1

A Case Study on Cerebrovascular Accident

In partial fulfillment of The course requirement of Clinical Pharmacy

Presented to the Faculty of University of Visayas College of Nursing

Submitted by: Alcesto, Jenifer P. BSP 4 Class of 2013

May 2013

2 Table of Contents I. Introduction II. Objectives III. Nursing Assessment 1. Personal History 1.1 Patients Profile 1.2 Family and Individual Information, Social and Health History 1.3 Level of Growth and Development 1.3.1 Normal Development at Particular Stage 1.3.2 The ill Person at Particular Stage of the Patient 2. Diagnostic Results 3. Present Profile of Functional Health Patterns 4. Pathophysiology and Rationale 4.1 Anatomy and Physiology 4.2 Schematic Diagram 4.3 Disease Process 4.4 Comparative Chart IV. Nursing Intervention 1. Care Guide for a Stroke Patient 2. Actual Patient Care V. Evaluation and Recommendation VI. Evaluation and Implication of This Case Study VII. Bibliography 3 5 6 6 7 7 8 8 10 10 14 17 17 23 24 27 31 31 31 46 46 48

3 I. Introduction Cerebrovascular Accident refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of the entire cerebrovascular system. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the vessel lumen with transient or permanent effects. If blood flow is disrupted at any point between the heart and the brain, portions of the brain relying on blood from the obstructed blood vessel become deprived of oxygen. Thus, making it starve to death. A stroke results in permanent damage to the brain tissue. Persons suffering from stroke may experience disruption of motor, sensory, cranial nerve, cognitive and other functions. Stroke is the third most common cause of death in developed countries. It is uncommon before the age of 40 and is more common in males. Stroke affects around 1.2% of Australian patients at sometime in their lives, which corresponds to 217,500 Australians affected. With the growing incidence of obesity in Australia (which contirbutes to stroke through hypertension and atherosclerosis- fatty plaques in blood vessels) the incidence of strokes is expected to sky-rocket by 2050. However, the incidence in younger age groups - eg. 40-60 is dropping with better control of hypertension. Stroke is more common in certain races like the Afro-Caribbean. Men are at greater risk of stroke than women up until the age of 55 years, after which both sexes have similar risks. Stroke is a major cause of morbidity and mortality in the elderly. While stroke is considered a disease more commonly affecting men, women are actually twice as likely to die from stroke than men. In addition, females have additional risk factors for stroke such as oral contraceptives, that are not present in men. Stroke is uncommon in children accounting for only a small percentage of stroke cases each year. Stroke in children is often secondary to congenital heart disease (embolic stroke), genetic disorders, abnormalities of intracranial vessels or blood disorders such as Thrombophilia. Half of strokes in children are haemorrhagic and these may be associated with long term disabilities.

4 Around 25% of people die in the first one month following an ischaemic stroke, and up to 75% after a haemorrhagic stroke. Furthermore, the patients that survive are at a high risk of further strokes - recurrent strokes occur are seen in 10% of survivors in the first year. In addition, patients that have suffered a stroke are also at a very high risk for a myocardial infarction (heart attack) due to concominant coronary artery disease. Patients that have surivived the initial period after a stroke are usually left with significant morbidity. Around 1/3 are independently mobile (move on their own), and 1/3 have a severe disability requiring on-going institutional care, and the rest are in between.There is usually some improvement in function after a stroke, although the patient may be left with a severe deficit. The improvement made in the first month can be used to indicate the likely improvement the patient will make in future.

The reason why the student chose Cerebrovascular Accident as her case study is because that, studies show that stroke is common nowadays and being one of the primary caregivers, nurses should be fully equipped with the knowledge about the disease process, attitude towards the clients and skills needed to perform in giving caring care to the clients. Nurses should also be competent enough in giving holistic caring care to the stroke clients.

After finishing this case study, the student is expected to have in depth knowledge and understanding of the nature, signs and symptoms and prognosis of cardiovascular accident.

5 II. Objectives General Objectives: At the end of this case study, the student is expected to acquire adequate knowledge, attitude and skills in providing holistic caring care for patients who has cerebrovascular accident with the cooperation of the family and the significant others and with the collaboration with other health care team.

