OUR LADY OF FATIMA UNIVERSITY

Valenzuela City College of Nursing

Case Study In Cerebrovascular Accident

Submitted by:
Jumao-as, Jamir M. Leader Chan, Laarnie S. De Castro, Chereez M. De Leon, Melanie V. Gain, Mark Angelo C. Gonzales, Rovelle C. Jalim, Madilyn N. Ladera, Rea I. Lanario, Jineva Portia E. Loza, Princess E. (BSN3Y3-11A)

Submitted to:
Ms. Reggie Lynn O. de Sierra

Nursing Management of a Patient with Cerebrovascular Accident

Patient X, a 86 year old male patient admitted to ER due to loss of consciousness and left-sided weakness, was diagnosed with Cerebrovascular Accident and a Category 5 Pulmonary Tuberculosis. According to his medical history, he has no yet any records of hospitalization. The patient is known to have dysphagia that is why a Nasogastric Tube is inserted. The patient also has an IV infusion of PNSS at 20gtts/min. Due to the Pulmonary Tuberculosis Category 5 the patient s muscle wasting is very visible that is why proper nutritional intake should be strictly monitored. Also the patients Respiratory response should be one prioritize even though difficulty of breathing is not often manifest on the patient. Another is the safety and mobilization, the patient s degeneration due to age and predisposing disease is the priority of care. And last maintenance and rehabilitation should be the long term plan of care for the patient upon discharge from the hospital.

Pathophysiology

Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than 24 hours. Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood vessel by cerebral thrombosis or embolism or

hemorrhage (leakage of blood from a vessel causes compression of brain tissue and spasm of adjacent vessels). Hemorrhage may occur outside the dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance itself (intracerebral).

Risk factors for stroke include transient ischemic attacks (TIAs) impending stroke

warning sign of

hypertension, arteriosclerosis, heart disease, elevated cholesterol,

diabetes mellitus, obesity, carotid stenosis, polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarette smoking. Complications of stroke include aspiration pneumonia, dysphagia, constractures, deep vein thrombosis, pulmonary embolism, depression and brain stem herniation.

History

Patient X, an 86 years old male, who arrived at the ER at 7:05 in the morning with chief complaint of left sided body weakness and altered consciousness. He doesn t have any previous history of hospitalization. He was diagnosed of Cerebrovascular
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Accident and Category 5 Pulmonary Tuberculosis. He doesn t have Hypertension, known allergies to foods, medication and environment. He didn t undergo any surgery. According to his wife the patient loves eating vegetables, doesn t smoke and a social drinker. Nursing Physical Assessment Patient X has loss of consciousness during admission to ER. He was accompanied by his wife and a daughter. The patient was disoriented and confused when he gained his consciousness. The patient s temperature was 37.6 C, pulse rate was 56, respirations were 28, and blood pressure was 130/70. He had an IV line in his right metacarpal vein with. Upon auscultation, there are no crackles, wheezes, retractors and murmurs. The patient has a left sided weakness and non-productive cough. The patient s skin was cold and clammy and appears frail and thin with some general weakness. He wasn t able to perform independent activities of daily living and assisted by his wife. Diagnostic Procedure TEST NAME Blood Urea Nitrogen Creatinine Sodium Potassium RESULTS 18.44 mg/dl 1.29 mg/dl 144.00 mEq/L 4.20 mEq/L NORMAL VALUE 10-20 mg/dl 0.7-1.4 mg/dl 135-145 mEq/L 3.5-5.0 mEq/L

Hematology

COMPONENTS WBC count Hemoglobin Hematocrit Different Count Neutrophil Lymphocytes Monocytes Eosinophils Basophils Platelet Count MCV MCH MCHC RDW

RESULT 6.5 10.7 0.310

SI UNITS X103/ml3 g/dL %

0.64 0.20 0.05 0.11 210 89.9 31.2 347 14.1

% % % %

X103/ml3 FL Pg g/L %

Review of system Psychological Our patient is a farmer, hard working person and a responsible father. He already have memory gap but he is able to recognize those person he knows. Role relationship and pattern Our patient is lives with his eldest child. He is 86 years old turning 87 on may. He stopped working when he started to have illness and his children started to have new own families. His family was extended. Cognitive Perceptual Pattern Patient X is not using any devices like auditory and visual devices even though he has impairment on those said sensory. Elimination When the patient is diagnosed with CVA, Laxative was prescribed to lessen straining from defecation. He defecate irregularly and the characteristics of his tool is slight yellow in color, sticky, smells bad and the bowel movement is hypoactive, he has an Indwelling Foley Catheter, the characteristics of his urine is yellow in color and clear. Rest and Activity Because he is too old, he doesn t exercise and has a sedentary lifestyle. His daily activity includes watching TV. . He has enough of sleep about 8 hours a day he respiratory distress is lessen when he has sufficient rest a day.

Sleep Rest Pattern When the patient not diagnosed in C.V.A. he sleeps 8 hours a day. He sleep 10 P.M. in the evening and woke up 6:00 A.M. he has a good quantity of sleep, but when he hospitalize with the diagnosed in C.V.A. he sleeps irregularly because having stroke feels pain, not comfortable, irritability and restlessness. Safety and Environment He doesn t have any allergies in the environment. Nutrition The patient was advised to have low salt, low fat and low cholesterol diet.

