I.

INTRODUCTION Nursing is a distinct body of knowledge that provides nursing care to patients who

are in need of nursing care in support of medical interventions, in collaboration with other members of the health team or exclusively or independently by the nurse herself. Our special area exposure at the Ignacio L. Arroyo Sr. Memorial District Hospital was another daring and momentous opportunity for us to develop our knowledge, skills and especially attitude. 24 hours on duty was indeed a tough challenge in our physical capacity. During our night shift we were blessed to have a pregnant woman in labor. We monitored for several hours and kept tracked on her pain but it didnt progress so some of us decided to go to the wards and there, they observed a familiar condition Cerebrovascular Accident (CVA), which we decided to present as a case study because our group wants to relate preventive measures to the people and our significant others and how we can decimate or banish this kind of condition. In doing this study, we can widen our minds capacity as we explore on the symptoms, diagnosis, treatment and control of this neurologic disorder. By studying this case, we can be able to understand more clearly and gain more useful knowledge that could benefit us as well as our future clients also. As we focus in this study, we include anatomy and physiology, pathophysiology, drugs, health teachings, and nursing care plans for our patient. Cerebrovascular Accident, commonly known as stroke is caused by a disruption in the normal blood supply to the brain. This disruption in blood supply may be in the form of an interruption in blood flow to the brain, which is called ischemic stroke, or it may also take the form of bleeding within or around the brain which is called hemorrhagic stroke. General signs and symptoms include numbness of face, arm, and legs; confusion or change in mental status, trouble speaking or understanding speech; visual disturbances, loss of balance, dizziness, difficulty walking or sudden severe headache. Stroke is the second most common cause of death and major disability worldwide. The incidence of strokes among people ages 30-60 years old is less than 1 %. This figure triples by the age of 80. Men are more prone to stroke due to physical needs and built. Persons with sedentary lifestyle are a higher risk for stroke than those with active life styles. The rate of occurrence for strokes in the United States fell by 15.52% but the number of deaths from stroke actually rose by 5%. Stroke is a medical emergency that strikes suddenly, and it should be treated immediately to prevent neurologic deficit and permanent disability. General Objectives: This study aims to identify and determine the underlying factors that will lead to ischemic stroke. This presentation also intends to promote health and put into practice the acquired knowledge in rendering effective nursing intervention in accordance to client condition. Specific Objectives: At the end of presentation, the student nurses will be able to:

1. Determine the underlying factors that cause Cerebrovascular Accident. 2. Identify the signs and symptoms of Cerebrovascular Accident. 3. Determine the anatomy and physiology affected by Cerebrovascular Accident as well
as its pathophysiology.

4.

Formulate a Realistic Nursing Care Plan based on priority needs to help patient recover.

5. Implement necessary interventions to our patient. 6. Identify the action, indication, contraindication of the drugs prescribed to the patient as well as the nursing responsibilities. 7. Look for suitable treatment for the patient. 8. Convey health teachings to the patient to address her condition. 9. Promote wellness to the patient. II. PRESENTATION OF PATIENTS DATA Name: Mrs. HPN Address: Brgy.5, Constancia, Isabela Age: 51 years old Birthdate: November 29, 1959 Birthplace: Isabela, Negros Occidental Gender: Female Religion: Roman Catholic Nationality: Filipino Date of Admission: March 1, 2011 Attending Physician: Dr. Prosia Chief Complaint: Bleeding Gums due to fall, increased BP Vital Signs upon Admission: T: 36C PR: 92bpm B. Past Medical History Usual childhood illness No surgeries or allergies Has familial history of hypertension and stroke Immunization status, none RR: 26cpm BP: 220/140 mmHg 7:40am Weight: 62 kgs.

A. Personal Information

A. History of Present Illness Mrs. HPN has been admitted several times to the hospital primarily because of hypertension. According to the patient, she has been taking religiously her medications. She was sent to the hospital due to her increased blood pressure that caused her to fall and her gums bled.

