Care of Client with

Cerebrovascular Accident
(CVA) and Hypertension
GROUP MEMBERS

ABDULKARIM, NAWIIRA S. ABDURAJAN, DAISY WALDA J.

AHADAIN, WADZRA M. ASIM, MARISSA K.

ASKALANI, ABDUT-TAWWAB G. BACALUCOS, HYDE R.

CAMBONGA, RYKA PATRICIA M. DEL PRADO, RYAN BOY V.

FERNANDEZ, ROSE LAIN E. GUITENG, ALI J.

GUMILAO, ROSA MAE A. HASAN, AIRA MAE P.

PISCO, VHINCE NORBEN C. PARIAN, PINABELLE D.

SUAREZ, MARIAN T. YASIN, FARNAIZA S.

 Patient A is a 52 – year old school principal who was brought
by an ambulance to the hospital yesterday due to spasms on the
right arm and leg, difficulty swallowing, 2 episodes of vomiting,
blurring of vision, and dizziness. During admission her vital signs
revealed: Temp – 38.2 degrees Celsius, Pulse rate – 104 bpm,
Respiratory rate – 24 br/min and BP – 160/100 mmHg. She was
responsive but could not immediately answer questions. She was
able to open and close her mouth when instructed.
 She was accompanied by her secretary. The ER doctor
examined her and advised blood tests for CBC, electrolytes and
blood sugar. A cardiac enzyme test was ordered for the following
day. An ECG was taken which showed tachycardia but with normal
sinus rhythm.
 A CT scan of the brain was done a few hours later. The CT
scan result revealed: “mild subdural clot at the right hemisphere
with minimal cerebral edema”. Her ICP was also measured at 17
mmHg. The admitting diagnosis was “Cerebrovascular Accident
CVA/ Stroke, Hypertension”. She was placed in a private room and
was kept under observation with her daughter as the watcher.
 EXECUTIVE SUMMARY
 A stroke or Cerebrovascular accident (CVA) occurs when a
blood vessel in the brain becomes blocked or bursts.
 Symptoms include sudden weakness, paralysis, and numbness
of your face or limbs.
 People who experience stroke may have difficulty thinking,
moving, and even breathing.
 Risk factors : hypertension (high blood pressure), personal or
family history of stroke or transient ischemic attack (TIA),
diabetes, high cholesterol.
This study concluded that chronic stress together with comorbidities

such as hypertension can precipitate the development of CVA.

The ICP of the patient increased and her right arm and leg

experienced spasms due to the interruption of nerve signal

transmission.
Patient was already experiencing tingling sensation on her right

arm, one of the most vulnerable part of her body when the accident

occurred.
Thus, patient A experienced spasm on her right arm and due to the

proximity of the nerves in her right arm to her right leg, the right

leg was also affected.

Orders Upon Admission:

Oxygen 2-3 L/min Nasal Cannula

O2 sat – 4 hrs
Patient is on NGT
Infused with NSS & D5% LR alternately –
2,500 ml/day
Blenderized feeding: Low fat, high caloric
diet
The primary drugs that were given to the patient worked:
Prevented Seizure
Managed the Hypertensive Crisis
Decreased Cerebral Edema
Decreased, Managing the ICP

phenytoin (Dilantin): PRN at 10 mg/kg to infuse IV at 25 mg/min.

nifedipine (Adalat): BID at 20 mg given PO or NGT.
mannitol (Osmitrol): q6, 10% at 1.25 g/kg infused IV over 30

minutes.
alteplase (Activase): infuse first 10% bolus over 1 minute and the

remainder to be infused over 60 minutes, at 0.9 mg/Kg of weight;

 This Case Analysis recommends that Range of Motion
exercises hastens the recovery process and it
prevents complications.
 The patient’s diet must be given emphasis by
coordinating with other members of the health care
team.
 Instruct the significant others which food to provide
and avoid during treatment and after discharge.
 Monitoring of vital signs and administration of
medication, prompt management of signs and
symptoms are also highlighted.
The formulation of NCP and HTP should include

both the patient and significant others.

Nurses should also act as a bridge: refer the

patient’s significant others to private and

government programs/organizations that can

help them with their hospital expenses.

