A Case Study on Cerebrovascular Accident

In partial fulfillment of The course requirement of Medical-Surgical Nursing

Presented to the Faculty of Cebu Doctors University College of Nursing

Submitted by: Adal, Aileen A. BSN 4A Class of 2008

June 2007

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 2.1 Brunswick Lens Model 2.2 Nursing Care Plan 2.3 SOAPIE 2.4 Health Teaching Plan V. Evaluation and Recommendation VI. Evaluation and Implication of This Case Study VII. Bibliography 3 5 7 7 7 7 8 8 10 10 14 17 17 23 24 27 31 31 31 34 35 42 43 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. The student also expected to gain the needed skills to care for a patient suffering with this kind of condition.

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:

Student-nurse centered: After 3 days of giving holistic caring care, the student nurse 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 nursing care rendered to the patient.

6 Patient-centered: After 3 days of rendering holistic caring care, the patient will be able to: 1. exhibit reduced anxiety level. 2. provide self care activities within level of own ability. 3. establish method of communication in which needs can be expressed. 4. demonstrate intact neurologic status and normal vital signs and respiratory patterns. 5. demonstrate ways to increase strength and function of affected body part as evidenced by performing ROM exercises without or with limited assistance. 6. evaluate nursing care rendered by the student nurse.

7 III. Nursing Assessment 1. Personal History 1.1 Patients Profile Name: Mrs. Constancia Borres Erasmo Age: 89 years old Sex: Female Civil Status: Widow Religion: Roman Catholic Date of Admission: March 15, 2007 Room No.: 506 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 has left the

8 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

9 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

10 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. 2. Diagnostic Test DIAGNOSTIC TEST CBC (4-9-07) Hemoglobin Hematocrit White Blood Cells Red Blood Cells MCV 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 PATIENTS RESULT 13.7 42.4 4.49 4.76 89.0 Normal Normal Normal Normal Normal SIGNIFICANCE

11 MCH MCHC 27.5-33.2 pg 33.4-35.5% 28.8 32.3 Normal decrease in a

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 Potassium 1.001-1.040 3.6-5.0 mmol/L 1.025 acidosis, ph is decreased. Normal 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

12 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: (March 16,2007) Head/Brain Completion 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:

13 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: (March 19, 2007) 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 (March 16, 2007) Interpretation: Minimal left carotid artery disease without hemodynamic significance. Normal right carotid and bilateral vertebral artery colors duplex scan. X-ray

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. Nursing 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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Name of patient: Mrs. Constancia Erasmo Chief complaints: Right sided hemiparesis Age: 89 yrs. old Sex:F Date: 03-15-07 Attending Physician: Dr. Manuel Lim Impression: Cerebrovascular Accident

BRUNSWICK LENS MODEL

I. PHYSIOLOGIC DEFICIT A. Hemiparesis/ right sided weakness Objective Cues: -limited range of motion - reluctance to attempt movement -decrease muscle tone -inability to perform fine or motor skills -inability to move purposefully with in physical environment - dependent on significant others Subjective Cues maglisod man siya ug lihok sa iyang tuo extremities nga kamot ug tiil,as verbalized by significant others B. Difficulty articulating words Objective cues: Measures to: A. Maximize physical mobility: - Change positions at least every 2 hours - Position in prone once or twice a day - Place pillow under axilla to abduct arm - Elevate hand and leg - Place knee in an extended position - Encourage and facilitate early ambulation - Encourage appropriate use of assistive devices - Provide positive reinforcement during activities - Allow patient to perform task at her own rate - Perform passive or active ROM exercises to all