Specific Objectives:

After thorough assessment, the student will be able to: 1. relate the patients history and stage of growth and development. 2. define Cerebrovascular Accident or stroke. 3. state the different types of stroke. 4. review the anatomy and physiology of the Central Nervous System. 5. explain the pathophysiology of CVA. 6. enumerate signs and symptoms manifested with patients having CVA. 7. formulate a comprehensive nursing care plan to bridge gap of communication between patient and caregivers. 8. integrate the formulated health teaching plan to the patient and the significant others. 9. evaluate the effectiveness of care rendered to the patient.

6 III. Nursing Assessment 1. Personal History 1.1 Name: Mrs. X Age: 90 years old Sex: Female Civil Status: Widow Religion: Roman Catholic Date of Admission: April 15, 2013 Room No.: 203 Complaints: Right sided Hemiparesis and slurred speech Impression/ Diagnosis: Cerebrovascular Disease Infarct Physician: Dr. Manuel T. Lim 1.2 Family and Individual Information, Social and Health History Mrs. Constancia B. Erasmo, 89 years of age, is an American Citizen, a widow and a retired teacher from outside the country. She is a very religious Catholic who loves to go to church all the time. She is a non-alcoholic beverage drinker and she also doesnt smoke cigarettes. She has no known food or drug allergies. She is a known hypertensive with a blood pressure normally ranging from 140-160/90-100 mmHg. She has maintenance medication which is Perindopril. Hypertension is common in her family. All her children already graduated. Some has already left the country and someone was shot and died. According to her daughter in law, the patient had a stroke attack when she went back here to the Philippines. The patient is very fond of her grandson whose father already died when he was still young. She talks to him whenever she has a problem and spends time with him or at his house after she went to church. She always visits the church everyday and staying there for long periods after which her daughter in law would pick her up. All of her children have left the Patients Profile

7 country except for her daughter who is still here in the Philippines and working as a nurse at Vicente Sotto Memorial Medical Center. 1.3 Level of Growth and Development 1.3.1 Normal development at particular stage Physical Changes The body changes continuously with age, but the effects on a particular adult depends on health, lifestyle, stressors and environmental stressors. The skin loses resilience and moisture in adulthood. Facial features become more pronounced for loss of subcutaneous tissues. The elderly visual acuity declines leading to presbyopia. Presbycussis is a common age-related change in auditory acuity. There is a decreased cardiac output and slow peristalsis and alterations in secretions in GIT. Muscle fibers are reduced in size. There is also a decreased sense of balance or uncoordinated muscle movement. Cognitive changes The mental profile of elderly is diverse. Fluid intelligence that controls emotions, retention of non-intellectual information, creativity, spatial perceptions, and aesthetic appreciation is thought to decline with age. Crystallized intelligence, involving the use of past learning and experiences for problem solving is maintained throughout adulthood.

Vigilance performance, the ability to retain information longer than 45 minutes, declines in old age. They are more easily distracted by irrelevant information and stimuli. They also have a reduced ability to perform task that are complicated or

8 demands simultaneous performance. Retrieval of information stored in long-term memory is lower. Emotional As we grown older, our amount of stress often increases while our ability to deal with it decreases. Elderly face a wide range of stressors: physical limitations or incapacity, dependence on others, physical pain, losses and fear of death. Psychosocial Elderly experiences Integrity vs. Despair phase in his psychosocial development. This phase, especially from the perspective of youth, seems like the most difficult of all. First comes a detachment from society, from a sense of usefulness, for most people in our culture. Some retire from jobs they've held for years; others find their duties as parents coming to a close; most find that their input is no longer requested or required. Then there is a sense of biological uselessness, as the body no longer does everything it used to. Women go through a sometimes dramatic menopause; men often find they can no longer "rise to the occasion." Then there are the illnesses of old age, such as arthritis, diabetes, heart problems, concerns about breast and ovarian and prostrate cancers. There come fears about things that one was never afraid of before -- the flu, for example, or just falling down. Along with the illnesses come concerns of death. Friends die. Relatives die. One's spouse dies. It is, of course, certain that you, too, will have your turn. Faced with all this, it might seem like everyone would feel despair. In response to this despair, some older people become preoccupied with the past. After all, that's where things were better. Some become preoccupied with their failures, the bad decisions they made, and regret that (unlike some in the previous stage) they really don't have the time or energy to reverse them. We find some older people become depressed, spiteful, paranoid, hypochondriacal, or developing the patterns of senility with or without

