case report cva wednesday 1

8/8/2019 Case Report CVA Wednesday 1

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Central Luzon Doctors Hospital Educational

InstitutionSan Pablo, Tarlac City

CerebrovascularAccident


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I. INTRODUCTION

For the purpose of privacy and confidentiality, the real name of the patient is withheld

and she will refer to as La Lola throughout the entire document.La Lola is a 77 year old female currently residing in Brgy. Tibag, Tarlac City, together

with her grand children. She was admitted to Central Luzon Doctors Hospital on September 22,2010 complaining of body weakness and inability to speak. A few hours before admission, shefirst felt body weakness at 12am accompanied by inability to speak, thus her family decided torush her to the emergency room to have her checked up.

A stroke is damage to a 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 braindeprived of blood dies and can no longer function. Blood is prevented from reaching brain tissuewhen 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 thedamage. Symptoms following a stroke come 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; troubleseeing with one or both eyes or double vision; confusion or personality changes; difficulty withmuscle movements such as swallowing moving arms and legs; loss of bowel and bladder


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among 65 year old and above; stroke affects more men than women and most of the cases are

among African American.

In the case of the patient, laboratory tests such as blood chemistry, HDL, LDL, DXTXand CT Scan revealed low levels of HDL, high in LDL, high value of DXTX and a CT scanrevealed of ischemic infarcts in white matter of left parietal lobe near the vertex, and at righttemporal lobe. She was complaining head ache for 2 weeks, with a manifested signs andsymptoms of body weakness and inability to speak few hours prior to admission. She was thendiagnosed with Cerebrovascular Accident (left hemisphere).

NURSING PROCESS

Nursing Health History A

A. Demographic data

Patient Name: La LolaDate admission:Sept. 22 2010

Ward:Female Ward Room no: 333

Age: 77 Sex: Female C/S: Married Religion: Roman CatholicExaminer: Dr. D


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D. Past Medical History(prior to admission and onset of illness)

a. Pediatric illness

Mumps ______ Pertusis________ HPN ___ ____

Measles ___ ___ Rheumatic___ ___ Heart Disease _______

Chicken Pox ___ ___Pneumonia______ Hepatitis _______

Rubella ______ Tuberculosis_____ Others ______

b. Immunization/Tests

BCG _____ Hepa B _____ Pneumonia _____

DPT _____ Measles _____ OPV _____

FLU _____ others: Tetanus toxoid

c. Hospitalization

Sh h it li d l t J 2008 d t t t i b th


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Before seeking help from health care professionals the patient did takeParacetamol and the alleged medicine given by the quack doctor.

h. Allergies

The significant others reported not having any allergies to either foodgroups or drugs.

E. Family History

Age Family Member Cause of death Disease Present in theFamily

L D* Mother Old age none

? Father Hypertension none* 1st sibling Hypertension none

77 2nd sibling CVA

72 3rd

sibling Diabetes Mellitus 2

F. Social and Personal History

Date of Birth:March 30, 1933 Birthplace:BulacanEducational Attainment: Elementary

(undergraduate)

Ethnic Background:Kapampangan

Position in the Family:2nd child


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d. Habits

La Lola spends her time doing some light household chores such as sweeping thefloor every morning, after which she just sits in her favourite hammock at the side of their house. La Lola smokes 3 sticks of cigarette per day.

e. DietShe eats three meals a day. She seldom eats vegetables and rather chooses meat and

processed foods. After her last confinement 2 years ago, La Lola started to lose her appetite, and now just eats about 5 tablespoons of rice every meal.

f. Physical Activity/Exercise

Light household chores were usually her form of exercise. According to the SO,she takes a walk every morning around their house for 5 minutes then sits to her favouritehammock throughout the day listening to her favourite radio station.

g. Brief Description of Average Day

La Lola usually wakes up as early as 4:00 in the morning. She takes her breakfastwith a cup of coffee then takes a walk for 5 minutes then starts doing light householdchores. She eats her lunch at 12:00pm. She then takes a nap in the afternoon for 2 to 3hours. La Lola takes her dinner at 6:00pm and usually retires at around 8:00-9:00 in theevening


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Notes: the patient experiences body weakness and fatigue because of her condition.

