Anda di halaman 1dari 27

Cerebrovascular Accident


Cerebrovascular Accident (CVA)

A stroke, also known as CVA or brain attack, is a sudden impairement of cerebral circulation in one or more blood vessels. A stroke interrupts or lessens O2 supply and commonly causes serious damage or necrosis in the brain tissue. The sooner the circulation returns to normal after a stroke, the better the chances are for a complete recovery. About of the patients who survived a stroke, remain permanently disabled and experience a recurrence with in weeks, months or years. Its the leading cause of admission to long term care. Stoke is the third most common cause of death in the US and the most common cause of neurologic disability. It strikes more than 500,000 people per year and is fatal in about of this people. There are two types of stroke the: Ischemic and Hemorrhagic depending on the underlying cause. Ischemic has 3 classifications; Thrombotic, the most common cause of stoke frequently results of artherosclerosis; also associated with hypertension, smoking and diabetes. Embolic, second most common type of stroke and Lacunar, a subtype of thrombotic stroke. Hemorrhagic the third most common type of stroke, typically cause by hypertension or rupture of aneurysm, diminished blood supply to area supplied by ruptured artery and compression by accumulated blood.

Demographic Data Patients Data Patient E.C. live at Quezon City. She is 66 years old and her birthday is on February 12, 1942. She is married but shes now living with her sons and daughters house. She is a Roman Catholic. She doesnt have any work because she is dependent to her siblings. She is a college undergraduate. She admits to the hospital because the patient complains of dizziness and History of the present illness On June 18, 2008 the patient was rash to the hospital because the patient complains of dizziness and her blood pressure was 180/100 mmHg. According to the family that hospital didnt admit the patient and the patient went home. After 2 days the patient brought to St. Agnes General Hospital and admitted with a diagnosis of vomiting CVA. Past Medical Illness The patient is already hypertensive and taking maintenance. Family Health History According to the family the patient inherit the disease from her mother side. Social history The patient has a harmonious relationship with other family members. They live in an apartment. The patient doest have any job because all her siblings are working already.

Gordons Approach
When patient E.C. is not yet confined in the hospital or when she is in her normal state of being the patient was oriented and coherent. She is kind to everyone. She has a harmonious relationship to her family as well as to their neighbors. The patient can do her own things and she do her responsibilities as a mother. She can eat everything she wants especially the bagoong which is her favorite. The patient do whatever she wants even though she knows that its dangerous to her health.

Physical Assessment
Vital Signs and Physical Assessment Name: EC Birth Date: February 12, 1942 Age: 66 years old Vital Signs Physical Assessment Vital Signs Body Temperature Pulse Respiration Actual Finding 37.60C 101bpm 19cpm Norms and Standards 36.5 0C-37.50C 60-100 12-20cpm Inferences Normal Slight deviation from normal Normal

Blood Pressure
Assessment Skin -Color -Uniformity -Moisture -Temperature -Skin turgor

150/90 mmHg
Actual Finding -Brown complexion -Generally uniform except in areas exposed to the sun. -Moisture in the skin folds and the axillae. -Normal range. -Back to the previous state in less than 1 second. -Evenly distributed hair -Hair is thick, grayish in color. -Hair is soft and oily enough. -No infection or infestation -Variable

120/80 mmHg
Norms and Standards Freckles, some birthmarks, some flat raised nevi; no abrasion or other lesions. When pinched, skin springs back to previous state

Inferences Normal

Hair -Evenness of growth -Thickness or thinness -Hair texture and oiliness -Presence of infections -Amount of body hair

Thick hair. Silky, resilient hair. No infection or infestation.


Nails -Fingernail plate shape -Fingernail and toenail texture -Fingernail and toenail bed color -Blanch test of capillary refill

-Normal curved -Smooth texture -Light pink in color -Return of pink color in less than 4 seconds.

When pressed, prompt return of pink or usual color (generally less than 4 seconds).


Skull and Face -Skull size, shape and symmetry -Palpation of the skull for masses or depression -Facial Features (Symmetry of structures) -Facial movements

-Rounded, symmetrical, normal size -No masses or depressions, uniform consistency -Symmetrical facial features, because both sides are paralyzed. -Eyebrows elevate together, Eyes close tightly together and the cheeks can puff.

Rounded (normocephalic and symmetrical, with frontal, parietal and occipital prominences) smooth contour. Absence of nodule or masses.

