Central Luzon Doctors’ Hospital Educational

Institution
San Pablo, Tarlac City

Cerebrovascular
Accident

A Case presented by:

Rose Salviejo

BSN IV-C Group 10

 I. INTRODUCTION

For the purpose of privacy and confidentiality, the real name of the patient is withheld
and she will refer to as “La Lola” throughout the entire document.

La Lola is a 77 year old female currently residing in Brgy. Tibag, Tarlac City, together
with her grand children. She was admitted to Central Luzon Doctors’ Hospital on September 22,
2010 complaining of body weakness and inability to speak. A few hours before admission, she
first felt body weakness at 12am accompanied by inability to speak, thus her family decided to
rush her to the emergency room to have her checked up.

A stroke is damage to a part of the brain when its blood supply is suddenly reduced or
stopped. A stroke may also be called a cerebral vascular accident, or CVA. The part of the brain
deprived of blood dies and can no longer function. Blood is prevented from reaching brain tissue
when a blood vessel leading to the brain becomes blocked (ischemic) or bursts (hemorrhagic).
The symptoms of a stroke differ, depending on the part of the brain affected and the extent of the
damage. Symptoms following a stroke come suddenly and may include: weakness; numbness or
tingling in the face, arm, or leg, especially on one side of the body; trouble walking; dizziness;
loss of balance or coordination; inability to speak or difficulty speaking or understanding; trouble
seeing with one or both eyes or double vision; confusion or personality changes; difficulty with
muscle movements such as swallowing, moving arms and legs; loss of bowel and bladder
control; severe headache with no known cause; and loss of consciousness.

The following are metabolic disorders that may contribute to stroke: excess weight
around the waist (waist measurement of more than 40 inches for men and more than 35 inches
for women); triglycerides blood level of 150 mg/dL or more; HDL cholesterol levels below 40
mg/dL for men and below 50 mg/dL for women; blood pressure of 130/85 mm HG or higher;
and prediabetes (a fasting blood sugar between 100 and 125) or diabetes (a fasting blood sugar
level over 125 mg/dL).

Many studies were conducted regarding cerebrovascular accidents tackling different

aspects of cerebrovascular accident such as: the cause; precipitating factors; predisposing factor;
and its prevalence throughout the world as one of the top ten leading causes of morbidity. The
severity associated with cerebrovascular accident can best be demonstrated by the following
facts: CVA is the leading cause of adult disability in the world; two–thirds of strokes appear
among 65 year old and above; stroke affects more men than women and most of the cases are
among African American.

In the case of the patient, laboratory tests such as blood chemistry, HDL, LDL, DXTX
and CT Scan revealed low levels of HDL, high in LDL, high value of DXTX and a CT scan
revealed of ischemic infarcts in white matter of left parietal lobe near the vertex, and at right
temporal lobe. She was complaining head ache for 2 weeks, with a manifested signs and
symptoms of body weakness and inability to speak few hours prior to admission. She was then
diagnosed with Cerebrovascular Accident (left hemisphere).

NURSING PROCESS

Nursing Health History A

A. Demographic data

Patient Name: La Lola

Date admission: Ward:Female Ward Room no: 333
Sept. 22 2010
Age: 77 Sex: Female C/S: Married Religion: Roman Catholic
Examiner: Dr. D

B. Chief Complaint

La Lola sought consultation to the hospital with a chief complaint of body weakness and
inability to speak.

C. History of Present Illness

La Lola has frequent episodes of headache 2 weeks ago; she took paracetamol for her
head ache every time she experienced it. She also sought advice form a quack doctor but her
condition was not relieved with the herbal medicines she advised to take. On September 22,
2010, 12am, La Lola experienced body weakness and inability to speak. Due to the presented
symptoms, the patient, together with her family decided to go for consultation at CLDH. She was
admitted and diagnosed then with Cerebral Infarct, Left Parietal Lobe, Right Temporal Lobe and
Pons, and hypertension stage II.
D.
Past Medical History (prior to admission and onset of illness)

a. Pediatric illness

Mumps ______ Pertusis________ HPN ___√____

Measles ___√___ Rheumatic___√___ Heart Disease _______

Chicken Pox ___√___Pneumonia______ Hepatitis _______

Rubella ______ Tuberculosis_____ Others ______

b. Immunization/Tests

BCG _____ Hepa B _____ Pneumonia _____

DPT _____ Measles _____ OPV _____

FLU _____ others: Tetanus toxoid

c. Hospitalization

She was hospitalized last June 2008 due to cataract in both eyes.

d. Injuries

La Lola doesn’t have any serious injury since childhood.

e. Transfusions

La Lola has not yet undergone any blood transfusions.

f. Obstetrics

No data taken from the SO.

g. Medication
 Before seeking help from health care professionals the patient did take
Paracetamol and the alleged medicine given by the quack doctor.

h. Allergies

The significant others reported not having any allergies to either food
groups or drugs.