B. Manage difficulty in producing speech - Listen for errors of conversation - Speak in normal tones

Patient will A case of a -Patient has difficulty in talking - Discuss familiar topics have 75 years old -Opens mouth but words arent produce - Respect patients preinjury capability 60-80% -Patient has slurring of speech - Maintain eye contact OLOF woman with -Patient has difficulty in articulating words - Give ample time to respond psychologic Subjevtive Cues: deficits and maglisod man siya ug storya A. Altered physical C. Promote Self care diagnosed C. Inability to perform ADL mobility: Right sided weakness - Maintain a supportive firm attitude with Bipolar Objective Cues: related to interaption of blood - Provide positive feedbacks Disorder 1 - Inability to wash body parts supply to the brain - Encourage significant others to - Difficulty completing toileting task B. Altered verbal communication: allow the patient to do as much Difficulty articulating words related - Place important things with in - Patient wears diaper to decrease cerebral tissue perfusion patients reach - Loss of involuntary movement C. Self care deficit: Inability to perform encourage good grooming Subjective Cues: ADL related to loss of muscle control Trapohan ug sudlayan namo siya kada buntag Actual state of Cues Nursing Diagnosis Nursing Actions Desired patients conditio Objectives: Goal: After 30-45 min. of student nurse-patient After 3 days of holistic care, interaction, the patient will be able to: the client will be able to 1. demonstrate ways to increase strength and regain optimum level of

35
function of affected body part. functioning. 2. use and accept alternative form of communication 3. identify resources that can provide assistance as needed

36 2.2 Nursing Care Plan Needs / Problems / Cues I. Physiologic Deficit 1. Hemiparesis/ right sided weakness Objective Cues: - reluctance to attempt movement on her right side - limited range of motion - decreased muscle endurance, strength, control or mass - inability to perform fine or motor skills as instructed - inability to move purposefully Altered Physical Mobility: right sided weakness related to interruption of blood supply to the brain. 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 voluntary motor control of one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. General Objectives: After 5 days of student nurseclient interaction, the client will be able to attain optimum level of functioning. Specific Objectives: After 8 hours of student nurseclient interaction, the client will be able to: 1. demonstrate ways to increase strength and function of affected body part Nursing Diagno-sis Scientific Basis / Significance Objectives of Care Nursing Actions Rationale

Measures to: A. maximize physical mobility. 1. change positions at least every 2 hours.

1. reduces risk of tissue ischemia/ injury - FA Davis NCP, 6th ed. 2. helps maintain functional hip extension. - FA Davis NCP, 6th ed. 3. prevents adduction of shoulder and flexion of elbows. - FA Davis NCP,6th ed. 4. promotes venous return and helps prevent edema formation. - FA Davis

2. position in prone once or twice a day if patient can tolerate.

3. place pillow under axilla to abduct arm.

4.elevate arm and hand.

37 within physical environment, including bed mobility, transfers and ambulation. Subjective Cue: maglisud man siya og lihuk sa iya tuo na kamut og tiil, as verbalized by significant others. as evidenced by movement of affected body part without or with limited assistance. NCP,6th ed. 5. place knee in an extended position. 5. maintains functional position. - FA Davis NCP,6th ed. 6. the longer the patient remains immobile, the greater the level of debilitation that will occur. - NCP by Myers. 7. mobility aids can increase level of mobility. - NCP by Myers. 8. patients maybe reluctant to move or initiate new activity due to fear of falling. - NCP by Myers. 9. hospital workers and family

Source: Textbook of Medical-Surgical Nursing by Brunner and Suddarth, 10th ed., vol. 2 p. 1889

6. encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change such as dangling, sitting in bed or chair and ambulation. 7. encourage the appropriate use of assistive devices in the home setting. 8. provide positive reinforcement during activity.

9. allow patient to perform tasks at her

38 own rate. Do not rush patient. Encourage independent activity as able and safe. caregivers are often in a hurry and do more for patient than needed, thereby, slowing the patients recovery and reducing her self-esteem. - NCP by Myers. 10. exercise promotes increased venous return, prevents stiffness and maintain muscle strength and endurance. - NCP by Myers.

10. perform passive or active assistive ROM exercises to all extremities.

2. Difficulty articulating words/ speech Objective Cues: - patient has difficulty in talking - opens mouth but words arent

Altered Verbal Communication : difficulty articulating words related to decreased cerebral tissue perfusion secondary to stroke.

Aphasia, which impairs the patients ability to understand what is being said and to express herself, may become apparent in various ways.

2. use and accept alternative form of communication as evidenced by effective use of alternative language to communication.

B. manage difficulty in producing speech. 1. place call light within reach. 2. listen for errors in conversation and provide feedback.