9 physical bases. Ego integrity means coming to terms with your life, and thereby coming to terms with the end of life. If you are able to look back and accept the course of events, the choices made, your life as you lived it, as being necessary, then you needn't fear death. Although most of you are not at this point in life, perhaps you can still sympathize by considering your life up to now. We've all made mistakes, some of them pretty nasty ones; yet, if you hadn't made these mistakes, you wouldn't be who you are. If you had been very fortunate, or if you had played it safe and made very few mistakes, your life would not have been as rich as is. 1.3.2 The ill person at particular stage of the patient The patient has been diagnosed with stroke. Primary management is through medication, rehabilitation and appropriate nursing care. She has a slurred speech and difficulty in hearing words spoken to her. The patient was noted to be very cooperative to the care rendered by the staff. What the patient is experiencing is common to individuals at the same age and development stage as hers. Bodily functions decline as a result of the bodys inability to keep with the systemic requirements, as theorized in the wear and tear theory. The bodys inability to cope up is coupled with disease and infections which contribute to the generalized deterioration of the body.

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2. Diagnostic Test DIAGNOSTIC TEST CBC (4-16-13) Hemoglobin Hematocrit White Blood Cells Red Blood Cells MCV MCH MCHC NORMAL VALUES M: 14-17.5 F: 12.3-15.3 41.5-50.4% 4.4-11.0*10^9/ml 4.5-5.9*10^12/L 80-90/L 27.5-33.2 pg 33.4-35.5% PATIENTS RESULT 13.7 42.4 4.49 4.76 89.0 28.8 32.3 Normal Normal Normal Normal Normal Normal decrease in a SIGNIFICANCE

A have

MCHC in

indicates that the erythrocyte decrease hemoglobin Platelets 3-28-07 Ph 150,000-450,000 7.35-7.45 156,000 6.0 concentration.

(hypochromic) Normal The ph is the hydrogen ion (H+) expressed negative actual as concentration a negative ph is ion

logarithm. Because it is a logarithm, hydrogen inversely proportional to the concentration. Therefore, as ph increases, the hydrogen ion concentration increases. In respiratory or metabolic Specific Gravity 1.001-1.040 1.025 acidosis, ph is decreased. Normal

11 Potassium 3.6-5.0 mmol/L Many diuretics in lower decrease the blood. blood

potassium Diuretics

pressure by helping your body eliminate sodium and water. This reduces blood volume and helps decrease pressure walls. on your your artery body When

excretes excessive amounts of water, it also loses extra potassium. This can lead to low potassium levels in your blood (hypokalemia). Eosinophil 0%-5%

A lower-than-normal eosinophil count may be due to alcohol intoxication and overproduction of certain steroids in the body (such as cortisol).

Monocyte

0%-8%

High monocyte count can indicate infection, often bacterial infection.

CT Scan Result: (April16,2013) Head/Brain Completion

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Follow up non-enhanced CT scan of the brain dated March 16, 2007 as compared to the previous study done on March 15, 2007 shows interval development of areas of low attenuation at the left deep temporal lobe, the posterior limb of the left internal capsule, the left periventricular region and left parieto-occipital lobes (small). There is no evidence of acute intracranial hemorrhage. The ventricles and basal systems are preserved. The midline structures are not displaced. The rest of the findings are unremarkable. Impression: Small subacute infarcts at the left deep temporal lobe, posterior limb of the left internal capsule, left periventricular region and left parieto-occipital lobe. No evidence of acute intracranial hemorrhage. ECG Report: (April 19, 2013) Interpretation: Atrial fibrillation with rapid ventricular response and an inferior wall myocardial ischemia. When compared to the tracing taken on March 15,2007, left ventricular hypertrophy and non-specific ST-T wave changes are still noted; first degree AV block is not appreciated.