Lastly, this case study concludes that thorough

assessment and individualized treatment always

works.
 INTRODUCTION
IDENTIFICATION THE FOCAL
PROBLEM
 A stroke also known as cerebrovascular accident (CVA)
occurs when a blood vessel in the brain becomes blocked
or bursts.
 The brain depends on a network of blood vessels to supply
it with oxygen-rich blood. A loss of blood flow causes
surrounding nerve cells to be cut off from their supply of
nutrients and oxygen during a stroke.
 Stroke can be divided into two major categories:
Hemorrhagic in which there is excavation of blood into the
brain or sub arachnoid space, and Ischemic in which
vascular occlusion and significant hypo perfusion occur.
Ischemic stroke is due to a clot in the
blood supply to the brain
When brain cells begin to die as a result
of the reduced blood flow. Symptoms
occur in the part of the body that those
brain cells control.
The majority of people who had their first
stroke had high pressure or hypertension.
High blood pressure causes weakened
arteries in the brain, which adds much
higher risk for stroke — which is why
controlling blood pressure is critical in
lowering the risk of getting a stroke.
Primary hypertension and Secondary
Hypertension are two types of
Hypertension.
 Most CVA / Strokes are managed with the

following: (Book-based)

1. Medical-Surgical Management:
 anticoagulants (such as heparin or warfarin)
 antiplatelets (such as aspirin)
 Thrombolytic Therapy (including tissue plasminogen activator

or tPA)
 HMG-CoA reductase inhibitors (statins)
 Endovascular Therapy
 Carotid Artery Stenting (CAS)
2. Nursing Care Management:
 Improving Mobility and
Preventing Joint Deformities
 Enhancing Self-Care
 Assisting With Nutrition
 Attaining Bladder And Bowel
Control
 Improving Thought
Processes
 Relieving Anxiety
 Maintaining Skin Integrity
 Improving Family Coping
 Monitoring And Managing
Potential Complications
 SIGNIFICANCE OF THE STUDY
This study will be great benefit to the following:
Patient: Optimize the patient's level of functioning and independence

through making the patient understand the disease process and

management of the cerebrovascular disease.

Patient Family: For them to develop effective ways to manage the

needs of patient and provide support to enrich their relationship for

being the support system.

Nursing Students: Enhance the knowledge, skills and attitude in

providing quality and evidence based nursing care to patients with

similar conditions and use this study as a basis for further

development.
ANATOMY AND PHYSIOLOGY
BRAIN
The brain receives information through
our five senses: sight, smell, touch, taste,
and hearing – often many at one time. It
assembles the messages in a way that has
meaning for us, and can store that
information in our memory. The brain
controls our thoughts, memory and
speech, movement of the arms and legs,
and the function of many organs within
our body.
NERVOUS SYSTEM

The nervous system is a complex

network of nerves and nerve cells
(neurons) that carry signals or
messages to and from the brain
and spinal cord to different parts
of the body. It is made up of the
central nervous system and the
peripheral nervous system.
HEART

The cardiovascular system is a closed

system if the heart and blood vessels. The

heart pumps blood through a closed

system of blood vessels. Blood vessels

allow blood to circulate to all parts of the

body. Arteries usually colored red because

oxygen rich, carry blood away from the

heart to capillaries within the tissues.

Veins usually colored blue because oxygen

poor, carry blood to the heart from the

capillaries. Capillaries are the smallest

vessels within the tissues where gas

exchange take place.

BLOOD VESSELS
Blood vessels transport blood throughout
the body. They are one of the most
important tissues as they are present
extensively in each and every organ of the
human body. Blood vessels are of mainly
three kinds: arteries, capillaries and veins.
Blood flowing through the circulatory
system transports nutrients, oxygen, and
water to cells throughout the body. The
journey might begin and end with the heart,
but the blood vessels reach every vital spot
along the way.
BLOOD PRESSURE

Blood pressure is the force

that blood exerts upon the

walls of the blood vessels or

chambers of the heart. The

components of blood

pressure include systolic

pressure, which results from

ventricular contraction, and

diastolic pressure, which

results from ventricular

relaxation.
REVIEW OF RELATED LITERATURE
Stroke is the world’s second leading cause of

death and the third leading cause of

disability. About 25% of strokes are

recurrent, the annual risk of recurrence is

about 4% and the mortality rate after a

recurrent stroke is 41% (Wajngarten, 2019).

 Strokeis divided into hemorrhagic and ischemic
strokes. The majority of strokes are ischemic,
although the relative burden of hemorrhagic
versus ischemic stroke varies among different
populations.

