AMA Computer Learning Center St. Augustine School of Nursing A Case Study Presented to the faculty of AMA Computer Learning Center Guagua, Pampanga Cerebrovascular Accident Submitted to: Mr. John Eric T. Salvador B.S.N, R.N Submitted by: Almario, Jeanette Cayanan. Gemmalyn Joy Quitaleg, Mary Jane
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AMA Computer Learning CenterSt. Augustine School of Nursing
A Case Study Presented to the faculty of AMA Computer Learning Center
Guagua, Pampanga
Cerebrovascular Accident
Submitted to:Mr. John Eric T. Salvador B.S.N, R.N
Submitted by:
Almario, Jeanette
Cayanan. Gemmalyn Joy
Quitaleg, Mary Jane
Santos, Cariza Joy M.
3k-PN
October ‘09
Table of Content Page
Introduction 1
Personal History 2
Lifestyle and Diet 3
Complete Physical Assessment 4-9
Neurological Assessment 10-11
Laboratory Procedure 12-13
Diagnostic Procedure 14
Anatomy and Physiology 15-17
Pathophysiology of Cerebrovascular Accident 18-19
Drug Study 20-21
Diet and Activity 23
SOAPIE (actual) 24
SOAPIE (potential) 25
Conclusion 26
Recommendations 27
Bibliography 28
NCP(actual/ potential ) 29-33
Introduction
A stroke is damage to part of the brain when its blood supply is suddenly reduced or stopped. A stroke may also be called a cerebral vascular accident, or CVA. The part of the brain deprived of blood dies and can no longer function. Blood is prevented from reaching brain tissue when a blood vessel leading to the brain becomes blocked (ischemic) or bursts (hemorrhagic). The symptoms of a stroke differ, depending on the part of the brain affected and the extent of the damage. Symptoms following a stroke come on suddenly and may include: weakness, numbness, or tingling in the face, arm, or leg, especially on one side of the body trouble walking, dizziness, loss of balance, or coordination inability to speak or difficulty speaking or understanding, trouble seeing with one or both eyes, or double vision, confusion or personality changes, difficulty with muscle movements, such as swallowing, moving arms and legs, loss of bowel and bladder control, severe headache with no known cause, and loss of consciousness.
There are following metabolic disorder that may contribute to stroke, excess weight around the waist (waist measurement of more than 40 inches for men and more than 35 inches for women) triglycerides blood level of 150 mg/dL or more, HDL cholesterol levels below 40 mg/dL for men and below 50 mg/dL for women, blood pressure of 130/85 mm HG or higher and prediabetes (a fasting blood sugar between 100 and 125) or diabetes (a fasting blood sugar level over 125 mg/dL).
Latest Trend(Medication for Cerebrovascular Accident)
Anti-platelet medicines like aspirin, clopidogrel, extended release dipyridamole and aspirin in combination, and ticlopidine help prevent stroke because they keep the blood from clotting. Like aspirin, these medicines keep your blood from clotting. They are available only prescription. dipyridamole and aspirin combination (Aggrenoxl®), clopidogrel (Plavixl®), ticlopidine (Ticlidl®).Anti-coagulant medicines keep you from getting blood clots. You may hear people call these medicines "blood thinners." Warfarin (Coumadinl®) is often used in patients who have heart problems or artificial heart valves. Tissue plasminogen activator (t-PA or thrombolytic therapy) dissolves blood clots, but it may cause bleeding (including bleeding into the brain).This medicine must be given within 3 hours of the start of stroke symptoms. You will not be given t-PA if your blood pressure is too high, if changes on a CT scan show it should not be given, or if the risk of bleeding is too great. Heparin / heparinoid medicines slow the creating of blood clots. But there is little, if any, benefit in treating stroke. The medicines also can cause bleeding.
Mr. D’s wife verbalized that Mr. D was already been confined on the hospital before due to mild stroke last year December 2008 , while he is in their house he experienced sudden headache, dizziness, numbness, blurred vision and that made his wife to bring him into the hospital. Mr. D was confined for 4 days and after a week he was able to work again as jeepney driver though the doctor said he need to take rest from work, avoid stress, smoking, alcohol intake, and high fat/ salt food to avoid the stroke.
