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 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 elevated cholesterol, cigarette smoking, alcohol abuse, physical inactivity, asymptomatic

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 clients condition in the ward from the day of admission until the student nurses assessment. 12. Discuss the appropriate discharge plan to the patient with CVA Bleed. 13. Evaluate all of the accumulated information about our clients 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.

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 Cardiac rate: 92 bpm C. History of Present Illness
4

Weight: 50 kls RR 24cpm

BP 180/120 T 37.4

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

Psychosocial Crisis Infancy Birth-18 Months Trust vs. Mistrust

Central Task

Positive Outcome

Ego Quality

Definition

Developmental Task Social attachment; Maturation of sensory, perceptual, and motor functions; Primitive causality

Receiving care

Trust in Hope people and the environment

Enduring belief that one can attain ones deep and essential wishes

Younger Years

Autonomy vs. Shame 18 Months-3 doubt Years

Imitation &

Pride in self; Will Assertion of will in the face of danger

Determination to Locomotion; exercise free choice and self- Fantasy play; control Language development; Self-control

Early Childhood 3-6 Years

Initiative vs. Guilt

Identification

Able to Purpose initiate activities and enjoy learning

Courage imagine pursue goals

to Sex-role and identification; valued Early moral development; Self-esteem; Group play;

Egocentrism Middle Childhood 6-12 Years Industry vs. Inferiority Education Acquire skills Competence for and develop competence in work; Enjoy achievement Early Adolescence 12-18 Years Ready to plan for the future Group Identity Peer group vs. Alienation A strong Loyalty group identity; Free exercise of Friendship; skill and intelligence in Skill learning; completion of tasks Self-evaluation; Team play

Ability to freely Physical pledge and maturation; sustain loyalty to others Emotional 7 development; 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 whomthese 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 (19021994), 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- 37.4C______ Clients Perception of Reason for Admission: ningkalit ra man togi-atake man gud sya sa iyang highblood How was the problem been managed at home? naa man syay 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 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/ - left cephalic vein *Other observations related: patient experienced deep and quick breaths II. Temperature Maintenance *Temperature: 37.2 C *Skin character: with dry, wrinkled, cold and clammy skin *Other observations related: not noted ___ ___ ___ *RR: 24 CPM (Character) Tachypneic,

III. Nutritional Fluids

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*Height/Weight:51/50 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 *Gravida/Parity: N/A *Menstrual Cycle: N/A *EDC: N/A *Family Planning Method Used: N/A *Children: 10 AOG: N/A Prenatal: N/A Gynecologic Problems: N/A

VIII. Stimulation-Activity *Work: Patient is a plain housewife. During hospitalization, she cant able to sit, cant be able to feed herself, cant able to *Recreation / Pastime: *Hobbies / Vices: perform ADL without the assistance from the children, she 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) *Husband (Living with) Client is presently living with her children. She has 9 siblings. 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: A. General Survey

December 9, 2009

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 12-7-09 12:00 4:00 8:00 12-08-09 12:00 4:00 TEMP. 36.7 38 37.2 36.5 36.2 BP 160/90 160/100 130/80 130/80 130/90 PR 80 86 84 93 90 RR
H2O-150cc

I&O
u-c diaper s-0 IVF-90cc OF-210cc

20 24 20 20 20

H20-50cc IVF-120cc OF-600cc

u-500cc s- 0

8:00 12:00

37.2 37

170/110 160/90

87 92

20 20

H2O-50cc IVF-400cc OF-600cc

u-1000cc s-0

4:00 8:00

37.9 38.5

170/110 220/110

95 93

23 21

H20-60cc IVF-110cc

u-1150cc s- 0

Mannitol-100cc

12-09-09 37 12:00 4:00 36.5 140/90 140/90 90 88 20 20

H2O-50cc IVF-150cc OF-400cc Mannitol-200cc u-500cc s-0

8:00 12:00

37.9 37.4

160/100 160/100

98 96

25 23

H2O-60cc IVF-510cc

u-750cc s-0

15

C. Nutritional Status Efficascent has a small body built, stands 51 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 Capsuloganglionic 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 thick. F. HEEN untrimmed and appear

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 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

in diameter less briskly reactive to light and

lesions and dilated veins not noted. Everted unclean navel noted. During auscultation, gurgling noises noted. Doesnt 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 & SHIFT 12-07-09 8am 8:10am NURSES NOTES DOCTORS ORDER RATIONALE

