ST.PAUL UNIVERSITY PHILIPPINES SCHOOL OF HEALTH SCIENCES DEPARTMENT OF NURSING Patients Initials, age, sex E.

Z, 53 y/o, Female evolution___________ Civil Status: Married 23, 2007 Date of Birth: February 3, 1958 Left sided body Address: Malummin, Tuao . Occupation: housewife Admitting Diagnosis: ____Stroke in Date of Admission: September Chief Complaint: __Slurring of Speech, Numbness______ Attending Physician: _Dr. Christy Babaran Religion: Roman Catholic

Nationality: Filipino

ASSESSMENT
MEDICAL/SOCIAL HISTORY: 4 days prior to admission patient was noted to have cough. No fever was noted. Morning prior to admission, patient experiencd left sided body weakness and slurring of speech. Persistence of the above symptoms prompted the S.O to consult SPH hance admitted CHIEF COMPLAINT: Slurring of Speech and Left sided body Numbness Before Hospitalization: During Hospitalization:

P
psychosocial

The patient has a good relationship and interacts well with family members and friends. Before Hospitalization:

The patient still maintained a good relationship with family members and friends. During Hospitalization: The patient urinates 6-8x in a day to clear, light yellow urine amounting to approximately 200 ml per voiding. She defecates once a day to dark brown, semi-formed stools. There is no difficulty with elimination. During Hospitalization: The patient is often disturbed by therapeutic monitoring but is able to resume sleep.

E
elimination

The patient urinates 4-5x a day to clear, light yellow urine amounting to approximately 100-150ml per voiding. She defecates once daily to dark brown, semi-formed stools. She experiences no difficulty with elimination. Before Hospitalization: The patient does not experience difficulty going to sleep and while sleeping. She sleeps 6-7 hours every night. She claimed that she doesnt take a nap in the afternoon.

R
Rest & activity

Before Hospitalization:

During Hospitalization: The patient feels safe with the thought that she is in the hospital and is taken cared of by nurses and her attending physicians. During Hospitalization: The patient received oxygen supplementation of 2-3 LPM upon admission, and then reduced to 2LPM until finally as needed when patient experiences dyspnea. During Hospitalization: Patients diet is Low Salt, Low Fat diet.

S
Safe environment

The patient feels safe within the family. She doesnt have any allergies in food, substances or medications. Before Hospitalization: Patient stated that she often gets tired easily when doing household chores. Before Hospitalization:

O
oxygenation

N
Nutrition

She eats vegetables and meat with rice during meal times. She said that she doesnt have problems with eating and with foods since she doesnt have allergies. She takes Centrum vitamins. She also claimed that she drinks coffee 3-4 cups a day. Before Hospitalization:

During Hospitalization: Since the patient is confined, she meets with the St. Paul sisters for gospel reading and receives communion.

S
Spiritual

The patient is a Roman Catholic and attends mass every Sunday at during special occasions.

HEALTH HISTORY
Current Health Problems Hypertension, Slurring of speech, Left sided body numbness Past Health Problems > Hypertension Family Risk Factors > Hypertension on both mother & fathers side

ELIMINATION
Stool Color: dark brown Gross Appearance: no gross blood seen Consistency: semi-formed Pattern: 1x a day Discomfort: none Problem in control: none Laxatives: no use of laxatives

REST & ACTIVITY

Current Activity Level > patient is able to tolerate activities such as walking, eating, going to the toilet.

Surgical History > none Obstetrical History > 3 children all delivered by NSD

Habits > chatting with significant others, neighbors > Doing household chores Health Maintenance & Practices > patient takes Centrum vitamins > patient takes Captopril as maintenance dose for Hypertension Medications List Name: dose, route, frequency

ADLs > able to perform self care, eating, toileting.

