cva presentation

Section 3, Group 11

Baylosis, KristineDe Castro, Maylyn

De Guzman, GeffreyDe Jesus, John Lord

Dela Cruz, Mark AnthonyDela Cruz, Rose Anne

Diaz, AndyDiaz, Maria Julie AnnDiang, Bobby JordanElepano, Mary AnnePanganiban, Rodolfo

Revibes, Rowena

Cerebrovascular disorder is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. Stroke is the primary cerebrovascular disorder in the world; it is the third leading cause of death behind heart disease and cancer.

Strokes can be divided into two major categories: ischemic (85%) in which vascular occlusion occur and significant hypo perfusion, and hemorrhagic (15%), in which there is extravasations of blood into the brain or subarachnoid space. Although there are some similarities between the two broad types of stroke, differences exist in etiology pathophysiology, medical management, surgical management, and nursing care.

An ischemic stroke, cerebrovascular accident (CVA), or “brain attack” is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. The term “brain attack” is being used to suggest to health care practitioners and the public that a stroke is an urgent health care issue similar to a heart attack.

Ischemic strokes are subdivided into five different types based on the cause: (1) large artery thrombotic strokes (20%), (2) small penetrating artery thrombotic strokes (20%), (3) cardiogenic embolic strokes (20%), (4) cryptogenic strokes (30%) and (5) other (5%).

Large artery thrombotic strokes are caused by

atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of atherosclerosis result in ischemia and infarction (deprivation of blood supply).

Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke. Small artery thrombotic strokes are also called lacunar strokes because of the cavity that is created after the death of infarcted brain tissue.

Cardiogenic embolic strokes are associated with cardiac dysrhytmias, usually atrial fibrillation. Embolic strokes can also be associated with valvular heart disease and thrombi in the left ventricle.

Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery resulting in a stroke. Embolic strokes may be prevented by used of anticoagulation therapy in patients with atrial fibrillation.

The last two classifications of ischemic stroke are cryptogenic strokes, which have no known cause and stroke from other causes, such as illicit drug use, coagulopathies, migraine and spontaneous dissection of the carotid or vertebral arteries.

The case was selected due to the following reasons:

This kind of case will present an additional information for student nurses like us and it will be very beneficial when we become registered nurses.

We want to know how and why it happens. To understand its anatomy and pathophysiology and what care plans that we nurses must utilize.

It is the first time that we had encounter this kind of case, we want to fully assess, understand and evaluate the condition of our client so we will be able to provide the proper nursing care.

PATIENT’S NAME : Mrs. READDRESS : Sta. Rosa CityBIRTHDATE : May 14, 1950AGE : 60 years oldRELIGION : CatholicOCCUPATION : HousewifeDATE OF ADMISSION : July 6, 2010

CHIEF COMPLAINT : Loss of Consciousness INITIAL DIAGNOSIS : Cerebrovascular Accident

General Data:

This is a case of a 60 years old female who was admitted last July 6, 2010 at UPH-Binan. She is known to have Hypertension and Type 2 diabetes.

History of Present Illness:

Two hours prior, according to her daughter, the patient was walking for almost an hour with her and when they got home, the patient went to the comfort room and eventually lost her consciousness. The patient was noted to be unresponsive and with slurred speech when she woke up.

Past Medical History:

For almost twenty years, she consistently had high blood pressure, a history of heart failure and known to be a diabetic. She is currently having her regular check up at the Philippine General Hospital in Manila.

Medications:

Patient had the following medications; Losartan, Metroporol, Felodipine and Simvastatin and Glemeperide but taken with poor compliance due to financial constraints.

Family Medical History:

Patient’s paternal side had a history of Diabetes Mellitus Type 2.

Lifestyle:

The patient is a non-alcohol drinker and a non-smoker. Her method of exercise is doing household chores and she lives with her husband who is an active smoker.

Date: July 6, 2010

Vital Signs:Blood Pressure: 180/100Temperature: 37.2˚CPulse Rate: 52bpmRespiratory Rate: 24cpm

General Status:

Glasgow Coma Scale: 12 (E=3, V=4, M=5) Level of consciousness: Obtunded Contralateral paralysis – Left side paralysis Impaired thought process Disoriented to time and place when asked Slurring speech Use of non-verbal cues Difficulty maintaining usual communication pattern Low fat, low salt diet On Complete Bed Rest w/o Bathroom Privileges Blisters in the left gluteal part of the body

SENSORY

Right side Left Side

100% 50%

100% 50%

MOTOR

Right Side Left Side

5/5 4/5

5/5 4/5

Interpretation:Based on the illustrations above, the patient have a sensory deficit. An equal stimuli is applied to the both sides of her body. The amount of stimuli felt in the right side of the body is greater than in the left side. When the patient was asked to use a scale to differentiate how weak or strong the other side is, she said if it is 100% in the right side, then the left side is only 50%.The patient is manifesting a motor deficit. She was graded 4/5 because she was able to move or perform a full range of motion against gravity with a moderate resistance.

