I.

Introduction

Cerebrovascular accident

The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain
is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a
stroke. Symptoms of a stroke depend on the area of the brain affected. The most common
symptom is weakness or paralysis of one side of the body with partial or complete loss of
voluntary movement or sensation in a leg or arm. There can be speech problems and weak
face muscles, causing drooling. Numbness or tingling is very common. A stroke involving
the base of the brain can affect balance, vision, swallowing, breathing and even
unconsciousness.

Causes:

➢Intracerebral hemmorhage (rupture of a blood vessel in the pia

mater or brain
➢Emboli (blood clots)
➢Atherosclerosis (formation of plaque) of the cerebral arteries.

Risk Factor:

1. Hypertension – leading risk factor for coronary heart disease and stroke
– treatable and can be controlled.
2. Modifiable by change in lifestyle
a. smoking
b. elevated serum cholesterol
c. obesity
d. heart disease
3. Modifiable by Medical mean
a. Transient Ischemic Attack
b. Asymptomatic carotid bruit
c. Diabetes Mellitus
d. Increased blood viscosity
e. HPN
4. Non – modifiable risk factors
a. age
b. sex
c. race
d. previous stroke
 Types of Stroke by Etilogy:
1.Hemorrhage stroke (intracranial hemorrhage)
• 5% of all strokes
• two division
a.Intracerebral (10%) – due to rupture of weakened vessels
within brain parenchyma as result of Hypertension,
arteriovenous malformation or tumor
b. Subarachnoid (5%) – result from aneurismal rupture of a cerebral artery with blood
loss into space surrounding the brain; evolve over 1 –2 hours.
2.Ischemic Strokes (remaining 85%)
• Large (40%) or small (20%) vessel thrombosis
-most commonly occur in presence of atherosclerotic cerebrovascular disease
-vascular changes or lipohyalinosis found in small deep penetrating arteries as associated
with chronic hypertension can lead to small vessel thrombosis.
-rapid or prolonged interval of onset and may lead last many hours
• Cerebral embolism (20%)
-usually a cardiac origin
-frequently result of chronic ischemic cardiovascular disease with secondary ventricular wall
hypokinessis or artial arrhythmia – both conditions increase risk of intracardiac thrombus
formation
-quick onset and fully develop in a matter of minutes
Temporal Classification of Stroke
1. Transient ischemic attack (TIA)
–neurologic symptoms develop and disappear over several
minutes and completely resolve in 24 hours
–most frequently associated with atherosclerotic carotid artery
disease
2. Reversible Ischemic Neurologic Deficit
–etiology unknown
–likely the result from small infarctions (Lacunes) of the deep
subcortical gray and white matter resulting in only temporary
impairment
3. Stroke in Evolution
–describe an unstable ischemic event characterized by the
progressive development of more severe neurologic impairment
–often associated with active occlusive thrombosis of a major
cerebral artery.
–Once stable called Complete Stroke
–Most important sign – Intellectual Regression

II. Patient’s Demographic Data

 Name: Mrs. XXX
Home Address: Blk 8 Lot 11 Kasiglahan, Montalban
Age: 39 yrs. old
Gender: Female
Date of Birth: July 28, 1973
Status: Married
Nationalty: Filipino
Religion:Catholic
Father: Maximo, Capili
Mother: Manuela, Marcos

III. Nursing history

1. Chief Complaint
Weakness
2. History of Present Illness
5 months PTC patient had weakness of R leg observed by the mother as
patient seems to be dragging legs no other associated symptoms. 3 months PTC, there
was progression of R side weakness with associated weakness and numbness of L
side and gradual blurring of vision patient also had cough. Non productive with
associated fever on the day of consult there was progression of weakness now
involving upper extremities with associated DOB and dysphagia.

PMXH (-) HTN (-)DM (-) BA(-) LA(-) allergy

FMHX (-) HTN (-) DM (-) BA (-) allergy
Non smoker non alcoholic beverage drinker ROS(+) wt loss
PE conscious and coherent, 2BM in 3 months. found few (+) cough 3 months pre
convulsion. A CAP-MR CVA problem infuse(+)

IV. Physical Assessment

The client’s pulse rate is 98 beats per minute, his respiratory rate is 20 breaths per minute,
temperature is 36.8°c. BP- 110/ 80

General appearance

The client is in medium frame with stooped posture, the client is bedridden since he was
admitted to the hospital last January. 5, 2011. Is not well groomed with body odor.

Mental status
The client is conscious and cooperative . The client has low comprehension and difficult to
talk.
Skin
The client’s skin is of normal racial tone which is brown. It is dry and smooth. The skin
turgor is wrinkled and loss of elasticity. The body hair is evenly distributed. She doesn’t have
any edema. But she has a skin lesion on his right elbow.
Nail
The client’s nail shape is convex clubbing, the nail is rough and the nail bed is pink. The
capillary refill is within 3 seconds and these is an absence of beau’s line.

Head and Face

The client’s skull is proportionate to the body size, These were no tenderness in the scalp.
These were no presence of nodules, and infestation. Her hair is evenly distributed and the
strands are thin and brittle. The color of his hair is a mixture of white and black. Her head is
round and symmetrical its consistency is hard. She can’t control her head and the shape of her
face is round and asymmetrical and its consistency is soft.

Eyes
The condition of his eyes is straight normal; the eye brows are evenly distributed. Eyelids
have effectively closure. The blink response is bilateral, eye balls are symmetrical, bulbar
conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral
slant is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is
transparent, the color of her eyes are brown, the shape are equal, it is uniform in color. Pupils
are equal in size. Pupils are equally round and reactive to light and accommodation. She can
execute the occular movements. The lacrimal apparatus are moist.

