Case study on CVA

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 country’s quest for health progress and development.

Specific Objectives: • •

• •

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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, Gordon’s 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.

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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.

PATIENT’S 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, patient’s chart, Record’s 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 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, 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 Alzheimer’s 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 didn’t 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 Alzheimer’s disease.

During Hospitalization The patient is comatose.

Role- Relationship Pattern Before Hospitalization According to the SO, before her mother was diagnosed with Alzheimer’s, 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 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

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•

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

4

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 Wernicke’s area. Speaking ability is in Broca’s area. Damage to Broca’s area causes speech impairment but not impairment of language comprehension. Lesions in Wernicke’s 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.