A grade of 5 is given when the patient will be able to move or perform a full range of motion against gravity with a full resistance applied; a grade of 3 if it is a full range of motion against gravity only; a grade of 2 if gravity is eliminated; a grade of 1 if there is a weak muscle contraction when muscle is palpated and a grade of 0 when there is no movement at all or complete paralysis.

The Siriraj Stroke Scoring - Used to differentiate supratentorial brain hemorrhage from infarction.

Variables Clinical Features Score Patient1. Consciousness Alert 0

Drowsy, stupor 2.5 2.5Semicoma, coma 5

2. Vomiting No 0 0Yes 2

3. Headache within two hours of stroke onset.

No 0Yes 2 2

4. Diastolic Blood Pressure Actual DBP in mmHg DBP x 0.1

100 x 0.1 = 10

5. Artheroma markers (DM, Angina, Hypertension)

None 0One or more 3 3

Constant -12 -12Total patient’s score

Total:17.5

+5.5

Score Interpretation:

> +2 = Most likely hemorrhage-1, 0 and +1 = Equivocal result (CT Scan recommended)< -2 = Most likely Infarction

The Nervous System can be divided into two parts – central and peripheral. The Central Nervous System (CNS) includes the brain and spinal cord. The Peripheral Nervous System includes the twelve (12) pairs of cranial nerves, the thirty-one (31) pairs of spinal nerve, and all their branches. The Peripheral Nervous System carries messages to the CNS from sensory receptors and from the CNS out to muscles and glands.

THE CENTRAL NERVOUS SYSTEM

Major parts of the Brain:

1.Cerebrum

The cerebral cortex is the cerebrum’s outer layer of nerve cell bodies, also called gray matter. The cerebral cortex is the center for human’s highest functions governing thought, memory, reasoning, sensation, and voluntary movement.

Each half of the cerebrum is a hemisphere. Each hemisphere is divided into four lobes: frontal, parietal, temporal and occipital.

The lobes have certain areas that mediate certain functions. Damage to these specific cortical areas produces a corresponding loss of function: motor deficit, paralysis, loss of sensation, or impaired ability to understand and process language.

Frontal - largest lobe located in the front of the skull. The major functions of the frontal lobes are concentration, abstract thought, information storage or memory, and motor function. It also contains Broca’s area, critical for motor control speech. It also responsible for the large part for a person’s affect, judgment, personality and inhibitions.

Parietal – a predominantly sensory lobe located near the crown of the head. It analyzes sensory information and relays the interpretation of this information to the thalamus and other cortical areas. It is also essential to a person’s awareness of the body in space, as well as orientation in space and spatial relation.

Temporal – contains the auditory receptive areas located around the temples. The temporal lobe contains a vital area called interpretative area that provides integration of somatization, visual, and auditory areas and plays the dominant role of any area of the cortex in thinking.

Occipital – the posterior lobe at the lower back of

the head responsible for visual interpretation.

2. Brain Stem

Medulla oblongata – contains the motor fibers from the brain to the spinal and sensory fibers from the spinal cord to the brain. Cranial nerve IX through XII connect to the brain in the medulla.

Pons – Situated in the front of the cerebellum between the midbrain and the medulla and is a bridge between the two halves of the cerebellum and between the medulla and cerebrum.

Midbrain – Connects the pons and the cerebellum with the cerebral hemispheres. It contains sensory and motor pathways and serves as the center for auditory and visual reflexes

3. Cerebellum

Separated from the cerebral hemispheres by a fold of duramater, the tentorium cerebella. It has both excitatory and inhibitory actions and is largely responsible for coordination of movements. It also control fine movement, balance, position sense (proprioception) and integration of sensory input.

The Spinal Cord

The Spinal Cord is connected to the brain and is about the diameter of a human finger. From the brain the spinal cord descends down the middle of the back and is surrounded and protected by the bony vertebral column. The spinal cord is surrounded by a clear fluid called Cerebral Spinal Fluid (CSF), that acts as a cushion to protect the delicate nerve tissues against damage from banging against the inside of the vertebrae.