Normal Deviation from normal

Eye Structure -Eyebrows for hair distribution -Eyelashes for evenness and direction of curl, color of sclera -Pupils color, shape and symmetry -Extraoccular muscle test

-Evenly distributed -Sclera is slight reddish. Iris shape is somehow distorted, pinkish conjunctiva. -Color black, round and around 4mm in diameter. -Both eyes coordinate with parallel alignment movement.

The conjunctiva is shiny, smooth and pink or red. Transparent capillaries, sometimes evident: sclera appears white. When lids open, no visible sclera above corneas and upper and lower borders or corneas are slightly covered. Hair is evenly distributed, skin intact.

-Normal -Normal -Normal

Ears -Auricle for color, symmetry of size and position -Auricle texture and elasticity

-Same color as facial skin, symmetrical and aligned to the eye. -Firm and recoils after it is folded.

Color same as facial skin, symmetrical. Firm auricles, the pinna recoils after it is folded


Nose and Sinuses -External nose shape, size and color -Palpate fir any masses; displacement of bone and cartilage. -Presence of swelling or discharge.

-Straight, uniform in color, medium in size. -No displacement and lesions. -No discharge.

The external nose is symmetric and straight, no discharge, no lesions. Air moves freely as the client breathes through the nares of both nasal cavity


Mouth and Oropharynx -Outer lips are symmetry, color and texture. -Inner lips for color -Teeth and gums -Tongue movement

-Pink in color but not too moist. -Pale and dry. -Patient has dentures. But is not worn at the time of assessment. -Does not move freely.

The outer lips are symmetric of contour. Uniform pink in color. Soft, moist smooth texture. Intact dentures. Teeth should be white. Gums and teeth should be intact. Tongue is pink in color and moves freely.

-Normal -Normal -Deviation from normal.

Neck -Neck muscles -Head movement -Palpation of neck

-Muscles are equal -Head does not move freely. -No masses, dislocation and enlargement.

When the head is in movement, it is coordinated, smooth with no discomfort. The lymph nodes are not palpable. The trachea is in central placement in midline of neck, spaces are equal on both sides. The thyroid gland is not visible.

Slight deviation from normal.

Thorax and Lungs -Shape and symmetry of the thorax -Spinal Alignment for deformities

-Chest is symmetric -Spine is aligned.

Chest is symmetric and the spine is aligned. Chest skins are intact and have uniform temperature, with no tenderness and no masses.


Feet Extremities Upper Extremities Lower extremities

No lesions and abrasions No masses, arms and hands do not move freely and an IV attached to the right metacarpal. No masses, legs and thighs do not move freely. Legs are not proportion to the rest of the body.

No lesions and abrasions No palpable masses, arms are able to move freely, no contraptions, proportion to the rest of the body. No palpable masses, legs and thighs are able to move freely, no contraptions, proportion to the rest of the body.

Normal Deviation from normal. Deviation from normal.

Diagnostic Procedures
Name Complete Blood Count (CBC) Definition/Description A complete blood count (CBC) is a calculation of the cellular makeup of blood. A CBC measures the concentration of white blood cells, red blood cells, and platelets in the blood. Indication To determine the hemoglobin(Hgb), hematocrit (Hct), and erythrocytes (RBC), count, and assess the bloods ability to carry oxygen; to determine the leukocytes (WBC) count, which signals infection when elevated Nursing Responsibilities Explain procedure to the client/relative Clean the site of extraction of the blood (put cotton and plaster)


Urinalysis is a diagnostic physical, chemical, and microscopic examination of a urine sample (specimen).

To detect urinary tract infections and glucose in the urine.

Explain procedure to the client/relative Assist in collecting the specimen Advise the relative on how to clean the genitalia


A1c is a compound created in your body when excess blood sugar sticks to a protein in your red blood cells called hemoglobin (Hb). The higher your blood sugar, the higher your A1c value.

To detect if the patient has Diabetes Mellitus

Tell relative not to give food to the patient 8 hours prior to collecting/getting specimen in the morning


The PTT test is ordered when someone has unexplained bleeding or clotting. Along with the PT (which evaluates the extrinsic and common pathways of the coagulation cascade), the PTT is often used as a starting place when investigating the cause of a bleeding or thrombotic episode

To determine the clotting factor of the patient

Laboratory Results
Biochemistry Report I Test Glucose (FBS) Triglycerides Blood Uric Acid (BUA) Reference Value 3.6 5.8 0.40 1.53 17 34 = 149 369 June 26, 2008 Result 7.9 umol/L 0.69 umol/L 283 umol/L Findings Increase of glucose indicates diabetes mellitus, Cushings syndrome, acute pancreatitis, severe liver disease. Increase of uric acid in the blood indicates alcoholism, gout, high protein weight reduction diet, leukemia, metastatic cancer, renal failure, heart failure.