Urine: Color: yellow Quantity/Voiding: 200 cc 24h = 1200 2000 cc Pattern: increased to 6-8x a day Problem in control: none

Sleep Pattern > often awakened by therapeutic monitoring Body Frame > medium in built

Accidents > Fall

Abdomen Bowel Sounds: active (between 5-10 bowel sounds per minute in each quadrant Contour: flat and round

Posture & Gait > good posture and gait, stands erect. Coordination > body movements are coordinated

Patient Education Needs

> the patient needs to be educated regarding caffeine intake and its effect on the BP

Palpation: no tenderness noted Toileting Ability > able to go to the bathroom for toileting Balance > needs assistance when standing or sitting on bed

SAFE ENVIRONMENT
Allergies/Reaction Medication: no known drug allergies Food: none Environment: none

OXYGENATION
Activity Tolerance > can tolerate ADLs without O2 therapy Airway Clearance Nose: none Mouth: none Bronchi: presence of secretions Respirations Rate Depth: 20 cpm Rhythm: Regular Position Assumed: MHBR Use of Accessory Muscles: none Lung Sounds: Normal lung sounds

NUTRITION
Hospital Diet/Restriction: > Low salt, Low fat diet Fluid Intake IVs: 3 PNSS x 42gtts/min Site: (L) arm Side Drip: 4 D5w+ 1amp Nicardipine x 15ugtts Height , Weight IBW > Tissue Turgor > skin springs back to previous state Ability to Chew: able to chew, no difficulty Swallow: able to swallow, no difficulty Gag Reflex: present Food Tolerance: able to tolerate solid food Nausea: none Feed Self: yes

Eyes/Vision Glasses: none Pupils: no vision-blurring, patient exhibited pupillary constriction, both pupils are equal in size (1-2 mm). Hearing/Hearing Aid: - Patients hearing was intact, no use of hearing devices. Skin Integrity Lesions/Scar: Surgical Incision/Wounds: None

Color of Skin, Nails & Lips > Skin- fair; Nails & Lips- pinkish Capillary Refill > 1 - 2 seconds Pulse Oximetry > not done

Mucous Membranes > lips, gums, conjunctiva = moist, pinkish > skin= moist Temperature (Route: axilla)

Apical Pulse: 89 bpm Blood Pressure: 160/100 mmHg Edema: none noted Lab Analysis:

> 36.8 C

Homans Sign: none Blood Chemistry report: Date: 9/24/11 Normal Analysis FBS: 6.64 3.89-5.84 increased Cholesterol 6.83 3.87-6.71 increased

Laboratory Analysis: Hematology Report Date: 09/23/11 Result: Normal Analysis WBC 8.08 5 10 x 9^/L Hgb 13.6 12 16 g/dL Hct 44 37 48 % Segmenters .58 Lymphocytes .34 Increased .60 - .70 % .20 - .30 %

Laboratory Analyses: Chest X-ray Date: 09/23/11 Normal Normal Normal Normal Oxygen Therapy: Oxygen supplementation @ 2-3LPM, reduced to 2LPM when condition became better until finally PRN for dyspnea. Impression: to consider cardiomegaly, suggest Clinical correlation

Predisposing Factors Factors -Age Alcoholism -Gender Hypercholesteromia -Genetics -History of stroke

Precipitating Etiology Unknown -Lifestyle , -Diet, -HPN

Accumulation of LDL in the blood vessel Macrophage engulf the LDL along the endothelial cells Injury to the blood vessels Platelets aggregation in the injured blood vessels Blood clot formation (Thrombus) Thickening and narrowing of the blood vessels Increase Blood Pressure Dislodgment of the clot (thrombus) Emboli formation Occlusion of the small vessels (Brain) Decrease oxygenation in the brain B Cerebral Edema Anaerobic respiration Decrease blood flow A

Build-up of lactic acid and Restlessness, headache Decrease LOC, edema

ICP Altered Cerebral Auto regulation

C A Increase BP to increase brain oxygen Aneurysm Blood Vessel Rupture

B Prolonged Hypoxemia Tissue Death Permanent Brain Damage of the affected part

Anterior Cerebral Artery Middle Cerebral Artery Lack of O2 and blood D

Infarction in the motor parietal lobe strip of the frontal cortex

urinary incontinence

infarction of sensory strip of hemisensory loss at right side

of the body loss of mental acuity, apraxia, hemiplagia D Cerebral Atrophy Frontal Lobe Hemiplagia, Brocas asphaxia Parietal Lobe hemisensory loss, unilateral neglect Temporal Lobe Wernickes aphaxia

