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 country’s 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, Gordon’s 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.
 PATIENT’S 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, patient’s chart, Record’s 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 Alzheimer’s 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 People’s 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 Alzheimer’s 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.
 GORDON’S 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 Alzheimer’s 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 didn’t 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 During Hospitalization
According to the SO, her mother is a retired teacher, The patient responds to stimuli by means of rubbing
she uses eyeglasses. She speaks dialects such as her sternum for her to wake up.
Ilocano, Tagalog and English.

Self- Perceptual Pattern

Before Hospitalization During Hospitalization
The patient suffers from Alzheimer’s disease. The patient is comatose.
Role- Relationship Pattern
Before Hospitalization
According to the SO, before her mother was
diagnosed with Alzheimer’s, 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.
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.

Coping- Stress Pattern

Before Hospitalization During Hospitalization
When her mother is tired, she sleeps for her to rest. 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 Alzheimer’s 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: 36.8°C

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 METHOD USED NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS
SKIN
- Color Inspection Fair complexion Pale d/t decreased tissue
perfusion and
peripheral
vasoconstriction

- Texture Inspection/ Smooth Wrinkled d/t loss of elastic

Palpation fiber and decreased
subcutaneous fat
from hypodermis
secondary to aging

Inspection Presence of d/t poor hygiene

rashes

- Temperature Palpation Normally warm Cold and d/t peripheral

clammy vasoconstriction

- Moisture Palpation Moist to dry Dry d/t decreased activity

of sebaceous and
sweat glands
secondary to aging

- Turgor Palpation Snaps back to Sagged d/t loss of elastic

previous fiber and decreased
subcutaneous fat
from hypodermis
secondary to aging

HAIR
- distribution Inspection/ Evenly distributed Evenly Normal
Palpation distributed

- Texture Inspection Silky, resilient Resilient Normal

 - Color Inspection Black Black w/ white d/t decreased
hairs melanocyte
production secondary
to aging
NAILS
- Color of the nail Inspection Pink transparent Pallor d/t poor arterial
bed circulation

- Capillary refill Palpation Delayed 1-2 sec. Delayed 4 sec. d/t poor arterial
time circulation

- Shape Palpation Convex Convex Normal

EYES/EYEBROWS
- Shape Inspection Round Round Normal

- Symmetry Inspection Equal in size Equal in size Normal

- Movement Inspection Symmetrical in Symmetrical in Normal

movement movement

- Ability to blink Inspection Blinks involuntarily Absence of blink d/t decrease activity
& bilaterally of CN V

CONJUNCTIVA
- Color Inspection Pink-red Pale d/t poor arterial
circulation

PUPILS
- PERRLA Inspection Response to Very slow to d/t compression of
penlight (dilates react to light CN III
and constricts)

- Size of the pupil Inspection 2mm

EXTERNAL AUDITORY
CANAL
- Hearing Inspection Hears equally in Hears equally in Normal
both ears both ears
NOSE
- Symmetry Inspection Symmetrical Symmetrical Normal

- Color Inspection Same color as the Same color as Normal

face and neck the face and
neck
LIPS & MOUTH
- Symmetry Inspection Symmetrical Symmetrical Normal

- Color (lips) Inspection Pink Pale d/t decrease

oxygenation

- Moisture Inspection Moist Dry d/t decreased

salivary production
r/t loss of vagal
stimulation
NECK
- Symmetry Palpation Symmetrical Symmetrical Normal
 - Appearance Inspection No distentions No distentions Normal

THORAX
- Chest contour Inspection Symmetrical Symmetrical Normal

- Clavicle Inspection Prominent Prominent Normal

- Chest wall Inspection Full chest Full chest Normal

expansion expansion

- Breathing Inspection Regular Irregular d/t decreased

pattern function of the
medulla
ABDOMEN
- General contour Inspection Non-tender Non-tender Normal
Auscultation
Percussion
Palpation

