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May 6


A case assignment in partial fulfillment of the

requirements for the Nursing Education Research
and Development of Makati Medical Center

Submitted by:
Dela Cruz, John Nikko L., RN
Nurse Residency Probationary Program
Part I. Introduction

A. Definition
Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen
when the blood flow to the brain is impaired by blockage or rupture of an artery to the
brain. A CVA is also referred to as a stroke. A hemorrhagic stroke occurs if an artery in
the brain leaks blood or ruptures (breaks open). An ischemic stroke occurs if an artery
that supplies oxygen-rich blood to the brain becomes blocked. Blood clots often cause
the blockages that lead to ischemic strokes. The pressure from the leaked blood
damages brain cells. A transient ischemic attack (TIA or mini-stroke) describes an
ischemic stroke that is short-lived where the symptoms resolve spontaneously. This
situation also requires emergency assessment to try to minimize the risk of a future
stroke. By definition, a stroke would be classified as a TIA if all symptoms resolved
within 24 hours.

(Shiel W.C. MD, 2019)

B. Statistics
B.1 International
Worldwide, cerebrovascular accidents (stroke) are the second leading cause of death
and the third leading cause of disability. Stroke, the sudden death of some brain cells
due to lack of oxygen when the blood flow to the brain is lost by blockage or rupture of
an artery to the brain, is also a leading cause of dementia and depression. Globally,
70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years
occur in low- and middle-income countries. Over the last four decades, the stroke
incidence in low- and middle-income countries has more than doubled. During these
decades stroke incidence has declined by 42% in high-income countries.3 On average,
stroke occurs 15 years earlier in – and causes more deaths of – people living in low-

and middle-income countries, when compared to those in high-income countries.2
Strokes mainly affect individuals at the peak of their productive life.The 2019 update of
statistics are yet to be studied in the International Stroke Conference of 2019 to be held
in Honolulu, Hawaii.

(Geneva: World Health Organization; 2012, Global Health Estimates)
(Bennett DA, et al., 2010 Global Burden of Diseases, Injuries, and Risk Factors Study)

B.2 Local
No less than 300,000 Filipinos are unknowingly suffering from AF (Atrial Fibrilation)
because they ignore the signs of the silent heart condition that can lead to massive
stroke and death. Based on the data he presented, one in every six stroke incidents in
the Philippines is AF-related. If the total ratio of AF-related strokes in the 200,000 cases
listed every year in the Philippines will be counted, Villela said no less than 17 percent
are from the irregular heart beat scenario.
“Those suffering from diabetes, hypertension, always stressed and are snoring have 50
percent of experiencing this kind of stroke in five years or less,”(Villela G. MD, 2019)
2.9 million will suffer from an AF-associated stroke. Villela’s data is supported by the
Department of Health; said AF-related stroke is the second leading cause of death in
the Philippines after heart disease.

(Villela G. MD, 2019)
(Velasco E., 2019 “300K Pinoys at risk of deadly stroke every year”)

C. Risk Factors
Risk factors of Stroke includes high blood pressure, Diabetes, Heart diseases, smoking,
age, gender, ethnicity, family history of stroke, and Brain aneurysms. Other risk factors
for stroke, many of which of you can control, are Alcohol and illegal drug use, including

cocaine, amphetamines, and other drugs Atrial Fibrilation is also a risk factor (Villela G.
MD, 2019). Certain medical conditions, such as sickle cell disease, vasculitis and
bleeding disorders, lack of physical activity, being overweight, stress, unhealthy
cholesterol levels, and unhealthy diet.

(National Heart, Lung, and Blood Institute USA, 2019)

D. Signs and Symptoms

Symptoms of a stroke depend on the area of the brain affected. The most common
symptom is weakness or paralysis of one side of the body with partial or complete loss
of voluntary movement or sensation in a leg or arm. There can be speech problems and
weak face muscles, causing drooling. Numbness or tingling is very common. A stroke
involving the base of the brain can affect balance, vision, swallowing, breathing and
even unconsciousness.

(Shiel W.C. MD, 2019)

E. Preventive Measures
Controlling the blood pressure and diabetes will lessen the risk of having stroke.
Withdrawal from smoking also helps. Screening and evaluation of the current health
status of narrowed carotid arteries and treating it will reduce the risk of stroke.
Maintenance medications to avoid blood clots are also beneficial. But the biggest
preventive measure is to maintain/have a healthy life style.

(Shiel W.C. MD, 2019)

F. Medical, Surgical, Pharmacological, and Nursing Management
Early use of anticoagulants to minimize blood clotting has value in some patients.
Treatment of blood pressure that is too high or too low may be necessary. The blood
sugar (glucose) in diabetics is often quite high after a stroke; controlling the glucose
level may minimize the size of a stroke. Drugs that can dissolve blood clots may be
useful in stroke treatment. Clot retrieving interventions can now be performed in some
stroke centers. Oxygen is given as needed. New medications that can help oxygen-
starved brain cells survive while circulation is reestablished are being developed.