June 29, 2008 Test High Density Lipoprotein (HDL) Low Density Lipoprotein (LDL) Total Cholesterol Triglyceride Reference Value 0.91 2.22 3.80 4.91 5.1 6.2 0.40 1.53 Result 1.08 mmol/L 4.15 mmol/L 5.47 umol/L 0.52 umol/L Findings Normal

Biochemistry Report II Test Sodium (Na +) Potassium (K +) Urinalysis Color Reaction Albumin Leucocytes Red Blood Cells Mucus Threads Yellow Acidic Trace 03 13 few Reference Value 137 145 3.6 5.0 July 30

July 3, 2008 Result 126 mmol/L 3.9 mmol/L 4.5 mmol/L June 25, 2008 Transparency Spec. Gravity Sugar Yeast Cell A.Urates Epithelial Cells Bacterial Haze 1.015 (-) / few + moderate Findings Normal

HBA1C Date June 26 , 2008 Reference Value 4.27 6.07 % Result 4.7 %

Test Hgt Blood Urea Nitrogen (BUN) Creatinine

Reference Value 80 120 2.5 6.4 62 106

Result 95 5.6 mmol/L 106

Findings Normal


Test Hemoglobin

Reference Value 12 14

June 25 12.5 gms %

July 5 14. 3 gms %

Findings Increase in hemoglobin indicates chronic obstructive pulmonary disease (COPD), heart failure, hemoconcentration, high altitudes, polycythemia. Increase in hematocrit indicates dehydration, eclampsia, high altitudes, polycythemia, congenital heart disease, burns. Increase in WBC indicates bacterial infections, collagen diseases, Cushings syndrome, gout, inflammatory disease, ketoacidosis, myelocytic leukemia, stress, acute infection. Increase in segmenter indicates Cushings syndrome, gout, inflammatory disease, ketoacidosis, myelocytic leukemia, stress. Decrease in Lymphocyte indicates chronic infections, hepatitis, lymphocytic leukemia, mononucleosis, multiple myeloma, viral infection.


36 40
5,000 10,000

37.2 vol %
13,000 cumm

42 vol %
22,700 cumm

Platelet Count

150,000 400,000

278,000 cumm

318,000 cumm


36 66 %



Lymphocyte PTT/APTT Results

22 40 %



Control INR % act

11.9 sec
12.5 1.0 112.4%

12 14 sec
Patient Control

Result 29.7 sec 27.9 sec

Reference Value 25 45 sec

Anatomy and Physiology

Human Brain


Predisposing factor

Aggreviating factor
Food intake with increase Na and increase fat content

Presipitating factor
Diet Lack of exercise Sedentary lifestyle Decrease blood circulation Decrease contractility of the heart Decrease C.O.


Fatty deposits in the blood That usually embeds in the vessel Cerebral Infarct

Increase BP

Stroke (CVA)

NURSING DIAGNOSIS Impaired physical mobility related to neuromuscular involvement as evidenced by limited range of motion. RATIONALE Highly prioritized because it needs immediate attention and intervention to help the client and the relatives to cope with the situation. RANKING 1

Self-care deficit related to neuromuscular impairment as manifested by impaired ability to perform ADLs.

Moderately prioritized because this involves patients self sufficiency. 5th stage of Maslows hierarchy of needs.

Risk for aspiration due to reduced level of consciousness and contraptions.

Not perceived as a problem by the client and the relatives,

Nursing Care Plan






SUBJECTIVE: hindi makagalaw yung buong katawan ng nanay ko. As verbalized by the patients son. OBJECTIVE: -BP=150/90 -Temp=37.6 -RR=19 -PR=101 -GCS=15 -pupils reaction to light=brisk

Impaired physical mobility related to neuromuscular involvement as evidenced by limited range of motion.

After 8 hours of nursing intervention the patient will maintain, increase Strength & endurance of upper & lower extremities. The relatives of the patient will know how to do ROM exercise.

