Presented to the Clinical Instructor of The Notre Dame of Tacurong College College of Nursing

CEREBROVASCULAR ACCIDENT
_________________________________________________

Mr. Richard Deo Rox Alave, RN Clinical Instructress

In Partial Fulfillment of the Course Requirements in NURSING CARE MANAGEMENT 106 RLE

Submitted by: Aguilos, Cristine Arboleras, Erika Calimbol, Norhata Dilanggalen, Asrizah Gentugaya, Shenette Ghazi, Rashea Gumisad, Richelle Mae Lumenda, Farrah Jade Mangudadatu, Marsha Mae

Date: August 27, 2013

TABLE OF CONTENTS
I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. Introduction Objectives of the Study Vital information Family Background History of Past Illness History of Present Illness Effects and Expectations Genogram Developmental Data Physical Assessment Textbook Discussion/ Anatomy & Physiology Definition of Terms Etiology/ Symptomatology Pathophysiology Doctors Order Laboratory Results List of Drugs Drugs Study List of Prioritized Problem Nursing Care Plan Prognosis References

XXII.

OBJECTIVES
General Objectives: After 2 hours of presenting the case, the listeners will be able to gain adequate knowledge on CVA and enhance knowledge and skills in dealing with patients having this kind of condition , hence allowing listeners to apply their learning appropriately in clinical setting and develop positive attitude in caring for patients with the same condition.

Specific Objectives:

After 1 hour and 30 minute of presenting the case, the listeners will be able to: Discuss the brief summary of the introduction about the deceases involved. Enumerate completely the general and specific objectives. Identify correctly with important information regarding patients data by presenting the following: Vital Information History of present and past Illness Family Background Effects and Expectations of illness to self and family Genogram Growth and Development Data Discuss the result of Physical Assessment Cephaloucaudically. Identify completely with Review of System.

Discuss comprehensive with complete diagnosed of the patient based on textbook discussion.

Relate the Anatomy and Physiology of the systems involved in CVA Hemorrhagic Enumerate the predisposing and precipitating factors involved with the diagnosis clearly. Enumerate the etiology of CVA Hemorrhagic. Discuss the pathophysiology of CVA Hemorrhagic. Identify the laboratory test undergone by the patient and interpret the result accurately. Discuss the doctors order for patient wellness and rationalize properly. Rationalize the drugs that the physicians ordered and discuss the mechanisms of action, side and adverse effects, contraindication, special precaution and drug interaction precisely.

Prioritized nursing diagnosis of patient and enumerate applicable nursing interventions correctly.

Enumerate the references/bibliography precisely.

INTRODUCTION
This is a case of Mrs. Pet, a 69 years old female patient of South Cotabato Provincial Hospital. She was admitted last July 23, 2013 at 4:35am with admitting diagnosis of Cerebrovascular accident, under the service of Dr. Xoxo Cerebrovascular accident (CVA) is the rapid loss of brain function 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. As a result, the affected area of the brain cannot function, which might result in an 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. A stroke is a medical emergency and can cause permanent neurological damage and death. Risk factors for stroke include old age, high blood pressure, previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation.[2] High blood pressure is the most important modifiable risk factor of stroke. It is the second leading cause of death worldwide. 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. About 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown how many hemorrhages actually start as ischemic stroke.

Each year in the United States, approximately 795,000 people experience new or recurrent stroke. Of these, approximately 610,000 represent initial attacks, and 185,000 represent recurrent strokes. Epidemiologic studies indicate that approximately 87% of strokes in the United States are ischemic, 10% are secondary to intracerebral hemorrhage, and another 3% may be secondary to subarachnoid hemorrhage. According to the World Health Organization (WHO), 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are left permanently disabled. The latest WHO data published in April 2011 stroke deaths in the Philippines reached 40,245 or 9.55% of total deaths. The age adjusted Death Rate is 82.22 per 100,000 of population rank Philippines #106 in the world. In a prospective, population-based registry study from Italy, the crude annual incidence rate of intracerebral hemorrhage was 36.9 per 100,000 population. When standardized to the 2006 European population, the rate was 32.9 per 100,000 population; standardized to the world population, the rate was 15.9 per 100,000 population. The global incidence of stroke has at least a modest variation from nation to nation, suggesting the importance of genetics and environmental factors, such as disparities in access to health care in developing countries. The age-adjusted incidence of total strokes per 1000 personyears for people 55 years or older has been reported in the range of 4.2 to 6.5. The highest incidences have been reported in Russia, Ukraine, and Japan. Asking the question of how this condition occurs, this case study will provide information that may help the readers/listeners understand the cause of condition. This case study will enhance the knowledge and skills in dealing with patient who suffers from this condition

Further complications will be prevented if immediate proper action is provided and intervention is rendered. Therefore it is important that the health care provider develop skills in proper management of the client having this condition.