(Shiel W.C. MD, 2019)

G. Complication
Following a stroke, patients may have limited mobility which predisposes them to
complications such as pressure sores and deep vein thrombosis. Stroke patients often
have swallowing difficulties which can increase the risk of choking and chest infection.
Chest infection following stroke is commonly due to aspiration, inhaling oral or gastric
contents into the lung due to swallowing difficulties. Stroke patients are prone to urinary
retention which increases the risk of urinary tract infections. Weakness, sensory
impairment, incoordination, imbalance and visual problems predispose the patient to
accidents and falls. Depression are also to be expected when patients thinks they are
incapable and feels like they are burden to their family

(Talabucon L. MD, 2019,Natinal Neuroscience Institute of Singapore)

Part II. Pathophysiology

Predisposing Factors Precipitating Factor

- High blood pressure - Lack of physical activity

- Diabetes - Overweight
- Heart diseases - Stress,
- Age - Unhealthy cholesterol levels
- Gender - Unhealthy diet
- Ethnicity - Drug and Alcohol abuse
- Fx of stroke -Unhealthy life Style
- Aneurysms - Atrial Fibrilation

Signs and Symptoms Preventive Measures

- Weakness -Healthy life style

- Paralysis (one side of body; Partial or -Screening and
total loss of movement in extremities) evaluation
- Speech problems -Stop smoking
- Weak muscles causing to drool, -Follow maintenance
difficulty in swallowing and breathing
Stroke medications
- Numbness or tingling
- Unstable balance
- Vision (partial or total loss)
- Unconsiuosness

Medical, Surgical, Pharmacological, and Nursing Management

-Anti coagulants
-Treatment of BP Through antihypertensive medicines
- Aneurysm Clipping/ Hematoma Evacuation
-Oxygen Therapy
-Physical Therapy
-Diet restriction
-Progress evaluation through NIH Stroke Scale
-Lifestyle modification


-Pressure sores

Part III. Nursing Care Plan

Assessment Nursing Planning Interventions Evaluation


1. establish rapport Short Term:

The patient has
Objective: Short Term: 2. monitor vital signs
Impaired Physical participated in
After 4 hrs. of 3. note activities
•right hemiplegia Mobility R/t nursing necessary for
•limited ROM intervention the emotional/behavioral
neuromuscular recovery.
patient will responses to problems
•difficulty turning involvement participate
•slowed willingly in of immobility
secondary to
activities 4. determine readiness Long Term:
movement CVA infarct necessary for The patient has
•Muscle strength recovery to engage in
improved and
of right arm: 0/5; activities/exercises increase
Long Term: strength and
right leg: 0/5; left 5. assist patient
After 3 days o function of
arm:5/5; left nursing reposition self on a affected body
intervention the part.
leg:5/5 6. regular schedule
patient will be
•gait changes able to improve 7. provide for safety
and increase measures including
•Postural strength and
Instability during function of fall prevention
affected body 8. identify energy
performance of part/s
routine ADL’s conserving techniques

•movement for ADL’s

induced 9. involve patient and SO

shortness of in care assisting them

breath/tremors to learn ways of

managing problems of
10. assist patient to do
passive range of
11. provide restful
environment for
patient after periods of

Assessment Nursing Planning Interventions Evaluation

1. Establish rapport Short Term:

Patient has
Objective: Short Term: 2. Monitor vital signs
Ineffective displayed
After 4 hours of 3. Check capillary refill decreased signs
 hemiplegia cerebral tissue nursing of tissue
intervention, the and conjunctiva for
 assess for perfusion r/t perfusion seen
patient will be paleness through gradual
muscle interruption of able to display improvement of
decrease signs of 4. elevate head of bed to
strength blood flow vital signs
ineffective tissue 30 degrees as ordered
 altered secondary to perfusion as
evidenced by 5. Advise patient to have
mental status CVA
gradual enough rest Long Term:
 restlessness improvement of Patient has
vital signs. 6. Avoid neck flexion and
 changes in improved tissue
extreme hip/knee perfusion seen
pupillary Long Term: through good
After 3 days of extension
reactions capillary refill
nursing 7. Provide and maintain and pink
 difficulty in intervention, the conjunctiva
patient will oxygen as ordered
swallowing gradually improve 8. Perform GCS /NIH
tissue perfusion
seen through a STROKE SCALE
good capillary monitoring as ordered
Subjective: refill, and pink
conjunctiva. 9. Administer
None medications as