Carotid Duplex Scan (April 16, 2013) Interpretation:

13 Minimal left carotid artery disease without hemodynamic significance. Normal right carotid and bilateral vertebral artery colors duplex scan.

14 3. Present Profile of Functional Health Patterns 3.1 Health Perception/ Health Management Pattern Mrs. Constancia Erasmo complains of right-sided hemiparesis. She looks at her condition as poor since the right side of her body has difficult and limited movement and also needs assistance to do activities of daily living. Her condition is poor compared to her previous condition prior to admission. She is a known hypertensive and has a maintenance medication of Perindopril. 3.2 Nutritional-Metabolic Pattern Prior to admission, the patient loves to eat chicken and those food with soup. But now, the patient is required to eat soft diet foods like lugaw. She has no problems with eating. 3.3 Elimination Pattern The patient has no problems with urinary and bowel elimination. She though has difficulty in going to the comfort room to urinate or defecate due to weakness. She uses adult diapers instead. 3.4 Activity Exercise Pattern She has difficulty in moving due to weakness in her body. Thus, activities requiring physical mobility are lessened. Exercise is only limited to passive ROM exercises like arm/leg flexion and extension. She still has difficulty in ambulating right now.

15 3.5 Sleep-Rest Pattern The significant others stated that she has difficulty in sleeping at night. The patient looked so tired. She had no difficulties in sleeping during his previous state or condition. The significant others noticed that she has frequent awakenings at night. 3.6 Cognitive/ Perceptual Management Pattern Mrs. Constancia Erasmo has difficulty in expressing and hearing words. This is the reason why she answers differently to questions asked. The significant others said that she can properly read and write before the occurrence of this condition. But after admission, her ability to read and write at her right hand and eye is limited. 3.7 Self-Perception Pattern The patient has difficulty expressing herself. She has difficulty in communicating and performing her usual activities of daily living. She has slurring of speech and a right sided hemiparesis. She has poor self-concept. Her significant others are there to support her throughout the course of her hospitalization. 3.8 Role Relationship Pattern The patient uses English language and is an American citizen. Her voice is very low as if shes talking to herself. When she is here in the Philippines, she lives with her daughter but turns to her favorite grandson whenever she has problems.

16 3.9 Sexuality-Reproductive Pattern The patient wore clothing appropriate for her age. Women of her age usually diminish in sexual desire. 3.10 Coping-Stress Tolerance Pattern She finds strength in her family in coping stress. She decides with her daughter and grandchildren. When she is under stress, she goes to church to pray and go to her favorite grandsons home to seek advice. 3.11 Values and Belief System The patient is a very religious Catholic. Prior to admission, she goes to church everyday and stayed there for long periods of time. She has strong faith in God. Now, she continuous to read the bible since she has only limited movement and with assistance.

17 4. Pathophysiology and Rationale 4.1 Anatomy and Physiology

BRAIN It is the portion of the central nervous system contained within the skull. The brain is the control center for movement, sleep, hunger, thirst, and virtually every other vital activity necessary to survival. All human emotionsincluding love, hate, fear, anger, elation, and sadnessare controlled by the brain. It also receives and interprets the countless signals that are sent to it from other parts of the body and from the external environment. The brain makes us conscious, emotional, and intelligent. Occupying the skull cavity (cranium), the adult human brain normally weighs from 2 1/4 to 3 1/4 lb (1-1.5 kg). Differences in weight and size do not correlate with differences in mental ability; an elephant's brain weighs more than four times that of a human. In invertebrates a group of ganglia or even a single ganglion may serve as a rudimentary brain. By means of electrochemical impulses the brain directly controls conscious or voluntary behavior, such as walking and thinking. It also monitors, through feedback circuitry, most involuntary behaviorconnections with the autonomic nervous system enable the brain to adjust heartbeat, blood pressure, fluid balance, posture, and other functions and influences automatic activities of the internal organs. There are no pain receptors in

