A

Case Presentation
On
Cerebrovascular
Accident

Group J
Marco Paul Velasco
Precious Jane Parungao
Rod Lambert de Leon
Carla Aleja Abijay
Mylene Narag
Jenalin Quilang
Krizzia Marie Palce
Jessica Datul
 OBJECTIVES

General Objective:

At the end of the case presentation, the presenters together with the audience will
enhance our understanding on the disease process of CVA, its nursing management and
paves a way to us student-nurses appreciate our roles of being health care providers in
the country’s quest for health progress and development.

Specific Objectives:

At the end of the presentation, presenters and audience will be able to:
• Define Cerebrovascular Accident.
• Discuss and interpret data gathered through theoretical analysis of Nursing
History, Gordon’s 11 Functional Pattern, Physical Assessment and Laboratory
Results.
• Explain the Anatomy and Physiology of Nervous System.
• Trace the Pathophysiology of Cerebrovascular Accdident.
• Create effective and efficient nursing care plan required by a patient with the
above mentioned disease process.
• Discuss the medications taken by the client, its action, side effects and nursing
responsibilities.
 INTRODUCTION

Cerebrovascular Accident

Cerebrovascular Accident is a sudden loss of function resulting from disruption of

the blood supply to a part of the brain. Stroke, also called brain attack or ischemic
stroke, happens when the arteries leading to the brain are blocked or ruptured. When
the brain does not receive the needed oxygen supply, the brain cells begin to die, a
stroke can cause paralysis, inability to talk, inability to understand, and other conditions
brought on by brain damage.

Four types of stoke:

1. Cerebral Thrombosis- caused by blood clots.
2. Cerebral Embolism- caused by blood clots.
3. Cerebral Hemorrhage- caused by bleeding inside the brain.
4. Subarachnoid Hemorrhage- caused by bleeding inside the brain.

Cerebral Thrombosis
 The most common type of brain attack.
 Occurs when a blood clot (thrombus) forms and blocks blood flow in an artery
leading to the brain arteries primarily affected by atherosclerosis and more
susceptible to blood clots.
 Most often occurs at night or in the morning when blood pressure in low.
 Often preceded by a transient ischemic attack (TIA) or “mini-stroke”.

Cerebral Embolism
 Occurs when a wondering clot (embolus) or some other particle forms in a blood
vessel away from the brain, usually in the heart. The clot then travels and lodges in
an artery leading on the brain.

Cerebral Hemorrhage
 Occurs when a defective artery in the brain busts.

Subarachnoid Hemorrhage
 Occurs when a blood vessel on the surface of the brain ruptures and bleeds into
the space between the brain and the skull.

The World Health Organization (WHO) definition of stroke is “rapidly developing

clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting
24 hours or longer or leading to death, with no apparent cause other than of (1) Non-
communicable disease. WHO Geneva (2) vascular origin” (3) By applying this definition
transient ischemic attack (TIA), which is defined to less than 24 hours, and patients with
stroke symptoms caused by subdural hemorrhage, tumors, poisoning, or trauma, are
excluded.

Based from the data gathered from TCGPH records section, there were 10 reported
cases of CVA as of January 2009 until December 2009 comprises of 2 mortality cases and
8 morbidity cases.

Why this case?

 We have chosen this case as our topic during the case presentation because we
would like that we, student-nurses, to be aware about CVA and also to broaden our
knowledge about the management and treatment of this disease.
 Having awareness and gaining more knowledge about CVA would enhance our
skills and attitudes in handling patients suffering from this disease.
  This case serves as a challenge for us student-nurses to be committed and
dedicated health professionals for the next days; we will take care of the health of
the citizens.

PATIENT’S PROFILE

Name: I.M.

Age: 80 y/o

Gender: Female

Civil Status: Widower

Birth date: Dec. 24, 1928

Nationality: Filipino

Religion: Roman Catholic

Address: Ugac Norte, Tuguegarao City

Educational Background: College Graduate

Occupation: Retired Teacher

Date of admission: November 19, 2009

Time of admission: 6:45 pm

Chief complaint: loss of consciousness

Mode of arrival: via stretcher

Admitting diagnosis: HPN t/c CVA

Final Diagnosis: CVA old recurrent

Sepsis secondary to pneumonia
NIDDM

Attending Physician: Dr. Valeriano Combate, JR

Dr. Marlene Cinco
Dr. Gerardo Pagaddu, JR

Source of information: SO, patient’s chart, Record’s section

Hospital: TCGPH-Pay Ward

 NURSING HISTORY

Past Health History

According to SO, when the patient suffered from headache, fever, and cough,
patient takes over the counter drugs like paracetamol, biogesic, alaxan and solmux.
Patient was diagnosed with Alzheimer’s disease on 2004, and undergone mastectomy
when she was 42y/o.