1. reduces anxiety. - Doenges, 7th ed. 2. helps patient realize why caregivers are not responding

39 produced - difficulty articulating words - patient has slurring of speech Subjective Cue: maglisud man siya sturya og bungol siya. Lahi ang iya itubag sa gipangutana sa iya, as verbalized by the significant others. The cortical area responsible for integrating the pathways required for the comprehension and formulation of language is called Brocas area. It is close to the left motor area and often affects the speech area. This is why so many patients paralyzed in the right side cant speak. Source: Medical-Surgical Nursing, 10th ed. by Smeltzer. p. 1889 6. respect patients pre-injury capability. appropriately. - FA Davis NCP, 6th ed. 3. anticipate and provide for patients needs. 3. helpful in decreasing frustration when dependent on others. - FA Davis NCP, 6th ed. 4. to prevent irritating or frustrating patients. - FA Davis NCP, 6th ed. 5. promotes meaningful conversation and provides opportunity to practice skills. - FA Davis NCP,6th ed. 6. enables patient to feel esteemed, because intellectual abilities often remain intact. - FA Davis\

4. speak in normal tones and avoid talking too fast.

5. discuss familiar topics.

40 NCP, 6th ed. 7. provides encouragement 7. maintain eye contact and support. and stand close in - Doenges, patients line of vision. NCP, 7th ed. 8. it is difficult to respond under pressure. - Doenges, NCP, 7th ed. 9. this enables the patient to maintain contact with reality or reduce stimuli to lessen anxiety that may worsen the problem. - Doenges, NCP, 9th ed. 10. to clarify discrepancies between verbal and nonverbal cues. - Doenges, NCP, 9th ed.

8. give ample time to respond.

9. provide environmental stimuli as needed or reduce stimuli.

10. use confrontation skills, when appropriate, within an established nurseclient relationship. 3. Inability to Self Care Self Care Deficit 3. identify C. promote self care:

41 perform Activities of Daily Living Deficit: inability to perform activities of daily living Objective Cues: related to loss - inability to of muscle wash body parts control. by herself - difficulty completing toileting task - needs assistance from the significant others to change her own clothes - patient wears diapers - loss of voluntary movement on right side of the body Subjective Cue: trapuhan og sudlayan namo siya kada buntag, as verbalized by the significant others. may range from not being able to reach with a weak arm to full dependence on others. This is applicable if an achievable outcome is obtained. Clients with complete paralysis and cognitive deficits may not be able to perform self care. resources that can provide assistance as needed. 1. maintain a supportive, firm attitude. 1. patient need empathy. - FA Davis NCP, 6th ed. 2. enhances sense of self worth. Promotes independence. - FA Davis NCP, 6th ed. 3. reestablishes a sense of independence and foster self worth. - FA Davis NCP, 6th ed. 4. to provide easy access to useful things. - FA Davis NCP, 6th ed. 5. to enhance patients self worth. - FA Davis NCP, 6th ed. 6. to prevent anxiety.

2. provide positive feedbacks for efforts and accomplishments.

3. encourage the significant others to allow the patient to do as much as possible.

Source: Textbook of Medical-Surgical Nursing by Black. p. 2128

4. place important things within the patients reach.

5. encourage good grooming of patient.

6. Allow patient sufficient time to

42 accomplish task. 7. avoid doing things that the patient can do for herself. FA Davis NCP, 6th ed.

7. patient may become fearful and dependent. - Doenges NCP, 7th ed. 8. encourage client and build on successes. - Doenges NCP, 9th ed. 9. enhances coordination and continuity of care. - Doenges NCP, 9th ed. 10. to enhance capabilities. - Doenges NCP, 9th ed.

8. assist with necessary adaptations to accomplish ADLs. Begin with familiar easily accomplished task. 9. provide for communication among those who are involved in caring for/ assisting the client. 10. assist with rehabilitation program.

43 2.3 SOAPIE SOAPIE # 1 April 12, 2007 S- Di mana niya malihuk ang iyang tuo nga lawas, as verbalized by the significant others. O- observed patient lying in bed in semi-fowlers position supported by 3 pillows, drowsy, has slurred speech, keeps on talking while asleep, restless, incoherent and with right sided weakness. Noted the following vital signs: BP= 130/80 mmHg T= 36.3 C PR= 76 bpm RR= 17 A- Altered physical mobility: Right sided weakness related to interruption of blood supply to the brain. P- to promote independent mobility with limited assistance from significant others. I- determined degree of immobility, noted emotional/behavioral responses to problems of immobility, assisted/ have client repositioned self on a regular schedule as dictated by individual situation, instructed the use of side rails, supported affected body parts/joints using pillows. E- patient rested and went back to sleep with pillows on her affected side.