E. Family History

Age Family Member Cause of death Disease Present in the

Family
L D
* Mother Old age none
? Father Hypertension none
st
* 1 sibling Hypertension none
77 2nd sibling CVA
72 3rd sibling Diabetes Mellitus 2

F. Social and Personal History

Date of Birth: March 30, 1933 Birthplace: Bulacan

Educational Attainment: Elementary Ethnic Background: Kapampangan
(undergraduate)
Position in the Family: 2nd child

a. Residence

La Lola and her family currently reside in Sitio Calero, Tibag, Tarlac City. Their
house is constructed with sawali and wood and stands near the road. Sawali is more
dominant, they do have adequate light source. According to her grandchild, the space is
adequate for them. She and her family have been living in Tibag for 10 years.

b. Occupation

La Lola doesn’t have a job, because of her age, her family advised her to stay
home.

c. Financial

Her financial support comes from her one of her children who is in Japan working
as domestic helper.
d. Habits

La Lola spends her time doing some light household chores such as sweeping the
floor every morning, after which she just sits in her favourite hammock at the side of
their house. La Lola smokes 3 sticks of cigarette per day.

e. Diet

She eats three meals a day. She seldom eats vegetables and rather chooses meat and
processed foods. After her last confinement 2 years ago, La Lola started to lose her
appetite, and now just eats about 5 tablespoons of rice every meal.

f. Physical Activity/Exercise

Light household chores were usually her form of exercise. According to the SO,
she takes a walk every morning around their house for 5 minutes then sits to her favourite
hammock throughout the day listening to her favourite radio station.

g. Brief Description of Average Day

La Lola usually wakes up as early as 4:00 in the morning. She takes her breakfast
with a cup of coffee then takes a walk for 5 minutes then starts doing light household
chores. She eats her lunch at 12:00pm. She then takes a nap in the afternoon for 2 to 3
hours. La Lola takes her dinner at 6:00pm and usually retires at around 8:00-9:00 in the
evening.

G. Review of Systems

Put check on significant (abnormal) findings

General Description

Weight loss Weight gain Anorexia √Fatigue

√Weakness Night sweats
Notes: the patient experiences body weakness and fatigue because of her condition.

Skin

Itch Bruising Rash Bleeding

Lesions Blisters Ecchymoses Burns
Drainage Scars

Notes: The above deviations from normal were not present in the patient.

Eyes

Pain Itch Vision Loss √Blurring

Diplopia Excessive Tearing Eye Glasses Contact Lenses

Notes: The patient was operated in both of her eyes two years ago because of cataract.

Ears

Pain Discharge Tinnitus Hearing loss

Notes: The above deviations from normal were not present in the patient.

Nose

Obstruction Epistaxis Discharges

 Notes: The above deviations from normal were not present in the patient.

Throat & Mouth

Sore throat Bleeding gums Tooth Ache √Tooth Decay

Notes: Decaying tooth is noted at central incisor.

Chest

Cough Hemoptysis Wheeze Pain on respiration

Dyspnea: Rest / Exertion Sputum:___________________
Breast: Lumps Pain Bleeding Discharge

Notes: The above deviations from normal were not present in the patient.

CVS

Chest pain Palpitation Dyspnea on Exertion

Edema
PND Orthopnea Others:___________

Notes: The above deviations from normal were not present in the patient.
GIT

Food Intolerance Heartburn Nausea Jaundice

Vomiting Pain: Bloating Excessive Gas
 Constipation Change in BM Melena

Notes: The above deviations from normal were not present in the patient.

GU

Dysuria Nocturia Retention Polyuria

Dribbling Hematuria Flank Pain

Notes: The above deviations from normal were not present in the patient.

Extremities

Joint Pains Varicose Veins Claudication Edema

Stiffness Deformities: none

Notes: The above deviations from normal were not present in the patient.