Related Treatments Hospitalization is always necessary, often in an intensive care unit. The initial treatment of CVA is first the prevention of complications. The patient has no allergies to latex, iodine or adhesives. The patient has an IV line in his right metacarpal vein. According to Ignatavicus (2006), insertion sites must be chosen carefully after consideration of skin integrity, vein condition and activities of daily living. Ignatavicus (2006) also has stated that IV therapy involves the entire vascular system or multiple systems.

In case of Ischemic CVA confirmation, the patient is treated with thrombolytic drug for the clearance of an artery with a blood clot. This technique can only be used

during the first 3 hours and in a specialized unit. It is a technique of the future which is as yet rarely possible. The existence of numerous side effects and the very short period of time after the occurrence of the cerebral infarction mean that this treatment is only reserved to a small number of patients.

In these cerebral infarctions and in transient ischemic accidents linked to atheroma, the prevention of repeat attacks is quickly set up by the platelet aggregation inhibiting drugs. It is started as soon as possible (as soon as there is a certainty that there is no hemorrhaging). These drugs prevent the aggregation of platelets in the atheromatous plaques. The anti-platelet that is the most widely used is aspirin.

In the case of embolisms of cardiac origin, repeat attacks are most often prevented by anticoagulants. Thromboses of the carotid detected during examinations (Doppler ultrasonography of the carotid is indispensable) are often secondarily treated surgically, in order to avoid a repeat.

Health education will then be essential. It can still greatly improve the recovery of the damaged functions. Health teaching is often started in a specialized institution and continued sometimes for several months at home. It is always a very difficult time for the patient and the patient s family. The role of those close to the patient is essential. They have to understand the consequences of CVA and learn what they can usefully do to resolve the many minor daily problems that they will create. Their participation in the success of the health teaching is fundamental.

Nursing Care Plan

Patient X s nursing diagnosis is Activity Intolerance related to left sided weakness secondary to Cerebrovascular Accident. According to Ignatavicus (2006), patients having stroke is expected to have difficulty in moving purposefully in his environment independent. The plan of care focused on providing assistance, mobilization and safety to the patient. Proper positioning is necessary with the body alignment maintained. Side-rails should also be padded for safety. Since the patient is also in old adulthood, his capability to tolerate activities is also reduced. Assisting him in his daily activities may be necessary.

Based on Ignatavicus (2006), clients who have experienced a stroke may exhibit flaccid or spastic paralysis. And in order to prevent muscle atony, Range of motion (ROM) exercises should be done. Ranges of motion (ROM) exercises are done to preserve or improve flexibility and mobility of the joints. The nurse or family member performs Passive ROM exercise at least every two to three hours for involved extremities. Providing Active ROM exercises on the unaffected extremities are necessary to maintain muscle integrity. Changing the patient s position frequently for at least every 2 hours also help the patient on mobilization. Also on Ignatavicus (2006), a major complication of immobilization is the development of DVT (deep vein thrombosis). And to prevent it, applying sequential compression stocking can help.

Recommendations Traditionally, the physical rehabilitation of individuals typically ended within several months after stroke because it was believed that mostly of the recovery of motor function occurred during this interval. Nevertheless, recent research studies have shown that aggressive rehabilitation beyond this time period, including treadmill exercise with or without body weight support, increases aerobic capacity and sensorimotor function. Consequently, rehabilitation programs designed to optimize functional motor performance in stroke survivors increasingly have incorporated aerobic exercise training, with and without partial body weight these are supported walking, to improve strength and timing of muscle activations and cardio-respiratory

fitness. Generally, this is complemented by specialized training to improve skill and efficiency in self-care, occupational, and leisure-time activities. In addition to improvement in measures of quality of life, functional capacity and mobility (e.g., improvement in Gait and Posture), neurological impairment, and motor function (e.g., lowering the energy cost of gait), 3 major rehabilitation goals for the stroke patient are preventing complications of prolonged inactivity, decreasing recurrent stroke and cardiovascular events, and increasing aerobic fitness.(Gordon et.al. 2004) Cochair(2004) has pointed out several important factors in the potential value of exercise training and physical activity in stroke survivors. Previous studies have demonstrated the trainability of stroke survivors and documented beneficial physiological, psychological, sensorimotor, strength, endurance, and functional effects

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of various types of exercise. Moreover, data from studies involving stroke and ablebodied subjects have documented the beneficial impact of regular physical activity on multiple cardiovascular disease risk factors and provided evidence that such benefits are likely to translate into a reduced risk for mortality from stroke and cardiac events. Although they require additional validation by randomized clinical trials and other appropriately designed studies, these observations make recommendations for stroke survivors to participate in regular physical activity highly compelling at the present time. References Ignativicius, D., & Workman, M. (2006). Medical-surgical nursing (5th ed.). St. Louis: Brunner, Medical-surgical nursing 12th ed. 2009 Kozier Fundamentals of nursing 7th ed. 2007 Gordon et.al.2004 http://circ.ahajournals.org/cgi/content/full/109/16/2031
http://www.medicinenet.com/stroke/article.htm (2011) http://nursingcrib.com/pathophysiology/pathophysiology-of-cerebrovascular-accident-cva/ (2011)

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