Ischemic 87%
Hemorrhagic
13%

4th Qtr
Johnson et al, (2016) stated that stroke
has risk factors that are similar to
coronary heart disease and other vascular
disorders. Targeting the main modifiable
factors of hypertension, elevated lipids,
and diabetes are all effective preventive
strategies. Comorbidities are a hallmark of
stroke that both increase the incidence of
stroke and worsen outcome.
 Modifiable and nonmodifiable risk factors for ischemic

stroke have been identified and include age; gender;

race/ethnicity; heredity; hypertension; cardiac

disease, particularly atrial fibrillation; diabetes

mellitus; hypercholesterolemia; cigarette smoking;

and alcohol abuse. The most important modifiable risk

factor for ischemic stroke is hypertension, and

antihypertensive treatment is critical for lowering

stroke mortality and morbidity (Pradhan et al, 2018).

Symptoms of stroke of depend upon the
affected region of brain, which in turn is
defined by the arterial anatomy involved.
During a stroke, elevated blood pressure
is completely possible, with 60–80 percent
of patients reporting a systolic blood
pressure (Systolic blood pressure) of
>140 mm Hg.
Lifestyle modification is appropriate at all
levels of intervention. Good lifestyle
campaigns, such as salt reduction and
increased physical activity, as well as
infographics on stroke and its risk factors,
must be expanded. Despite advances in
stroke prevention strategies and
treatments, stroke recurrence is still the
major threat to any stroke survivor.
 PATHOPHYSIOLOGY

 Cerebrovascular accident (CVA) is the medical

term for a stroke. A stroke occurs when blood flow to
a part of the brain is disrupted either by a blockage or
the rupture of a blood vessel.CVA refers to a
functional abnormality of the central nervous system
(CNS) that occurs when the blood supply to the brain
is disrupted.
 Strokes can be divided into two major
categories. These are ischemic
(approximately 87%), in which
vascular occlusion and significant
hypoperfusion occur, and hemorrhagic
(approximately 13%), in which there
is extravasation of blood into the brain
or subarachnoid space. Although there
are some similarities between the two
types of stroke, differences exist in
etiology, pathophysiology, disease
management and nursing care.
A transient ischemic attack or TIA is a neurologic

deficit typically lasting 1 to 2 hours. A TIA is

manifested by a sudden loss of motor, sensory, or

visual function. The symptoms result from temporary

ischemia or the process of impairment of blood flow

to a specific region of the brain; however, when brain

imaging is performed, there is no evidence of

ischemia.
A TIA may serve as a warning of impending stroke.
Accordingly, approximately 15% of all strokes are
preceded by a TIA. Lack of evaluation and treatment
of a patient who has experienced previous TIAs
may result in a stroke
and irreversible deficits.
 PATHOGENESIS
The pathogenesis of essential hypertension is multifactorial and highly

complex. Factors that play an important role in the pathogenesis of

hypertension include genetics, activation of neurohormonal systems such

as the sympathetic nervous system and renin-angiotensin-aldosterone

system, obesity, and increased dietary salt intake. Arterial hypertension is

the condition of persistent elevation of systemic blood pressure (BP).

Cerebrovascular disease includes all disorders in which an area of the

brain is temporarily or permanently affected by ischemia or bleeding and

one or more of the cerebral blood vessels are involved in the pathological

process. Cerebrovascular disease includes STROKE. Thus, Clot formation

(thrombosis), blockage (embolism) or blood vessel rupture (hemorrhage).

Lack of sufficient blood flow (ischemia) affects brain tissue and may cause
PATHOGENESIS

Figure 3. Pathogenesis of the Patient’s Condition

Figure 3.1. Subdural Hematoma
 PATIENT’S PROFILE
 Name: Patient A
 Sex: Female
 Address: Zamboanga City
 Birthdate: May 01, 1969
 Birthplace: Zamboanga City
 Age: 52
 Occupation: High School Principal
 Religion: Roman Catholic
 Civil Status: Widow
 Nationality: Filipino
 Weight: 60 kgs
 Height: 5’6”
 HISTORY OF PAST ILLNESS

According to the daughter of the patient,

 The patient was diagnosed with Primary
Hypertension 5 years ago.
 Nifedipine (Adalat) 20mg PO was prescribed to
the patient and still takes it as maintenance.
 HISTORY OF PRESENT ILLNESS