18 brain tissue. A headache is felt because of sensory impulses coming chiefly from the meninges or scalp. Anatomically the brain has three major parts, the hindbrain (including the cerebellum and the brain stem ), the midbrain, and the forebrain (including the diencephalon and the cerebrum). Every brain area has an associated function, although many functions may involve a number of different areas. 1.1 Brain stem The brain stem is the lowest part of the brain. It serves as the path for messages travelling between the upper brain and spinal cord, and is also the seat of basic and vital functions such as breathing, blood pressure, and heart rate, as well as reflexes like eye movement and vomiting. The brain stem has three main parts: the medulla, pons, and midbrain. A canal runs longitudinally through these structures carrying cerebrospinal fluid. Also distributed along its length is a network of cells, referred to as the reticular formation, that governs the state of alertness. The medulla, which is part of the brainstem, controls basic functions such as breathing rate, heartbeat and the activity of the intestines. The midbrain, also part of the brainstem, controls movements and contains nerve centres involved in hearing and vision.

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1.2 Cerebellum The cerebellum coordinates body movements. Located at the lower back of the brain beneath the occipital lobes, the cerebellum is divided into two lateral (side-by-side) lobes connected by a fingerlike bundle of white fibers called the vermis. The outer layer, or cortex, of the cerebellum consists of fine folds called folia. As in the cerebrum, the outer layer of cortical gray matter surrounds a deeper layer of white matter and nuclei (groups of nerve cells). Three fiber bundles called cerebellar peduncles connect the cerebellum to the three parts of the brain stemthe midbrain, the pons, and the medulla oblongata. The cerebellum coordinates voluntary movements by fine-tuning commands from the motor cortex in the cerebrum. The cerebellum also maintains posture and balance by controlling muscle tone and sensing the position of the limbs. All motor activity, from hitting a baseball to fingering a violin, depends on the cerebellum.

20 1.3 Cerebrum The cerebrum consists of two hemispheres that are incompletely separated by the great longitudinal fissure. This sulcus separates the cerebrum into the right and left hemispheres. The two hemispheres are joined at the lower portion of the fissure by the corpus callosum. The outside surface of the hemispheres has a wrinkled appearance that is the result of many folded layers or convolutions called gyri, which increase the surface area of the brain, accounting for the high level of activity carried out by such a small-appearing organ. The external or outer portion of the cerebrum (the cerebral cortex) is made up of gray matter approximately 2 to 5 mm in depth; it contains billions of neurons/cell bodies, giving it a gray appearance. White matter makes up the innermost layer and is composed of nerve fibers and neuroglia (support tissue) that form tracts or pathways connecting various parts of the brain with one another (transverse and association pathways) and the cortex to lower portions of the brain and spinal cord (projection fibers). The cerebral hemispheres are divided into pairs of frontal, parietal, temporal, and occipital lobes. The four lobes are as follows:

21 Frontal the largest lobe. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It also contains Brocas area, critical for motor control of speech. The frontal lobe is also responsible in large part for an individuals affect, judgment, personality, and inhibitions. Parietal a predominantly sensory lobe. The primary sensory cortex, which analyzes sensory information and relays the interpretation of this information to the thalamus and other cortical areas, is located in the parietal lobe. It is also essential to an individuals awareness of the body in space, as well as orientation in space and spatial relations. Temporal contains the auditory areas. Contains a vital area called the interpretive area that provides integration of somatization, visual, and auditory areas and plays the most dominant role of any area of the cortex in cerebration. Occipital the posterior lobe of the cerebral hemisphere is responsible for visual interpretation. Corpus Callosum Is a thick collection of nerve fibers that connects the two hemispheres of the brain and is responsible for the transmission of information from one side of the brain to the other.