Introduction Cerebrovascular accident is the term that refers to any functional abnormality of the Central Nervous System that occurs when the normal blood supply to the brain is disrupted, as by a blood clot or a ruptured blood vessel, and vital brain tissue dies. Cerebrovascular accident is commonly called Strokes. Cerebrovascular accident is a very serious condition in which the brain is not receiving enough oxygen to function properly. A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemic strokes are those that are caused by interruption of the blood supply, while hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. There are two types of cerebrovascular accidents. An ischemic cerebrovascular accident occurs when a brain artery has been blocked. A hemorrhagic cerebrovascular accident occurs when an artery ruptures or leaks. There are three primary causes of cerebrovascular accidents: cerebral thrombosis, cerebral embolism and cerebral hemorrhage. A cerebrovascular accident caused by a cerebral thrombosis is the result of a build-up of plaque and inflammation in the arteries, called atherosclerosis. This process narrows the brain arteries and lowers the amount of oxygen-rich blood that reaches the brain tissue. Arteries narrowed by atherosclerosis are more likely to develop a blood clot that completely blocks blood flow to an area of the brain. Risk factors for atherosclerosis include having high cholesterol, diabetes, and hypertension. Cerebrovascular accident cause by a cerebral embolism occurs when a clot forms in another part of the body and travels in the bloodstream to a brain artery, blocking the flow of blood to the brain. A cerebrovascular accident caused by cerebral hemorrhage occurs when a brain artery breaks or leaks blood into the surrounding brain tissue. The extent of the damage done to the brain and resulting symptoms of a cerebrovascular accident vary depending on the type, the area or areas of the brain affected, and how much time passes before the cerebrovascular accident is treated. Complications of cerebrovascular accident include permanent neurological damage, disability and death. For more information on key hallmark symptoms and other complications, refer to symptoms of cerebrovascular accident.

Making a diagnosis of cerebrovascular accident includes completing a complete medical evaluation and history and physical examination, including a neurological examination. This is often done in an emergency room. Diagnostic testing includes imaging tests, such as a CT or MRI and cerebral angiogram of the brain. A cerebral angiogram is an imaging test that reveals obstructed or narrowed arteries in the brain and can show blood flow or obstruction through the arteries of the brain. Symptoms of a stroke depend on the area of the brain affected. The most common symptom is weakness or paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm. There can be speech problems and weak face muscles, causing drooling. Numbness or tingling is very common. A stroke involving the base of the brain can affect balance, vision, swallowing, breathing and even unconsciousness. The following are the symptoms of Cerebrovascular accident:

Headache Dizziness and confusion Visual disturbance Slurred speech or loss of speech Difficulty of swallowing

Risk factors:

Age Gender High blood pressure weakens the walls of arteries Atherosclerosis narrowed artery channels Heart disease cause blot clot in the heart that may break off and migrate to the brain. Diabetes mellitus accelerated degeneration of small blood vessel Smoking increase the risk of hypertension Polycythemia a raised level of red cells in the blood. Hyperlipidemia high level of fatty substances in the blood

The causes of stroke An artery to the brain may be blocked by a clot (thrombosis) which typically occurs in a blood vessel that has previously been narrowed due to atherosclerosis ("hardening of the artery"). When a blood clot or a piece of an atherosclerotic plaque (a cholesterol and calcium deposit on the wall of the artery) breaks loose, it can travel through the circulation and lodge in an artery of the brain, plugging it up and stopping the flow of blood; this is referred to as an embolic stroke. A blood clot can form in a chamber of the heart when the heart beats irregularly, as in atrial fibrillation; such clots usually stay attached to the inner lining of the heart but they may break off, travel through the blood stream, form a plug (embolus) in a brain artery and cause a stroke. A cerebral

hemorrhage (bleeding in the brain), as from an aneurysm (a widening and weakening) of a blood vessel in the brain, also causes stroke. Thrombosis and embolism both lead to cessation of blood supply to part of the brain thus to infarction (tissue death). Rupture of a blood vessel in or near the brain may cause an intracerebral hemorrhage or subarachnoid hemorrhage. Cerebrovascular accident may be caused by any of three mechanisms.