History of Present Illness

According to SO, at the evening of November 19, 2009, 45 minutes PTC, SO

noticed that patient was still sleeping at around 6:00pm. She then tried many times to
wake up the patient and called her to eat but she did not receive any response. The SO
was alarmed and decided to rush the patient to People’s Emergency Hospital and was
admitted around 6:45pm. . At the age of 52 patient was hospitalized and diagnosed of
HPN and manages it by taking maintenance drugs such as amlodipine, simvastatin &
aspirin taken twice a day.

Family Health History

The patient has a history of Asthma on her paternal side. Her father died of Asthma
and her mother died due to hypertension.

Social Health History

Patient is a retired teacher; she lives with her daughter and grand children.
According to the SO before the patient was diagnosed of Alzheimer’s disease, the patient
loves to mingle with her neighbors and loves to take care of her grand children. SO also
verbalized that patient does not drink alcohol nor smoke cigarettes.
 GORDON’S 11 FUNCTIONAL PATTERN

Health Perception-Health Management Pattern

Before Hospitalization During Hospitalization
According to the SO, her mother According to the SO, she stated that her
has been pampered starting when she mother is not in good condition. She believes
was diagnosed with Alzheimer’s that doctors, nurses and other medical
disease 5 years ago. When she members will help her mother to recover. SO
suffered from the sickness, they also added that they obediently follow all the
treated her immediately by taking OTC orders of the doctors.
drugs for cough, colds and fever. With
regards to her maintenance drugs to
her hypertension, they give it at right
time as prescribed.

Nutritional- Metabolic Pattern

Before Hospitalization
According to the SO, her mother eats
everything she wants and sees. She has no
preference diet. She eats 3 times a day
with mid afternoon snacks. She drinks 6-8
glasses of water a day. She has no
difficulty in swallowing and has no allergy
with any type of food.
During Hospitalization
Upon admission, the patient was
inserted NGT and was ordered with PNSS
1liter to run for 8 hours. The diet was
osteorized feeding with SAP.

Elimination Pattern
Before Hospitalization
According to the SO, she defecates once a
day with semi- formed and brown in color
and being eliminated in morning. She voids
6-8 times a day with yellowish in color.
During Hospitalization
During our shift, the patient didn’t
defecate. She has IFC connected to urine
bag with 700 ml and yellow amber in color.

Activity Exercise Pattern

Before Hospitalization
According to the SO, the patient is like a
child. She plays with her neighborhood.
Sometimes walking around their house.
About her hygiene, they see to it that
cleanliness must maintain to her.
During Hospitalization
The patient is in comatose state.
Student-nurses and SO initiated passive
range of motion for her to exercise.

Sleep- Rest Pattern

Before Hospitalization During Hospitalization
According to the SO, her mother sleeps at Patient is comatose but can respond to
around 8 in the evening and wakes up at physical stimuli.
around 5 in the morning. She takes naps at
afternoon. She has no rituals before
sleeping she added.

Cognitive Perceptual Pattern

Before Hospitalization
According to the SO, her mother is a
retired teacher, she uses eyeglasses. She
speaks dialects such as Ilocano, Tagalog
and English.
During Hospitalization
The patient responds to stimuli by means
of rubbing her sternum for her to wake up.
Self- Perceptual Pattern
Before Hospitalization During Hospitalization
The patient suffers from Alzheimer’s The patient is comatose.
disease.

Role- Relationship Pattern

Before Hospitalization
According to the SO, before her mother
was diagnosed with Alzheimer’s, she was a
loving mother and responsible to her
children. She provides their needs and sees
to it that they are comfortable in their way
of life.
During Hospitalization
Due to her condition, her daughter
stated that they will do all their best to
take care of their mother. They will make
sure to give back the care they have
received from her.

Coping- Stress Pattern

Before Hospitalization During Hospitalization
When her mother is tired, she sleeps for During her present condition, she is in a
her to rest. stressful state. Her family is there to
comfort and give her necessary needs just
to show their love.