NEURO

Headaches Dizziness Memory Loss Fainting

√Numbness Tingling Seizures
Paresis √Paralysis
Others:_______________________

Notes: The patient has paralysis and numbness in the right side of the body because of
the effect of the left hemisphere cerebral infarction.
 Mental Health Status

Anxiety (mild) Depression Insomnia Sexual Problems Fear

Notes: The above deviations from normal were not present in the patient.

B. Nursing Health History B

Health Perception-Health Management

According to SO, the patient doesn’t comply with proper diet and exercises. She eats
what she wants and is especially fond of meat. She smokes 3 sticks of cigarette daily. Once she
feels something wrong, she, along with her family seeks medical consultation. They also
believed in quack doctors and use herbal medicines such as guava leaves, pito-pito and oregano.
Nutritional-Metabolic
According to her grandchild, when she was not paralyzed yet, she was able to play with
her great grandchildren. She was also a picky eater and usually just takes what she wants among
the food prepared.

Elimination

La Lola, according to her grandchild, defecates once a day and urinates 4 times a day.

Activity – Exercise Pattern

Walking around their house every morning for 5 minutes and doing light house hold
chores, among other light activities, are what she considers exercise.

Sleep-Rest

La Lola, according to her grandchild, sleeps early and wakes up early. She has her
maximum sleep of 8 hours. She doesn’t have any difficulty in sleeping except for the times that
she has headache attacks.

Cognitive-Perceptual

She can do activities easily with her bare hands. She communicates with people through
Kapampangan dialect.

Role-relationship

She is living with her two children. They live peacefully even though there are hardships
and difficulties that come every now and then. Through good communication they can easily fix
family problems. When family experiences difficulty of caring for the patient they just take it as
trials given by God. They have harmonious relationship as a family and with their neighbours.

Self-perception

According to her grandchild, she was strong and confident to do household chores.

Sexuality-Reproductive
 The patient is not sexually active because of her age. According to her grandchild, her
relationship with her husband is like that of best of friends.

Coping-Stress Tolerance

The patient engages herself in other forms of recreational activity as well as family
activities according to her grandchild. She is family centered and gain strength from them.

Value-Belief

La Lola is a Roman Catholic member. Although she does not attend mass, she does listen
to sermons through radio broadcast.

Anatomy and Physiology

Cerebellum

The cerebellum is involved in the coordination of voluntary motor movement, balance

and equilibrium and muscle tone. It is located just above the brain stem and toward the back of
the brain. It is relatively well protected from trauma compared to the frontal and temporal lobes
and brain stem.

Cerebellar injury results in movements that are slow and uncoordinated. Individuals with
cerebellar lesions tend to sway and stagger when walking.
 Damage to the cerebellum can lead to: 1) loss of coordination of motor movement
(asynergia), 2) the inability to judge distance and when to stop (dysmetria), 3) the inability to
perform rapid alternating movements (adiadochokinesia), 4) movement tremors (intention
tremor), 5) staggering, wide based walking (ataxic gait), 6) tendency toward falling, 7) weak
muscles (hypotonia), 8) slurred speech (ataxic dysarthria), and 9) abnormal eye movements
(nystagmus).

Cerebrum

The cerebrum is the part of the brain that occupies the top and front portions of the skull.
It is responsible for control of such abilities as movement and sensation, speech, thinking,
reasoning, memory, sexual function, and regulation of emotions. The cerebrum is divided into
the right and left sides, or hemispheres.

Depending on the area and side of the cerebrum affected by the stroke, any, or all, of the
following body functions may be impaired:

• movement and sensation

• speech and language
• eating and swallowing
• vision
• cognitive (thinking, reasoning, judgment and memory) ability
• perception and orientation to surroundings
• self-care ability
• bowel and bladder control
• emotional control
• sexual ability

Limbic System

The limbic system is a set of evolutionarily primitive brain structures located on top of
the brainstem and buried under the cortex. Limbic system structures are involved in many of our
emotions and motivations, particularly those that are related to survival. Such emotions include
fear, anger, and emotions related to sexual behavior. The limbic system is also involved in
feelings of pleasure that are related to our survival, such as those experienced from eating and
sex.

Broca’sArea

An area located in the frontal lobe usually of the left cerebral hemisphere and associated
with the motor control of speech. Also called Broca's center.

Temporal Lobe
 The temporal lobes are involved in the primary organization of sensory input. Individuals
with temporal lobes lesions have difficulty placing words or pictures into categories.