PATIENTS DATA
Vital Information

Patients Name: Age: Sex: Birth Date: Birth Place: Address: Occupation: Tribe: Citizenship: Religion: Civil Status: Educational Attainment: Name of Institution:

Mrs. Pet 69 years old Female November 13, 1943 Dumalag, Capiz Prk. San Vicente, Bai Sarifirang, Bagumbayan, Sultan Kudarat House keeper Ilonggo Filipino Roman Catholic Widowed None South Cotabato Provincial Hospital

Date and Time of Admission: July 23, 2013 @ 4:35 am Chief Compliant: Admitting Diagnosis: Attending Physician: Spouse Name: Age: Educational Attainment: Not assessed from patient (Coma) Cerebro Vascular Accident Dr. Xoxo Mr. Dedo Deceased Deceased

Occupation:

Deceased

Siblings: (The informant was not familiar with the patients siblings)

Children: Name 1. F 2. M 3. M 4. M 5. M 6. F 7. M 8. F Age 48 46 45 44 43 40 37 28 Educational Attainment None None None None None None Highschool Graduate College Graduate Occupation Farmer Farmer Farmer Farmer Farmer Delivery Boy OFW Teacher

Source of Information: Patients Chart Patients relative

FAMILY BACKGROUND

Mrs. Pet was born on August 27, 1962 at Dumalag, Capiz. She is an ilonggo and an affiliate of Roman Catholic. She does not know how to read and write (according to the patients son, Emo) because she was not given the chance to attend school. As far as Mr. Emo can remember about the story that their mother have shared to them, she and her siblings help their parents in farming to have enough money for their basic needs particularly with food. Mrs. Pet was married to Mr. Pot and had eight children. The eldest daughter is Mrs. Abie, a farmer who has diabetes mellitus and hypertension, while Mr. Boyet, Mr. Carl, Mr. Dante, Mr. Earl, Mr. Fifito are all farmers and has no known disease. Mrs. Gale, an OFW in Saudi Arabia with no known disease, and the youngest Mrs. Hazel, a public teacher with no known disease. Their house was made of kugon and kalakat; they have vegetable plants such as eggplant, squash, kangkong, beans, okra and alugbati. Mrs. Pet is fond of eating dried fish like bulad and she uses bagoong pang saw-saw sa talong. The family income ranges from 3,000-6,000 pesos every month. In 2001, Mr. Dedo died due to kidney failure.The family usually used herbal meds like sambong, lagundi and guava leaves and they sometimes utilize Over-The-Counter drugs such as paracetamol, Bioflu, and salbutamol for their coughs and colds. The family experienced common illnesses such as fever, cough, cold & flu and headache. Presently, Mrs. Pet is living with her two grandchildren; she took care of Mrs. Gales children because she works in abroad. According to Mr. Emo she loves to use mama as what he verbalized gamama na siya.

HISTORY OF PAST ILLNESS The patient experienced stroke for three times as verbalized by her son. For the first and second stroke, she was admitted to the same hospital which is Sto. Nino Hospital with the same physician. After her first and second stroke, she was feeling well as verbalized by the son but her condition became worse on her third stroke and the doctor Blabla refer her to South Cotabato Provincial Hospital for further observation and management. Six months prior to his 1st admission, she experienced dizziness and blurred vision but she didnt take any OTC drugs or seek medical advice; he was rushed into the South Cotabato Provincial Hospital with a diagnosis of Cerebrovascular Accident, Hemorrhagic. Mr. Talky returned to his home and does his usual work as a farmer after being discharged in the hospital.

HISTORY OF PRESENT ILLNESS One week prior the 3rd admission, the patient once again experienced dizziness and blurring vision as verbalized by her son (Mr. Emo). She was rushed to the Sto. Nino hospital but the Dr. Blabla says that she needs to be refer at South Cotabato Provincial Hospital for further observation and proper treatment. So the patient admitted to South Cotabato Provincial Hospital last July 23, 2013 at around past four in early morning with the admitting diagnosis of Cerobrovascular Vascular Accdent, hemorrhagic under the service of Dr. Soso.

EFFECTS AND EXPECTATION OF ILLNESS TO SELF AND FAMILY

To self: (no verbal cues) To family: Family verbalized that they worried about the patients condition and expect that the patient will recovered soon so that the expenses will be lessen. According to Mr. Emo, his mother cant perform her activity of daily living; he is worried about their expenses in the hospital. The family expects that the patient will recover soon.

DEVELOPMENTAL DATA DEVELOPMENTAL TASK THEORY Robert Havighurst He believes that learning is basic to life and that people continue to learn throughout life. He describes growth and development as occurring during six stages each associated with from six to ten tasks to be learned. Havighurst developmental task provide a framework that the nurse can use to evaluate a persons general accomplishments. THEORY Robert Havighurst (Later Maturity) TASK Adjusting to decreasing physical strength and health. JUSTIFICATION SO says that decreasing physical strength and health in older people is a normal process of life and that he assumed that his mother already accepted it. Adjusting to death of a spouse. napatay naman si papa kag nadawat naman to ni mama as verbalized by the patient`s son. Establishing an explicit affiliation with ones age group. According to the SO that patient is used to attend meeting in their barangay concerning their groups but now she is unable to do it because of her condition. Meeting social and civil obligations. Not achieved Not achieved Partially Achieved Achieved REMARKS Achieved

The SO says that her mother has difficulty of living right now because of

Establishing satisfactory physical living arrangements.

her present condition and that she is unable to do things she wants.