B. Physical Assessment HEENT: Head is proportion to the body, skull is rounded and symmetrical Face is light in color, smooth, symmetrical facial movements, no lesions, inflammation or masses noted Eyes are equally aligned and conjunctiva is pink in color. Pupils are equal, respond to light and accommodation. Ears have no discharges and inflammation noted Nose is symmetric with no discharge Mouth is dry with cracked lips, pink mucosa and gingivae, no lesions or bleeding. Neck is symmetric and at midline position, head centered, smooth ranged movement and without discomfort INTEGUMENTARY: No skin lesions Redness at the gluteal site

RESPIRATORY:

No adventitious lung sounds heard as auscultated Respiratory rate: 19cpm Symmetrical chest expansion

CARDIOVASCULAR:

With ongoing IVF #2 D5 0.3NaCl 1L @ right arm regulated at 28 gtts/min BP: 120/80 mmHg With palpable pulses Pulse rate: 74bpm

NEUROLOGIGAL: Conscious Delayed response to stimuli

MUSCULOSKELETAL: Generalized weakness

A. Medical Diagnosis HTN GIII Status post CVA V. Laboratory and Diagnostic Exams HEMATOLOGY REPORT March 1, 2011

Name: Mrs. HPN Ward: Female Medical Ward Physician: Dr. Prosia

Age: 51 years old Sex: Female

Civil Status: Married

Hematology Hematocrit Hemoglobin RBC WBC Neutrophils Lymphocytes

III.

Result 0.37% 123g/L 3.9million/ul 13.3x10/L 93% 7%

Normal Values 0.37%-0.47% 120-160 g/L 4.2-5.5million/ul 4.5-10.0x10/L 55%-70% 20%-35%

Significance

May indicate anemia Indicates infection Indicates infection

ANATOMY AND PHYSIOLOGY

NERVOUS SYSTEM The nervous system is a very complex system in the body. It has many, many parts. The nervous system is divided into two main systems, the central nervous system (CNS) and the peripheral nervous system. The spinal cord and the brain make up the CNS. Its main job is to get the information from the body and send out instructions. The peripheral nervous system is made up of all of the nerves and the wiring. This system sends the messages from the brain to the rest of the body. One of the parts of the CNS is the brain. It keeps the body in order. It helps to control all of the body systems and organs, keeping them working like they should. The brain also allows us to think, feel, remember and imagine. In general, the brain is what makes us behave as human beings. The brain communicates with the rest of the body through the spinal cord and the nerves. They tell the brain what is going on in the body at all times. This system also gives instructions to all parts of the body about what to do and when to do it. There are five main senses - touch, smell, taste, hearing and sight. These are the external sensory system, because they tell you about the world outside your body. Your senses tell you what is happening in the outside world. Your body's sense organs constantly send signals about what is happening outside and inside it to your control center - the brain. The

cerebrum is part of the forebrain. The cerebral cortex is the outer layer of the cerebrum. Certain areas of the cerebral cortex are involved with certain function. The second main part of the nervous system is the peripheral nervous system. The nervous system is made up of nerve cells or neurons that are "wired" together throughout the body, somewhat like communication system. Neurons carry messages in the form of electrical impulses. The messages move from one neuron to another to keep the body functioning. Neurons have a limited ability to repair themselves. The Circle of Willis The Circle of Willis is a vital formation of arteries at the base of the brain which supplies all thought processes with the necessary fuel. There is a grouping of arteries near the base of the brain which is called the Arterial Circle of Willis. It is named after a very influential English physician named Thomas Willis, who discovered it and then published his findings in his 1664 work. The Circle of Willis is truly one of the most important, yet overlooked areas in the brain, and one of the most efficiently designed systems in the human body. It does not specifically help one to think or react but the more glamorous portions of the brain could not possibly function without the Circle. The key element which makes the Circle of Willis so spectacularly effective in doing its job and so very remarkable in its design is the fact that the arteries contained therein (the Anterior Cerebral and the Posterior Cerebral Arteries being two of the main ones) are arranged in a looping pattern which allows for a complex system of redundancy built into the flow of the blood. This is important because if for some reason one of the arteries is having problems, the others can do their best to pick up the slack and maintain cerebral profusion, wherein the pressure of blood flowing through the various parts of the brain is kept at normal levels. While the ingenious design of the Circle helps significantly to prevent certain conditions from developing within the brain related to blood flow, it is not entirely perfect. There is always the possibility of several conditions occurring, such as arterial blockage (usually due to a blood clot) or cerebral hemorrhage, either of which can cause devastating strokes and other cerebral abnormalities. PATHOPHYSIOLOGY An ischemic stroke typically comes from blockage of an artery resulting from an inadequate supply of blood and oxygen to the brain. An ischemic neuron becomes depolarized as ATP is depleted and membrane ion-transport systems fail. The resulting influx of calcium leads to the release of a number of transmitters including large quantities of glutamate which in turn activates N-methyl-D-aspartate (NMDA) and other excitatory receptors on other neurons. These neurons then become depolarized, causing further calcium influx, further glutamate release and local amplification of the initial ischemic insult. This massive calcium influx also activates degradative enzymes leading to the destruction of the cell membrane and other essential structures. VIII. Prognosis