2.3 Present Health History
Mr. D was been confined again in the hospital of DPMMH last August 27, 2009 and he spent more than 7 days in the hospital. Mr. D’s wife said that while Mr. D is talking with his friend and drinking alcohol he experienced severe headache, sudden dizziness, paralysis in the right part of his body, numbness, blurred vision and loss of consciousness. And made his family to bring him into the hospital.
3. Lifestyle and Diet
Mrs. D said that his husband was a smoke, he consumed more than 30-40 pieces a day (1 1/2 pack) since 20 years old and he also drink 1 bottle of alcohol since 23 years old. Mrs. D said that her husband likes to eat pork after a long day of handling his jeep.
3.
4. Complete Physical Assessment
Date assessed: September 4, 2009Time Assessed: 9:00 A.MInitial Vital Signs:
Moisture Palpation Soft and moist Dry Due to decrease oxygen.
GUMSColor Inspection Pinkish Pale Due to
decrease oxygen.
Moisture Palpation Moist Moist Normal BUCCAL MUCOSAColor Inspection Glistening pink Slightly pale Due to
decrease oxygen.
Texture Palpation Soft Soft Normal Moisture Palpation Moist Moist Normal TOUNGEColor Inspection Pinkish Slightly pinkish Due to
decrease oxygen.
Size Inspection Medium Medium Normal Symmetry Inspection Symmetrical Symmetrical Normal Mobility Inspection Moves freely Moves freely NormalUVULALocation Inspection At the midline At the midline Normal Symmetry Inspection Symmetrical Symmetrical Normal TONSILSColor Inspection Pinkish Pinkish NormalDischarges Inspection No discharges No discharges Normal TEETHColor Inspection Ivory/yellowish Yellowish NormalNumber of teeth Inspection 32 28 Due to tooth
decay (teeth extraction)
NECKPosition Inspection Head-centered Head-centered Normal Movement Inspection Moves freely Moves freely Normal Range of motion Inspection Full range No ROM Abnormal due
to neuromuscular impairement.
Consistency Inspection No enlargement No enlargement Normal HEARTHeart rate Auscultation 60-100bpm 77 bpm Normal Heart sounds Auscultation Clear, without
cracklesClear Normal
Lung field Auscultation Resonant Resonant Normal
THORAX & LUNGS POSTERIOR THORAXSymmetry Inspection Symmetrical Symmetrical Normal
Cranial Nerve Date Done Normal Result Actual Result Interpretation
Olfactory Nerve September 04. 2009
Can smell on both nostrils.
Cannot able to extinguish smell
Due to decrease LOC.
Optic Nerve With 20/20 vision
Without 20/20 vision.
Due to the damage of left hemisphere and decrease LOC.
Occulomotor Nerve
PERRLA PERRLA Normal
Abducens Nerve Lateral movement.
Cannot move eyes in lateral direction.
Due to the damage of left hemisphere and decrease LOC.
Trochlear Nerve Up and down movement.
Pt. cannot move eyes up and down.
Due to the damage of left hemisphere and decrease LOC.
Trigeminal Nerve For touch and pain sensation.
Pt. cannot localize sensation.
Due to the damage of left hemisphere and decrease LOC.
Facial Nerve Can smile, frown, puff the cheek and can feel the cotton.
Cannot follow specific command.
Due to the damage of left hemisphere and decrease LOC.
Acoustic Nerve Can hear on both ears.
Cannot follow specific command.
Due to the damage of left hemisphere and decrease LOC.
Glossopharengeal Can swallow. Inability to swallow due to presence of
Due to the damage of left hemisphere and
NGT. decrease LOC.
Vagus Nerve Check for gag reflex
With NGT inserted.
Due to the damage of left hemisphere and decrease LOC.
Accessory Nerve With strength on both shoulder.
With no muscle strength.
Due to the damage of left hemisphere and decrease LOC.
Hypoglossal Nerve
Sense of taste. Cannot localize taste.
Due to the damage of left hemisphere and decrease LOC.
5. Laboratory Procedures
LaboratoryProcedure
Date Done
Normal Values
Result Nursing Interpretatio
n
NursingResponsibilities
Creatine August 28, 2009
53-115.0 63.6 Normal Pretest:Explain the procedure to the patient.