The SO says that her mother is having difficulty of doing her physical living arrangement due to her present condition.

PSYCHOSOCIAL THEORY Erik Erikson He envisions life as a sequence of level of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial or unsuccessfully. Erikson believes that the greater the task achievement, the healthier the personality of the person failure to achieve the task influences the ability of the person to achieve the next task. This developmental task can be viewed as a series of crisis and unsuccessful resolution of this crisis is damaging to the ego. After attaining ones stage, the person may fall back and need to approach it again. THEORIST Positive Resolution Integrity vs. Despair Erik Eriksons Psychosocial Theory (Maturity 65 yrs-death) Acceptance of death Acceptance Sense of loss, Patient`s son says that even though they have difficulties in their daily living, they are living their lives happily as long as they are safe even though some of his siblings are living in far places. He stated that the patient is contented with their life achieved Negative Resolution JUSTIFICATION REMARKS

of worth and contempt for others uniqueness of ones own life

and never felt insecurities with other people.

Westerhoffs Four Stages of Faith

Westerhoff describes faith away of being and behaving that evolves from an experienced faith guided by parents and others during a persons infancy and childhood to an owned-faith that is internalized in adulthood and serves as directive for personal action. For the client who is ill faith-whether in a higher authority(e.g. Allah, GOD, Jehovah), in the clients own self, in the health care team or in a combination of all provides strength and trust. Theorist Westerhoffs four stages of faith owned faith. Middle adulthood/old age Behavior Puts faith into personal and social action and is for what he believes even against the nurturing communication Justification Our patient is a catholic in religion her son says that her mother used to go to church when she was strong she said that being a Christian is her will and she does what other do like following the rule of God. Remarks Achieved

Diagnosis: Cerebrovascular Accident PHYSICAL ASSESSMENT

Date and time: August 6, 2013 11:30 AM General Appearance: The patient is an older female, with IVF D5LR 1L @ 20 gtts/min hooked at right basillic vein, patent and infusing well. Patient is unconscious, hair is not well-fixed, with Nasogastric tube inserted on her right nostril and her right hand is tied on the side of the bed. The patient wears striped sando and lavender shorts. The patient also wears a diaper. Vital signs: BP: 110/70 mmHg T- 37 C RR- 20 cpm PR-72 bpm GCS- 8

Head/Hair/Scalp: Inspection: Head is proportional to the body and skull is rounded and symmetrical, no dandruff and lice noted, hair is evenly distributed, gray in color with dry texture. Palpation: No tenderness and masses noted. Face: The face is symmetrical, skin is brown in complexion and has poor skin turgor.

Eyes: Eyes are symmetrical, eyebrows are black in color. Yellowish discharges noted. Pupils are equal in size and reacts to light. Eye opening is poor.Conjunctiva is yellowish in color and sclera is well lubricated. Nose: Inspection: The external nose is symmetrical, align at the midline, nasogastric tube noted inserted through the right nostril, mucosa is moist, nasal septum is intact, no lesions and nose deformities noted. Palpation: There is no tenderness noted. Ears: Inspection: Ears are symmetrical, normal in size with equal color to the body complexion, no lesions noted, small amount of dirt accumulates at the external ear, earwax noted, auricle has no deformities, pinna recoils when folded. Palpation: No tenderness and nodules noted. Mouth and Lips: Inspection: Lips are pale in with dry and flaky texture, no presence of stomatitis, no lesions noted, the tongue is pinkish in color with white spots. Incomplete set of teeth and yellow-orange color of the teeth is noted. Gums and mucosa is light pink and no lesion noted. Tonsils are not inflamed; uvula is bell in shape, pinkish in color, and at the midline. Neck: Inspection: Jugular veins are not inflamed and no stiffness noted. Palpation: Lymph nodes at the neck are not palpable. Breast:

Inspection: Brown areola and nipple noted, areola are equal in size. Palpation: No tenderness and masses noted. Lungs: Auscultation: Breathing pattern is normal and no irregular rhythm noted. Crackles noted on the left lung.

