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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.

A stroke is a medical emergency. Anyone suspected of having a stroke should be taken immediately to a medical facility for diagnosis and
treatment.

The causes of stroke: An artery to the brain may be blocked by a clot (thrombosis) which typically occurs in a blood vessel that has previously
been narrowed due to atherosclerosis ("hardening of the artery"). When a blood clot or a piece of an atherosclerotic plaque (a cholesterol and calcium
deposit on the wall of the artery) breaks loose, it can travel through the circulation and lodge in an artery of the brain, plugging it up and stopping the
flow of blood; this is referred to as an embolic stroke. A blood clot can form in a chamber of the heart when the heart beats irregularly, as in atrial
fibrillation; such clots usually stay attached to the inner lining of the heart but they may break off, travel through the blood stream, form a plug (embolus)
in a brain artery and cause a stroke. A cerebral hemorrhage (bleeding in the brain), as from an aneurysm (a widening and weakening) of a blood vessel in
the brain, also causes stroke.

The diagnosis of stroke involves a medical history and a physical examination. Tests are done to search for treatable causes of a stroke and help
prevent further brain damage. A CAT scan (a special X-ray study) of the brain is often done to show bleeding into the brain; this is treated differently
than a stroke caused by lack of blood supply. A CAT scan also can rule out some other conditions that may mimic a stroke. A soundwave of the heart
(echocardiogram) may be done to look for a source of blood clots in the heart. Narrowing of the carotid artery (the main artery that supplies blood to
each side of the brain) in the neck can be seen with a soundwave test called a carotid ultrasound. Blood tests are done to look for signs of inflammation
which can suggest inflamed arteries. Certain blood proteins are tested that can increase the chance of stroke by thickening the blood.

Stroke look-alikes: Just because a person has slurred speech or weakness on one side of the body does not necessarily mean that person has had a
stroke. There are many other nervous system disorders that can mimic a stroke including a brain tumor, a subdural hematoma (a collection of blood
between the brain and the skull) or a brain abscess (a pool of pus in the brain caused by bacteria or a fungus). Virus infection of the brain (viral
encephalitis) can cause symptoms similar to those of a stroke, as can an overdose of certain medications. Dehydration or an imbalance of sodium,
calcium, or glucose can cause neurologic abnormalities similar to a stroke.

Treatment of a stroke: Early use of anticoagulants to minimize blood clotting has value in some patients. Treatment of blood pressure that is too
high or too low may be necessary. (Lowering elevated blood pressure into the normal range is no longer recommended during the first few days
following a stroke since this may further reduce blood flow through narrowed arteries and make the stroke worse.) The blood sugar glucose in diabetics
is often quite high after a stroke; controlling the glucose level may minimize the size of a stroke. Drugs that can dissolve blood clots may be useful in
stroke treatment. Oxygen is given as needed. New medications that can help oxygen-starved brain cells survive while circulation is reestablished are
being developed.

Rehabilitation: When a patient is no longer acutely ill after a stroke, the aim turns to maximizing the patient's functional abilities. This can be
done in an inpatient rehabilitation hospital or in a special area of a general hospital and in a nursing facility. The rehabilitation process can involve speech
therapy to relearn talking and swallowing, occupational therapy for regaining dexterity of the arms and hands, physical therapy for improving strength
and walking, etc. The goal is for the patient to resume as many of their pre-stroke activities as possible.
OBJECTIVES:

General Objective: To be able to acquire knowledge on how to deal or manage a patient with Cerebrovascular Accident.

Specific Objective:

1. To thoroughly assess the clinical manifestations of patient with CVA based on the patient’s history.
2. To formulate comprehensive nursing diagnosis for a client with CVA.
3. To formulate a plan of care for patients with CVA.
4. To formulate appropriate nursing interventions that can be applied for a patient with CVA.
5. To evaluate the plan of care for a patient with CVA.
SIGNIFICANCE OF THE STUDY

The case study regarding patient with colon tumor provides awareness and knowledge regarding the disease and its warning signs that can be
used as a tool for further management of the disease and its prevention.
NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA
Name: Mrs. A P
Address: San Jose Paombong Bulacan
Age: 52 yrs old
Sex: F
Race: Filipino
Marital Status: Married
Occupation: Housewife
Religious Orientation: Roman Catholic
Health Care Financing: Phil health