22 Basal Ganglia Are masses of nuclei located deep in the cerebral hemispheres that are responsible for control of fine motor movements, including those of the hands and lower extremities. Thalamus Lies on either side of the third ventricle and acts primarily as a relay station for all sensation except smell. All memory, sensation, and pain impulses also pass through this section of the brain. Hypothalamus Located anterior and inferior to the thalamus. The hypothalamus lies immediately beneath and lateral to the lower portion of the wall of the third ventricle. It includes the optic chiasm (the point at which the two optic tracts cross) and the mamillary bodies (involved in olfactory reflexes and emotional response to odors). The infundibulum of the hypothalamus connects it to the posterior pituitary gland. The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance and maintains temperature regulation by promoting vasoconstriction or vasodilation. The site of the hunger center and is involved in appetite control. It contains the centers that regulate the sleep-wake cycle, blood pressure, aggressive and sexual behavior, and emotional responses. The hypothalamus also controls and regulates the autonomic nervous system. Pituitary Gland

23 Located in the sella turcica at the base of the brain and is connected to the hypothalamus. The pituitary is a common site of brain tumors in adults; frequently they are detected by physical signs and symptoms that can be traced to the pituitary, such as hormonal imbalance or visual disturbances secondary to pressure on the optic chiasm. 1.4 Diencephalon The thalamus , which forms the major part of the diencephalon, receives incoming sensory impulses and routes them to the appropriate higher centers. The hypothalamus , occupying the rest of the diencephalon, regulates heartbeat, body temperature, and fluid balance.

4.2 Schematic Diagram Precipitating - Hypertension - Cardiovascular Disease - Diabetes Mellitus - Intracranial Aneurysm Predisposing - High Cholesterol Levels - Obesity - Elevated Hematocrit - Smoking - Drug Abuse - Excessive Alcohol

Cerebrovascular Accident

24 Signs and Symptoms - Hemiparesis - Aphasia - Ataxia - Hemiplegia - Dysphagia Management - Loss of peripheral vision - Homonymous hemianopsia - Paresthesia - Dysarthia - Diplopia

Nursing Turning of patient every 2 hours Bed rest to prevent agitation and stress Management of vasospasm Patient is fitted with plastic Compression stockings to Prevent deep vein thrombosis heparin

Medical - Surgical or medical treatment to prevent rebleeding - Analgesics( codeine, acetaminophen) may be prescribed for head and neck pain - Alteplase - Anticoagulations with - Aspirin

Optimum Level of Functioning 4.3 Disease Process A stroke is damage to the brain due to an interruption in the blood flow. The interruption may be caused by a blood cot, constriction of a blood vessel, or rupture of a vessel accompanied by bleeding. A pouch like expansion of the wall of a blood vessel, called an aneurysm, may weaken and burst, for example, because of high blood pressure. Sufficient quantities of glucose and oxygen, transported through the bloodstream, are needed to keep nerve cells alive. When the blood supply to a small part of the brain is interrupted, the cells in that area die and function of the area is

25 lost. A massive stroke can cause a one-side paralysis (hemiplegia) and sensory loss on the side of the body opposite the hemisphere damaged by the stroke. The Pathophysiology of hemorrhagic stroke depends on the cause and type of cerebrovascular disorder. Symptoms are produced when an aneurysm or AVM enlarges and presses on nearby cranial nerves or brain tissue or, more dramatically, when an aneurysm or AVM ruptures, causing subarachnoid hemorrhage (hemorrhage into the cranial subarachnoid space). Normal brain metabolism is disrupted by the brain being exposed to blood; by an increase in ICP resulting from the sudden entry of blood into the subarachnoid space, which compresses and injures brain tissue; or by secondary ischemia of the brain resulting from the reduced perfusion pressure and vasospasm that frequently accompany subarachnoid hemorrhage. An intracerebral hemorrhage, or bleeding into the brain substance, is most common in patients with hypertension and cerebral atherosclerosis because degenerative changes from these diseases cause rupture of the vessel. They also may be due to certain types of arterial pathology, brain tumor, and the use of medications (oral anticoagulants, amphetamines and illicit drugs such as crack and cocaine). The bleeding is usually arterial and occurs most commonly in the cerebral lobes, basal ganglia, thalamus, brain stem (mostly the pons), and cerebellum. Occasionally, the bleeding ruptures the wall of the lateral ventricle and causes intraventricular hemorrhage, which is frequently fatal. An intracranial (cerebral) aneurysm is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. The cause of aneurysm is unknown, although research is ongoing. An aneurysm may be due to atherosclerosis, resulting in a defect in the vessel wall with subsequent weakness of the wall; a congenital defect of the vessel wall with subsequent weakness of the