UPPER EXTREMITIES
- Symmetry Inspection Symmetrical Symmetrical Normal

- ROM Inspection/ (+) ROM upon (+) ROM upon Normal

Palpation movement movement

LOWER EXTREMITIES
- Size Inspection Equal in size Equal in size Normal

- Symmetry Inspection Symmetrical Symmetrical Normal

- ROM Inspection (+) ROM upon (+) ROM upon Normal

movement movement
 LABORATORY RESULTS

HGT

Date Result Normal Range Analysis

11-21-09 6am 284 mg/dl 80-120 mg/dl
11-21-09 6pm 155 mg/dl 80-120 mg/dl
11-22-09 6am 186 mg/dl 80-120 mg/dl
11-22-09 153 mg/dl 80-120 mg/dl
11-23-09 170 mg/dl 80-120 mg/dl
11-24-09 215 mg/dl 80-120 mg/dl
11-27-09 172 mg/dl 80-120 mg/dl
11-28-09 152 mg/dl 80-120 mg/dl
11-30-09 120 mg/dl 80-120 mg/dl
12-01-09 133 mg/dl 80-120 mg/dl

Na

Date Result Normal Range Analysis

11-24-09 131 mmOl/L 135-145 mmOl/L Normal
11-29-09 132 mmOl/L 135-145 mmOl/L Normal

Date Result Normal Range Analysis

11-24-09 3.0 mmOl/L 3.5-5.5 mmOl/L
11-29-09 4.0 mmOl/L 3.5-5.5 mmOl/L Normal

CBC
11-20-09

Parameters Result Normal Range Analysis

WBC 12.4x103 /mm3 3.5-10 d/t increase pyrogens
RBC 3.83x106 /mm3 3.8-5.8 Normal
Hgb 11.4 g/dl 11.0-16.5 Normal
Hct 37.0% 35-50 Normal
PLT 188x103/mm3 150-390 Normal
 INTAKE AND OUTPUT MONITORING SHEET

12-05-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 500 100 600 600 600
3-11 1000 430 700 700 700
11-7 660 200 800 800 800
Total: 2890 Total: 2100

12-04-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 720 100 75 895 200 250
3-11 1000 250 1250 500 500
11-7 600 250 850 200 200
Total: 2995 Total: 950

12-03-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 750 350 75 1175 290 290
3-11 1000 200 4 1204 350 350
Total: 2379 Total: 640

12-02-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 900 550 75 1525 790 790
3-11 832 120 75 1027 660 660
11-7 600 200 75 875 550 550
Total: 3427 Total: 2000

11-30-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 600 340 940 1000 1000
3-11 890 475 1365 1100 1100
11-7 550 200 750 900 900
Total: 2055 Total: 3000

11-29-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

3-11 800 300 1100 400 400
Total: 1100 Total: 400
11-28-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 830 550 1380 1350 1350
3-11 1030 700 1730 600 600
11-7 700 700 1400 1650 1650
Total: 4510 Total: 3600

11-27-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 1030 600 1630 1630 1630
3-11 600 450 1050 1050 1050
Total: 2680 Total: 2680

11-26-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 860 475 1335 600 600
3-11 1250 400 1650 1250 1250
Total: 2985 Total: 1800

11-25-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 770 350 1120 500 500
3-11 810 200 1010 800 800
11-7 800 200 1000 1250 1250
Total: 3130 Total: 2550

11-24-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 715 400 1115 350 350
3-11 850 200 1050 1400 1400
Total: 2165 Total: 1750

11-23-09

Intake Output

Time Oral Parenterral Others Total Urine Drainage Others Total

7-3 1030 200 1230 300 300
3-11 700 500 1200 600 600
11-7 600 750 1350 700 700
Total: 3780 Total: 1600
 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 Wernicke’s area. Speaking ability is in Broca’s area. Damage to
Broca’s area causes speech impairment but not impairment of language comprehension. Lesions in Wernicke’s
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.