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
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 During 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.
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 wants and sees. She has no preference diet. She eats 3 times a day with mid afternoon snacks. She drinks 6-8 glasses of water a day. She has no
difficulty in swallowing and has no allergy with any type of food.
Upon admission, the patient was
inserted NGT and was ordered with PNSS 1liter to run for 8 hours. The diet was osteorized feeding with SAP.
Elimination Pattern
Before Hospitalization During 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 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 During 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.
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 the evening and wakes up at around 5 in the morning. She takes naps at afternoon. She has no rituals before
sleeping she added.
Patient is comatose but can respond to physical stimuli.
Cognitive Perceptual Pattern
Before Hospitalization During Hospitalization According to the SO, her mother is a
retired teacher, she uses eyeglasses. She speaks dialects such as Ilocano, Tagalog and English.
The patient responds to stimuli by means of rubbing her sternum for her to wake up.
Self- Perceptual Pattern
Before Hospitalization During Hospitalization The patient suffers from Alzheimer’s
disease. The patient is comatose.
Role- Relationship Pattern
Before Hospitalization During 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.
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 ASSESSED METHOD USED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS SKIN – Color – Texture – Temperature – Moisture Inspection Inspection/ Palpation Inspection Palpation Fair complexion Smooth Normally warm Pale Wrinkled Presence of rashes Cold and clammy d/t decreased tissue perfusion and peripheral vasoconstriction d/t loss of elastic fiber and decreased subcutaneous fat from hypodermis secondary to aging d/t poor hygiene d/t peripheral vasoconstriction d/t decreased
– Turgor HAIR – distribution – Texture – Color NAILS – Color of the nail bed – Capillary refill time – Shape EYES/EYEBROWS – Shape – Symmetry – Movement – Ability to blink Palpation Palpation Inspection/ Palpation Inspection Inspection Inspection Palpation Moist to dry Snaps back to previous Evenly distributed Silky, resilient Black Pink transparent Delayed 1-2 sec. Dry Sagged Evenly distributed Resilient Black w/ white hairs Pallor Delayed 4 sec. Convex activity of sebaceous and sweat glands secondary to aging d/t loss of elastic fiber and decreased subcutaneous fat from hypodermis secondary to aging Normal Normal d/t decreased melanocyte production secondary to aging d/t poor arterial circulation d/t poor arterial circulation Normal Normal
CONJUNCTIVA – Color PUPILS – PERRLA – Size of the pupil EXTERNAL AUDITORY CANAL – Hearing NOSE – Symmetry – Color
LIPS & MOUTH
– Symmetry – Color (lips) – Moisture NECK Palpation Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Convex Round Equal in size Symmetrical in movement Blinks involuntarily & bilaterally Pink-red Response to penlight (dilates and constricts) Hears equally in both ears Symmetrical Round Equal in size Symmetrical in movement Absence of blink Pale Very slow to react to light 2mm Hears equally in both ears Symmetrical Same color as the face and neck Normal Normal d/t decrease activity of CN V d/t poor arterial circulation d/t compression of CN III Normal Normal Normal Normal
– Symmetry – Appearance THORAX – Chest contour – Clavicle – Chest wall – Breathing pattern ABDOMEN – General contour UPPER EXTREMITIES – Symmetry – ROM LOWER EXTREMITIES – Size – Symmetry – ROM Inspection Inspection Inspection Palpation Inspection Inspection Inspection Inspection Inspection Inspection Auscultation Percussion Palpation Same color as the face and
neck Symmetrical Pink Moist Symmetrical No distentions Symmetrical Prominent Full chest expansion Regular Non-tender Symmetrical Pale Dry Symmetrical No distentions Symmetrical Prominent Full chest expansion Irregular Non-tender d/t decrease oxygenation d/t decreased salivary production r/t loss of vagal stimulation Normal Normal Normal Normal Normal d/t decreased function of the medulla Normal Normal Normal
Inspection Inspection/ Palpation Inspection Inspection Inspection Symmetrical (+) ROM upon movement Equal in size Symmetrical (+) ROM upon movement Symmetrical (+) ROM upon movement Equal in size Symmetrical (+) ROM upon movement Normal Normal Normal 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 k
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 Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge
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 Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge Others Total 3-11 800 300 1100 400 400 Total: 1100 Total: 400 11-28-09 Intake Output Time Oral Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge
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 Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge 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 Parenter
ral
Other s
Total Urine Draina ge 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.
