OUR LADY OF FATIMA UNIVERSITY- VALENZUELA

COLLEGE OF NURSING
120 McArthur Highway, Marulas, Valenzuela City

CASE ANALYSIS IN GERONTOLOGICAL NURSING:

CEREBROVASCULAR ACCIDENT

RESIDENT: FERRER, ROSALINDA

SUBMITTED BY:
GALOLO, ANDREA PAULINE NIU
BSN 3 - Y1 - 17
GROUP F
 I. INTRODUCTION

A cerebral vascular accident (CVA), often known as a stroke, is a severe and

frequently fatal medical event that happens when the blood supply to the brain is
suddenly disrupted. Strokes can take many different forms, but they are commonly
classified. There are two types of strokes: ischemic strokes and hemorrhagic strokes.
The most frequent type of stroke is an ischemic stroke, which occurs when a blood clot
or other blockage restricts blood supply to a portion of the brain. Hemorrhagic strokes,
on the other hand, are caused by a blood vessel rupture. Within the brain, causing
bleeding and damage. Depending on the degree and location of the brain damage,
strokes can have dramatic and long-term impacts on an individual's physical and
cognitive capacities. A stroke is characterized by sudden weakness or paralysis of the
face, arm, or leg, trouble speaking, vision issues, and severe headaches. Prompt
medical attention is critical to minimizing harm and improving recovery chances, since
therapies such as clot-busting medicines or surgical interventions may be successful in
some circumstances. Reduced risk factors such as high blood pressure, smoking,
obesity, and diabetes can also help reduce the likelihood of having a stroke.
Furthermore, ongoing therapy and lifestyle changes are frequently required for stroke
patients to regain as much function and independence as possible.

II. ANATOMY AND PATHOPHYSIOLOGY

ISCHEMIC AND HEMORRHAGIC STROKE
 Strokes are typically classified into two types: ischemic and hemorrhagic.
Ischemic strokes occur when a blood clot or other obstruction, frequently caused by
atherosclerosis or embolism, plugs a blood vessel. supplying the brain. This causes
decreased blood flow and deprivation of oxygen and nutrients to brain tissue, resulting
in damage. Hemorrhagic strokes, on the other hand, are caused by a blood artery
rupture in the brain, resulting in bleeding into the surrounding tissue. This bleeding can
cause pressure, inflammation, and brain cell destruction.

The stroke's pathophysiology is characterized by a series of events. In ischemic

strokes, the initial obstruction of a blood vessel causes oxygen and glucose deficiency
in the afflicted area. This deprivation causes brain cells to die quickly, triggering an
inflammatory reaction and the production of poisonous chemicals. The bleeding in
hemorrhagic strokes generates a mass effect, squeezing and injuring adjacent brain
tissue in addition to the adverse effects of the blood itself.

III.COURSE IN THE WARD

Date and Time DAY 1

7:00 am - 9:00 am - Logged in

- Orientation

9:00 am -12:00 pm - Taking Vital Signs

- Massage Therapy
- Morning exercise
- Changing Diapers
- Music Therapy
- Preparation of meals
- Helping feed the lolas who are not
able
- Music Therapy/Karaoke

12:00 pm - 1:00 pm - Lunch break

- Quiz
- Journal
1:00 pm - 6:00 pm - Taking Vital Signs
- Art therapy
- Changing of diapers
- Music Therapy
- Giving Merienda
- End of shift

Date and Time DAY 2

7:00 am - Logged in

8:00 am -12:00 pm - Taking Vital Signs

- Assisted the residents with their
morning snacks
- Massage Therapy
- Morning exercise
- Changing Diapers
- Music Therapy
- Preparation of meals
- Helping feed the lolas who are not
able
- Music Therapy/Karaoke

12:00 pm - 1:00 pm - Lunch break

- Quiz
- Journal

1:00 pm - 6:00 pm - Taking Vital Signs

- Art therapy
- Changing of diapers
- Music Therapy
- Giving Merienda
- End of shift
 I. MMSE, PERSON OR GORDON’S AND OTHER ASSESSMENT METHOD

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Before Hospitalization During Hospitalization

Pattern
1. Health
Perception - Patient responded saying she thinks Patient responded that she is
Health that she is okay, and if she ever feels okay as well.
Management sick she just sleeps it off.
Pattern

2. Nutritional - Patient is ordered on a Low salt,

Metabolic Patients stated that they eat whatever low cholesterol diet.
Pattern it is that is available.