Language can be affected by temporal lobe damage. Left temporal lesions disturb recognition of
words. Right temporal damage can cause a loss of inhibition of talking.

The temporal lobes are highly associated with memory skills. Left temporal lesions result in
impaired memory for verbal material. Right side lesions result in recall of non-verbal material,
such as music and drawings.

Parietal Lobe

Damage to the left parietal lobe can result in what is called "Gerstmann's Syndrome." It
includes right-left confusion, difficulty with writing (agraphia) and difficulty with mathematics
(acalculia). It can also produce disorders of language (aphasia) and the inability to perceive
objects normally (agnosia).

Damage to the right parietal lobe can result in neglecting part of the body or space
(contralateral neglect), which can impair many self-care skills such as dressing and washing.
Right side damage can also cause difficulty in making things (constructional apraxia), denial of
deficits (anosagnosia) and drawing ability.

Occipital Lobe

The occipital lobes are the center of our visual perception system. They are not
particularly vulnerable to injury because of their location at the back of the brain, although any
significant trauma to the brain could produce subtle changes to our visual-perceptual system,
such as visual field defects and scotomas. The Peristriate region of the occipital lobe is involved
in visuospatial processing, discrimination of movement and color discrimination (Westmoreland
et al., 1994). Damage to one side of the occipital lobe causes homonomous loss of vision with
exactly the same "field cut" in both eyes.

Frontal Lobe
The frontal lobes are considered our emotional control center and home to our
personality. There is no other part of the brain where lesions can cause such a wide variety of
symptoms. The frontal lobes are involved in motor function, problem solving, spontaneity,
memory, language, initiation, judgement, impulse control, and social and sexual behavior. The
frontal lobes are extremely vulnerable to injury due to their location at the front of the cranium,
proximity to the sphenoid wing and their large size.
 Cranial Nerves Major functions

I Olfactory Smell

II Optic vision

III Oculomotor eyelid and eyeball movement

IV Trochlear innervates superior oblique

turns eye downward and laterally

V Trigeminal chewing
face & mouth touch & pain

VI Abducens turns eye laterally

VII Facial controls most facial expressions

secretion of tears & saliva
taste

VIII Vestibulocochlear hearing

(auditory) equillibrium sensation

IX Glossopharyngeal taste
senses carotid blood pressure

X Vagus senses aortic blood pressure

slows heart rate
stimulates digestive organs
taste

XI Spinal Accessory controls trapezius & sternocleidomastoid

controls swallowing movements

XII Hypoglossal controls tongue movements

Vascular Anatomy
Blood

 Transport oxygen, nutrients and other substances for brain functioning

 Carries away metabolites
 Approximately 18% of total blood volume in brain.

 Brain uses 20% of oxygen absorbed in the lungs

 Two major arteries supplying blood to the brain are the INTERNAL CAROTID
ARTERY & VERTEBRAL ARTERY.
 Branches of ICA: ophthalmic, middle cerebral and anterior cerebral artery.
 Vertebral artery unites to form the basilar artery in the pons.
 Branches of vertebrobasilar artery: posterior cerebral, posterior and anterior inferior
cerebellar, pontine and internal auditory arteries.
 The circle of Willis is formed by the PCA, ACA, anterior communicating and posterior
communicating arteries.
 The MIDDLE CEREBRAL ARTERY does not form part of the circle of Willis
 The venous drainage of the cerebrum includes the veins of the brain itself, dural venous
sinuses, meningeal veins (dura) and diploic veins.

CEREBRAL ARTERIES

1. MIDDLE CEREBRAL ARTERY (MCA)

 From internal carotid artery

 Blood supply to deep structures
 Enters lateral fissure – sends cortical branches to lateral aspect of FRONTAL,
TEMPORAL, PARIETAL, & OCCIPITAL LOBES.
 Basal MCA – sends small penetrating lenticulo striate arteries to supply internal capsule
and adjacent structures.

2. ANTERIOR CEREBRAL ARTERY (ACA)

 Also branch of the internal carotid artery

 Internal carotid artery – to longitudinal fissure to genes of corpus callosum - sends
branches to medial frontal and parietal lobes and adjacent cortex, extending posteriorly.