-maintain the pt. on bed rest and place the pt. in different position (e.g. supine, sidelying) -monitor V/S -promote conducive circulation -encouraged the pt. to assist with movement and exercises using unaffected extremity to support/move weaker side.

-To have a good circulation of blood -For based line purposes -To reduce sympathetic stimulate& promotes relaxation. -May responds as if affected side is no longer part of the body and needs encouragement and active training to reincorporate it as a part of own body.

After nursing intervention the patient maintained, increased Strength & endurance of upper & lower extremities. The relatives of the patient knew how to do ROM exercise.

ASSESSMENT SUBJECTIVE: medyo mahina pa si nanay at hindi nakakagala w kaya kami ang nagpapalit at naglilinis ng mga dumi niya. As verbalized by the patients daughter. OBJECTIVE: -BP=150/90 -Temp=37.6 -RR=101 -PR=19 -GCS=11

NURSING DIAGNOSIS Self-care deficit related to neuromusc ular impairment as manifested by impaired ability to perform ADLs.

PLANNING After 8 hours of nursing intervention patient and the relatives will be able to: -identify personal/ community resources that can provide assistance as needed. -able to demonstrate techniques/ lifestyle changes to meet self care needs. -perform self-care activities within level of own ability.

NURSING INERVENTION -Monitor V/S & neurological status. -Assess abilities and level of deficit (0-4 scale) for performing ADLs. -Provide positive feedback for efforts and accomplishments. -Assist the patient in taking a bath. -Teach the client as well as the relatives about the different techniques/ lifestyle changes in self-care needs.

RATIONALE -For based line purposes and to identified early neurological changes. -Aids in anticipating/ planning for meeting individual needs. -Enhances sense of selfworth, promotes independence, and encourages patient to continue endeavors. -To promote cleanliness and proliferation of bacteria and microorganism in the body. -To enhance their knowledge about self-care.

EVALUATION After nursing intervention patient and the relatives identify personal/ community resources that can provide assistance as needed, demonstrate techniques/ lifestyle changes to meet self care needs, and perform self-care activities within level of own ability.






Objective: -cough/ Gag reflex -presence f phlegm -with NGT -with IVF -Lethargic -BP=150/90 -Temp=37.6 -RR=101 -PR=19 -GCS=11

Risk for aspiration related to reduce level of consciousness and contraptions.

After an hour of nursing intervention, the presence of gag reflex will lessened and fluids will be able to pass with ease.

Frequent suctioning to remove secretions and clear the airways. Maintain operational suction equipment at bedside. Refrain from using oxygen mask. Auscultate lung sounds frequently to determine presences of secretions/silent aspiration. Ascertain that feeding tube is in correct position.

After an hour of nursing intervention, the presence of gag reflex is lessened. Fluids was able to pass with ease as reported by the relatives.

Medical Management Drug Study Name of Drug Contraindication Side Effect / Adverse Reaction Nursing Responsibility

Ranitidine Hydrochlorite >Zantac

Cirrhosis of the liver, impaired renal or hepatic function

GI constipation, coma, diarrhea, abdominal pain CV bradycardia or tachycardia

Give antacids for gastric pain although they may interfere with ranitidine absorption No dilution is required for IM use
should not be given during pregnancy as it may cause fetal/neonatal morbidity or mortality Dont use preservatives when given epidurally If drug is to be discontinued, do so gradually over a period of 2-4 days. Many OTC and prescription products contain acetaminophen, be aware of this when calculating total daily dose.


Patients with known hypersensitivity to ACE inhibitors

dry cough, discomfort in the throat, headache and rash

Clonidine Hydrochloride >Catapress

Epidurally : Presence of an injection site infection, clients on anti coagulant therapy, in bleeding diathesis.

CV CHF, severe hypotension, postural hypotension, sinus bradycardia GU Impotence, urinary retension, loss of libido, nocturia

Paracetamol >Aeknil


Skin eruption, hematological toxicity

Ceftriaxone Sodium >Rocephin

Use cautiously in breastfeeding women and in patient with history of renal insufficiency

CV Phlebitis GU Candidiasis Skin Pain, induration

Obtain specimen for culture and sensitivity test before giving first dose If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of infections Increase fluid intake


Hypersensitivity to amlodipine besylate and valsartan or to any of the excipients

GI - Diarrhea, nausea, abdominal pain, constipation, dry mouth. Vascular Hypotension Urinary - polyuria.