Heart: Auscultation: No abnormal sound noted. Abdomen: Inspection: No scars noted upon inspection. No lesion noted. Auscultation: Gurgling sound noted. 7 gurgling sound/min. Palpation: No tenderness noted, no masses noted. Extremities: Inspection: Extremities are proportionate to the trunk; skin is brown in complexion, symmetrical on both upper and lower extremities. Immobility noted on the right leg and arms. No withdrawal even on evoked pain stimulus. Skin: Inspection: Skin is dry and flaky, no lesions noted. Skin has poor skin turgor. Palpation: No masses and tenderness noted. Cool to touch. Nails: Inspection: Nails are dirty, and pinkish in color. Capillary refills after 3 seconds. Clubbed nails noted.

Anatomy and Physiology

Forebrain - is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. There are two major divisions of forebrain: the diencephalon and the telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. The telencephalon contains the largest part of the brain, the cerebral cortex. Most of the actual information processing in the brain takes place in the cerebral cortex. Midbrain- and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. Hindbrain- extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assists in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion. Basal Ganglia Involved in cognition and voluntary movement

Brainstem Relays information between the peripheral nerves and spinal cord to the upper parts of the brain

 Consists of the midbrain, medulla oblongata, and the pons Broca's Area Speech production Understanding language Central Sulcus (Fissure of Rolando)

Deep grove that separates the parietal and frontal lobes Cerebellum Controls movement coordination Maintains balance and equilibrium Cerebral Cortex Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes Cerebral Cortex Lobes

Frontal Lobes -involved with decision-making, problem solving, and planning

Occipital Lobes -involved with vision and color recognition

Parietal Lobes - receives and processes sensory information

Temporal Lobes - involved with emotional responses, memory, and speech

Cerebrum Largest portion of the brain Consists of folded bulges called gyri that create deep furrows Corpus Callosum Thick band of fibers that connects the left and right brain hemispheres Cranial Nerves Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck and torso Fissure of Sylvius (Lateral Sulcus) Deep grove that separates the parietal and temporal lobes Hypothalamus directs a multitude of important functions such as body temperature, hunger, and homeostasis

Olfactory Cortex receives sensory information from the olfactory bulb and is involved in the identification of odors Thalamus mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum Medulla Oblongata Lower part of the brainstem that helps to control autonomic functions Meninges Bulb-shaped end of the olfactory lobe Involved in the sense of smell

Pineal Gland Endocrine gland involved in biological rhythms Secretes the hormone melatonin Pituitary Gland Endocrine gland involved in homeostasis Regulates other endocrine glands Pons Relays sensory information between the cerebrum and cerebellum Reticular Formation Nerve fibers located inside the brainstem Regulates awareness and sleep Substantia Nigra Helps to control voluntary movement and regulates mood Wernicke's Area Region of the brain where spoken language is understood Source: http://biology.about.com/od/humananatomybiology/a/anatomybrain.htm

Textbook Discussion

A Stroke occurs when an infarct (damage) to the brain occurs, either because there is not enough blood or oxygen (nonhemorrhagic Stroke) going to the brain, or due to bleeding into the brain (hemorrhagic Stroke). A Non-hemorrhagic Stroke is more common than a hemorrhagic Stroke. Strokes because symptoms and physical findings depending on the area injured in the injured brain. Source: http://www.ecureme.com/emyhealth/data/Cerebrovascular_Accident.asp

Cerebrovascular accident (CVA) prevention: In many cases, a person may have a transient ischemic attack (TIA), a neurological event with the symptoms of a stroke, but the symptoms go away within a short period of time. This is often caused by the narrowing or ulceration of the carotid arteries (the major arteries in the neck that supply blood to the brain). If not treated, there is a high risk of having a major stroke in the future. If you suspect a TIA, you should seek medical attention right away. An operation to clean out the carotid artery and restore normal blood flow through the artery (a carotid endarterectomy) markedly reduces the incidence of a subsequent stroke. In other cases, when a person has a narrowed carotid artery, but no symptoms, the risk of having a stroke can be reduced with medications such as aspirin and ticlopidine (TICLID). These medications act by partially blocking the function of blood elements, called platelets, which assist blood clotting Source: http://www.medterms.com/script/main/art.asp?articlekey=2677

Cerebrovascular accident (CVA) is the medical term for what is commonly termed a stroke. It refers to the injury to the brain that occurs when flow of blood to brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die because of lack of nutrients and oxygen.

Source: http://www.healthline.com/galecontent/cerebrovascular-accident

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. Worldwide, one-quarter of all strokes are fatal. Stroke is the third leading cause of death in the United States and the leading cause of disability.

It is estimated that four of every five families in the United States will be affected by stroke in their lifetime,

More than half a million people in the United States experience a new or recurrent stroke each year.

Stroke kills about 150,000 Americans each year, or almost one out of three stroke victims.

Three million Americans are currently permanently disabled from stroke. In the United States, stroke costs about $43 billion per year in direct costs and loss of productivity.

Two-thirds of strokes occur in people over the age of 65. Strokes affect men more often than women, although women are more likely to die from a stroke.

Strokes affect African Americans more often than Caucasians, and are more likely to be fatal among African Americans.

The incidence of strokes among people ages 30 to 60 is less than 1%. This figure triples by the age of 80.