Instruct the patient to wear easily manipulated clothing to get blood samples easily.
HDL 0.78-2.21 1.30 Normal Tell the pt. to relax because the procedure is painless.
Hematocrit0.37-0.54
g/l
0.44 g/l
Normal Intra-test:Instruct the patient to look away when the needle is being inserted.
Leucocytes5-10 x 10
12.4 x 10 g/l
Abnormal due to infection
Post-test:Put cotton balls
g/l weakened immune response.
on the puncture site to avoid bleeding.
Platelets150-450 x
10/l
648 x 10/l
Abnormal due to blood clot formation.
Tell the patient to rest after the test.
12.
LaboratoryProcedure
Date Done
Normal Values Result Nursing Interpretation
NursingResponsibilities
URINALYSISAugust 29, 2009
ColorStraw/ yellow amber
Yellow Normal Pre-test:Explain the procedure to the pt. and how he can cooperate.
TransparencyClear
Turbid Due to infection
Provide privacy.
Reaction4.5-8.0
6.0 Normal Intra-test:Instruct the pt. on how to get urine samples (it should be midstream/ sterile technique).
Specific Gravity1.010-1.025
1.030 Normal Tell the pt. that the procedure is painless.
SugarNegative
Albumin Negative
Negative
Positive
Normal
Due to nearly kidney damage and hypertension.
Post-test:Bring the urine samples in the
laboratory.
13.
6. Diagnostic Procedure
Diagnostic Procedure
Date Done Result Interpretation Nursing Responsibilities
Electrocardiogram Report
September 1, 09
Rhythm:Sinus
Sinus tachycardia
Post-test:Explain the procedure to the pt.and how he can cooperate.
AL:120/m
Tell him to remove all jewelry and coins.
PR:0.20 sec.
Tell him to relax and lie still.
QRS:0.40 sec.
Intra-test:Monitor for the result.
QT:0.32 sec.
Post-test:Assist the pt. when he will stand.
Axis:+250
Remind him about his jewelry
and coins or any metal he remove will he is doing the procedure.
14.
7. Anatomy and Physiology
Cerebellum
The cerebellum is involved in the coordination of voluntary motor movement, balance and equilibrium and muscle tone. It is located just above the brain stem and toward the back of the brain. It is relatively well protected from trauma compared to the frontal and temporal lobes and brain stem.
Cerebellar injury results in movements that are slow and uncoordinated. Individuals with cerebellar lesions tend to sway and stagger when walking.
Damage to the cerebellum can lead to: 1) loss of coordination of motor movement (asynergia), 2) the inability to judge distance and when to stop (dysmetria), 3) the inability to perform rapid alternating movements (adiadochokinesia), 4) movement tremors (intention tremor), 5) staggering, wide based walking (ataxic gait), 6) tendency toward falling, 7) weak muscles (hypotonia), 8) slurred speech (ataxic dysarthria), and 9) abnormal eye movements (nystagmus).
Cerebellum
The cerebrum is the part of the brain that occupies the top and front portions of the skull. It is responsible for control of such abilities as movement and sensation, speech, thinking, reasoning, memory, sexual function, and regulation of emotions. The cerebrum is divided into the right and left sides, or hemispheres.
Depending on the area and side of the cerebrum affected by the stroke, any, or all, of the following body functions may be impaired:
movement and sensation speech and language eating and swallowing vision cognitive (thinking, reasoning, judgment and memory) ability perception and orientation to surroundings self-care ability bowel and bladder control emotional control sexual ability
15.
Limbic System
The limbic system is a set of evolutionarily primitive brain structures located on top of the brainstem and buried under the cortex. Limbic system structures are involved in many of our emotions and motivations, particularly those that are related to survival. Such emotions include fear, anger, and emotions related to sexual behavior. The limbic system is also involved in feelings of pleasure that are related to our survival, such as those experienced from eating and sex.
Broca's Area
An area located in the frontal lobe usually of the left cerebral hemisphere and associated with the motor control of speech. Also called Broca's center.
Temporal Lobe
The temporal lobes are involved in the primary organization of sensory input (Read, 1981). Individuals with temporal lobes lesions have difficulty placing words or pictures into categories.