3 days PTA the patient complained of tingling

sensation in her fingertips
 According to patient’s secretary she saw the
patient on the floor and was breathing heavily
and can’t speak clearly.
A CT scan was done, and the result revealed: “
mild subdural clot at the right hemisphere with
minimal cerebral edema”
 The admitting diagnosis was “ Cerebrovascular
Accident CVA/ Stroke , Hypertension”.
 GORDON'S 11 FUNCTIONAL HEALTH PATTERNS

 Health Perception Health Management Pattern

According to the daughter, the patient was taking nefedifine (Adalat) 20 mg
as maintenance because of hypertension. The daughter also claimed that the
patient has been complaining of “tingling sensation” in her fingertips but did
not pay much attention to it.

 Nutrition and Metabolic Pattern

The patient’s daughter said that her mother eat three times a day, her
favorite food was spaghetti and ice cream and her digestive metabolism or
bowel movement were loose at times. Current, the patient cannot drink well
from a cup and she was prescribed with NGT 250 ml feeding at q 6 intervals
with 3,200 ml input in the past 24 hours. Her current body weight is 60
kilograms with a BMI of 21.3 which is normal.
.
 Elimination Pattern

According to the daughter, patient A's bowel habits is regular. She

has vomited once and in the past 24 hours patient A has urinated 4

times with 2,400 ml urine output, but still has no bowel movement

since admission.

 Activity and Exercise Pattern

Patient A's daughter claimed that her mother spend too much time

at work and had less time for leisure activities. Further, because of

admission patient is currently confined to bed.

 Sleep and Rest Pattern

According to the daughter the patient works overtime in most cases and

hardly has time for rest. The patient comes home late, sleeps late to

finish her office works, goes to work early and stays in the office even

on Sundays. At present, the daughter claimed that patient A is sleeping

most of the time.

 Cognition and Perception Pattern

The daughter says that before the incident, the patient was always
alert, oriented, and could answer questions quickly and correctly.
Currently the patient is conscious, responsive with signs of confusion,
can follow direction when instructed but cannot recall some personal
information like the name of her dead husband.
 Self-perception and self-concept Pattern

Her daughter said that the patient was a very kind person but strict
when it comes to work. Her daughter also added that patient A was
organized and sets deadlines in almost all tasks. Due to the patient’s
current condition no further data was assessed.

 Roles and Relationship Pattern

The daughter claimed that patient A is a principal in a secondary

school for 15 years. She is a widow and a mother of only one child.
No further data was mentioned by the daughter.
 Sexuality and Reproductive Patter

According to the daughter patient A become a widow 8 years ago,

she only have one child and she underwent cesarean section when
she was 26 years old. She also had her menopause last year as
claimed by the daughter.

 Coping and Stress Tolerance Pattern

Patient faces the stress head-on and she works her way to finish the
tasks on the time schedule.

 Values and Beliefs Pattern

The daughter claimed that her mother is a Roman Catholic but

seldom goes to church and prefers to read the Bible alone.
 CEPHALO-CAUDAL ASSESSMENT
General Appearance:
 During the initial contact the patient was wearing a six-
buttoned office uniform, three of which are unbuttoned
paired with a semi tight black pants. Her hair is messy
and she was wearing her eyeglasses. The patient
appears weak, flushed and distressed. The patient was
conscious, responsive but could not instantaneously
answer the questions. Signs of confusion were also
noted.
Head

a. Hair, Cranial bones/skull, fontanels, sutures, others.

• Gray hair is completely distributed in the head with presence of

dandruff on scattered areas, no lesions, no scars and no wounds noted.

b. Eyes

• Wears eyeglasses +1.5 (since 30 years old), PERRLA, corneal blinking

reflexes were present, sclerae were white, complained of “blurring” and

cannot correctly identify letters in the magazine when shown to her.

c. Nose

• Nasal passageways were patent, septum was in place, upon

illumination, the sinuses revealed faint red color, cannot identify the

scent of mild soap when introduced.

d. Ears

• Ears had intact ear canal with minimal cerumen noted, no

discharges were present. During the whisper test, patient kept

asking the nurse to repeat what she said because according to

her she “did not hear” anything.

e. Mouth and Throat

• Mouth was clean, with missing right upper molar 1, left lower
molar 1 and right lower molar 1. No odor noted from the mouth,
uvula was intact, tonsils not inflamed.

• Cannot drink well from a cup, Speech was slurred.