Sexual- Reproduction Pattern

The patient has five children and had her menopause at the age of 50.

Value Belief Pattern

She is a Roman Catholic. When she was diagnosed with Alzheimer’s disease, her
family never allowed her to go to mass, preventing her to lose her way home.
 PHYSICAL ASSESSMENT

• Date Assessed: December 03, 2009, 5:15 PM

• Vital Signs:
• BP: 140/90 mmHg
• PR: 92 bpm
• RR: 23 cpm
• T: 36.8°C

General Appearance:

➢ Patient is lying on bed, comatose with ongoing IVF of PNSS 1L x 20 gtts/minute

at 500 cc level hooked at left metacarpal vein patent and infusing well.
➢ With NGT patent.
➢ With IFC connected to urine bag draining yellow amber.

AREA METHOD NORMAL ACTUAL ANALYSIS

USED FINDINGS
ASSESSED FINDINGS

SKIN

– Color Inspection Fair Pale d/t decreased

complexion tissue perfusion
and peripheral
vasoconstriction

– Texture
d/t loss of elastic
fiber and
Inspection/ Wrinkled decreased
Smooth subcutaneous fat
Palpation
from hypodermis
secondary to
aging

– Temperature
d/t poor hygiene

Inspection Presence of
– Moisture rashes

d/t peripheral
vasoconstriction
Cold and
Palpation
clammy
Normally warm
d/t decreased
 activity of
sebaceous and
– Turgor Dry
sweat glands
Palpation Moist to dry secondary to
aging

d/t loss of elastic

fiber and
decreased
Sagged
subcutaneous fat
Palpation Snaps back to from hypodermis
previous secondary to
HAIR aging
– distribution

Normal

– Texture Evenly
Evenly distributed
Inspection/
– Color distributed
Palpation

Normal
NAILS
Resilient
– Color of the d/t decreased
nail bed melanocyte
Inspection
Silky, resilient production
Black w/
– Capillary secondary to
white hairs
refill time aging
Inspection
Black
– Shape
d/t poor arterial
EYES/EYEBROWS circulation

– Shape Pallor

d/t poor arterial

– Symmetry
Inspection circulation
Pink
– Movement transparent
Delayed 4
sec. Normal

Palpation
– Ability to
Delayed 1-2
blink
sec.
Convex Normal
 Palpation

Normal

CONJUNCTIVA Convex Round

– Color Inspection Normal

Equal in size

Inspection Round

PUPILS Symmetrical d/t decrease

in movement activity of CN V
– PERRLA Inspection Equal in size

Absence of
Symmetrical in
blink
movement
Inspection
d/t poor arterial
– Size of the
circulation
pupil Blinks
involuntarily &
bilaterally
EXTERNAL
AUDITORY Pale d/t compression
CANAL Inspection of CN III

– Hearing

Pink-red

NOSE
Very slow to
– Symmetry Inspection react to light

– Color Response to
penlight
2mm Normal
(dilates and
constricts)
Inspection
LIPS & MOUTH

– Symmetry Normal

Hears equally
in both ears
– Color (lips) Inspection Normal

Symmetrical
– Moisture Hears equally
in both ears
Inspection
Same color
Normal
as the face
Symmetrical
and neck
NECK Inspection
 – Symmetry d/t decrease
oxygenation
Same color as Symmetrical
the face and
– Appearance
neck
d/t decreased
Inspection Pale
salivary
THORAX
production r/t
– Chest loss of vagal
Inspection stimulation
contour Symmetrical
Dry

– Clavicle Pink Normal

Inspection
– Chest wall
Normal

– Breathing Moist
pattern Symmetrical

Normal
ABDOMEN Palpation No
distentions
– General Normal
contour
Inspection
Symmetrical
Normal
Symmetrical
No distentions
Inspection
Prominent
d/t decreased
UPPER function of the
EXTREMITIES Inspection
Symmetrical medulla
Full chest
– Symmetry expansion
Inspection
Prominent Normal
– ROM Irregular

Full chest
Inspection expansion

LOWER Regular
EXTREMITIES Non-tender

– Size Normal
Inspection
– Symmetry
Auscultation
Normal
Percussion Non-tender
– ROM
Palpation
 Symmetrical