Skin

Itch Bruising Rash Bleeding

Lesions Blisters Ecchymoses BurnsDrainage Scars

Notes: The above deviations from normal were not present in the patient.

Eyes

Pain Itch Vision Loss Blurring

Diplopia Excessive Tearing Eye Glasses Contact Lenses

Notes: The patient was operated in both of her eyes two years ago because of cataract.


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Throat & Mouth

Sore throat Bleeding gums Tooth Ache Tooth Decay

Notes: Decaying tooth is noted at central incisor.

Chest

Cough Hemoptysis Wheeze Pain on respiration

Dyspnea: Rest / Exertion Sputum:___________________

Breast: Lumps Pain Bleeding Discharge



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Constipation Change in BM Melena


GU

Dysuria Nocturia Retention Polyuria

Dribbling Hematuria Flank Pain


Extremities

Joint Pains Varicose Veins Claudication Edema

Stiffness Deformities: none


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Mental Health Status

Anxiety (mild) Depression Insomnia Sexual Problems Fear



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Nutritional-MetabolicAccording to her grandchild, when she was not paralyzed yet, she was able to play with

her great grandchildren. She was also a picky eater and usually just takes what she wants amongthe food prepared.

EliminationLa Lola, according to her grandchild, defecates once a day and urinates 4 times a day.

Activity Exercise Pattern

Walking around their house every morning for 5 minutes and doing light house holdchores, among other light activities, are what she considers exercise.

Sleep-Rest

La Lola, according to her grandchild, sleeps early and wakes up early. She has her maximum sleep of 8 hours. She doesnt have any difficulty in sleeping except for the times thatshe has headache attacks.

Cognitive-Perceptual

She can do activities easily with her bare hands. She communicates with people through


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The patient is not sexually active because of her age. According to her grandchild, her

relationship with her husband is like that of best of friends.

Coping-Stress Tolerance

The patient engages herself in other forms of recreational activity as well as familyactivities according to her grandchild. She is family centered and gain strength from them.

Value-Belief

La Lola is a Roman Catholic member. Although she does not attend mass, she does listento sermons through radio broadcast.


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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 (intentiontremor), 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).

Cerebrum

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 intothe right and left sides, or hemispheres.

Depending on the area and side of the cerebrum affected by the stroke, any, or all, of thefollowing 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

Limbic System


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The temporal lobes are involved in the primary organization of sensory input. Individualswith temporal lobes lesions have difficulty placing words or pictures into categories.

Language can be affected 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 inimpaired memory for verbal material. Right side lesions result in recall of non-verbal material,such as music and drawings.

Parietal LobeDamage 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 perceiveobjects 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.

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 anysignificant 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 involvedin visuospatial processing discrimination of movement and color discrimination (Westmoreland
http://open%28%27scotoma.html%27%29/http://open%28%27scotoma.html%27%29/


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Cranial Nerves Major functions

I Olfactory SmellII Optic vision

III Oculomotor eyelid and eyeball movement

IV Trochlear innervates superior obliqueturns eye downward and laterally

V Trigeminal chewingface & mouth touch & pain

VI Abducens turns eye laterally

VII Facial controls most facial expressionssecretion of tears & salivataste

VIII Vestibulocochlear (auditory)

hearingequillibrium sensation

IX Glossopharyngeal tastesenses carotid blood pressure

X Vagus senses aortic blood pressure

slows heart ratestimulates digestive organstaste


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Blood

Transport oxygen, nutrients and other substances for brain functioningCarries away metabolitesApproximately 18% of total blood volume in brain.

Brain uses 20% of oxygen absorbed in the lungsTwo major arteries supplying blood to the brain are the INTERNAL CAROTID

ARTERY & VERTEBRAL ARTERY.Branches of ICA: ophthalmic, middle cerebral and anterior cerebral artery.Vertebral artery unites to form the basilar artery in the pons.Branches of vertebrobasilar artery: posterior cerebral, posterior and anterior inferior

cerebellar, pontine and internal auditory arteries.The circle of Willis is formed by the PCA, ACA, anterior communicating and posterior

communicating arteries.The MIDDLE CEREBRAL ARTERY does not form part of the circle of Willis

The venous drainage of the cerebrum includes the veins of the brain itself, dural venoussinuses, meningeal veins (dura) and diploic veins.