Cerebral Thrombosis blockage in the thrombus (clot) that has built up on the wall of the brain artery. Cerebral Embolism blockage by an embolus (usually a clot) swept into the artery in the brain. Hemorrhage Rupture of a blood vessel and bleeding within or over the surface of the brain.

Diagnosis The diagnosis of stroke is begun with a careful medical history, especially concerning the onset and distribution of symptoms, presence of risk factors, and the exclusion of other possible causes. A brief neurological exam is performed to identify the degree and location of any deficits, such as weakness, incoordination, or visual losses. Once stroke is suspected, a computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scan is performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a critical distinction that guides therapy. Blood and urine tests are done routinely to look for possible abnormalities. Other investigations that may be performed to guide treatment include an electrocardiogram, angiography, ultrasound, and electroencephalogram. Treatment: Emergency treatment Emergency treatment of stroke from a blood clot is aimed at dissolving the clot. This "thrombolytic therapy" currently is performed most often with tissue plasminogen activator, or t-PA. t-PA must be administered within three hours of the stroke event. Therefore, patients who awaken with stroke symptoms are ineligible for t-PA therapy, as the time of onset cannot be accurately determined. t-PA therapy has been shown to improve recovery and decrease long-term disability in selected patients. t-PA therapy carries a 6.4% risk of inducing a cerebral hemorrhage, and is not appropriate for patients with bleeding disorders, very high blood pressure, known aneurysms, any evidence of intracranial hemorrhage, or incidence of stroke, head trauma, or intracranial surgery within the past three months. Patients with clot-related (thrombotic or embolic) stroke who are ineligible for t-PA treatment may be treated with heparin or other blood thinners, or with aspirin or other anti-clotting agents in some cases. Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial pressure. Intravenous urea or mannitol plus hyperventilation is the most common treatment. Corticosteroids also may be used. Patients with reversible bleeding disorders, such as those due to anticoagulant treatment, should have these bleeding disorders reversed, if possible. Surgery for hemorrhage due to aneurysm may be performed if the aneurysm is close enough to the cranial surface to allow access. Ruptured vessels are closed off to prevent rebleeding. For aneurysms that are difficult to reach surgically,

endovascular treatment may be used. In this procedure, a catheter is guided from a larger artery up into the brain to reach the aneurysm. Small coils of wire are discharged into the aneurysm, which plug it up and block off blood flow from the main artery. Rehabilitation Rehabilitation refers to a comprehensive program designed to regain function as much as possible and compensate for permanent losses. Approximately 10% of stroke survivors are without any significant disability and able to function independently. Another 10% are so severely affected that they must remain institutionalized for severe disability. The remaining 80% can return home with appropriate therapy, training, support, and care services. Rehabilitation is coordinated by a team of medical professionals and may include the services of a neurologist, a physician who specializes in rehabilitation medicine (physiatrist), a physical therapist, an occupational therapist, a speech-language pathologist, a nutritionist, a mental health professional, and a social worker. Rehabilitation services may be provided in an acute care hospital, rehabilitation hospital, long-term care facility, outpatient clinic, or at home. Prevention Damage from stroke may be significantly reduced through emergency treatment. Knowing the symptoms of stroke is as important as knowing those of a heart attack. Patients with stroke symptoms should seek emergency treatment without delay. The risk of stroke can be reduced through lifestyle changes: quitting smoking controlling blood pressure getting regular exercise keeping body weight down avoiding excessive alcohol consumption getting regular checkups and following the doctor's advice regarding diet and medicines, particularly hormone replacement therapy.