• Drooling noted on one side of the mouth.

Neck
a. Trachea
• Neck was aligned, no complaints of discomfort claimed when
palpated.

b. Thyroid Gland
• The thyroid gland was hardly palpable.

c. Great vessels
• No bruit or abnormal sounds was identified, large vessels were
intact and not swollen, and the carotid pulse rate was 104 b/min.
Anterior Thorax

• Anterior thorax showed no evidence of lesions, both

breasts showed no signs of mass or discharges, during
auscultation, the breath sounds were clear, and the RR is 24
br/min.

Posterior Thorax

• Posterior thorax showed no evidence of lesions, scars or

wounds, percussion sounds showed no abnormal results, no
lesions nor masses were palpated, during auscultation, the
breath sounds were clear, and the RR is 24 br/min.
Abdomen

• Abdomen was soft, a scar is noted, no lesions, bowel sounds

were heard at 2x per minute in all 4 quadrants, percussion

sounds were tympanic at the epigastric region and dull at the

hypochondriac regions; no masses were palpated, and no

unusual findings noted.

Perineal and Rectal Areas

• Genital area appeared intact, no discharges noted, no

hemorrhoids or any sign of abnormality noted with inspection

and palpation.
Neurologic Assessment

Cranial Nerves revealed:

I - Cannot identify the scent of the mild soap.

II - Blurred vision, cannot see objects in periphery
III – Can move eyes up and down and vice versa.
IV - Patient can perform eye-rolling
V - Sensation was felt on the face when touched, slurred

speech, there is also reduced mastication.

 VI - The eyes can move from one side to another.
 VII - Drooling was noted on one side of the mouth.
 VIII - Hearing difficulty was noted.
 IX – Difficulty swallowing
X – PR – 99 b/min, Carotid PR – 104 b/min, RR – 24

br/min
 XI - Present stiff neck
 XII - Speech was slurred, difficulty swallowing
Extremities

2+ scores in both upper and 3+ scores in both

lower areas for resistance. Cannot raise arms
and legs independently but can identify dull
and sharp stimulations in all 4 limbs. With
some “pins and needles” feelings claimed in
fingertips.
DRUG STUDY
 Based on the assessment data, major nursing diagnosis may
include the following:

 Ineffective cerebral tissue perfusion related to Decreased cerebral

blood flow
 Altered Bladder Elimination Pattern (decreased) related to the
Disease Process
 Impaired physical mobility related to Limitations imposed by
physical condition
 Risk for impaired skin integrity related to Decreased mobility
 Impaired swallowing related to Disease condition
 hyperthermia related to Disease process as evidence by body
temperature of 38.2°C
 Acute confusion related to Present condition
 Self care deficit related to Neuromuscular and musculoskeletal
impairment
 Altered bowel elimination related to Neurological Impairment
 Disturbed sensory perception (visual, auditory, olfactory) related
to Neurological Impairment
 COMPREHENSIVE
NURSING CARE PLAN
Table 7: Nursing Care Plan, Priority No.3
HEALTH TEACHING
PLAN
 Conclusions
 1. The physical and mental stresses with the presence
of hypertension as comorbidity and risk factors such as
lack of physical activity, sedentary lifestyle, and stress
can precipitate CVA/Stroke.
 2. With CVA/Stroke the ICP increases due to the
pressure secondary to a clot that has formed and
caused a blockage in the artery.
 3. Early and prompt management can lead to early
treatment to prevent further complications.
 4. Stroke has an impending signs such as
tingling sensation and spasm and these signs
should not be ignored.
 5. Past and present history of medical admission
and medical interventions have something to do
with the current condition but not all is correlated
to the development of CVA, However,
comorbidities like hypertension contribute to the
development of the disease.
 6. All medications such as phenytoin, mannitol,
alter phase, Adalat, and oxygen therapy help to
improve the condition and treatment of the
condition.
 7. Good Quality nursing care and support system
helps contribute to faster recovery.
 Recommendations
 Based on this study the following recommendations
are made.

 1. CVA/Stroke should be managed through a unified

team approach including medical, pharmacologic,
nutritional, and assistive management.
 2. Signs and symptoms must not be ignored and
prompt medical assistance should be emphasized.
 3. Significant others should be educated and
empowered so that they can have a better
understanding of the disease and provide
effective ways of management.
 4. Client-centered nursing care plans shall be
applied in all areas in providing quality nursing
care.