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 countrys 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, Gordons 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.

PATIENTS 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, patients chart, Records 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 Alzheimers 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 Peoples 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 Alzheimers 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.

GORDONS 11 FUNCTIONAL PATTERN

Health Perception-Health Management Pattern
Before Hospitalization
According to the SO, her mother has been
pampered starting when she was diagnosed
with Alzheimers disease 5 years ago. When she
suffered from the sickness, they treated her
immediately by taking OTC drugs for cough,
colds and fever. With regards to her
maintenance drugs to her hypertension, they
give it at right time as prescribed.

During Hospitalization
According to the SO, she stated that her mother is not in
good condition. She believes that doctors, nurses and other
medical members will help her mother to recover. SO also
added that they obediently follow all the orders of the
doctors.

Nutritional- Metabolic Pattern

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

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 didnt 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 around 8 in Patient is comatose but can respond to physical
the evening and wakes up at around 5 in the
stimuli.
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.
Self- Perceptual Pattern
Before Hospitalization
The patient suffers from Alzheimers disease.

During Hospitalization
The patient responds to stimuli by means of rubbing
her sternum for her to wake up.

During Hospitalization
The patient is comatose.

Role- Relationship Pattern

Before Hospitalization
According to the SO, before her mother was
diagnosed with Alzheimers, 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.

Coping- Stress Pattern

Before Hospitalization
When her mother is tired, she sleeps for her to rest.

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.

During Hospitalization
During her present condition, she is in a 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 Alzheimers 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: 36.8C

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
ASSESSED
SKIN
-

METHOD USED

NORMAL
FINDINGS

ACTUAL
FINDINGS

ANALYSIS

Color

Inspection

Fair complexion

Pale

d/t decreased tissue

perfusion and
peripheral
vasoconstriction

Texture

Inspection/
Palpation

Smooth

Wrinkled

d/t loss of elastic

fiber and decreased
subcutaneous fat
from hypodermis
secondary to aging

Presence of
rashes

d/t poor hygiene

Inspection

Temperature

Palpation

Normally warm

Cold and
clammy

d/t peripheral
vasoconstriction

Moisture

Palpation

Moist to dry

Dry

d/t decreased activity

of sebaceous and
sweat glands
secondary to aging

Turgor

Palpation

Snaps back to
previous

Sagged

d/t loss of elastic

fiber and decreased
subcutaneous fat
from hypodermis
secondary to aging

Inspection/
Palpation

Evenly distributed

Evenly
distributed

Normal

Inspection

Silky, resilient

Resilient

Normal

HAIR
- distribution

Texture

Color

NAILS
- Color of the nail
bed

Inspection

Black

Black w/ white
hairs

d/t decreased
melanocyte
production secondary
to aging

Inspection

Pink transparent

Pallor

d/t poor arterial

circulation

Capillary refill
time

Palpation

Delayed 1-2 sec.

Delayed 4 sec.

d/t poor arterial

circulation

Shape

Palpation

Convex

Convex

Normal

Inspection

Round

Round

Normal

EYES/EYEBROWS
- Shape
-

Symmetry

Inspection

Equal in size

Equal in size

Normal

Movement

Inspection

Symmetrical in
movement

Symmetrical in
movement

Normal

Ability to blink

Inspection

Blinks involuntarily
& bilaterally

Absence of blink

d/t decrease activity

of CN V

CONJUNCTIVA
- Color

Inspection

Pink-red

Pale

d/t poor arterial

circulation

PUPILS
- PERRLA

Inspection

Response to
penlight (dilates
and constricts)

Very slow to
react to light

d/t compression of
CN III

Size of the pupil

Inspection

2mm

EXTERNAL AUDITORY
CANAL
- Hearing

Inspection

Hears equally in
both ears

Hears equally in
both ears

Normal

NOSE
- Symmetry

Inspection

Symmetrical

Symmetrical

Normal

Inspection

Same color as the

face and neck

Same color as
the face and
neck

Normal

Inspection

Symmetrical

Symmetrical

Normal

Color

LIPS & MOUTH

- Symmetry
-

Color (lips)

Inspection

Pink

Pale

d/t decrease
oxygenation

Moisture

Inspection

Moist

Dry

d/t decreased
salivary production
r/t loss of vagal
stimulation

Palpation

Symmetrical

Symmetrical

Normal

NECK
- Symmetry

Appearance

THORAX
- Chest contour

Inspection

No distentions

No distentions

Normal

Inspection

Symmetrical

Symmetrical

Normal

Clavicle

Inspection

Prominent

Prominent

Normal

Chest wall

Inspection

Full chest
expansion

Full chest
expansion

Normal

Breathing
pattern

Inspection

Regular

Irregular

d/t decreased
function of the
medulla

Inspection
Auscultation
Percussion
Palpation

Non-tender

Non-tender

Normal

Inspection

Symmetrical

Symmetrical

Normal

Inspection/
Palpation

(+) ROM upon

movement

(+) ROM upon

movement

Normal

Inspection

Equal in size

Equal in size

Normal

ABDOMEN
- General contour

UPPER EXTREMITIES
- Symmetry
-

ROM

LOWER EXTREMITIES
- Size
-

Symmetry

Inspection

Symmetrical

Symmetrical

Normal

ROM

Inspection

(+) ROM upon

movement

(+) ROM upon

movement

Normal

LABORATORY RESULTS
HGT
Date
11-21-09 6am
11-21-09 6pm
11-22-09 6am
11-22-09
11-23-09
11-24-09
11-27-09
11-28-09
11-30-09
12-01-09

