A Case Presentation On Cerebrovascular AccidentMarco Paul Velasco Precious Jane Parungao Rod Lambert de Leon Carla Aleja Abijay Mylene Narag Jenalin Quilang Krizzia Marie Palce Jessica Datul

Group J

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 guest for health progress and development .

Specific Objectives : 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 Discuss the Pathophysiology of Cerebrovascular Accident 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

erebrovascular 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 in the next days , we will take care of the health of the citizens .

PATIENT S PROFILEName : 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 Admitting diagnosis : HPN t / c CVA Final Diagnosis : CVA recurrent Sepsis secondary to Pneumonia NIDDM

Attending Physician :

Dr . Valeriano Combate , Jr . Dr . Marlene Cinco Dr . Gerardo Pagaddu

Source of information : SO Patient s chart Record s section Hospital : TCPGH - 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 .

Gordons 11 Functional Pattern

Before Hospitalization During Hospitalization According to the SO, According to the SO, she her mother has been stated that her mother is pampered starting when she not in good condition. She was diagnosed with believes that doctors, Alzheimers disease 5 years nurses and other medical ago. When she suffered from members will help her the sickness, they treated mother to recover. SO also her immediately by taking added that they obediently OTC drugs for cough, colds follow all the orders of and fever. With regards to the doctors. her maintenance drugs to her hypertension, they give it at right time as prescribed.

Health Perception - Health Management Pattern

Nutritional - Metabolic Pattern Before Hospitalization During Hospitalization According to the SO, Upon admission, the her mother eats everything patient was inserted NGT she wants and sees. She has and was ordered with PNSS no preference diet. She 1liter to run for 8 hours. eats 3 times a day with mid The diet was osteorized afternoon snacks. She feeding with SAP. drinks 6-8 glasses of water a day. She has no difficulty in swallowing and has no allergy with any type of food.

Elimination PatternBefore Hospitalization During Hospitalization According to the SO, Upon admission, the eats everything her motherand sees. She has patient was inserted NGT she wants and was ordered with PNSS no preference diet. She 1liter to run for 8 hours. The diet was osteorized eats 3 times a day with mid afternoon snacks. She feeding with SAP. drinks 6-8 glasses of water a day. She has no difficulty in swallowing and has no allergy with any type of food.

Activity Exercise PatternBefore During Hospitalization SO, Hospitalization in According to the The patient is the patient is like a comatose state. child. She plays with Student-nurses and SO her neighborhood. initiated passive range Sometimes walking of motion for her to around their house. exercise. About her hygiene, they see to it that cleanliness must maintain to her.

Sleep - Rest PatternBefore During Hospitalization SO, Hospitalization According to the Patient is comatose her mother sleeps at but can respond to around 8 in the evening physical stimuli. and wakes up at around 5 in the morning. She takes naps at afternoon. She has no rituals before sleeping she added.

Cognitive Perceptual PatternBefore During Hospitalizationthe Hospitalization According to The patient responds SO, her mother is a to stimuli by means of retired teacher, she rubbing her sternum for uses eyeglasses. She her to wake up. speaks dialects such as Ilocano, Tagalog and English.

lf - Perceptual PatternBefore The patient suffers Hospitalization from Alzheimers disease. During Hospitalization The patient is comatose.

Role - Relationship Pattern Before Hospitalization According to the SO,During Hospitalization Due to her condition, before her mother was her daughter stated that diagnosed with Alzheimers, they will do all their best she was a loving mother and to take care of their responsible to her mother. They will make sure children. She provides to give back the care they their needs and sees to it have received from her. that they are comfortable in their way of life.

Coping - Stress Pattern Before DuringHospitalization is When her mother tired, she sleeps for her to rest.

Hospitalization 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.

had her menopause at the age of 50 .

Sexual - Reproduction Pattern The patient has five children and

Value Belief PatternShe 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 .

PHYSICALASSESSMENT

Date Assessed: December 03, 2009, 5:15 PM Vital Signs: BP: 140/90 mmHg PR: 92 bpm RR: 23 cpm T: 36.8C 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 SKIN Color

METHOD USEDNORMAL ACTUAL FINDINGS FINDINGS Inspection Fair complexion Pale

ANALYSIS 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

Texture

Inspection/ Palpation

Smooth

Wrinkled

Inspection Temperature Palpation

d/t peripheral Normally warm Cold and clammy vasoconstriction

Presence of rashes

Moisture

Palpation

Moist to dry

Dry

d/t decreased activity of sebaceous and sweat glands secondary to aging

Turgor

Palpation

Snaps back to previous

Sagged

d/t loss of elastic fiber and decreased subcutaneous fat from hypodermis secondary to aging

HAIR Distribution

Inspection/ Palpation

Evenly distributed

Evenly distributed

Normal

Texture Color

Inspection Inspection

Silky, resilient Black

Resilient Black w/ white hairs

Normal d/t decreased melanocyte production secondary to aging

NAILS Color of the nail bed Capillary refill time Shape EYES/ EYEBROWSShape Symmetry Movement Ability to blink

Inspection

Pink transparent Pallor Delayed 1-2 sec. Convex

d/t poor arterial circulation d/t poor arterial circulation Normal

Palpation

Delayed 4 sec.

