruption of blood flow

MRI CB C PT Intracerebral Hemorrhage

Central Nervous System: Brocas Aphasia Hemiplegia

Digestive System: Dysphagia

Impaired verbal communication related to decreased circulation to brain.

Self care Deficit related to neuromuscular impairment as evidenced by impaired ability to perform ADLs.

Impaired physical mobility related to hypotonic paralysis as evidenced by decreased muscle strength.

Impaired swallowing related to neuromuscular impairment

LEGEND: Pathology

Nursing Care Plan

Laboratory Tests

Assessment Subjective: -Weakness Objective: -Paralysis on the left side of the body -Impaired ability to perform ADLs

Diagnosis Self care Deficit related to neuromuscula r impairment as evidenced by impaired ability to perform ADLs

Planning Intervention After 1 week 1. Assessed of nursing abilities and interventions, level of the patient deficit (0-4 will able to scale) for perform performing activities ADLs. within level of own ability. 2. Avoided doing things for patient that patient can do for self, but provided assistance if necessary.

Rationale 1) Aids in anticipating/ planning for meeting individual needs.

2) This patient may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for the patient to do as much as possible for self to maintain self esteem and promote recovery.

Evaluation GOAL MET: After 1 week of nursing interventions the patient was able to perform activities within level of own ability.

3. Maintained a supportive, firm attitude. Allowed patient sufficient time to accomplish tasks.

3) Patients need empathy and to know caregivers will be consistent in their assistance

4. Provided positive feedback for efforts and accomplish ments 5. Encourage so to allow patient to do as much as possible for self.

4) Enhances sense of self worth, promotes independence, and encourages patient to continue endeavors

5) Reestablishes sense of independence and fosters self worth and enhances rehabilitation process. a. NOTE: This may be very difficult and frustrating for the SO / caregivers, depending on degree of disability and time required for the complete activity.

ASSESSMENT Subjectsive: Weakness Objective: Limited range of motion (client cant fully extend his right arm and hold up his right shoulder) Limited ability and difficulty to perform gross motor skills like extending and lifting of the right arms Slowed movement

NURSING DIAGNOSIS Impaired physical mobility related to hypotonic paralysis as evidenced by decreased muscle strength

PLANNING After 1 week of nursing interventio n the patient will able to maintain strength and function of the affected body part.

INTERVENTIONS 1) Assessed functional ability extent of impairment initially and on a regular basis classify according to 0-4 scale.

RATIONALE 1. Identifies strengths deficiencies and may provide information regarding recovery. Assist in choice of interventions because different techniques are used for flaccid and spastic paralysis.

EVALUATION GOAL MET: After 1 week of nursing interventions, the patient was able to maintained strength and function of the affected body part

2) Changed positions at least every 2 hours and possibly more often if placed on the affected side.

2. Reduces risk of tissue ischemia/inju ry. Affective side has poor circulation and reduce sensation and is more predisposed to skin breakdown.

3) Inspected skin regularly particularly

3. Pressure points over bony

ASSESSMENT Subjective: namamanhi d yung kaliwang kamay nya as verbalized by the patient relative. Objective: Lef t hand paralysis

NURSING DIAGNOSIS Ineffective cerebral Tissue perfusion related to interruptio n of blood flow

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

After 8hrs of nursing interventio ns, the patients will able to demonstrat e stable v/s and absence of signs of increased icp.

1) Determined factors related to individual situation/ cause for coma/ decreased cerebral perfusion and potential for increased ICP.

1) Influences choice of interventions. Deterioration in neurological signs/sympto ms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient be transferred to critical care area for monitoring of ICP. 2) Assesses treands in level of consciousnes

After 8hrs of nursing interventi ons, the patients was able to demonstr ate stable v/s and absence of signs of increased icp.

2) Monitored/ documented neurological status frequently and compare with baseline.

s and potential for increased ICP and is useful in determining loacation and progreesion of CNS damage.

3) Monitored V/S: Hypertension

3) Fluctuations in pressure may occur because of cerebral pressure/injur y in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor.
4) Fluctuations

in pressure may occur because of

4) Heart rate and rhythm; ausculate for murmurs;

cerebral pressure/injur y in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhthmias and murmurs may reflect cardiac disease, which may have precipitated CVA.

5) Assessed higher functions,

5) Changes in cognition and

including speech, if patient is alert.

6) Positioned with head slightly elevated and in neutral position.

speech content are an indicator of location/ degree of cerebral involvement and may indicate increased ICP.

7) Maintained Bed rest; provided quiet environment, restricted / activities as indicated.

6) Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation. 7) Continual stimulation/ activity can increase ICP. Absolute rest and quiet may be needed to prevent bleeding in the case of

8) Administered supplementa l oxygen as

indicated.

hemorrhage.

8) Reduces hypoxemia which can cause cerebral vasodilaton and increase pressure.

Assessment Subjective: -weakness

Diagnosis Impaired verbal communication related to decreased circulation to brain.

Planning After 8 hours of nursing interventions, the patient will be able to demonstrate understanding even if not able to speak.

Intervention 1. Monitored and recorded changes in patients speech pattern or level of orientation. 2. Spoke slowly and distinctly in a normal tone when addressing patient, can see and hear you. 3. Used short, simple phrases and yes-orno questions when patient is very frustrated. 4. Allowed ample time for a response. Did not answer questions

Rationale 1. Changes may indicate improvemen t or deterioration of condition.

Evaluation GOAL MET: After 8 hours of nursing interventions, the patient was able to demonstrate understanding even if not able to speak.

Objective: -Difficulty expressing thought verbally.

2. These actions promote comprehensi ons.

3. To reduce frustration.

4. This improves patients selfconcept and reduces frustration.

yourself if patient has the ability to respond. 5. Repeated or rephrased questions if necessary. 6. Did not pretend to understand if you dont.

5. To improved communicati on. 6. To avoid misundersta nding.

Assessment

Diagnosis Impaired swallowing related to neuromuscular impairment.

Planning After a 1 week interventions the patients will be able to maintain fluid and dietary intake remains within established daily limits.

Intervention 1. Positioned patients on his side when recumbent, if applicable. 2. Monitored intake and output and weight daily until stabilized. Established an intake goal. 3. Consulted with a dysphagia rehabilitatio n team, if available. 4. Provided mouth care three times daily.

Rationale 1. To decreased the risk of aspiration. 2. Evaluating calorie and protein intake daily allows any necessary modificatio n. 3. To obtain expert advice.

Evaluation After a 1 week interventions the patients was able to maintain fluid and dietary intake remains within established daily limits.

Objective: -Drooling of saliva -choking and coughing -difficult to swallow food. -decreased gag reflex

4. To promote comfort and enhance

appetite.