Result
284 mg/dl
155 mg/dl
186 mg/dl
153 mg/dl
170 mg/dl
215 mg/dl
172 mg/dl
152 mg/dl
120 mg/dl
133 mg/dl

Normal Range
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl

Analysis

Result
131 mmOl/L
132 mmOl/L

Normal Range
135-145 mmOl/L
135-145 mmOl/L

Analysis
Normal
Normal

Result
3.0 mmOl/L
4.0 mmOl/L

Normal Range
3.5-5.5 mmOl/L
3.5-5.5 mmOl/L

Analysis
Normal

Result
12.4x103 /mm3
3.83x106 /mm3
11.4 g/dl
37.0%
188x103/mm3

Normal Range
3.5-10
3.8-5.8
11.0-16.5
35-50
150-390

Analysis
d/t increase pyrogens
Normal
Normal
Normal
Normal

Na
Date
11-24-09
11-29-09
k
Date
11-24-09
11-29-09
CBC
11-20-09
Parameters
WBC
RBC
Hgb
Hct
PLT

INTAKE AND OUTPUT MONITORING SHEET

12-05-09
Intake
Time
7-3
3-11
11-7

Oral
500
1000
660

Output

Parenterral Others Total

100
600
430
700
200
800
Total: 2890

Urine
600
700
800

Drainage

Others

Total
600
700
800
Total: 2100

Others

Total
250
500
200
Total: 950

12-04-09
Intake
Time
7-3
3-11
11-7

Oral
720
1000
600

Output

Parenterral Others Total

100
75
895
250
1250
250
850
Total: 2995

Urine
200
500
200

Drainage

12-03-09
Intake
Time
7-3
3-11

Oral
750
1000

Output

Parenterral Others Total

350
75
1175
200
4
1204
Total: 2379

Urine
290
350

Drainage

Others

Total
290
350
Total: 640

12-02-09
Intake
Time
7-3
3-11
11-7

Oral
900
832
600

Parenterral
550
120
200

Output
Others Total
75
1525
75
1027
75
875
Total: 3427

Urine
790
660
550

Drainage

Others

Total
790
660
550
Total: 2000

Others

Total
1000
1100
900
Total: 3000

Others

Total
400
Total: 400

11-30-09
Intake
Time
7-3
3-11
11-7

Oral
600
890
550

Parenterral Others Total

340
940
475
1365
200
750
Total: 2055

Output
Urine
1000
1100
900

Drainage

11-29-09
Intake
Time
3-11

Oral
800

Parenterral Others Total

300
1100
Total: 1100

Output
Urine
400

Drainage

11-28-09
Intake
Time
7-3
3-11
11-7

Oral
830
1030
700

Parenterral Others Total

550
1380
700
1730
700
1400
Total: 4510

Output
Urine
1350
600
1650

Drainage

Others

Total
1350
600
1650
Total: 3600

Others

Total
1630
1050
Total: 2680

Others

Total
600
1250
Total: 1800

Others

Total
500
800
1250
Total: 2550

Others

Total
350
1400
Total: 1750

Others

Total
300
600
700
Total: 1600

11-27-09
Intake
Time
7-3
3-11

Oral
1030
600

Parenterral Others Total

600
1630
450
1050
Total: 2680

Output
Urine
1630
1050

Drainage

11-26-09
Intake
Time
7-3
3-11

Oral
860
1250

Parenterral Others Total

475
1335
400
1650
Total: 2985

Output
Urine
600
1250

Drainage

11-25-09
Intake
Time
7-3
3-11
11-7

Oral
770
810
800

Parenterral Others Total

350
1120
200
1010
200
1000
Total: 3130

Output
Urine
500
800
1250

Drainage

11-24-09
Intake
Time
7-3
3-11

Oral
715
850

Parenterral Others Total

400
1115
200
1050
Total: 2165

Output
Urine
350
1400

Drainage

11-23-09
Intake
Time
7-3
3-11
11-7

Oral
1030
700
600

Parenterral Others Total

200
1230
500
1200
750
1350
Total: 3780

Output
Urine
300
600
700

Drainage

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 Wernickes area. Speaking ability is in Brocas area. Damage to
Brocas area causes speech impairment but not impairment of language comprehension. Lesions in Wernickes
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.