8:15am 8:30am

8:35am

D- Admitted this 68y.o. @8:00am female, in due to cough and right sided weakness. BP -Please admit 160/80 -LSLF A- CBC, ECG 12L, FBS, 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 S. Crea watcher for approval 8:15am Lipid Profile A- Captopril 50mg 1tab SL ECG,CT Scan Cranial, given CXR PA, UA A- Venoclysis of PNSS 1L - Meds: regulated @ KVO rate Citicholine 1gm IVTT q8 A- Transported to room, Cefuroxime 750 mg endorsed to NOD IVTT q8 ANST ( )

LSLF diet-Low Salt

Low Fat diet in order to prevent further complications brought by sodium and fat.

CBC- help determine their general health status. If they are healthy and they have cell populations that are within normal limits, then they may not require another CBC until their health status
18

R- BP-140/80, cranial CT scan still for approval.

ADDENDUM to care >Seen and examined by Dr Llanos Losartan + HCTZ 50/12.5 1 tab OD >Inserted NGT and closed distal end -VS q4 -I&O q4 >CXR-PA and cranial CT -Inform AP scan done. -Refer

Captopril 50mg now, then q6 PRN BP > 160/100

changes or until their doctor feels that it is necessary.

FBS- is ordered in order to determine the serum glucose level of the patient.

-Pls insert NGT -Cranial CT Scan Plain -Give oral meds/NGT -Star OF 1,800 kcal/day in three divided feedings -Paracetamol 500mg 1 tab q4 PRN 5:05pm -IVF TF c PNSS 1L @ SR 10:20pm -Start Mannitol 100 cc q6 -Amlodipine 5g OD/NGT -Insert Foley catheter -I & O q shift

SUA- done to

measure the levels of uric acid in blood serum or in urine

S. Creatinine- is ordered to determine whether the kidneys/ renal system of the patient are functioning well.

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.

Citicholinestimulant

CNS

Mannitol- an osmotic diuretic Cefuroxime- an

antibiotic for the clients cough for she was been also diagnosed with CAP

12-08-09 7am

D- Received from ER per @11am 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 S-Huyang gayud kayo siya 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 5:45pm -IVF TF PNSS 1L @ SR 8:18 pm -Start Nicardipine drip: Nicarl 10 g + 90 cc D5W to run @ 10 mgtts/min, titrate by 5 mgtts/min until BP140/90 8:40 pm -D/C temporarily nicardipine drip and 21 Nicardipine- for hypertension; a calcium channel blocker

12-08-09 3pm

muscle strength 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.

resume once BP is elevated

6pm

>NGT checked, patent: PRN paracetamol given per NGT EAfter 6 hours of nursing care, goal unmet as evidenced by: 10pm- still needs assistance in turning to sides.

22

12-09-09 73

D-Received on bed awake and responsive with IVF #2 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 cc/hour -Start Cefuxime 1.5 g IV q 8hours (ANST) -Captopril 20g TID/NGT -Losartan 500g 1 tab OD/NGT -Paracetamol 500mg 1 tab q4 / NGT RTC x 4

Captopril- ordered for hypertension Losartan + HCTZordered for hypertension

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G. LABORATORIES AND DIAGNOSTIC EXAMINATIONS

HEMATOLOGY

TESTS

RESULTS

NORMAL VALUES M: 140-160 F: 120-140

INTERPRETATION

ANALYSIS

Hemoglobin Mass Concentration Hematocrit Leukocytes No. Concentration

147 g/L

Normal

0.44 15.06 x 10 g/L

0.36-0.48 5.0-10.0 x 10^3/uL

Normal Increase Increased due to Pneumonia. Leukocytes will normally increase to fight against infection. Decrease due to infection.
24

Lymphocytes

0.06

0.24-0.40

Decrease

Eosinophils Basophils Monocytes Thrombocytes

0.04 0.01 0.02 246.6

0.01-0.05 0-1 0.02-0.06 150-400 x 10^3/uL

Normal Normal Normal Normal

Segmenters

0.90

0.40-0.60

Increase

Exam: URINALYSIS Color: Yellow Sugar: Negative Albumin: TRACE Platelet: 6.0 Specific Gravity: 1.015 Epithelial Cells: Few Pus Cells: 1-2/HPF M. threads: FEW RBC: 2-4 HPF