The rate of occurrence for strokes in the United States fell by 15.52% between 1988 and 1998. But the number of deaths from stroke actually rose by 5%.

Causes and symptoms

Arterial blood carries oxygen and nutrients to the cells of the body. When arteries are unable to carry out this function due to rupture, constriction, or obstruction, the cells nourished by these arteries die. There are two forms of stroke, ischemic, which is caused by a blocked blood vessel that supplies blood to the brain, and hemorrhagic, which is bleeding into or around the brain.

The most common type of stroke is ischemic, which refers to the loss of oxygen and nutrients for brain cells that occurs because the blood supply to a portion of the brain has been cut off. Ischemic strokes account for approximately 80% of all strokes, and can be further broken down into two subtypes: thrombotic, also called cerebral thrombosis, and embolic, also termed cerebral embolism.

Thrombotic strokes are by far the more prevalent of ischemic strokes, and can be seen in nearly all aging populations worldwide. As people grow older, atherosclerosis, or hardening of the arteries, occurs. This results in a buildup of a waxy, cholesterol-laden substance in the arteries, which eventually narrows the interior space, or lumen, of the artery. This arterial narrowing occurs in all parts of the body, including the brain. As the process continues, the occlusion, or shutting off, of the artery eventually becomes complete so that no blood supply can pass through. Usually the occurrence of the symptoms of a thrombotic stroke are much more gradual and less dramatic than other strokes due to the slow, ongoing process that produces it.

Embolic strokes are usually a more spectacular, emergency event. They take place when the heart's rhythm is changed for a number of reasons, and blood clot formation takes place. Such a blood clot can move through the circulatory system until it blocks a blood vessel and stops the blood supply to cells in a specific portion of the body. If the blood clot occludes an artery that nourishes heart muscle, it causes myocardial infarction, or heart attack. If it blocks off a vessel that feeds brain tissue, it is termed an embolic stroke. Normally, these blockages occur in the brain itself, as when arteries directly feeding portions of brain tissue are blocked by a clot. But occasionally, the obstruction is found in the arteries of the neck, especially the carotid artery.

Approximately 20% of cerebrovascular accidents are termed hemorrhagic strokes, and are generally classified as subarachnoid hemorrhage or intracerebral hemorrhage, depending upon the location of the hemorrhage. Hemorrhagic strokes occur when an artery to the brain has a weakness and balloons outward, producing an aneurysm. Such an aneurysm often ruptures due to this inflation and thinning of the arterial wall, causing a hemorrhage in the affected portion of the brain.

Both ischemic and hemorrhagic strokes display similar symptoms. However, which symptoms appear depends upon which portion of the brain is cut off from its supply of oxygen and nourishment. The brain is divided into left and right hemispheres, which control bodily movement on opposing sides of the body. For example, the left hemisphere of the brain is responsible for both motor control of the right side of the body, and its sensory discrimination, just as the right hemisphere is responsible for body movements and feeling on the left side. Deeper brain tissue in the left hemisphere of the brain directs muscle tone and coordination for both the right arm and leg. As the communication and speech centers for the brain are also located in the left hemisphere of the brain, interruption of blood supply to that area can also affect the person's ability to speak.

Besides age, high blood pressure (hypertension) is one of the foremost causes of thrombotic stroke. Heart disease, obesity, diabetes, smoking, oral contraceptives in women, polycythemia (an increased number of red blood cells), and sleep apnea are also risk factors for thrombotic stroke, as is a diet high in cholesterol-producing, or fatty, foods.

The risk factors for hemorrhagic stroke include high blood pressure that can, over a period of time, cause the ballooning out of arteries known as aneurysm, and also causes the hereditary malformation that produces defective and weakened veins and arteries. Substance abuse is another major cause of hemorrhagic stroke. Cocaine, stimulants such as amphetamine drugs, and chronic alcoholism can cause a weakening of blood vessels that can result in hemorrhagic stroke.

The symptoms of stroke depend upon the part of the brain that is affected, and how large a portion of brain tissue has been damaged by the CVA. Unconsciousness and even seizures can

be initial components of a stroke. Other effects materialize over a time period ranging from minutes to hours, and even, in some rare instances, over several days. Headache, mental confusion, vertigo, vision problems, difficulty speaking and communicating, including slurring of words (aphasia), and weakness or paralysis of one side of the body (hemiplegia) are all symptoms of stroke that are frequently observed. Stroke victims often have facial drooping, or slackness of the facial muscles, on the affected side, as well as difficulty swallowing. The severity of these symptoms will depend upon the amount of brain tissue that has been damaged and its location in the brain.

Diagnosis

Normally, initial diagnosis will be made based upon observation by health care professionals, and usually a complete neurological examination. Once stroke is suspected, a computed tomography (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 associated with ischemic activity within the body. Electrocardiogram (EKG), angiography, and lumbar puncture are all used to rule out any other possible causes of the symptoms

A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. When blood flow to the brain is impaired, oxygen and glucose cannot be delivered to the brain. Blood flow can be compromised by a variety of mechanisms.