Language can be effected by temporal lobe damage. Left temporal lesions disturb recognition of words. Right temporal damage can cause a loss of inhibition of talking.
The temporal lobes are highly associated with memory skills. Left temporal lesions result in impaired memory for verbal material. Right side lesions result in recall of non-verbal material, such as music and drawings.
Parietal Lobe
Damage to the left parietal lobe can result in what is called "Gerstmann's Syndrome." It includes right-left confusion, difficulty with writing (agraphia) and difficulty with mathematics (acalculia). It can also produce disorders of language (aphasia) and the inability to perceive objects normally (agnosia).
Damage to the right parietal lobe can result in neglecting part of the body or space (contralateral neglect), which can impair many self-care skills such as dressing and washing. Right side damage can also cause difficulty in making things (constructional apraxia), denial of deficits (anosagnosia) and drawing ability.
16.
Occipital Lobe
The occipital lobes are the center of our visual perception system. They are not particularly vulnerable to injury because of their location at the back of the brain, although any significant trauma to the brain could produce subtle changes to our visual-perceptual system, such as visual field defects and scotomas. The Peristriate region of the occipital lobe is involved in visuospatial processing, discrimination of movement and color discrimination (Westmoreland et al., 1994). Damage to one side of the occipital lobe causes homonomous loss of vision with exactly the same "field cut" in both eyes.
Frontal Lobe
The frontal lobes are considered our emotional control center and home to our personality. There is no other part of the brain where lesions can cause such a wide variety of symptoms. The frontal lobes are involved in motor function, problem solving, spontaneity, memory, language, initiation, judgement, impulse control, and social and sexual behavior. The frontal lobes are extremely vulnerable to injury due to their location at the front of the cranium, proximity to the sphenoid wing and their large size.
17.
8. Pathophysiology (Patient Base)
Pathophysiology (Book Base)
9. Drug Study
Drugs Classification
Indication Side Effect Nursing Responsibilities
Generic Name: Mannitol
Brand Name:Osmitrol
Diuretic Reduction of intracranial pressure and brain mass.
Pulmonary congestion, fluid and electrolyte imbalance, electrolyte loss, dryness of mouth, thirst, marked diuresis, urinary retention, edema, headache, blurred vision, convulsions, nausea, vomiting, rhinitis, arm pain, skin necrosis, chills, dizziness, dehydration, hypotension, tachycardia, fever and angina-like chest pains.
Monitor blood pressure.
Check for hypervolemia, urinary tract obstruction and signs of fluid imbalance.
Generic Name:Hydralazine
Brand Name:Apresoline
Anti-hypertensive drug
Severe essential hypertension when the drug cannot be given orally or when there is an urgent need to lower blood pressure.
Difficulty of breathing, swelling of face, lips, tongue or throat, fast pounding heart beats, numbness, joint pain and loss of appetite.
Patient must avoid orthostatic position.
Pt. must get up slowly to avoid fall.
Monitor Bp.
Generic Name: Metropolol
Brand Name:Neobloc
Anti-hypertensive drug
Metoprolol tartrate tablets are indicated for the treatment of hypertension. They may be used alone or in combination with
Tiredness and dizziness, Shortness of breath, diarrhea and alopecia.
Metoprolol should be used with caution in patients with impaired hepatic function.
other antihypertensive agents.
Should not be given in breast feeding mother.
Generic Name: Aspirin
Brand Name:Zorprin
Anti-thrombosis Treatment of mild to moderate pain; fever; various inflammatory conditions; reduction of risk of death or MI in patients with previous infarction or unstable angina pectoris or recurrent transient ischemia attacks or stroke in men who have had transient brain ischemia caused by platelet emboli.
Take Aspirin by mouth with or without food. If stomach upset occurs, take with food to reduce stomach irritation.
Swallow Aspirin whole. Do not break, crush, or chew before swallowing.
Take Aspirin with a full glass of water (8 oz/240 mL).
Generic Name:
Nicholin
Brand Name:
Citicoline
Cerebral circulation stimulant
Disturbances of consciousness associated with head and brain injury.
Dropped blood pressure, chest discomfort, dyspnea, nausea, headache and dizziness.
Monitor blood pressure.
Check for the correct site for injection.
21.