CEREBRAL ARTERIES

1. MIDDLE CEREBRAL ARTERY (MCA)

From internal carotid arteryBlood supply to deep structuresEnters lateral fissure sends cortical branches to lateral aspect of FRONTAL,TEMPORAL PARIETAL & OCCIPITAL LOBES


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Pathophysiology

Modifiable Factors:

>Sedentary Lifestyle

>Cigarette Smoking (3 sticks per day)

>High salt and fat diet

Non ModifiableFactors:

>Age: 60 above

>family history of Hypertension

Accumulation of fats and nicotine in blood

Hardening of bloodvessel

Atherosclerosis Formation of plaque

Narrowing passageway of blood flow

Increased vascularressure

Decreased blood vesselelasticity

Decrease in Blood flow

Decrease supply of oxygenated blood Increase vascular

E l i f bl d


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ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONALE

EXPECTEDOUTCOME

S= 0

O>Change in

pupillary

reactions

>Change in

Mental Status

>Behavioral

Changes

>Capillary

refill longer

than 3 secs.

Impaired

tissue

perfusion

related to

vascular

occlusion

secondary to

disease

condition

In cerebral tissue

perfusion, there is

a decrease in

oxygen supply

which results in

the failure to

nourish the tissues

at the capillary

level. Blood

vessels which

function is to

supply blood to the

different parts of

the brain are

impaired. Thus,the O2 supply

going to the brain

is also impaired.

Proper perfusion is

needed in order to

After 5 hours

of nursing

intervention,

Demonstrate

increase

perfusion and

behaviors

which mayimprove

proper

circulation

such as

compliance

to health

management

& therapies

provided.

>Assist semifowlers

position.

>Administer medications

as ordered such as

antihypertensive or

diuretics.

>Encourage quiet

and restful atmosphere.

>Exercise caution in

using hot or cold pads.

>Encourage use of

relaxation techniques or

exercises.

>To aid with proper perfusion or

flow of blood (circulation or

venous drainage).

>To probably decrease cardiac

workload and in maximizing

tissue perfusion

>To conserve energy this could

aid in lowering the O2 tissue

demand.

>The t issues may have

decreased sensitivity due to

ischemia.

>To decrease the tension level

Demonstrated

increase

perfusion and

behaviors which

may improve

proper

circulation such

as compliance to

health

management &

therapies

provided.


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give adequate

nourishment to the

different parts of

the brain in order for it to function

well.

>Discuss the importance

of preventing exposure to

cold or extreme cold

temp

>Discuss to the patients

SO the importance of

care of dependent limbs,

body hygiene, and foot

care when circulation is

impaired.

>To retain heat or warmth

efficiently

>To promote wellness


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GENERICNAME

CLASSIFICATION

DOSAGE ACTION INDICATION CONTRA

INDICATION

SIDE EFFECTS NURSING RESPONSIBILITY

Ranitidine

Brandname:Zantac

H2

antagonist,Anti ulcer drug

1 ampule

IVP q8

Inhibits the

action of histamine atthe H2receptor sitelocated

primarily ingastric

parietal cells,resulting in

inhibition of gastric acidsecretion.

Prevention and

treatment of self stress induceupper GI

bleeding incritically ill

patient.

Short termtreatment of active duodenalulcers and

benign ulcer.

Prophylaxis of duodenal ulcer.

Management of GERD.

Prevention andtreatment of heartburn, acidingeston andsour stomach

Ranitidine is

contraindicated in patientsknown tohavehypersensitivity toranitidine

bismuthcitrate or any

of itsingredients.

-constipation

- diarrhea;- headache;- stomach

pain;- upsetstomach;- vomiting;

>Antacids should be taken one hour

before or one hour after ranitidine, asthey inhibit the effectiveness.

>Instruct the patient to take themedication as directed for the fullcourse of therapy, even if feeling

better.

>Inform the patient that smoking

interferes with the action of histamineantagonist. >Advise the patient toavoid alcohol products containing toavoid aspirin or NSAIDS, and foodsthat may cause increase in GIirritation.

>Inform the patient that increase fluidand fiber intake and exercise may

minimize constipation.

>Watch for signs of GI bleeds.

>Have regular medical follow-up toevaluate the response.


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case report cva wednesday 1

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