3. Elimination Patient voids multiple times in

Pattern Patient voids and defecates once a the diaper and defecates once in
day, does not have a problem with diaper as well, patient has
bladder control, does not feel any pain. bladder incontinence.

4. Activity- Patient no longer exercises as

Exercise Pattern she is bedridden and cannot
Patient used to exercise everyday. stand up.

5. Cognitive - Patient was still aware and oriented Patient is aware of time or place,
Perceptual upon admission. but the patient has trouble
Pattern remembering simple
conversation and instructions.

6. Sleep - Rest Patient sleeps early and wakes up Patient sleeps at 7:00 pm and
Pattern early. wakes up at 4:00 am but wakes
in between those times and
takes naps at mid-morning and
afternoon.
 7. Self-perception Patient still wear make- up everyday Patient still knows how to use
- Self-concept after baths. her make- up and wear it
Pattern everyday.

8. Role- Patient did not respond. Patient have daughter and 1

Relationship grandchild
Pattern

9.Sexuality - Patient did not respond. Patient has refused to answer

Reproductive
Pattern

10. Coping- Patient did not respond. Patient has refused to answer
Stress Tolerance
Pattern

V. 2 NCP
VI. DRUG STUDY
VII. RECOMMENDATIONS USING METHODS

Medication:
• Instruct the patient to take the medication given by the doctor on time.

Environment:
• Assure that the patient's living space is free of potential tripping risks, such as loose
rugs or clutter. If required, install grab bars in the bathroom and near the bed, and utilize
them with mats that are non-slip.
Treatment:
• Patients and caregivers are frequently urged to undertake lifestyle modifications in
order to lessen the possibility of having another stroke. This can include treating
hypertension, diabetes, and other conditions with high cholesterol, as well as following a
healthy diet and exercise routine.

Health Teaching:
• Address the need for controlling excessive blood pressure, which is a major risk factor
for stroke. Teach the necessity of consistently monitoring blood pressure and taking
prescribed anti-hypertensive medications.
• Include caregivers in the education process because they are critical to the patient's
recovery. Give them knowledge and resources to help them get the best treatment
possible.

Out-patient follow up:

• The healthcare practitioner will review the patient's medications during follow-up
appointments. They may change prescriptions, adjust dosages, or eliminate particular
medications. Medicines are prescribed based on the patient's improvement and any
side effects.

Diet:
• Encourage a fruit and vegetable-rich diet with at least five servings each day. These
are high in fiber, vitamins, minerals, and antioxidants, all of which help with digestion
and general health.

Social:
• Encourage involvement in adaptive activities such as wheelchair sports, art therapy,
and adaptable yoga courses, which can improve both physical and mental well-being
while promoting a sense of belonging.
 NURSING CARE PLAN

Assessment Nursing Inference Planning Nursing Rationale Evaluation

Diagnosis Intervention

Objective: Impaired Impaired After a 1. Establish 1. To After a 2-hour of

mobility mobility 2-hour of rapport promote nursing intervention
ВР: 130/90
PR: 89 related to related to a nursing trust and the resident was
RR: 22
mild mild stroke intervention 2. Take the compliance able to:
Temp: 36.5
Oz stat: 95 stroke is evident the resident resident's 2. To get the
in the will be able vital signs. resident's Short term:
- Bedridden patient's to: baseline
- (+) Lower
muscle Short term: 3.Instruct data for any ● Establish
extremities
weakness weakness • Establish on how to discomfort. and
and goals for improve 3. Ongoing implement
- (+) imbalance
- (+) poor unsteady improving mobility by exercise goals for
range of motion
gait, mobility. doing helps improving
reflecting • Identify exercise. maintain mobility
partial potential fall and further ● identify
neurologica hazards. 4. improve every
l deficits on After a Demonstrat mobility, potential fall
one side of 6-hour of e and preventing hazard.
the body. nursing educate all muscle
intervention the fall weakness After a 6-hour of
the resident hazards and joint nursing intervention
will be able around his stiffness. the resident was
to: environmen 4. Fall able to:
Long term: t. prevention Long term:
• Walk with 5. education is ● Use assistive
assistance Demonstrat essential for devices like
Prevent falls e how to enhancing walkers.
use safety and ● Prevent
assistive preventing falling.
devices like injuries that
walkers or could
canes. exacerbate
6. Educate mobility
the resident issues.
and 5. Assistive
caregiver devices
about fall enhance
prevention mobility and
strategies safety,
and facilitating
techniques, independent
such as movement
how to rise and risk of
from a falls.
seated 6. Falls can
position or lead to
move secondary
safety. complication
s, such as
pressure
sores,fractur
es, or
injuries.
Preventing
falls helps
avoid these
additional
health
challenges
and
supports the
residents'
recovery
from the
mild stroke.
 Assessment Nursing Inference Planning Nursing Rationale Evaluation
Diagnosis Intervention