B. CHIEF COMPLAINT
“Nanghina ang kaliwag bahagi ng akng katawan”, as verbalizes by the patient

C. HISTORY OF PRESENT ILLNESS


One day prior to admission, the patient felt weak on the left side of her body, she also has high blood pressure that day, so they decided to
go to the hospital for further management and treatment

D. PAST HISTORY
The client received 2 immunizations only (BCG and DPT) because the family is not aware of its importance. The client commonly had
cough and fever. The childhood diseases that she acquired are mumps, measles, and chicken pox and sore eyes .There were no known food or
medication allergy. Client has no history of accidents or injuries. She does not smoke or drink alcohol

E. FAMILY HISTORY OF ILLNESS


The clients father and mother has a history of hypertension.
F. HEALTH PERCEPTION PATTERN

BEFORE HOSPITALIZATION
The client experienced weakness on the left side of her body when she does some household task like gardening. She manages it by
having a period of rest in bed. She is still uncomfortable with her state of health because it greatly affects her daily activities. She cannot perform
the things she likes and usually do. Client believed that proper diet, exercises, and adequate financial support are the things needed to maintain
proper health diet and no vices are factors of having a healthy body. She does not perform self-breast examination. When signs and symptoms
arise they sought medical consultation. The client also believed in “albularyo” and use herbal medicines such as lagundi, guava leaves, pito-pito
(7 different kinds of leaves).

DURING HOSPITALIZATION
The client still feels left sided body weakness

G. NUTRITIONAL AND METABOLIC PATTERN

PRIOR TO HOSPITALIZATION
The client’s typical food intake is composed of rice, meat, and fish. Occasionally she eats vegetables and fruits. She’s fond of eating
processed food like corned beef, anything with preservatives, tocino, chicharon and fried dish (porkchop, chicken). She used a lot fish sauce,
MSG when cooking. Her appetite was good and drinks 6 glasses of water daily. Client wound heals well and she wears complete upper and lower
dentures but this doesn’t affect her food intake.

H. ELIMINATION PATTERN

BEFORE HOSPITALIZATION
Client usually defecates at least 2-3 times of soft and watery stool consisting of small amounts which is light brown color with presence of
blood (fresh blood), with discomfort or difficulties and experienced excessive sweating. Client urinates 6x a day which is yellowish- orange color
w/out any discomfort.
Stool Characteristics
Color Light brown
Consistency Formed stool
Smell Foul odor
Frequency and amount Once a day

Urine Characteristics
Color Yellowish- orange
Smell aromatic
Frequency and Amount 6 times a day at least 1000ml/day

DURING HOSPITALIZATION
Client usually defecate at least 1-2x a day semi formed stool with the presence of blood which is light brown to brown. She has difficulty
in defecation with excessive sweating.
Client urinates 4x a day which is yellow in color w/out any discomfort.
Stool Characteristics
Color Light brown to brown
Consistency Semi formed
Smell Foul odor
Frequency and Amount 1-2 times a day in small amounts

Urine Characteristics
Color yellow
Smell aromatic
Frequency and Amount 6 times a day at least 1000ml/day

I. ACTIVITY-EXERCISE PATTERN
BEFORE HOSPITALIZATION
The client said that her activities at home were limited because she has experience high blood pressure. She spends her days with minimal
cleaning like gardening and watching TV. She also played with her grand daughter and grandsons. She walks short distances as form of her
exercise.

DURING HOSPITALIZATION
Client shows tiredness and limited movement. A client doesn’t perform any routine exercise. In the hospital the client instructed to
Perform ROM by the health care provider.
3-FEEDING 3-GROOMING 3-TOILETTING 3-GENERAL MOBILITY 4-COOKING
3-BED MOBILITY 4-BATHING 3-DRESSING 4-HOME MAINTENANCE

Level 0 - Full self care


Level 1 - Requires use of equipment or device
Level 2 - Requires assistance or supervision from another person
Level 3 - Requires assistance or supervision from another person or device
Level 4 - Is dependent and does not participate

J. SLEEP-REST PATTERN

BEFORE HOSPITALIZATION
The client sleeps for 8-9 hours usually from 8pm-5am but not continuous because of prompt abdominal pain. She doesn’t take any sleep
medications. She also does take naps during afternoon. The client sleeps inadequately at night. Clients usually watch TV shows and played with
her grand daughter and grandsons.