Inspection

(+) ROM Normal

upon
Inspection/ Symmetrical
movement
Palpation
Normal

(+) ROM upon

movement
Normal

Equal in size
Inspection

Symmetrical
Inspection Equal in size

(+) ROM
Inspection Symmetrical
upon
movement

(+) ROM upon

movement

LABORATORY RESULTS

HGT

Date Result Normal Range Analysis

11-21-09 6am 284 mg/dl 80-120 mg/dl

11-21-09 6pm 155 mg/dl 80-120 mg/dl

11-22-09 6am 186 mg/dl 80-120 mg/dl

11-22-09 153 mg/dl 80-120 mg/dl

11-23-09 170 mg/dl 80-120 mg/dl

11-24-09 215 mg/dl 80-120 mg/dl

11-27-09 172 mg/dl 80-120 mg/dl

11-28-09 152 mg/dl 80-120 mg/dl

11-30-09 120 mg/dl 80-120 mg/dl

12-01-09 133 mg/dl 80-120 mg/dl

Na

Date Result Normal Range Analysis

11-24-09 131 mmOl/L 135-145 Normal

mmOl/L

11-29-09 132 mmOl/L 135-145 Normal

mmOl/L

Date Result Normal Range Analysis

11-24-09 3.0 mmOl/L 3.5-5.5 mmOl/L

11-29-09 4.0 mmOl/L 3.5-5.5 mmOl/L Normal

CBC
11-20-09

Parameters Result Normal Range Analysis

WBC 12.4x103 /mm3 3.5-10 d/t increase

pyrogens

RBC 3.83x106 /mm3 3.8-5.8 Normal

Hgb 11.4 g/dl 11.0-16.5 Normal

Hct 37.0% 35-50 Normal

PLT 188x103/mm3 150-390 Normal

 INTAKE AND OUTPUT MONITORING SHEET

12-05-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 500 100 600 600 600

3-11 1000 430 700 700 700

11-7 660 200 800 800 800

Total: 2890
Total: 2100

12-04-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 720 100 75 895 200 250

3-11 1000 250 1250 500 500

11-7 600 250 850 200 200

Total: 2995
Total: 950

12-03-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 750 350 75 1175 290 290

3-11 1000 200 4 1204 350 350

Total: 2379
Total: 640

12-02-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge
7-3 900 550 75 1525 790 790

3-11 832 120 75 1027 660 660

11-7 600 200 75 875 550 550

Total: 3427
Total: 2000

11-30-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 600 340 940 1000 1000

3-11 890 475 1365 1100 1100

11-7 550 200 750 900 900

Total: 2055
Total: 3000

11-29-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

3-11 800 300 1100 400 400

Total: 1100
Total: 400

11-28-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 830 550 1380 1350 1350

3-11 1030 700 1730 600 600

11-7 700 700 1400 1650 1650

Total: 4510
Total: 3600

11-27-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 1030 600 1630 1630 1630

3-11 600 450 1050 1050 1050

Total: 2680
Total: 2680

11-26-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 860 475 1335 600 600

3-11 1250 400 1650 1250 1250

Total: 2985
Total: 1800

11-25-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 770 350 1120 500 500

3-11 810 200 1010 800 800

11-7 800 200 1000 1250 1250

Total: 3130
Total: 2550

11-24-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 715 400 1115 350 350

3-11 850 200 1050 1400 1400

Total: 2165
Total: 1750

11-23-09

Intake Output

Time Oral Parenter Other Total Urine Draina Others Total

ral s ge

7-3 1030 200 1230 300 300

3-11 700 500 1200 600 600

11-7 600 750 1350 700 700

Total: 3780
Total: 1600
 CRANIAL CT-SCAN

Plain and contrast-enhanced axial tomographic sections of the head shows ill defined
hypoattenvation in the both fronto-parietal periventrical and both occipital
periventricular areas.
The ventricles are unenlarged
The midline structures are undisplaced
The sulci and cisterns are prominent
No abnormal extra-axial fluid collection detected
The brain stem, pineal region and posterior fossa do not appear unusual
The internal carotid basilar and vertebral arteries are calcified
The sella turcica is not enlarged
Soft tissue attenvation is noted in the right maxillary sinus

IMPRESSION:
Acute infarcts, both fronto-parietal periventricular and both occipital
periventricular areas.
Cerebral Atrophy
Atherosclerotic Internal Carotid, basilar and vertebral arteries
Sinusitis vs polyp, right maxillary sinus
 ANATOMY AND PHYSIOLOGY

Central Nervous System

The Central Nervous System (CNS) is composed of the brain and spinal cord. The
CNS is surrounded by bone-skull and vertebrae. Fluid and tissue also insulate the brain
and spinal cord.