10. Diet and Activity
Activity Date Ordered Indication Nursing Responsibilities
Turn side to side (every 2 hrs.)
August 28, 2009 To prevent bed sores and
pneumonia.
Accompany the relative whenever mobility is done
(q2 hrs.)
Diet Date Ordered Indication Nursing Responsibilities
Osteorize feeding
August 30, 2009 To prevent aspiration (NGT).
Make sure that the NGT is intact whenever feeding is to be made.
Check for stomach content to prevent overfeeding.
23.
11. SOAPIE (actual)
Subjective“Nahihirapan siyang magsalita, kung minsan umuungol din siya, as verbalized
by Mr. D’s wife.”
Objective
Received pt. on lying position on bed, unconscious , with ongoing PNSS 1L regulated @ 10-15 gtts./min. (KVO) 200 ml. level infusing well @ left hand. (+) difficulty in speaking (+) weakness (+) headache (+) dizziness (+) blurred vision (+)Paralysis on right part of the body With NGT inserted With Foley catheter inserted
Assessment Impaired verbal communication related to impaired cerebral circulation possibly
evidence by impaired articulation.
PlanningAfter 4-6 hrs. of N.I the patient will learn techniques on how to communicate
with others.
Interventions Established rapport. Monitored and recorded vital signs. Maintained good verbal/ non-verbal means of communication. Thought the patient that loss of ability to talk does not mean loss of
intelligence. Provided time for the patient to respond. Conversation should be continue to practical and concrete matter,
supplemented with gestures, pictures, and object. Medications compliance on time (with the doctor’s permission).
Evaluation Goal met as evidence by the patient learn techniques on how to communicate non-verbal cues and in which needs are can be expressed.
24.
11. SOAPIE (potential)
Subjective:
Objective
Received pt. on lying position on bed, unconscious , with ongoing PNSS 1L regulated @ 10-15 gtts./min. (KVO) 200 ml. level infusing well @ left hand.
(+) difficulty in speaking (+) weakness (+) headache (+) dizziness (+) blurred vision (+)Paralysis on right part of the body With NGT inserted With Foley catheter inserted
Assessment Risk for aspiration related to decreased level of consciousness.
PlanningAfter 2-4 hrs. of N.I the client/ SO shall be able to identify causative factor that
may lead to aspiration.
Interventions Established rapport. Monitored and recorded vital signs. Monitored administration of NGT feeding. Checked for the NGT if intact in the stomach. Provided information about the effect of aspiration in the lung. Always keep the bed elevated whenever feeding. Keep wire cutter or scissor at bedside all the time.
Evaluation Goal partially met as evidence by the pt./SO was able to avoid factors that may
cause aspiration.
25.
13. Conclusion
We therefore conclude that CVA or stroke may lead to permanent brain
damage or death to individuals with sedentary lifestyle. People who consumed large
amount of food high in cholesterol, alcohol, cigarette smoking, obesity, and high blood
pressure can increase the possibility of stroke. This may also lead to heart disease
and maybe worsen if we don’t prevent the common factors that cause Stroke. Self
discipline is very important for us not to acquire this feared or killing disease.
26.
14. Recommendations
For the Patient and Family Members
Patient and family members should be given proper instruction and knowledge
on how to help the patient to cope in his condition. Dealing with emotional stress and
changing his sedentary lifestyle can reduce the risk of stroke. Patient way of living
should be carefully understand to limit the anxiety and self-pity. Showing emotional
and moral support can aid the anxiety and self-pity. If family members adjusted to this
kind of treatment to the patient, a fast recovery can be possibly.
For Health Care Provider/ Institutions
Cerebrovascular accident is one of the most common disease that cause dead
in the world. It can happen to anyone, especially to those of people who have
sedentary lifestyle and most commonly to people who acquired it through genes.
Though we don’t know when it will come, we have to be aware of the main factors that
bring our lives into danger. Maintaining good lifestyle and avoiding smoking, alcohol
intake, high fat and salty food, exercise, and low sugar food can decrease the possible
stroke. Health care provider and Institutions should give the enough knowledge to
everyone. Dealing with this kind of condition is one of the healthy processes of fast
recovery. It helps the patient and family members to adapt this knowledge and
behavior for the sake of the wellness of their love ones.