26 wall; a congenital defect of the vessel wall; hypertensive vascular disease; head trauma; or advancing age. Any artery within the brain can be the site of cerebral aneurysms, but they usually occur at the bifurcations of the large arteries at the circle of Willis. The cerebral arteries most commonly affected by an aneurysm are the internal carotid artery (ICA), anterior cerebral artery (ACA), anterior communicating artery (ACoA), posterior communicating artery (PCoA), posterior cerebral artery (PCA), and middle cerebral artery (MCA) Multiple cerebral aneurysms are not uncommon. An AVM is due to an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed. The absence of a capillary bed leads to dilation of the arteries and veins and eventual rupture. They are commonly a cause of hemorrhage in young people. A subarachnoid hemorrhage (hemorrhage into the subarachnoid space) may occur as a result of an AVM, intracranial aneurysm, trauma, or hypertension. The most common cause is leaking aneurysm in the area of the circle of Willis or a congenital AVM of the brain.

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The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. A comprehensive assessment will reveal the extent of the neurologic deficits. Many of the same motor, sensory, cranial nerve, cognitive, and other functions that are disrupted following ischemic stroke are altered following a hemorrhagic stroke. In addition to the neurologic deficits that are similar to ischemic stroke, the patient with an intracranial aneurysm or AVM can have some unique clinical manifestations. Rupture of an aneurysm or AVM usually produces a sudden, unusually severe headache and often loss of consciousness for a variable period. There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to meningeal irritation. Visual disturbances (visual loss, diplopia, ptosis) occur when the aneurysm is adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemiparesis may also occur. At times, an aneurysm or AVM leaks blood, leaking to the formation of a clot that seals the site of rupture. In this instance, the patient may show little neurologic deficit. In other cases, severe bleeding occurs, resulting in cerebral damage followed rapidly by coma and death. Prognosis depends on the neurologic condition of the patient, age, associated diseases, and the extent and location of an intracranial aneurysm. Subarachnoid hemorrhage from an aneurysm is a catastrophic event with significant morbidity and mortality.

28 4.4 Comparative Chart Classical Symptom Clinical Symptom Rationale

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Visual Field Deficits 1. Homonymous hemianopsia (loss of half of the visual field) Manifested patient can only see in her left eye visual-perceptual dysfunctions disturbances of the primary sensory pathways between the eye and visual cortex. The affected side of vision corresponds to the paralyzed side of the body. 2. Loss of peripheral vision 3. Diplopia Motor Deficits 1. Hemiparesis Manifested patient sided She has moving has right weakness. difficulty her right a stroke is a lesion of the upper motor neurons and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate, a disturbance of Not manifested

Not manifested

extremities. She can flex her right arm but she cant gain full control of it.

30 IV. Intervention 1. Care Guide for a Stroke Patient Assessment asses medical history and risk note frequency and duration of symptoms take vital signs closely monitor blood pressure listen for abnormal sounds in the carotid and peripheral arteries note changes in the level of consciousness determine current cardiac status assess hemoglobin level, platelets and clotting time

Signs and Symptoms Arm or leg weakness and paralysis Speech difficulties Balance problems when walking Numbness or lack of sensation Hand clumsiness Sudden vision loss Confusion Nausea Room spinning Seizure Coma

Diagnosis MRI (Magnetic Resonance Imaging) CAT scan (Computerized Axial Tomography)

31 DSA (Digital Subtraction Angiography) A transcranial or carotid doppler ultrasound test Radionucleotide angiography EEG (Electroencephalogram)

Medical Treatment Alteplase (a tissue plasminogen activator, or t-PA) is an intravenous thrombolytic enzyme used to treat acute ischemic stroke Anticoagulations with heparin Aspirin

Surgical Treatment Carotid ebartectomy> removal of blood clots from carotid arteries feeding the brain Carotid angioplasty> uses a catheter- guided balloon and/ or stent to open up a blocked carotid artery Risk Factors Heredity Age> 5% of population over age 65 have had at least one stroke Gender> Men are at a higher risk for stroke Hypertension. 70% of all stroke victims have hypertension Heart and carotid artery disease Diabetes Cigarette smoking Alcohol and substance abuse Anticoagulant medications Geographic location and climate