BLOOD CHEMISTRY

Test FBS Creatinine Uric acid

Result 5.51 mmo/l 74.26 376 mmo/L

Unit mmol/L umol/L mmo/L

Reference Range 4.56-6.38 mmol/L 45-84 umol/L

140 340 mmo/L Total Cholesterol Triglycerides 142 mg/dL 110 mg/dL mg/dL mg/dL 150- 200 mg/dL 325 mg/dL

25

HDL LDL

37 mg/dL 83

mg/dL mg/dL

48-65 mg/dL 66 -178 mg/dL

X-RAY REPORT Clinical diagnosis: Cough Refered By: Llanos

DATE: 12/07/09 EXAMINED: CHEST PA (X-Ray) 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 CLINICAL DIAGNOSIS: CVA Refered By: Llanos CT-SCAN of the Brain

DATE: 12/07/09 EXAMINED: CRANIAL ( CT-SCAN) Department: In-patient

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 patients 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
CLINICAL DIAGNOSIS: CVA Refered By: Llanos

DATE: 12/07/09 EXAMINED: CRANIAL ( CT-SCAN) 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.

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Figure 24 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 24 illustrates the flow of CSF through the central nervous system.

Major regions of the brain and their functions

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The major regions of the brain (Figure 25) are the cerebral hemispheres, diencephalon, brain stem and cerebellum.

Figure 25 Major Regions of the Brain. (Reproduced from [Marieb 1991]).

Cerebral hemispheres The cerebral hemispheres (Figure 26), 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. Interpretation and production of symbolic information:language, Left Hemisphere Sequential Analysis: systematic, logical interpretation of information. 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 bodys 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.

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Figure 26 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.

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Figure 27 Major cerebral arteries and the circle of Willis. (Reproduced from [Marieb 1991]).

Blood supply to the brain Figure 27 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 brains 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 brains surface. Hence occlusion of these arteries usually results in localised tissue damage.

I. SYMPTOMATOLOGY

CLINICAL MANIFESTATIONS 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 Sudden confusion or

PRESENT IN THE PATIENT

RATIONALE 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.

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 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. Hypoglossal nerve(Cranial nerve XII) is affected which is responsible for speaking, chewing and swallowing.

Difficulty 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 arteries (cerebral amyloid angiopathy), which affects primarily the elderly. Lobar hemorrhages may be multiple and recurrent.
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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). 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 &
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Huether, 2006). There is a very high probability of reoccurrence in these patients if left untreated (McCance & Huether, 2006). Like thrombotic strokes TIAs are usually caused by atherosclerosis (Corwin, 2008). It has been hypothesized that TIAs 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: Gender Age Precipitating Factors: Lifestyle Uncontrolled HTN

Hypertension

Hyperlipidemia

Shearing force

Fatty disposition into arterial wall 37

Damage of arterial endothelial layer

Inflammatory response & intramuscular clotting

Atheromatous aorta S: Sx BP, dyspnea, Angina, edema, Dizziness, swollen Neck vein, LVH

Thrombus Formation

Narrowing of the lumen

Embolic occlusion in myocardial artery 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

CVA

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Prognosis

If Treated

If untreated

Return of normal perfusion

Coma

Cerebral death Decreased Edema

Loss of neural feedback mechanism

Cessation of physiologic functions

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L. SYNTHESIS OF THE CLIENTS 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 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
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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. Patients 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 ones 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-thecounter 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. Exercise Everyone needs regular physical activity that strengthens body structures. Regular exercises are good for the heart and lungs and could stimulate proper
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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 doctors 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, HMGCoA 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 of acquiring infection. Daily bath is recommended as well as frequent hand hygiene, not only for the client but also for the clients significant others.

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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 highfiber 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.

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M. EVALUATION After our thorough assessment, comprehensive observation, interpretation of the patients laboratory results, the nursing responsibilities of the prescribed medication, knowing the factors that affect the disease process and the
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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 patients 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. 5.) The predisposing and precipitating factors that contributed to the disease process and present comprehensively in a written and diagrammatic illustration were identified.
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6.) The pathophysiology of CVA Bleed, HCVD, CAD, LVH, MI, CAP MR, its symptomatology and complications of the client was discussed. 7.) The clients 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.

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