Definition of Terms

Brain The brain is the most important organ in your body because it controls everything in your body. It can be seen as supersense or sensory motor. The brain controls the functioning of the body electrical impulses.

Cerebrovascular accident (CVA), is the rapid loss of brain function due to disturbance in the blood supply to the brain.

Hemiplegia The inability to move a group of muscles in one side of the body. When hemiplegia is caused by a stroke, it often involves muscles in the face, arms and legs.

ETIOLOGY Predisposing Factor

FACTOR

RATIOANLE

REMARKS

Age (69)

The chances of having stroke approximately for each decade of life after age 55 due to changes in the vascularity of the Blood Vessel and decreased of body functions.

Present

Heredity (HTN)

Those whose blood pressure relatively with cerebrovascular Accident has a great risk of developing CVA in later years due to its complication if left untreated.

Present

Sex (Female)

A stroke is more common in men than in women about 46% of men develop stroke and 24% are women. So it is most common on men.

Not Present

Precipitating Factor

FACTOR

RATIOANLE

REMARKS

DM

This condition bring hyperviscosity in the blood due to increase glucose level and increase risk of hypertension and may progress to CVA Theses substance cause also changes in the normal shape of the blood vessel thus restriction of blood flow occur also triggers HTN It was clinically proven that too much take of fatty foods and high in sodium (salt) can increase BP and casue deposition of thrombus in the blood vessel which can restrict blood flow. It is also believed that this etiology can cause blood vessel to weaken thus when hypertension occur the weakened area to protrudes resulting to 35% of those people who have already a previous stroke attacks will have a cerebrovascular accident reccurence within five years of their life.

Not Present

Lifestyle (Alcohol Intake and Smoking)

Not Present

Diet

Present

Not Present

Trauma

Previous Stroke attack

Present

SYMPTOMATOLOGY FACTOR RATIOANLE Due to deprivation of the exact oxygen needed by the brain. It tends also to altered its function thus consciousness decreased Due to the occurrence of the increase intracranial pressure which results to this symptoms Due to irreversible damage to the right hemisphere of the brain, normal neurotransmissions impaired resulting in ability of the left arm to make normally and in longer time is physical appearance deteriorate as well as its function resulting to atrophy This is also due to the irreversible damage to a certain part of the brain which primarily involved for the speech This is the damage to the brain in the right hemispheres of the brain its effects is that paralysis on one side of body Its because of the defect in the neurotransmission cause by the damage to the brain with motor action is altered REMARKS

Decrease LOC

Present

Headache, Nausea and vomiting

Not Present

Atrophy

Not Present

Slurring Speech

Not Present

Left Hemiplegia

Not Assessed

Paralysis

Present

DATE/TIME 7-23-13 4:35 am

ORDER -Admit pt.

RATIONALE -For further observation and management

REMARKS -Done

-NPO -TPR q4 shift -Lab Test: CBC, urinalysis, Fecalysis, ECG,Chest Brain scan -PLR 1L @3O gtts/min -For baseline data -To monitor any complications and abnormalities

-Done -Done and monitored -Done, patient had a lab test.

-Used to replace fluid lost by the body. It is commonly used for fluid resuscitation, meaning that the patient needs aggressive fluid replacement for their injury or illness. -Increase osmotic pressure of plasma in glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes.

-Done, patients IVF was hooked ,and regulated to desired rate

-Mannitol 20%-100 ml IV now q6

-Given and recorded.

-Ranitidine 50mg q6 IVTT

-Competitively -Given and recorded. inhibits acion of histamine on the H2 at receptors sites of parietal cells, decresing gastric acid secretion. -Citicholine seems to increase brain chemical phosphatidychloline. The brain chemical is important for brain function.It might also decrease brain -Done, carried out.

-Citicholine 1amp IVTT q6

damage when the brain is injured. -Clonidine 75mg IVTT q6 -Stimulates alpha andrenergic receptors in CNS decreasing symphatetic out flow, inhibiting vasoconstriction and ultimately reducing blood pressure -Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying -Second generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability usually bactericidal -Done and carried out.

-Metochlopromide 1amp IVTT PRN

-Done and carried out.

-Cefuroxime 750mg IVTT q6

-Done and carried out.

-Paracetamol 500mg PRN

-Inhibits the synthesis -Done and carried out of prostaglandins that may serve as mediators of pain and fever primarily in the CNS. -Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. -Done and carried out

Aspirin 80mg/tab (NGT) BID

27-24-13

-Follow up CT scan RBS now

-Monitor the status of the patient

-Done and recorded

-To follow D5LR 1L @20gtts/min regulated @prese

-For fluid replacement -Done and regulated to desired rate

-Vital signs q4

-For patient vital information

-Done and monitored

7-25-13

-Liquid diet with aspiration percaution -Decrease mannitol q8 -Referral to Dr,Xoxo a neurologist for further information -Pls.xerox the Lab.result for Pt. file

To prevent aspiration and easy swallowing

-Given and recorded.

