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
Jessica Datul

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 countrys 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, Gordons 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) Noncommunicable 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.

PATIENTS PROFILE

Name:
Age:
Gender:

I.M.
80 y/o
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:
Hospital:

SO, patients chart, Records section

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 Alzheimers 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 Peoples 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 Alzheimers 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

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

During Hospitalization
During our shift, the patient didnt
defecate. She has IFC connected to urine
bag with 700 ml and yellow amber in color.

Activity Exercise Pattern

Before 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.

During Hospitalization
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
Patient is comatose but can respond to
around 8 in the evening and wakes up at
physical stimuli.
around 5 in the morning. She takes naps at
afternoon. She has no rituals before
sleeping she added.
Cognitive Perceptual Pattern
Before Hospitalization
According to the SO, her mother is a
retired teacher, she uses eyeglasses. She
speaks dialects such as Ilocano, Tagalog
and English.

During Hospitalization
The patient responds to stimuli by means
of rubbing her sternum for her to wake up.

Self- Perceptual Pattern

Before Hospitalization
The patient suffers from Alzheimers
disease.

During Hospitalization
The patient is comatose.

Role- Relationship Pattern

Before Hospitalization
According to the SO, before her mother
was diagnosed with Alzheimers, 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.

During Hospitalization
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
When her mother is tired, she sleeps for
her to rest.

During 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.

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 Alzheimers 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: 36.8C

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

METHOD
USED

NORMAL
FINDINGS

Inspection

Fair
complexion

ACTUAL

ANALYSIS

FINDINGS

SKIN

Color

Texture

Inspection/
Palpation

Pale

Wrinkled
Smooth

d/t decreased
tissue perfusion
and peripheral
vasoconstriction

d/t loss of elastic

fiber and
decreased
subcutaneous fat
from hypodermis
secondary to
aging

Temperature
d/t poor hygiene
Inspection

Presence of
rashes

Moisture

Palpation
Normally warm

Cold and
clammy

d/t peripheral
vasoconstriction

d/t decreased

Turgor

Dry
Palpation

Moist to dry

Sagged
Palpation
HAIR

Snaps back to
previous

activity of
sebaceous and
sweat glands
secondary to
aging

d/t loss of elastic

fiber and
decreased
subcutaneous fat
from hypodermis
secondary to
aging

distribution

Normal

Texture
Color

Inspection/

Evenly
distributed

Evenly
distributed

Palpation
Normal
NAILS

Color of the
nail bed
Capillary
refill time

Resilient
Inspection

Inspection

Silky, resilient

Black w/
white hairs

Black

Shape
d/t poor arterial
circulation

EYES/EYEBROWS

Shape

Symmetry

d/t decreased
melanocyte
production
secondary to
aging

Pallor

Inspection

Movement

Ability to
blink

Pink
transparent

d/t poor arterial

circulation
Delayed 4
sec.

Normal

Convex

Normal

Palpation
Delayed 1-2
sec.

Palpation
Normal
CONJUNCTIVA

Color

Convex

Round

Inspection

Normal
Equal in size

Inspection

Round

PUPILS

PERRLA

Inspection

Inspection

Size of the
pupil

EXTERNAL
AUDITORY
CANAL

Equal in size

Symmetrical in
movement

Symmetrical
in movement

d/t decrease
activity of CN V

Absence of
blink
d/t poor arterial
circulation

Blinks
involuntarily &
bilaterally
Pale
Inspection

d/t compression
of CN III

Hearing
Pink-red

NOSE

Symmetry

Color

Very slow to
react to light

Inspection

Inspection

Response to
penlight
(dilates and
constricts)

2mm

Normal

LIPS & MOUTH

Symmetry

Color (lips)

Moisture

Normal
Hears equally
in both ears

Inspection

Hears equally
in both ears
Inspection
Symmetrical

NECK

Inspection

Normal

Symmetrical

Same color
as the face
and neck

Normal

Symmetry
Same color as
the face and
neck

Appearance
Inspection

Symmetrical

Pale

THORAX

Chest
contour

Inspection

Symmetrical

d/t decrease
oxygenation

d/t decreased
salivary
production r/t
loss of vagal
stimulation

Dry

Clavicle

Chest wall

Normal

Pink
Inspection

Normal

Moist

Breathing
pattern

Symmetrical
Normal

ABDOMEN

General
contour

Palpation

Inspection

No
distentions

Normal

Symmetrical
Symmetrical

Normal

No distentions
Inspection
Prominent
UPPER
EXTREMITIES

Inspection

Symmetry
Inspection

Full chest
expansion

Prominent

ROM

Normal
Irregular

Inspection

LOWER
EXTREMITIES

Symmetrical

d/t decreased
function of the
medulla

Full chest
expansion

Regular

Non-tender
Normal

Size
Inspection

Symmetry

Auscultation
Percussion

ROM

Palpation

Non-tender

Normal

Symmetrical
Inspection

Inspection/
Palpation

Symmetrical

(+) ROM
upon
movement

Normal
(+) ROM upon
movement

Normal
Equal in size

Inspection

Inspection

Equal in size

Inspection

Symmetrical

Symmetrical

(+) ROM
upon
movement

(+) ROM upon

movement

LABORATORY RESULTS
HGT
Date
11-21-09 6am

Normal

Result

Normal Range

284 mg/dl

80-120 mg/dl

Analysis

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

Result

Normal Range

Na
Date

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

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

Result

Normal Range

Analysis

Normal

CBC
11-20-09
Parameters

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 Total
s

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 Total
s

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 Total
s

Urine

Draina
ge

Others

Total

7-3

750

350

75

1175

290

290

3-11

1000

200

1204

350

350

Total: 2379
Total: 640
12-02-09
Intake
Time

Oral

Parenter
ral

Output
Other Total
s

Urine

Draina
ge

Others

Total

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 Total
s

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
Time

Oral

Parenter
ral

3-11

800

300

Output
Other Total
s
1100

Urine

Draina
ge

Others

400

Total
400

Total: 1100
Total: 400

11-28-09
Intake
Time

Oral

Parenter
ral

7-3

830

3-11
11-7

Output
Other Total
s

Urine

Draina
ge

Others

Total

550

1380

1350

1350

1030

700

1730

600

600

700

700

1400

1650

1650

Total: 4510
Total: 3600
11-27-09
Intake
Time

Oral

Parenter
ral

7-3

1030

600

Output
Other Total
s

Urine

1630

1630

Draina
ge

Others

Total
1630

3-11

600

450

1050

1050

1050

Total: 2680
Total: 2680
11-26-09
Intake

Output

Time

Oral

Parenter
ral

Other Total
s

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 Total
s

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 Total
s

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 Total
s

Urine

Draina
ge

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

Others

Total

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 Wernickes area.
Speaking ability is in Brocas area. Damage to Brocas area causes speech impairment
but not impairment of language comprehension. Lesions in Wernickes 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.