A Case Presentation of a Patient with

Hemorragic Crebrovascular Accident

Submitted by: Filomeno, Gerald V. Group 9 Submitted to: Ms. Rosa Reyes RN,MAN

Introduction A stroke is damage to part of the brain when its blood supply is suddenly reduced or stopped. 4. Specific Objectives 1. 2. or CVA. Blood is prevented from reaching brain tissue when a blood vessel leading to the brain becomes blocked (ischemic) or bursts (hemorrhagic). and loss of consciousness. or leg. To be able to formulate effective nursing care plan for the . To be able to discuss the pathology of the disease. To be able to discuss the effects of the drugs taken to the patient's condition. A stroke may also be called a cerebral vascular accident. loss of balance. The symptoms of a stroke differ. numbness. or tingling in the face. Symptoms following a stroke come on suddenly and may include: weakness. dizziness. especially on one side of the body trouble walking. severe headache with no known cause. such as swallowing. moving arms and legs. 3. confusion or personality changes. or double vision. LEARNING OBJECTIVES: General Objective This case presentation aims to increase my knowledge and skills regarding Cerebrovascular Accident thus enabling me to learn how to render a quality health care to patient with this kind of diagnosis. The part of the brain deprived of blood dies and can no longer function. trouble seeing with one or both eyes. loss of bowel and bladder control. To be able to state the significance of laboratory findings to patient's condition. difficulty with muscle movements. or coordination inability to speak or difficulty speaking or understanding. arm. depending on the part of the brain affected and the extent of the damage.

HPN. Rustico Jimenez Final Diagnosis: CVA Hmg.F. DEMOGRAPHIC PROFILE Name: J. UTI Source of Information: Patient and Chart . Tagalog Date of Admission: August 02. 1975 Place of Birth: Negros Occidental Citizanship : Filipino Religion: Roman Catholic Occupation: Security Guard Language Spoken: English.patient diagnosed of Cerebro Vascular Accident.R Age: 37 y/o Gender: Male Civil Status: Married Date of Birth: June 07. 2010 Chief Complain: Increase blood pressure Admitting Diagnosis: CVA bleed Admitting Physician: Dr.

patient suddenly experienced dizziness with elevated blood pressure of 200/120mmhg.R (+) hx of hypertension Allergic to Seafoods and chicken No history of DM No hx of asthma . Patient was initially brought to Olivarez General Hospital and was subsequently transferred to Medical Center Paranaque with an admitting diagnosis of CVA bleed under the care of Dr. Rustico Jimenez Social History The patient doesn’t smoke and occasionally drink alcoholic beverages Family History Father (+) allergy to seafoods (+) hx of asthma No hx of DM No hx of heart Mother (+) hx of hypertension No history of DM No hx of asthma No hx of allergy PATIENT J.Past Medical History The pt was never been hospitalized before and had not experienced any kind of diseases that needs hospitalization. History of Present Illness Few hours prior to admission. He was a known hypertensive but no medications taken.F. Patient also vomited once but he did not loss consciousness.

is conscious and coherent With IVF of PNSS 1L x 16hrs regulated at 20-21 gtts/min With O2 inhalation via nasal cannula With Nasogastric Tube inserted. On Osteorized feeding Area Assessed SKIN color Turgor Temperature NAILS Color of Nail bed Capillary refill time FACE Skin color EYES PUPILS Reaction to light Size Lips Color NECK Movement Range of motion HEART Heart rate THORAX & LUNGS POSTERIOR Findings Tan Skin snaps back immediately When pinched Warm to touch Pink and clear 2-3 seconds Tan Anicteric sclera. With Foley catheter inserted.Physical Assessment Date assessed: August 09.4C Pulse Rate: 64 bpm Respiratory Rate: 16 cpm Blood Pressure: 150/100 mmHg • • • • • • General Appearance: The pt.2010 Vital Signs: Temperature: 36. pink palpebral conjunctiva Pupils Equally Round and React to Light Accommodation Equal Pinkish to slightly brown Moves freely Limited ROM Normal. regular rate 64bpm .

3 None.z Verbal 5 Motor 6 .5 Flexion pain4 Abnormal flexion.6 Localized pain. person and place.THORAX Respiratory rate 16cpm ANTERIOR THORAX Breathing pattern Lung/ breath sounds ABDOMEN Contour EXTREMITIES Breathing is automatic and effortless.2 None-1 Oriental.. Interpretati on 8/15 pts. Pt is alert. regular and even and produces no noise Clear breath sounds Flat .5 Confused. good prognosis (15 pts.3 To pain.1 Result 4 Total GCS Total GCS= 15/15 points.2 Flaccid. can follow simple commands and is completely oriented to time.3 Abnormal extension.) (3= indicates deep coma and poor prognosis.) (7 or less= pt is comatose.1 Obeys command. soft with no tenderness No gross deformities Neurological Assessment (August 09.4 Inappropriat e word.2010) Glasgow Coma Scale Eyes Normal Values Spontaneous -4 To speech.