7-26-13

-follow up check up

-To monitor the condition of the patient. -Patient conditions

-Instruct

7-27-13

GCS7( glasgow coma scale) -RBS now and O2 inhalation 2-3 litters - To follow Plain NSS

-Done and monitored

07-28-13 8:45am

-Decrease Mannitol for tomorrow q12

-Instruct the relatives to try dropper for H2o if tongue tolerate -For NGT insertion to secure consent -NGT @ 1,200 Kcal/day to be given in 4 divided dose(200 every 6hrs) -NGT removed by the patient -Patient is lethargic but understand -Resume citicoline as ordered -Decrease mannitol OD -Pt. still lethargic

Increase osmotic pressure of plasma in glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes -For prevent dry lips and to monitored patient following instruction

-Done and recorded

-Done and recorded

-Done and monitored

07-29-13 10:35am

-Patient nourishment

-Given and recorded

-Patients comfort with her condition

-Done and monitored

07-30-13 8:35am

-Done and recorded

07-31-13 1:00pm

-IVF to follow D5LR 1L @20gtts/min

-Fluid replacement of the patient

-Done and regulated to desired rate

08-01-13 11:30am BP: 160/100

-IVF to follow PNSS 1L Lx KVO -Reinsertion of NGT and resume feeding once inserted IVF to follow PNSS 1L Lx@ KVO

-Fluid replacement of the patient

-Done and regulated to desired rate -Done and recorded

08-02-13 8:20am BP:150/90

-Fluid replacement of the patient

-Done and regulated to desired rate

08-03-13 9;30am

-RBS-152 -RBS now -may use ENSURE If no oral feeding -IVF to follow PNSS 1L @ KVO

-Done and recorded -Patient nourishment -Instruct the SO

08-04-13 11:15am

-Fluid replacement of the patient

-Given and regulated to desired rate

08-05-13 9:45am BP:100/60

-Nebulized with PNSS(3ml)TID

-To lossen secretion and patient comfort

-Given and recorded

08-06-13 8:am BP:110/80

-IVF to follow PNSS 1L @KVO -D/C Ranitidine -Decrease Mannitol OD -Simvastatin 40mg 1tab/NGT in pulvorized RBS now >Repeat ECG >MGH once with watcher able to feed NGT

-Fluid replacement of the patient

-Done and regulated to desired rate

-Net effects of total cholesterol and serum triglyceride reductions.

-Done and carried out

LABORATORY RESULTS HEMATOLOGY- The branch of science concerned with the study of blood and blood forming tissue and disorder associated with them. DATE:07-24-13 COMPONENT NORMAL RESULT VALUE HGB MASS 140131 CONCENTRATION 170g/dl INTERPRETATION Decreased NURSING RESPONSIBILITIES Inform patient to take food rich in iron such as animal liver. Give antibiotic as ordered Always check IV patency Inform patient that an antibacterial medication is needed to prevent bacterial infection. Instruct patient to eat vegetables that is rich in iron and increase oral fluid intake. Instruct patient to eat vegetables that is rich in iron and increase oral fluid intake. Increase oral fluid intake.

WBC

5.1X10g/l

14.2

Increased

HCT

0.37-0.43

0.41

Normal

SEGMENTERS

0.55-0.65

0.93

Increased

EOSINOPHILS

0.02-0.04

0.02

Normal

MONOCYTE

0.02

0.03-0.04

Decreased

PLATELET

268

150-450 x 10 cu/ml

Normal

BLOOD TYPE RESULT: O+

SODIUM POTASSIUM DETERMINATION COMPONENT Potassium (K+) Sodium (Na+) NORMAL RESULT VALUE 3.5-5.3 3.86 mmol/L 135-148 141 mmol/L INTERPRETATION Normal Normal

Troponine Test: NEGATIVE

Arterial Blood Gas- is a blood test that is performed using blood from an artery. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The most common puncture site is the radial artery at the wrist, but sometimes the femoral artery in the groin or other sites are used. The blood can also be drawn from an arterial catheter.

COMPONENT pH PCO2

NORMAL VALUE 7.35-7.45 35-45 mmHG

RESULT 7.415 30.7

INTERPRETATION Normal Decrease

PO2 HCO3

80-100 mmhg 22-26 mEq/L

110 19.3

Increase Decrease

B.E O2 sat

(-1 + 2 mEq/L) 90-100%

-5.3 98.1% Normal

Urinalisys- an analysis of the volume and physical, chemical and microscopic properties of urine. COMPONENT Color NORMAL VALUE Light Straw/amber RESULT Light Yellow INTERPRETATION Normal NURSING RESPONSIBILITIES > Maintain hydration status of the pt. continuation of the pt. IVF therapy help to this condition. > Maintain hydration status of the pt. continuation of the pt. IVF therapy help to this condition. > Maintain hydration status of the pt. continuation of the pt. IVF therapy help to this condition. > Maintain hydration status of the pt. continuation of the pt. IVF therapy help to this condition.