DURING HOSPITALIZATION
The client sleeps is lessen to 6 hours due to abdominal pain and interrupted when the health care provider give medication and monitor
her vital signs during the night. She takes naps in the afternoon for about 1 hour.

K. COGNITIVE-PERCEPTUAL PATTERN
The client does not have any hearing difficulty and can’t remember past events She has a visual problem –far-sightedness. Through
demonstration she could easily learn things. Abdominal pain is the one which alters her comfort and she manages it with taking prescribed
medications.
L. SELF PERCEPTION AND SELF CONCEPT PATTERN
The client said that her condition was not improve, she still experience left sided body weakness and high blood pressure. Client feels that
she lose some weight. Financial problems and health condition usually makes her worried. When this things are encountered the client diverts her
attention through talking to a family member and praying.

M. ROLE-RELATIONSHIP PATTERN
The client lives in extended family. They live peacefully even there are hardship and difficulties that arrives to their lives. By means of
good conversation they can easily fixed family problems. When family experienced difficulty of caring for the client they just take it as trials
given by god. They have harmonious relationships with the family and their neighbors.

N. SEXUALITY-REPRODUCTIVE PATTERN
The client is done in stage of menopausal. There is no sexual activity. According to the client, decreased sexual activity is not a problem
because they were already old. They spent most of their time by taking care of each other and with that they are showing their love for one
another.

O. COPING STRESS TOLERANCE PATTERN


The client was observed to be withdrawn but the behavior improved as evidenced by her socialization with other people. When things are
not so well, she finds her husband to be the most helpful person in talking things over. When big problems encountered, she always prays and ask
assistance with the Lord. Some of the time they failed to attain what they want and try other alternatives in solving it.

P. VALUE-BELIEF PATTERN
The client is a Roman Catholics usually go to the church to attend mass every Sundays, first Friday of the month and novena. She is very
active in participating religious activities. She helps spread the word of god through catechism.
The Brain

Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon),

the midbrain (mesencephalon), and the hindbrain (rhombencephalon).

During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. The names of these vesicles and the major

adult structures that develop from the vesicles follow (see Table 1 ):

• The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia).

• The diencephalon generates the thalamus, hypothalamus, and pineal gland.

• The mesencephalon generates the midbrain portion of the brain stem.

• The metencephalon generates the pons portion of the brain stem and the cerebellum.

• The myelencephalon generates the medulla oblongata portion of the brain stem

TABLE 1 The Vesicles and Their Components


Primary Vesicles Secondary Vesicles Adult Structure Important Components or Features
prosencephalon (forebrain) telencephacerebrum cerebral (cerebral hemispheres) cerebral cortex (gray matter): motor areas, sensory areas, association areas
prosencephalon (forebrain) telencephacerebrum cerebral (cerebral hemispheres) cerebral white matter: association fibers, commisural fibers, projection fibers
prosencephalon (forebrain) telencephacerebrum cerebral (cerebral hemispheres) basal ganglia (gray matter): caudate nucleus & amygdala, putamen, globus pallidus
prosencephalon diencephalon diencephalon thalamus: relays sensory information
prosencephalon (forebrain) diencephalon diencephalon hypothalamus: maintains body homeostasis
prosencephalon (forebrain) diencephalon diencephalon mammillary bodies: relays sensations of smells to cerebrum
prosencephalon (forebrain) diencephalon diencephalon optic chiasma: crossover of optic nerves
prosencephalon (forebrain) diencephalon diencephalon infundibulum: stalk of pituitary gland
prosencephalon (forebrain) diencephalon diencephalon pituitary gland: source of hormones
prosencephalon (forebrain) diencephalon diencephalon epithalamus: pineal gland
mesencephalon (midbrain) mesencephalon brain stem midbrain: cerebral peduncles, sup. cerebellar peduncles, corpora quadrigemina, superior
colliculi
rhombencephalon (hindbrain) metencephalon brain stem pons: middle cerebellar peduncles, pneumotaxic area, apneustic area
rhombencephalon (hindbrain) metencephalon cerebellum sup. cerebellar peduncles, middle cerebellar peduncles, inferior cerebellar peduncles
rhombencephalon (hindbrain) myelencephalon brain stem medulla oblongata: pyramids, cardiovascular center, respiratory center
• .