Areas of the Brain

The brain is composed of three parts: the cerebrum (seat of consciousness), the
cerebellum, and the medulla oblongata (these latter two are “part of the unconscious
brain”).

The medulla oblongata is closest to the spinal cord and is involved with the
regulation of heartbeat, breathing, vasoconstriction (blood pressure), and reflex centers
for vomiting, coughing, sneezing, swallowing and hiccupping. The hypothalamus
regulates homeostasis. It has regulatory areas for thirst, hunger, body temperature,
water balance and blood pressure and links the nervous system to the Endocrine
System. The midbrain and pons are also part of the unconscious brain. The thalamus
serves as a central relay point for incoming nervous messages.

The cerebellum is the second largest part of the brain, after the cerebrum. It
functions for muscle coordination and maintains normal muscle tone and posture. The
cerebellum coordinates balance.

The conscious brain includes cerebral hemispheres, which are separated by the
corpus callosum. In reptiles, birds, and mammals, the cerebrum coordinates sensory
data and motor functions. The cerebrum governs intelligence and reasoning, learning
and memory. While the cause of memory is not yet definitely known, studies on slugs
indicate learning is accompanied by a synapse decrease. Within the cell, learning
involves change in gene regulation and increased ability to secrete transmitters.

The Brain
During embryonic development, the brain first forms a tube, the anterior end
which enlarges into three hollow swellings that form the brain, and the posterior of which
develops into spinal cord. Some parts of the brain have changed little during vertebrate
evolutionary history.

Parts of the Brain as seen from the Middle of the Brain

Vertebrate evolutionary trends include:

1. Increase in brain size relative to body size.

2. Subdivision and increasing specialization of the forebrain, midbrain and hindbrain.
3. Growth is relative in size of the fore brain, especially the cerebrum, which is
associated with increasingly complex behavior in mammals.

The Brain Stem and Midbrain

The brain stem is the smallest and from an evolutionary viewpoint, the oldest and
most primitive part of the brain. The brain stem is continuous with the spinal cord, and is
composed of the parts of the hindbrain and midbrain. The medulla oblongata and pons
control heart rate, constriction of blood vessels, digestion and respiration.

The midbrain consists of connections between the hindbrain and forebrain.

Mammals use this part of the brain only for eye reflexes.
The Cerebellum

The cerebellum is the third part of the hindbrain, but it is not considered part of
the brain stem. Functions of the cerebellum in clued fine motor coordination and body
movement, posture and balance. This region of the brain is enlarged in birds and
controls muscle action needed for flight.

The Forebrain

The forebrain consists of the diencephalon and cerebrum. The thalamus and
hypothalamus are parts of the diencephalon. The thalamus acts as a switching center for
nerve messages. The hypothalamus is a major homeostatic center having both nervous
and endocrine functions.

The Cerebrum

The cerebrum, the largest part of the human brain, is divided into left and right
hemispheres connected to each other by the corpus callosum. The hemispheres are
covered by a thin layer of gray matter known as the cerebral cortex, amphibians and
reptiles have only rudiments of this area.

The cortex in each hemisphere of the cerebrum is between 1and 4mm thick. Folds
divide the cortex into four lobes: occipital, temporal, pariental, and frontal. No region of
the brain functions alone, although major functions of various parts of the lobes have
been determined.

The occipital lobe (back of the head) receives and processes visual information.
The temporal lobe receives auditory signals, processing language and the meaning of
words. The pariental lobe is associated with the sensory cortex and processes
information about touch, taste, pressure, pain, and heat and cold. The frontal lobe
conducts three functions:

1. Motor activity and integration of muscle activity

2. Speech
3. Thought processes

Most people who have been studied have their language and speech areas on the left
hemisphere of their brain. Language comprehension is found in Wernicke’s area.
Speaking ability is in Broca’s area. Damage to Broca’s area causes speech impairment
but not impairment of language comprehension. Lesions in Wernicke’s area impair ability
to comprehend written and spoken words but not speech. The remaining parts of the
cortex are associated with higher thought processes, planning, memory, personality and
other human activities.