3. POSTERIOR CEREBRAL ARTERY (PCA)

 Basilar artery – sends branch to medial and inferior surface of the temporal lobe and
medial occipital lobe.
 Blood supply to choroids plexuses of III & IV ventricles
With calcarine artery and perforating branches to posterior thalamus and subthalamus.
 Pathophysiology

Modifiable Factors: Non – Modifiable

Factors:
>Sedentary Lifestyle
>Age: 60 above
>Cigarette Smoking (3 sticks
per day) >family history of
Hypertension
>High salt and fat diet

Accumulation of fats and nicotine in blood

stream

Hardening of blood Atherosclerosis Formation of plaque

vessel

Decrease in Blood flow Decreased blood vessel Narrowing passageway of

elasticity blood flow

Decrease supply of
Increased vascular
oxygenated blood Increase vascular pressure

Tissue necrosis Explosion of blood

Hypertension
Ischemia Injury to the (150/90 mmHg)

Formation of blood Decrease O2 in the

Manifestations (left
side): paralyzed right side
of the body, impaired Decrease blood
speech, slow performance,
depression and anxiety
Hypoxemia

Body Decrease blood

Decrease in supply to different
weakness Disturbances nueromuscularco
organ and brain
Inability to in motor ntraction of vocal
speak area cords Decrease aerobic
Headache respiration of neurons
 NURSING SCIENTIFIC EXPECTED
ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

S= 0 Impaired In cerebral tissue After 5 hours >Assist semifowler’s >To aid with proper perfusion or Demonstrated
tissue perfusion, there is of nursing position. flow of blood (circulation or increase
perfusion a decrease in intervention, venous drainage). perfusion and
related to oxygen supply behaviors which
Demonstrate >To probably decrease cardiac
vascular which results in >Administer medications may improve
O>Change in increase workload and in maximizing
occlusion the failure to as ordered such as proper
pupillary perfusion and tissue perfusion
secondary to nourish the tissues antihypertensive or circulation such
reactions behaviors
disease at the capillary diuretics. as compliance to
which may
>Change in condition level. Blood health
improve >Encourage quiet >To conserve energy this could
Mental Status vessels which management &
proper aid in lowering the O2 tissue
function is to and restful atmosphere. therapies
>Behavioral circulation demand.
supply blood to the provided.
Changes such as
different parts of >The t issues may have
compliance
>Capillary the brain are >Exercise caution in decreased sensitivity due to
to health
refill longer impaired. Thus, using hot or cold pads. ischemia.
management
than 3 secs. the O2 supply
& therapies >Encourage use of >To decrease the tension level
going to the brain
provided. relaxation techniques or
is also impaired.
exercises.
Proper perfusion is
needed in order to
give adequate >Discuss the importance
nourishment to the of preventing exposure to
>To retain heat or warmth
different parts of cold or extreme cold
efficiently
the brain in order temp
for it to function
>Discuss to the patient’s
well.
SO the importance of >To promote wellness
care of dependent limbs,
body hygiene, and foot
care when circulation is
impaired.
 GENERIC CLASSIFICA DOSAGE ACTION INDICATION CONTRA SIDE EFFECTS NURSING RESPONSIBILITY
NAME TION
INDICATION

H2 1 ampule Inhibits the Prevention and Ranitidine is -constipation >Antacids should be taken one hour
antagonist, IVP q8 action of treatment of self contraindicat - diarrhea; before or one hour after ranitidine, as
Ranitidine Anti ulcer histamine at stress induce ed in patients - headache; they inhibit the effectiveness.
Brand drug the H2 upper GI known to - stomach
receptor site bleeding in have pain; >Instruct the patient to take the
name:
located critically ill hypersensitiv - upset medication as directed for the full
Zantac
primarily in patient. ity to stomach; course of therapy, even if feeling
gastric ranitidine - vomiting; better.
parietal cells, Short term bismuth
resulting in treatment of citrate or any >Inform the patient that smoking
inhibition of active duodenal of its interferes with the action of histamine
gastric acid ulcers and ingredients. antagonist. >Advise the patient to
secretion. benign ulcer. avoid alcohol products containing to
avoid aspirin or NSAIDS, and foods
Prophylaxis of
that may cause increase in GI
duodenal ulcer.
irritation.
Management of
GERD. >Inform the patient that increase fluid
and fiber intake and exercise may
Prevention and minimize constipation.
treatment of
heartburn, acid >Watch for signs of GI bleeds.
ingeston and
sour stomach >Have regular medical follow-up to
evaluate the response.