A Closer Look on:

CEREBROVASCULAR ACCIDENT

Prepared by:Jacqueline y. pineda

Staff nurse, surgery ward

DEMOGRAPHIC DATA

Name: Mr. XAge:89Gender: MaleCase Number: 167947Diagnosis: CVA, ARF, Pneumonia,

NSTEMI, DVT, Subacute Pulmonary Edema, DM II, Parkinson’s Disease

PHYSICAL ASSESSMENT

General Appearance:

BedriddenConsciousWeak-lookingPale in appearanceThin

Vital Signs:Blood Pressure: 130/80Pulse Rate: 89Respiratory Rate: 23Temperature: 36.8

Skin: IntactWarmPoor skin turgorWrinklyScaly

PHYSICAL ASSESSMENT

Head and Neck:Skull is smooth, no depression.Loss of hair on scalp.Neck veins are slightly distended.

Thorax:Symmetrical though the ribs are prominent.

Abdomen:Rigid, with active peristalsis.

PHYSICAL ASSESSMENT

Genital Area:Minimal pubic hair. No hernia noted.

Upper limbs:Nail beds are thick and dry.

Lower limbs:With non-pitting edema on both feet,

grade 1 to 2.

PHYSICAL ASSESSMENT

PATIENT HISTORY

I. PAST MEDICAL HISTORY

With history of Parkinson’s disease, CVA, Hypertension, transferred to our hospital from another hospital where he was intubated due to acute respiratory failure and sepsis.

PRESENT MEDICAL HISTORY

CVA, ARF, Pneumonia, NSTEMI, DVT, Subacute Pulmonary Edema, DM II,

Parkinson’s Disease

Nursed in ward with:

Limb and chest physiotherapyNGT Feeding of Jevity 250ml plus 100ml

water every four hours with strict aspiration precaution.

Nebulization, suctioning and changing of position

Tracheostomy tube with oxygen support at 3 liters per minute

Foley catheter connected to urine bag

MEDICATIONS:

MEDICATIONS

INVESTIGATIONS:

PATHOPHYSIOLOGY

TOPIC PRESENTATION

INTRODUCTION:

A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain function due to disturbance in the blood supply to the brain.

Blood Flow Blockage. The brain receives about 25% of the body's oxygen, but it cannot store it. Brain cells require a constant supply of oxygen to stay healthy and function properly. Therefore, blood needs to be supplied continuously to the brain through two main arterial systems:

The carotid arteries come up through either side of the front of the neck. (To feel the pulse of a carotid artery, place your fingertips gently against either side of your neck, right under the jaw.)

The basilar artery forms at the base of the skull from the vertebral arteries, which run up along the spine, join, and come up through the rear of the neck.

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

ETIOLOGY Ischemic stroke. About 85 percent of strokes are ischemic

strokes. The most common ischemic strokes include: Thrombotic stroke.  Embolic stroke. 

Hemorrhagic stroke. Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures..

Transient ischemic attack (TIA). A transient ischemic attack (TIA) — also called a ministroke — is a brief episode of symptoms similar to those you'd have in a stroke. A transient ischemic attack is caused by a temporary decrease in blood supply to part of your brain. TIAs often last less than five minutes.

ETIOLOGY

CT Scan of brain without contrast:

FINDINGS: The brain is morphologically normal. No acute hemorrhage.

IMPRESSION: Diffuse cerebral atrophy with small periventricular white matter chronic ischemic changes.

SIGNS AND SYMPTOMS

Trouble with walking. Trouble with speaking and understanding. Paralysis or numbness of the face, arm or

leg. Trouble with seeing in one or both eyes. Headache.

INTERVENTION

Nursing Intervention includes:

Monitor Vital Signs, especially the blood pressure

Monitor the Neurovascular StatusRefer any untoward change in sensorium.

Give stat medications immediately as ordered

Give due medications on timeInstitute safety and aspiration precautions

TREATMENT

ThrombolysisHemicraniectomy

COMPLICATIONS

Aspiration pneumoniaDecubitus ulcersDementiaDisability:

Difficulty speakingDifficulty swallowingArm weakness

(unilateral)Leg weakness

(unilateral)Facial weakness

Inability to live independently

Urinary incontinenceBowel incontinenceMemory lossMuscle spasmsOsteoporosisChronic painRecurrent strokeTremor

PRIORITIZATION OF NURSING PROBLEMS

BREATHING Ineffective Airway Clearance Ineffective Breathing Pattern

ACTIVITY AND REST Disturbed Sleep Pattern Impaired Physical Mobility Risk for Activity intolerance

FATIGUE Ineffective Breathing Pattern Decreased Cardiac Output Risk for Decreased Cardiac Tissue Perfusion Self Care Deficit

PRIORITIZATION OF NURSING PROBLEMS

NUTRITION Imbalanced Nutrition Less Than Body Requirement Risk for Electrolyte Imbalance Deficient Fluid Volume

ELIMINATION Risk for Urinary Incontinence Impaired Urinary Elimination/Urinary Retention Bowel Incontinence Risk for Constipation Impaired Gas Exchange

PRIORITIZATION OF NURSING PROBLEMS

PERCEPTION/COGNITION Disturbed Sensory Perception Impaired Memory Impaired Verbal Communication

SAFETY Risk for Infection Risk for Aspiration Risk for Injury Risk for Impaired Skin Integrity Ineffective Thermoregulation – Hyperthermia/Hypothermia

THERAPEUTIC Effective Therapeutic Regimen Management

NURSING HEALTH TEACHING

Family health teaching is an important role of the nurse which includes the following:

Maintaining skin care Adequate hydration Feeding with aspiration Scheduled and strict positioning Monitoring vital signs such as temperature, pulse,

and blood pressure Strict compliance to rehabilitation – physical therapy,

occupational therapy and  speech-language pathology

PRESSURE ULCER MANAGEMENT

Strict turning every two hours.Keeping prominent areas dry, clean

and free from pressure.Applying creams/ointments as

prescribed.Dressing wound/bed sores.

PAIN MANAGEMENT

Pain Medications as ordered.Promoting rest and sleep.Instituting comfort measures.

MORSE FALL RISK ASSESSMENT

GLASGOW COMA SCALE

NCP: INEFFECTIVE AIRWAY CLEARANCE

NCP: IMPAIRED SKIN INTEGRITY

NCP: IMPAIRED SKIN INTEGRITY

CONCLUSION

CVA is a medical emergency which can be prevented if the risk factors are reduced. In case of stroke, the patient must be instantly brought to the hospital and be given immediate interventions. Some complications can be avoided if the patient is closely monitored and given due attention and care. The manifestations and recovery depend on the location and severity of the damage or bleeding in the patient’s brain.

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