32 Stroke Prevention Blood Pressure monitoring Smoking cessation Limiting alcohol consumption Exercise Healthy diet

Causes: Certain irregularities such as atrial fibrillation to the brain, cause the blood clot to The blood clot moves from the carotid arteries to the brain Blood vessels to the brain become narrow due to cholesterol blockage Severely Low Blood Sugar Decreased oxygen in the blood due to lung problems Myocardial Infarction (heart attack), in which the heart does not pump enough A heart arrythmia does not allow the heart to pump enough blood to the brain Very High Blood pressure move from the valve of the heart

blood to the brain

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V. EVALUATION AND RECOMMENDATION The patient is slowly recovering from her condition. The patient can perform limited passive ROM exercise in her right arm with assistance from her significant others. The patients blood pressure reduced from 140/100 to 130/90 due to intake of maintenance medications such as Perindopril. The significant others know the importance of strictly following the turning schedule. They truly had a great role in caring for the patient. They provided her the support that she needed. Through this case study, the student nurse realized the effectiveness of her care. After several days of nursing management, the student nurse observed a change in the clients condition compared to the first day of interaction. The student nurse thinks that there is a great possibility for the patient to recover and fully attain the optimum level of functioning prior to her present condition. Therefore, the student nurse recommends that the patient follows strict compliance to the maintenance medications prescribed by the physician. The student nurse also recommends the patient and the significant others of following continuous consultation and rehabilitation with the physical therapist, cardiologist and neurologist. The student nurse also recommends the significant others to encourage the patient to live a healthy lifestyle free from stress.

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VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO: PRACTICE: This case study will improve the practice of giving holistic care to patients with stroke or cerebrovascular accidents putting emphasis on their psychological and physiologic needs. EDUCATION: The disorder is a common disease and highly emerging as a worldwide epidemic. Stroke is the number one killer in the Western hemisphere next to heart disease and cancer. Education is primarily focused on rehabilitative care. Trainings and modules on the role of nurses in the rehabilitative setting should highly be emphasized. Our role on the care for the emotional impact on the client is also important. Patients who suffer from stroke often suffer emotional liability, in which sudden switch from emotional highs and lows is observed. The student initial knowledge on how to react to patients emotional struggle is needed at this stage. RESEARCH Having this research about Cerebrovascular Accident, the student was able to have a positive view towards the nature of the disease. The research gives the student nurse information that is necessary in the collection of ideas that greatly contributed to the success of this research. By having this research, the skills of the student in collecting ideas were enhanced. Not only that this research gives us more

35 information but it also aided the student to come up with ideas that could contribute to the wellness of the patients with stroke.

VII. Bibliography 1. Black, Joyce and Esther Mantassarin-Jacobs. Luckmann and Sorensens Medical-Surgical Nursing: A Psychophysiologic Approach. 4th Ed. Philadelphia. W.B. Saunders Company. 1993 2. Craven, Ruth and Constance Hirnle. Fundamentals of Nursing: Human Health and Function. Philadelphia. J.B. Lippincott Company. 1992 3. Doenges, Moorehouse and Geisslers Nursing Care Plans . 6th Ed F.A. Davis Publishers Incorporated. 2004 4. Kozier, Barbara, et al. Fundamentals of Nursing: Concepts, Process and Practice. 5th Ed. U.S.A. Addison-Wesley Publishing Company Incorporated. 1998Smeltzer, 5. Marieb, Elaine, Essentials of Human Anatomy and Physiology. 4th Ed. California. The Benjamin/Cummings Publishing Company Incorporated. 1994 6. PDR Nurses Handbook. 1999 Ed. Philippines. Delmar Publishers and Medical Economic Company Incorporated. 1999 7. Suzanne and Brenda Bare. Brunner and Suddarths Textbook of Medical-Surgical Nursing. 10th Ed. Philadelphia. Lippincott Wilkins and Williams Incorporated. 2000

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