About 10% of people who have an ischemic stroke recover almost all normal function, and about 25% recover most of it. About 40% of people have moderate to severe impairments requiring special care, and about 10% require care in a nursing home or other long-term care facility. Some people are physically and mentally devastated and unable to move, speak, or eat normally. About 20% of people who have a stroke die in the hospital. The proportion is higher among older people. About 25% of people who recover from a stroke have another stroke within 5 years. Subsequent strokes impair function further. During the first few days after an ischemic stroke, doctors usually cannot predict whether a person will improve or worsen. Younger people and people who start improving quickly are likely to recover more fully. About 50% of people with one-sided paralysis and most of those with less severe symptoms recover some function by the time they leave the hospital, and they can eventually take care of their basic needs. They can think clearly and walk adequately, although use of the affected arm or leg may be limited. Use of an arm is more often limited than use of a leg. Most impairment still present after 12 months is permanent. In the case of our patient the prognosis is good. The emergency treatment and comprehensive rehabilitation which involves proper medication, exercise, hygiene, regular follow-up visits after hospitalization, and proper diet would significantly improve both survival and recovery. IX. Health Teaching

MEDICATIONS Avoid over the counter medications without checking the physician. Emphasize the importance of not stopping medications unless instructed by the physician. EXERCISE

Encourage patient to have a daily exercise but no heavy exercise is permitted. It will
increase blood pressure. TREATMENT Follow doctors order for taking medications. Avoid eating high cholesterol rich foods. Control blood pressure by eating a healthful diet and have a regular exercise. Adequate intake of vitamins.

HYGIENE Stress the importance of hand washing Follow proper hygiene. Maintain cleanliness on surroundings.

OUTPATIENT Avoid stress because it is capable of increasing blood pressure.

Advise patient to take the prescribed medication at right time and right dosage.

 DIET

Stress the importance of regular follow-up visits after discharge. Check blood pressure regularly to detect any increase and if it is found to be consistently elevated, a physician should be consulted. Keep your weight under control.

Proper nutrition and fluid intake should be observed. Educate patient the importance of diet. Increase fiber in the diet. and sodium diet.

Eat a healthy diet that is low in saturated fat, transfat and maintain a low cholesterol

SPIRITUALITY Provide patient support, advice, and comfort. the first thing in healing. X. Evaluation At the end of presentation, the student nurses were able to: Create a trusting relationship with the client so that any religious concerns or practices can be openly discussed and addressed.

Encourage the patient to accept and cope up with current situation. Acceptance is

1. Determine the underlying factors that cause Cerebrovascular Accident. 2. Identify the signs and symptoms of Cerebrovascular Accident. 3. Determine the anatomy and physiology affected by Cerebrovascular Accident as well
as its pathophysiology. 4. Formulate a workable Nursing Care Plan based on priority needs to help patient recover. 5. Implement necessary interventions to our patient. 6. Identify the action, indication, contraindication of the drugs prescribed to the patient as well as the nursing responsibilities. 7. 8. 9. Look for suitable treatment for the patient. Convey health teachings to the patient to address her condition. Promote wellness to the patient.

Recommendation As a group, we recommend Mrs. HPN to strictly follow the discharge instructions of the physician as well as the nurse. Have a follow up check up to monitor health status. Adherence to the medications especially anti-hypertensive drugs, thrombolytic is strongly recommended. Ensure a healthy nutritious meal that is low in fats, salt to avoid or decrease

the risk of having the same complications. Regular exercise but not heavy is encouraged to promote good blood flow to the bodys system, thus, providing more oxygen to the body. Maintenance of adequate oral fluid intake atleast 2-3 L per day is advised to promote wellness. Check blood pressure regularly to detect any increase and if it is found to be consistently elevated, a physician should be consulted. It is further recommended that the patients significant others should be aware of signs and symptoms of cerebrovascular accident and its complications and should immediately report it to the physician.