Acetaminophen >Paracetamol

Contraindicated to patients with hypersensitivity to drug Use cautiously in patients with long term alcohol use.
Contraindicated in patients with conditions in which sodium and chloride administration is detrimental Persistent or chronic cough or when cough is accompanied by excessive secretions

Jaundice, hemolytic anemia, rash, hypoglycemia

Many OTC and prescription products contain acetaminophen, be aware of this when calculating total daily dose.
Monitor electrolyte levels


Abscess, local tenderness, thrombophlebitis

Dextromethorphan hydrobromide >Delsym

Dizziness, drowsiness, stomach pain

Avoid tasks that require mental alertness until drug effects realized

Atorvastatin calcium >Lipitor

Active liver disease

Headache, paresthesia,asthenia,insomnia,muscle pain

Give as single dose at any time of the day, w/ or w/o food Do not use ocular lubricant if you have a bacterial, viral, or fungal infection in the eye

Eye Lubricant >Tears natural

Possible adverse effects of carboxymethyl cellulose and other similar lubricants include eye pain, irritation, continued redness, or vision changes


Acute surgical abdomen, abdominal pain, nausea, vomiting or symptoms of appendicitis; intestinal hemorrhage or obstruction, persistent diarrhea
Contraindicated in patients hypersensitive to drug or its components and in those with pathologic bleeding Use cautiously in patients at risk for increased bleeding from trauma, surgery, or other pathologic conditions.

Mild abdominal discomfort; diarrhea w/ excessive loss of water & electrolytes

The effectiveness or the toxicity of other drugs may be intensified when stimulant laxatives are overused

Clopidogrel bisulfate >Plavix

Depression, dizziness, fatigue, edema, epistaxis, UTI,rash

Platelet aggregation wont return to normal for at least 5 days after drug has been stopped.

dexamethasone >Decadron

Contraindicated in patients hypersensitive to drug or its ingredients. Use with caution in patient with recent MI

Insomnia, vertigo, headache, cataract, glaucoma , edema,

Determine whether patient is sensitive to other corticosteroids

Bisacodyl > Dulcolax

Contraindicated in patients hypersensitive to drug or its components and in those with rectal bleeding.

Dizziness, faintness, electrolyte imbalance, hypokalemia

Before giving for constipation, determine whether patient has adequate fluid intake


Patients with known hypersensitivity to cinnarizine. Contraindicated to patients hypersensitive to drug

headache, dry mouth, weight gain, perspiration or allergic reactions

Do not give to patient which is allergic to cinnarize Monitor VS, including central venous pressure and fluid intake and output hourly.

Osmitrol >Mannitol

Blurred vision, urine retention, edema, headache

Clomipramine hydrochloride >Placil

Use cautiously in patients with history of seizure disorders or with brain damage

Dry mouth, constipation, pharyngitis, nausea

Monitor mood and watch for suicidal tendencies. Allow patient to have only minimal amount of drug

Treatment O2 therapy to provide constant flow of oxygen into the body No open flame or combustible products should be permitted when oxygen is in use Nebulizer - device used to administer medication to people in the form of a mist inhaled into the lungs Make sure to measure the right amount of medicine that will be put into the medication cup NGT - Nasogastric tubes are used for diagnostic, therapeutic, preventative, and feeding purposes Do not insert NGT to patients who have trauma to the jaw, base of skull and neck

CT SCAN - used to image a wide variety of body structures and internal organs Assess for allergic reactions to contrast medium, encourage client to drink fluids if not contraindicated
Diet Rice,chicken,fish and shrimp Low Fat and Salt Diet

Evaluation M-Medication- the patient is still presently confined within the hospital therefore no medications to be taken at home and given yet. E-Exercise the patient was referred/recommended for therapy. For vascular function patients legs should be elevated to promote venous return to the heart. Leg exercise; flexion and extension of the feet. For cardiac function; high fowlers position to decrease ICP (Intra-Cranial Pressure) and reduce pulmonary congestion T-Treatment the patient was prescribed to be oxygenated at 2-3L, for nebulization, NGT, CT SCAN and therapy H-Health Teaching it is important to discuss that maintaining a normal weight through diet and exercise is essential to lower the risk of hypertension. Cholesterol level should be screened regularly to monitor for a hyperlipidemia

D- Diet the patient is advised to take low fat low salt diet, no beef and no pork. This is important to maintain or decrease cholesterol level and weight