A second method for classifying brain regions is by their organization in the adult brain. The following four divisions are recognized (see Figure 1 ).

• The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible

part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the

convolutions:

A gyrus (plural, gyri) is an elevated ridge among the convolutions.

A sulcus (plural, sulci) is a shallow groove among the convolutions.

A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)—the frontal lobe, the parietal love, the

temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain.

A cross section of the cerebrum shows three distinct layers of nervous tissue:

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control

of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas.

The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres

(association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection

fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral

hemispheres.
Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the

basal ganglia—the caudate nuclei, the putamen, and the globus pallidus—are involved in relaying and modifying nerve impulses passing

from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here.

• The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions:

The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are

sorted and grouped here before being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are

evaluated here also.

The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock

(sleep-wake cycles).

The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion,

behavior, hunger, thirst, body temperature, and the biological clock. It also produces two hormones (ADH and oxytocin) and various

releasing hormones that control hormone production in the anterior pituitary gland.

The following structures are either included or associated with the hypothalamus.

The mammillary bodies relay sensations of smell.

The infundibulum connects the pituitary gland to the hypothalamus.

The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye cross over

to the cerebral hemisphere on the opposite side of the brain.


• The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber

tracts surrounding a core of gray matter. The brain stem consists of the following four regions, all of which provide connections between various

parts of the brain and between the brain and the spinal cord. (Some prominent structures are illustrated in Figure 2 ).
Figure 2 Prominent structures of the brain stem.

The midbrain is the uppermost part of the brain stem.

The pons is the bulging region in the middle of the brain stem.
The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum.

The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain

regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one component of the reticular

formation, is responsible for maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other

components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles.

• The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the

surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and

coordinates motor movements by comparing actual skeletal movements to the movement that was intended.

The limbic system is a network of neurons that extends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to

behaviors, experiences, and memories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic

system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and encircles the inside border of

the cerebrum. The following components are included:

• The hippocampus (located in the cerebral hemisphere)

• The denate gyrus (located in cerebral hemisphere)

• The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate nucleus of the basal ganglia)

• The mammillary bodies (in the hypothalamus)

• The anterior thalamic nuclei (in the thalamus)


• The fornix (a bundle of fiber tracts that links components of the limbic system)

PATHOPHYSIOLOGY

Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of blood supply to the brain, which precipitates neurologic

dysfunction lasting longer than 24 hours. Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood vessel by cerebral thrombosis or

embolism or hemorrhage (leakage of blood from a vessel causes compression of brain tissue and spasm of adjacent vessels). Hemorrhage may occur outside the

dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance itself (intracerebral).

Risk factors for stroke include transient ischemic attacks (TIAs) – warning sign of impending stroke – hypertension, arteriosclerosis, heart disease, elevated

cholesterol, diabetes mellitus, obesity, carotid stenosis, polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarette smoking. Complications of stroke

include aspiration pneumonia, dysphagia, constractures, deep vein thrombosis, pulmonary embolism, depression and brain stem herniation.
Labaoratory Result

Blood Chemistry

RESULT

Glucose 110mg/dl (high)

Uric acid 5.9 mg/dl

CHL 269 mg/dl (high)

Tryglycerides 169mg/dl ( high)

Directhol 63 mg/dl (high)

LL 173 mg/dl (high)

VLDL 34

Alanine Amino Transferase 115 U/L (high)

Fasting Blood Glucose

Result
Crea 113 mg/dl
Alanine Transferase 0.9mg/dl
Na 151mg/dl
K 4.2mmol/L

DRUG STUDY

Name of Drug, Dosage, Route, Adverse Nursing


Generic,Brand Frequency Action Indication Contraindication Reaction Responsibility
name

Generic Name: 75 ml, q6 Increase osmotic - to reduce - contraindicated to -Seizure -monitor vital sign
Mannitol pressure of intraocular or patient -Edema
glomerular filtrate, intracranial hypersensitive to -Heart Failure -to relieve thirst
Brand Name: inhibiting tubular pressure drugs -Urine retention give frequent mouth
Osmitrol reabsorbption of -Blurred Vision care
water and -chills
Drug electrolytes, drug -don’t give
Classification: elevates plasma electrolyte free
Diuretics osmolality, solution with blood
increasing water
flow into
exracellular fluid