Palpation

ConvexNormal Round Equal in size Symmetrical in movement Absence of blink Normal Normal

Round Inspection Equal in size Symmetrical in movement Blinks involuntarily & bilaterally

InspectionInspection

Inspection

d/t decrease activity of CN V

CONJUNCTIVA Color PUPILS PERRLA Size of the pupil EXTERNAL AUDITORY CANAL Hearing

Inspection Inspection Inspection

Pink - red Response to penlight ( dilates and constricts )

Pale Very slow to react to light 2mm

d / t poor arterial circulation d/t compression of CN III

Inspection

Hears equally Normal in both ears Hears equally in both ears

NOSE Symmetry Color LIPS & MOUTH Symmetry Color ( lips ) Moisture

Inspection Inspection Inspection Inspection Inspection

Symmetrical Symmetrical Same color as Same color as the face and the face and neck neck Symmetrical Symmetrical Pink Pale Moist Dry

Normal Normal

Normal d / t decrease oxygenation d / t decreased salivary production r / t loss of vagal stimulation

NECK Symmetry Appearance THORAX Chest contour Clavicle Chest wall Breathing pattern ABDOMEN General contour

Palpation Inspection Inspection Inspection Inspection Inspection

Symmetrical No distentions Symmetrical Prominent Full chest expansion Regular

Symmetrical No distentions Symmetrical Prominent Full chest expansion Irregular Non - tender

Normal Normal Normal Normal Normal d / t decreased function of the medulla Normal

Inspection Auscultation Non - tender Percussion Palpation

UPPER EXTREMITIES Symmetry ROM Inspection Inspection / Palpation Inspection Inspection Inspection Symmetrical (+) ROM upon movement Equal in size Symmetrical (+) ROM upon movement Symmetrical (+) ROM upon movement Normal Normal

LOWER EXTREMITIES Size Symmetry ROM

Equal in size Normal Symmetrical Normal (+) ROM upon Normal movement

LABORATORY RESULTS

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

NaDate 11 - 24 - 09 11 - 29 - 09 Result 131 mmOl / L 132 mmOl / L Normal Range Analysis 135 - 145 Normal mmOl145 135 - / L Normal mmOl / L

KDate 11 - 24 - 09 11 - 29 - 09 Result 3 . 0 mmOl / L 4 . 0 mmOl / L Normal Range Analysis 3.5-5.5 mmOl /.L 3.5-5 5 Normal mmOl / L

CBC 11 - 20 - 09Parameters WBC RBC Hgb Hct PLT Result 12 . 4x10 3 /mm 3 3 . 83x10 6 /mm 3 11 . 4 g / dl 37 . 0 % 188x10 3 /mm 3 Normal Range 3 . 5 - 10 3.8-5.8 11 . 0 - 16 . 5 35 - 50 150 - 390 Analysis d / t increase pyrogens Normal Normal Normal Normal

INTAKE AND OUTPUT MONITORING SHEET12 - 05 - 09 Time 7-3 3-11 11-7 Oral 500 1000 660

Intake Parent Others erral 100 430 200

Output

Total Urine Drainag Others Total 600 600 e 600 700 700 700 800 800 800Total : 2100 Total : 2890

12 - 04 - 09 Time 7-3 3-11 11-7 2995 Oral 720 1000 600

Intake Parenterra Othe l rs 100 75 250 250

Output Total Urine Drainage 895 200 1250 500 850 200 Total : 950 Othe Total rs 250 500 200 Total :

12-03-09 Time 7-3 3-11 Oral 750 1000

Intake

Output

Parent Others Total Urine Draina Others Total erral 75 ge 350 1175 290 290 200 4 1204 350 350Total : 640 Total : 2379

12-02-09 Time 7-3 3-11 11-7

Intake Oral Parenterra Others Total l 900 550 75 1525 832 600 120 200 75 75 1027 875 Urine 790 660 550

Output Drainage Others Total 790 660 550 Total: 3427

Total: 2000 11-30-09 Intake Output

Time 7- 3 3-11 11-7

Oral 600 890 550

Parenterra Others l 340 475 200

Total 940 1365 750

Urine Drainage Others Total 1000 1000 1100 1100 900 900Total: 2055

Total: 3000

11-29-09

Intake

Output

Time Oral Parenterra Others Total l 3-11 800 300 1100

Urine 400

Drainage Others Total 400Total: 1100

Total: 400 11-28-09 Intake Output

Time 7- 3 3-11 11-7

Oral 830 1030 700

Parente Others Total rral 550 1380 700 700 1730 1400

Urine 1350 600 1650

Drainag Others Total e 1350 600 1650Total: 4510

Total: 3600

11-27-09

Intake

Output

Time Oral Parenterra Others Total Urine Drainage l 7- 3 1030 600 1630 1630 3-11 600 450 1050 1050Total: 2680 11-26-09

Others Total 1630 1050

Total: 2680

Intake

Output

Time Oral Parenterra Others Total Urine l 7-3 860 475 1335 600 3-11 1250 400 1650 1250

Drainage Others Total 600 1250 Total: 2985

Total: 1850

11-25-09

Intake Output Time Oral Parenterra Others Total Urine Drainage l 7-3 770 350 1120 500 3-11 11-7 810 800 200 200 1010 1000 800 1250

Others

Total 500 800 1250

11-24-09

Total: 2550 Intake Output

Total: 3130

Time OralParenterral 7-3 715 400 3-11 850 200

Others Total 1115 1050Total: 1750

Urine 350 1400

Drainag Others Total e 350 1400Total: 2165

11-23-09

Intake

Output

Time 7- 3 3-11 11-7

Oral 1030 700 600

Parenterra Others Total Urine Drainage Others l 200 1230 300 500 1200 600 750 1350 700Total: 1600

Total: 3780

Total 300 600 700

Cranial CT ScanPlain 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 un enlarged 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 donot 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 and polyp, right maxillary sinus

Anatomy of the Brain