SOAPIE # 2 April 13 ,2007 S- Naa man siyay bedsores. Wala gihapon naayo, ning uga ra cya, as verbalized by the significant others. O- received patient dangling her legs at the edge of the bed, resting, conscious, has slurred speech, doing passive exercises assisted by the significant others, her back supported with pillows, her foot is wrinkled, with skin lesions, black in color, has bed sores in both feet. Noted the following vital signs: BP= 130/90 mmHg T= 36.1 C PR= 70 bpm RR= 24 A- Altered Skin Integrity: pressure ulcers related to immobility. P- promote blood circulation. I- encouraged implementation and posting of a turning schedule, restricted time in one position for two hours or less or customizing the schedule to patients routine and caregivers needs; increased tissue perfusion by massaging around affected area, limited/ avoided the use of plastic materials, used appropriate padding devices when indicated, encouraged early ambulation or mobilization, applied calmoseptine ointment to the bed sores. E- Salamat day ha as verbalized by the significant others, patient continued sitting at the edge of the bed, dangling her legs.

44 2.4 Health Teaching Plan Objectives General Objectives: After three days of student nurse-client interaction the significant others will be able to acquire adequate knowledge, attitude, and skills in the care of a patient with cerebovascular accident Specific Objectives: After 8 hours of student nursesignificant others interaction, the significant others will be able to: 1. Define stroke in their own level of understanding. - Stroke is a term used to describe neurologic changes caused by an interruption in the blood supply to a part of the brain. - Informal Discussion - the significant others were able to understand in their own level of understanding. Content Methodology Evaluation

2. Give some risk factors of stroke.

Risk Factors: - hypertension - cardiovascular disease - atrial fibrillation - diabetes mellitus - hyperlipidemia - cigarette smoking - heavy alcohol consumption - cocaine use - obesity

- Informal Discussion

- the significant others were able to enumerate the risk factors of stroke

45 3. Enumerate the general clinical manifestations of stroke. Clinical Manifestation: - headache - vomiting - seizures - transient hemiparesis - loss of speech - hemisensory loss - changes in mental status - changes in ECG results Causes: - certain irregularities such as atrial fibrillation to the brain, cause the blood clot to move from the valve of the heart - 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 blood to the brain - a heart arrythmia does not allow the heart to pump enough blood to the brain - very high blood pressure 5. Show positive attitude in providing care to the patient. - The patient needs the support of the family throughout the hospitalization course. This may give them strength and enhance their self worth. - Reflection - They were cooperative throughout the patients hospitalization. - Informal Lecture and Discussion - the significant others were able to enumerate clinical manifestations of stroke.

4. Enumerate some causes of stroke.

- Informal Lecture and Discussion

- the significant others were able to enumerate some causes of stroke.

46 6. Enumerate some treatment for stroke. Treatment: Medical: - alteplase - anticoagulations with heparin - aspirin Surgical: - carotid ebartectomy - carotid angioplasty 7. Enumerate some ways to prevent stroke. Stroke Prevention: - blood pressure monitoring - smoking cessation - limiting alcohol consumption - exercise - healthy diet - Informal Discussion - the significant others were able to enumerate some ways to prevent stroke. - Informal Discussion - the significant others were able to enumerate some treatments for stroke.

47 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. VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO: NURSING PRACTICE: This case study will improve the nursing practice of giving holistic care to patients with stroke or cerebrovascular accidents putting emphasis on their psychological and physiologic needs. The student nurse will be able to improve her skills in

48 assessment and be able to formulate appropriate nursing interventions for identified problems and needs. NURSING 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. Nursing education is primarily focused on rehabilitative care. Trainings and modules on the role of nurses in the rehabilitative setting should highly be emphasized. Nurses 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 nurses initial knowledge on how to react to patients emotional struggle is needed at this stage. NURSING RESEARCH Having this research about Cerebrovascular Accident, the student nurse 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 nurse in collecting ideas was enhanced. Not only that this research give us more information but it also aided the student nurse to come up with ideas that could contribute to the wellness of the patients with stroke.

49 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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