Treatment of atrial fibrillation may significantly reduce the risk of stroke. Preventive anticoagulant therapy may benefit those with untreated atrial fibrillation. Warfarin (Coumadin) has proven to be more effective than aspirin for those with higher risk. FACTS: According to the World Health Organization, 1 in ten in the 55 million deaths that occurs every year worldwide is due to stroke and two-thirds of which occur in people living among developing countries. Strokes are much more common among older people than among younger adults, usually because the disorders that lead to strokes progress over time. Over two thirds of all strokes occur in people older than 65. Slightly more than 50% of all strokes occur in men, but more than 60% of deaths due to stroke occur in

women, possibly because women are on average older when the stroke occurs. (www.who.org) In the Philippines, stroke remains to be the leading cause of disability, afflicting 400,000 Filipinos yearly. (Manila Bulletin, 13 September 2008) making it one of the leading causes of death together with vascular diseases. The former Health Secretary Alberto G. Romualdez said in a press release that the cost of treating uncomplicated stroke for 5-7 days ranges from Php 15,000-20,000 making it not only a burden emotionally but also economically to the family and community. (www.doh.gov.ph) But before a stroke occurs, one needs to understand its risk factors so that the medical intervention is administered early and aggressively. The non-modifiable risk factors include age, sex, family history, race, and ethnicity factors that we cannot control. However there are modifiable risk factors for stroke which when eliminated or controlled reduce the risk of stroke significantly. These are hypertension, cardiac diseases (particularly atrial fibrillation), diabetes, hyperlipidemia or elevated cholesterol, cigarette smoking, alcohol abuse, physical inactivity, asymptomatic carotid stenosis, and transient ischemic attack. There is a growing concern because of lifestyle and diet of Asians, particularly Filipinos, cholesterol levels are rising, resulting in an increased risk for stroke (brain attack). In addition to be a leading cause of heart attacks, high cholesterol is emerging as a major risk factor that is known as ischemic stroke. In this type of stroke, the blood supply to the part of the brain is cut off because either atherosclerosis or a blood clot has blocked the vessel

ASSESSMENT Mari nak kurunga makakaturug, nu meawatan nakkun e mari nak makakaturug ngin as verbalized by the patient. Restlessness Frequent yawning

DIAGNOSIS Sleep Deprivation r/t external stimuli

PLANNING At the end of the shift, the patient will be able to demonstrate an understanding of ways on having adequate sleep.

INTERVENTIONS Instructed to observe adequate hygiene before bed time. Advised to have adequate physical exercise activity during day. Recommended quiet activities such as listening to soothing music. Instructed SO to provide calm, quiet environment and manage controllable disrupting factors such as noise and light.

RATIONALE To promote feeling of comfort. Enhances expenditure of energy or release of tension so that client feels ready for sleep/rest. To reduce stimulation so client can relax.

EVALUATION Goal met. The patient was able to recall the different ways on having adequate sleep.

To promote comfortable environment, conducive for sleep.

ASSESSMENT Marik peba megguyu yo takak antre yo imak! as verbalizedby the patient. Restlessness Altered sensation BP: 160/100

DIAGNOSIS Ineffective Tissue Perfusion r/t right sided paralysis secondary to interruption of blood flow in the brain.

PLANNING At the end of the shift, the patient will be able to demonstrate an understanding on ways on how to improve perfusion.

INTERVENTIONS Performed assistive/active ROM exercises. Encouraged bed positioning (every 2 hours). Encouraged to avoid constrictive/tight clothes. Advised to apply warm compress on edematous areas. Instructed to elevate affected part.

RATIONALE Enhances venous return. Prevent bed sores.

EVALUATION Goal met. The patient was able to state the different ways on how to improve perfusion. The patient was able to recall and perform assistive/active ROM exercises.

This might add up in the interruption of blood circulation To reduce edema through vasodilatation

Increase gravitational blood flow

A CASE STUDY ON

C.V.A
Submitted by: Krishia Angelie S. Flores BSN- IV RLE Group B1

Submitted to: Ms. Arvee Macanaya Clinical Instructor

September 29, 2011 SPUP