Ear
The color of the ear is of normal racial tone which is brown, it is symmetrical. The
alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. The
mastoid process is tender. The auditory canal contains some cerumen, the color is brown and
there is an absent of discharges.

Nose
The color of the client’s nose is of racial tone which is brown. His septum is in the
midline. The mucosa is pink, nostrils are both patent, nasal flaring is absent. Landmarks are
visible. Sinuses are non-tender. There is an NGT in his right nostrils.

Mouth and Oropharynx

The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the
gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue
movements are not that smooth. Its texture is rough.
 Neck
The neck has involuntary movement and with resistance, the muscle strength 3/5. The trachea
is in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are
palpable.

Upper extremities

The client cannot resist force when asked to resist. Muscle strength is 3/5. The peripheral
pulses are equal. The IV site is in his left arm.

Lower extremities
The client cannot resist force when asked to resist. Muscle strength is 2/5. She doesn’t
have any deformity. The peripheral pulses are equal.

V. Anatomy and Physiology

 BRAIN
Cerebrum- The biggest part of the brain is the cerebrum. The cerebrum makes up 85% of the
brain's weight, and it's easy to see why. The cerebrum is the thinking part of the brain and it
controls your voluntary muscles
Cerebellum- The cerebellum is at the back of the brain, below the cerebrum. It's a lot smaller
than the cerebrum at only 1/8 of its size. But it's a very important part of the brain. It controls
balance, movement, and coordination (how your muscles work together).
Brain Stem- The brain stem sits beneath the cerebrum and in front of the cerebellum. It
connects the rest of the brain to the spinal cord, which runs down your neck and back. The
brain stem is in charge of all the functions your body needs to stay alive, like breathing air,
digesting food, and circulating blood.
Midbrain/ Mesencephalon- the rostral part of the brain stem, which includes the tectum and
tegmentum. It is involved in functions such as vision, hearing, eyemovement, and body
movement. The anterior part has the cerebral peduncle, which is a huge bundle of axons
traveling
from the cerebral cortex through the brain stem and these fibers (along with other structures)
are
important for voluntary motor function.
Pons- part of the metencephalon in the hindbrain. It is involved in motor control and sensory
analysis... for example, information from the ear first enters the brain in the pons. It has parts
that
are important for the level of consciousness and for sleep. Some structures within the pons
are
linked to the cerebellum, thus are involved in movement and posture.
medulla oblongata is the lower portion of the brainstem. It deals with autonomic functions,
such
as breathing and blood pressure. The cardiac center is the part of the medulla oblongata
responsible for controlling the heart rate.
Hypothalamus- The hypothalamus is like your brain's inner thermostat (that little box on the
wall
that controls the heat in your house). The hypothalamus knows what temperature your body
should be (about 98.6° Fahrenheit or 37° Celsius).

VI. Pathophysiology

PATHOPHYSIOLOGY OF HEMMORHAGIC STROKE

Tissue injury
↓
Causing compression of tissue
↓
Expanding hematoma or hematomas
 ↓
Distort and injure tissue
↓
The pressure may lead to a loss of blood supply to affected tissue with resulting
infarction
↓
The blood released by brain hemorrhage appears to have direct toxic effects on brain
tissue and
vasculature

VII. Diagnostic Studies

1. Name of Diagnostic Procedure:
Hematology

Components Results Normal Values

WBC 20.0 Adult 5-10
Hemoglobin 111 Female 120-140
Hematocrit 0.35 Female 0.38-0.48
Differential Count
Neutrophil 0.91 Adult 0.45-0.65
lymphocytes 0.04 0.25-0.50
monocyte 0.04 0.02-0.06
eosinophils 0.01 0.02-0.04
Platelet Count 350 150-450
MCV 64.3 80-100
MCH 20.3 27.31
MCHC 315 320-360
RBW 13.1 11.6-14.6

Clinical Chemistry Section

Test Name Unit Normal Result Unit Normal

Values Count Values
Blood Urea Nitrogen 2.4 low Mmol/L 2.50-6.1 6.72 Mg/dl 7-17
Creatinine 47 low Mmol/L 53.0-115.0 0.53 Mg/dl 0.60-1.30
Sodium 137 Mmol/L 135-148 137.0 Mg/dl 135-148
Potassium 3.1 low Mmol/L 5.70-3.10 3.10 Mg/dl 3.60-5.20

VIII. Theoretical Framework

IX. Pharmacology
X. Problem List
Patient has admitted Janauary 5, 2011as a case of CAP MR with aspiration; T/C
CVA infarct LMCA upon admission patient was velodyzed with PNSS 1L at 30 gtts/min
and medications were given.
M-edication
Patient has to continue his medication. Amlodipine 5mg/ tab once a day, Zantac 150 mg
twice a day, 8am and 6pm.
E-xercise
The patient was advised to have complete bed rest until strength is regained. Have turn
side to side every 2 hours to prevent bed soars. Have ROM exercise on to enhance
client's body function.
T-reatment
Insist physical therapy for improving strength and walking. Occupational therapy for
regaining dexterity of the arms and hands. Should undergo speech therapy to learn
talking and
swallowing. Oxygen inhalation if necessary and if possible 3-4 liters per minute.
H-ealth teaching
Teach the client how to have a healthy lifestyle. Teach patient the foods to eat and the
foods to avoid. Teach the family members how to prepare low sodium and low fat diet.
Encourage environmental modification to enhance safety and prevent injury.
O-ut Patient
The client was advised to have a follow-up check-up, as indicated by the physician.
D-iet
Patient was instructed to maintain the low salt and low fat diet. The low salt diet is
designed to induce a loss of sodium and water from the body or avoid sodium retention.
A 2000
mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose
weight to
decrease risk of having CVA again