Objective: Impaired Open After a 1. Establish 1. To After a 2-hour of

skin wounds, 2-hour of rapport promote nursing intervention
BP: 130/100
PR: 89 integrity including nursing trust and the resident was
RR: 22
cuts, intervention 2. Take the compliance able to:
Temp: 36.3
02 stat: 95 abrasions the resident resident's 2. To get the
- (+) skin
are clear will be able vital signs. resident's Short term:
lesions
-(+) dry skin indicators to: baseline ● Understand
- (+) itchy skin
of impaired Short term: 3. Explain data for any and repeat
sensation on
lower skin • Understand how the discomfort. verbally the
extremities
integrity, and repeat resident 3. Early ways of
exposing verbally the can prevent detection of prevention
the ways of further skin and skin
underlying prevention complicatio changes care.
tissues to and skin ns by doing enables ● Use skin
potential care. skin timely protectants
harm. Use skin assessment intervention, and lessen
Prolonged protectants to . reducing the complication
pressure minimize and 4.Demonstr risk of s.
on the skin, prevent ate on how complication ● Stop from
especially further to do skin s. scratching
in immobile complications care to 4.
individuals, . lessen the Maintaining After a 6-hour of
can lead to Prevent itself itching. clean, dry nursing intervention
pressure from skin the resident was
sores or scratching. 5. Give skin reduces the able to:
ulcers, After a protectants risk of skin Long term:
underscorin 6-hour of that can irritation, ● Develop a
g the nursing use to infection, plan and use
impairment intervention lessen the and for
of skin the resident itchy moisture-rel self-non-phar
integrity. will able to: sensation. ated skin macologic al
damage. pain
Long term: 6. Instruct management.
● Devel the resident 5. Proper ● Reposition
op a to cut nails wound from bed and
plan frequently care avoid
for to reduce reduces the bedsores.
pain friction and risk of ● Minimize the
● manag shearing. complication itching
ement s like sensation
using 7. Assist infection and
non- the resident and discomfort
pharmacologi to develop promotes
cal a plan for timely
interventions. pain healing.
● Repos manageme
ition nt using 6. Reducing
most non- friction and
of the pharmacolo shearing
time to gical forces is
preven intervention crucial in
t s like preventing
bedsor pressure-rel skin tears,
es. ief devices. which can
● Lesse 8. Instruct be painful
n the the resident and slow
itching to always down the
of the reposition healing
affecte itself to process.
d avoid 7. These
area. bedsores. devices
distribute
pressure
more
evenly, thus
decreasing
the risk of
pressure
sores. They
are
particularly
beneficial
for residents
who spend
extended
periods in
bed or in a
wheelchair.
8.Reposition
ing helps
alleviate
pressure on
vulnerable
areas and
promotes
blood
circulation.
GALOLO, ANDREA PAULINE NIU

BSN-3-17-F

FOCUS D-data A-action R- response

- Impaired Skin DATA - (+) Itching of the skin

Integrity
(1) Dryness if the skin

- (t) Discoloration of the skin

11/30/23
ACTION - Performed skin inspections: Noticed skin color,
texture, and turgor.

- Maintained and instructed in good skin hygiene to reduce

risk of dermal trauma, improve circulation, and promote
comfort.

- Developed a regularly timed repositioning schedule for

clients using turn sheets.

- Provided adequate clothing and

covers.

- Kept bedclothes dry and wrinkle free; used non irritating

linens.

- Used appropriate padding and pre pressure-reducing

devices.

- Recommended keeping nails d

short or wearing gloves.

- Advised to use moisturizers for the dryness of the skin.

RESPONSE - (-) Itching of the skin

- (-) Dryness of the skin

 - (-) Discoloration of the skin

FOCUS D-data A-action R- response

FOCUS D-data A-action R- response
FOCUS D-data A-action R- response