Appearance

Clear

Clear

Normal

Reaction

4.5-8.0

7.0

Normal

Sugar

(-)

(-)

Normal

Protein

(-)

(-)

Normal

>M the status of the patient maintain

Ketone

(-)

(-)

Normal

Specific Gravity

1.005-1.030

1.015

Normal

PUS Cells

1-2/hpf

20-25/hpf

Increase

> Maintain Hydration Status; Monitor V/S and regulate IV well as ordered rate. > Maintain Hydration Status; Monitor V/S and regulate IV well as ordered rate. > Indicates that the pt. has infection and thus should administer/ managed with

RBC

0-1/hpf

8-10/hpf

Increase

antiinfectives and increase fluid intake. > Bleeding is present. Monitor the Laboratory; CBC and be prepare for BT if Problem persist. > Maintain Hydration

Amorphous urates

Occasional/ few

Few

Normal

Oxygen Supplement of 80% FiO2 COMPONENT Creatinine RESULT 1.70g/dl NORMAL VALUES 0.6-1.3 INDICATION Increase NURSING RESPONSIBILITIES - Possible for MI; Administer antiangina drugs as ordered. - Pt. has possible gout; protect joints by putting pillow under. -avoid high sodium diet -Potassium Loss; Administer KCL to replace K+ Loss. Provide adequate hydration.

Uric Acid

9.32mg/dl

2.6-7.2 mg/dl 135-148 mmoL/L 3.5-5.3 mmoL/L

Increase

Sodium Potassium

138mmoL /L 2.46mmo L/L

Normal Decrease

Blood Glucose Examination- used to measure glucose level in the blood. COMPONENT Glucose RESULT 124mg/dl NORMAL VALUES 70-105 mg/ dl INDICATION Increase NURSING RESPONSIBILITIES > Diabetes is noted. Decrease sugar intake and give & give the Calculated KCAL. > Pt. is at risk for Obstruction of any artery leads to prone/risk to stroke. Administer anticoagulant as ordered. > Pt. is at risk for

Cholesterol

231.00g/dl

0-200

Increase

Triglyceride

137g/dl

0-150

Increase

HDL

42g/dl

Greater than 60

Low

LDL

161.6g/dl

0.150

Increase

Obstruction of any artery leads to prone/risk to stroke. Administer anticoagulant as ordered. > Pt. is at risk for Obstruction of any artery leads to prone/risk to stroke. Administer anticoagulant as ordered. > Pt. is at risk for Obstruction of any artery leads to prone/risk to stroke. Administer anticoagulant as ordered.

Criteria

Good

Fair

Poor

Justification

Onset of Illness

Mrs. Pet had already Cerebrovascular attack for three times. It is already Mrs. Pets 3rd attack.

Duration of Illness

Mrs. Pets duration of Cerebrovascular attack is already 3 years.

the patient has Hygiene poor hygiene. She is dependent to her watcher, but the watcher is

not maintaining good gygiene to Mrs. Pet. It is visible that her clothes are soiled and her mouth is not clean. .

Diet

- Pt. has a poor diet because he is only fed through NGT. And Mrs. Pet also tries to remove the NGT with her left hand.

Age

-The patient is 69 years old. The patient is not strong enough to take care of herself because she is physically weak.

Performance Level

- Upon assessment patient is unconscious.

Willingness to undergone the treatment

- The pt. is admitted to SCPH and her relatives are

willing to undergo the treatment that the physician has ordered.

Family Support

- The patients family is not supportive because the pt.s watcher is her goddaughter. Mrs. Pets son only visits her when he is badly needed.

Computations: Good: 0/8 x 100 = 0% Fair: 1/8 x 100 = 12.5% Poor: 1/8 x 100 = 87.5% 100%

Interpretation: Based on the patients prognosis the result is poor because the patient illness is chronic because it is present for more than 3 years and the patient is unconscious and poor in hygiene. The family also lacks in family support.

BIBLIOGRAPHY

1. CerebrovascularAccident.Retrieved last August 19, 2013 from http://www.ecureme.com/emyhealth/data/Cerebrovascular_Accident.asp 2. Definition of Cerebrovascular accident (CVA) prevention. Retrieved last August 19, 2013 from http://www.medterms.com/script/main/art.asp?articlekey=2677 3. Mary Ellen Ellis (2013). Cerebrovascular Accident. Retrieved las August 19, 2013 from http://www.healthline.com/galecontent/cerebrovascular-accident 4. Regina Bailey. Anatomy of the Brain. Retrieved las August 19, 2013 from http://biology.about.com/od/humananatomybiology/a/anatomybrain.htm