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
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 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 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 .
Gordon’s 11 Functional Pattern
Health Perception - Health Management 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, Alzheimer’s 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.
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 Pattern Before Hospitalization During Hospitalization According to the SO, Upon admission, the mother eats everything patient was inserted NGT •her she wants and sees. She has 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 Pattern •
Before During Hospitalization According to the SO, Hospitalization The patient is in 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 Pattern Before During Hospitalization According to the SO, Hospitalization 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 Pattern Before During Hospitalization Hospitalization According to the 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 Pattern Before The patient suffers Hospitalization from Alzheimer’s 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 Alzheimer’s, 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 During Hospitalization When her mother is 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.
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: ØPatient 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. ØWith NGT patent. ØWith IFC connected to urine bag draining yellow amber.
AREA ASSESSED SKIN Color
Texture
METHOD USEDNORMAL ACTUAL FINDINGS FINDINGS Inspection Fair complexion Pale
Inspection/ Palpation
Smooth
Wrinkled
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
Inspection Temperature
Palpation
Presence of rashes
d/t peripheral Normally warm Cold and clammy vasoconstriction
Moisture
Turgor
Palpation
Palpation
Moist to dry
Snaps back to previous
Dry
Sagged
d/t decreased activity of sebaceous and sweat glands secondary to aging
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
Inspection
Silky, resilient
Resilient
Normal
Black w/ white hairs
d/t decreased melanocyte production secondary to aging
Color
Inspection
Black
NAILS Color of the nail bed
Inspection
Capillary refill time
Palpation
Shape
Palpation
EYES/ EYEBROWS
Delayed 1-2 sec.
d/t poor arterial circulation
Delayed 4 sec.
Normal Convex Normal
Round Inspection
Symmetry
Inspection
Ability to blink
d/t poor arterial circulation
Convex
Shape
Movement
Pink transparent Pallor
Inspection
Inspection
Equal in size Symmetrical in movement Blinks involuntarily & bilaterally
Round
Normal
Equal in size
Normal
Symmetrical in movement Absence of blink
d/t decrease activity of CN V
CONJUNCTIVA Color PUPILS PERRLA
Inspection
Pink - red
Pale
d / t poor arterial circulation
Inspection
Response to penlight ( dilates and constricts )
Very slow to react to light
d/t compression of CN III
Size of the pupil EXTERNAL AUDITORY CANAL
Inspection
Hearing
Inspection
2mm
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
Inspection Auscultation Non - tender Percussion Palpation
Symmetrical No distentions Symmetrical Prominent Full chest expansion Irregular Non - tender
Normal Normal Normal Normal Normal d / t decreased function of the medulla Normal
UPPER EXTREMITIES
Symmetry ROM
LOWER EXTREMITIES
Size Symmetry ROM
Inspection Inspection / Palpation
Symmetrical (+) ROM upon movement
Symmetrical (+) ROM upon movement
Normal Normal
Inspection Inspection Inspection
Equal in size Symmetrical (+) ROM upon movement
Equal in size Normal Symmetrical Normal (+) ROM upon Normal movement
LABORATORY RESULTS
Hgt Date
Result
Normal Range
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
Analysis
Na Date 11 - 24 - 09 11 - 29 - 09
Result 131 mmOl / L 132 mmOl / L
Normal Range Analysis 135 - 145 Normal mmOl /L 135 - 145 Normal mmOl / L
K Date 11 - 24 - 09 11 - 29 - 09
Result 3 . 0 mmOl / L 4 . 0 mmOl / L
Normal Range Analysis 3.5-5.5 mmOl 3 . 5 - 5/.L5 Normal mmOl / L
CBC 11 - 20 - 09 Parameters 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 SHEET 12 - 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 600 700 700 700 800 800 800 Total : 2100
Total : 2890
12 - 04 - 09 Time 7-3 3-11 11-7 2995
Oral 720 1000 600
Intake Parenterra Othe l100 rs 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 ge 350 75 1175 290 290 200 4 1204 350 350 Total : 640
Total : 2379
12-02-09 Time
Intake
Output Urine
7-3
Oral Parenterra Others Total l 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
Time 7- 3 3-11 11-7
Intake
Oral 600 890 550
Drainage Others Total
Output
Parenterra Others l340 475 200
Total 940 1365 750
Total: 3000
Urine Drainage Others Total 1000 1000 1100 1100 900 900 Total: 2055
11-29-09
Intake
Output
Time Oral Parenterra Others Total l 3-11 800 300 1100
Urine 400
Intake
Time
Oral
7- 3
400 Total: 1100
Total: 400 11-28-09
Drainage Others Total
Output
Urine
830
Parente Others Total rral 550 1380
3-11
1030
700
1730
600
600
11-7
700
700
1400
1650
1650
Total: 3600
1350
Drainag Others Total e 1350
Total: 4510
11-27-09
Intake
Output
Time Oral Parenterra Others Total Urine Drainage l 7- 3 1030 600 1630 1630 3-11 600 450 1050 1050 Total: 2680 11-26-09
Intake
Others Total 1630 1050
Total: 2680
Output
Time Oral Parenterra Others Total Urine l 7-3 860 475 1335 600 3-11 1250 400 1650 1250
Drainage Others Total
Total: 1850
600 1250 Total: 2985
11-25-09
Intake Output Time Oral Parenterra Others Total Urine Drainage l 7-3 770 350 1120 500
Others
Total 500
3-11
810
200
1010
800
800
11-7
800
200
1000
1250
1250
11-24-09
Total: 3130
Total: 2550 Intake
Time OralParenterral 7-3 715 400 3-11 850 200
Output
Others Total 1115 1050 Total: 1750
Urine 350 1400
Drainag Others Total e 350 1400 Total: 2165
11-23-09
Time 7- 3 3-11 11-7
Oral 1030 700 600
Intake
Output
Parenterra Others Total Urine Drainage Others l200 1230 300 500 1200 600 750 1350 700 Total: 1600
Total: 3780
Total 300 600 700
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 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