The nerves within the spinal cord are grouped together in different bundles called Ascending and Descending tracts. Ascending tracts within the spinal cord carry information from the body, upwards to the brain, such as touch, skin temperature, pain and joint position. Descending tracts within the spinal cord carry information from the brain downwards to initiate movement and control body functions.

The level of the spinal cord segments do not relate exactly to the level of the vertebral bodies i.e. damage to the bone at a particular level e.g. L5 vertebrae does not necessarily mean damage to the spinal cord at the same spinal nerve level.

THE PERIPHERAL NERVOUS SYSTEM

Cranial NervesCranial nerves enter and exit the brain

rather than the spinal cord. The twelve (12) pairs of cranial nerves supply primarily the head and neck, with the exception of vagus nerve which travels to the heart, respiratory muscles, stomach and gallbladder.

Spinal NervesThe thirty-one (31) pairs of spinal nerves

arise from the length of the spinal cord and supply the rest of the body. They are named for the region of the spine from which they exit: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. They are mixed nerves because they contain both sensory and motor fibers.

Modifiable:• Hypertension• Heart Disease - CHF • Diabetes Mellitus Type II• Passive smoke from husband• Poor compliance on medication •Overweight – BMI: 28

(Ht: 4’11”, Wt: 65kg)

Non-Non-Modifiable:

• Age (60 years old)• Gender (Female)

Rupture of Cerebral Artery

Middle Cerebral ArteryAphasia, Dysphagia,

Hemiperesis

Anterior Cerebral ArteryWeakness, Numbness,

Impaired motor sensory function

Hemorrhagic

Decrease blood flow to the brain

Increased ICP

Cerebral edema

Hypoxia

Cerebrovascular Accident

Signs and symptoms:• Confusion – disoriented to time• Impaired thought process• Contralateral paralysis – difficulty moving – blisters on the gluteal area• Urinary incontinence in the comfort room• Sensory Deficit - Cranial Nerve V (Trigeminal)• Slurring of speech • Use of non-verbal cues • difficulty maintaining usual communication pattern• Motor deficit• Loss of Consciousness – Obtunded• Tongue protrudes on the right side Cranial Nerve XII (Hypoglossal) dysfunction• Headache

DIAGNOSTIC NORMAL VALUES

RESULT INTERPRETATION

Hemoglobin 12.0 - 16.0 13.5g/dl NormalHematocrit 33.0 - 46.0 39.4% NormalRBC 4.20 - 5.40 4.58mil/mm3 NormalMCV 80 -100 fl 86 fl NormalMCH 30 27 -35pg NormalMCHC 32 – 36 % 34% NormalWBC Count 4 800 – 10 800 12 000/mm3

(high)Increased in presence of infections

Neutrophils 2 000 – 7 000 10 608/mm3(high)

Increased with acute infections, and necrosis

Lymphocytes 1 500 – 4 000 768/mm3(low)

Decrease with aplastic anemia

Monocytes 200 – 800 600/mm3 NormalEosinophils 40 – 500 24/mm3

(low)Decreased with stress,

Basophils 10 – 100 0/mm3(low)

Decreased with allergic reactions, stress,

HEMATOLOGYNAME: Mrs. RESPECIMEN: BloodDATE TAKEN: July 6, 2010

Drug Name Action Indication Contraindication

Side Effects Nursing Consideration

Generic name:Enalapril

Brand name:Pharex Enalapril

Dosage, frequency route:5mg 1tab OD PO

Classification:Cardiovascular drug

Stock Dosage: 5mg, 10mg, 25mg

To normalize/ lower patient’s blood pressure.Also treatment for heart failure to reduce the incidence of coronary ishemic events, including myocardial infarction.

Treatment for Hypertension and Heart Failure.

Should not be given with patients with aortic stenosis or outflow tract obstruction.

CNS: headache, dizziness, fatigue, vertigo

CV: hypotension, chest pain

GI: diarrhea, abdominal pain, vomiting

GU: decreased renal function

RESPIRATORY: dyspnea, dry, nonproductive cough

METABOLIC: hyperkalemia

Obtain history of patient’s blood pressure before starting therapy and reassess regularly.

Before administration of medicine check for the right patient, right medication, right dose, right time and right route.

> Monitor renal status.> Monitor blood pressure.


Side effects Nursing consideratio

n

Generic name:Amlodipine

Brand name:Amcal

Dosage, frequency, route:10mg OD PO

Classification:Cardiovascular drugs

Stock dose:5mg, 10mg

To decrease blood pressure.

For hypertension, chronic stable of angina; vasospastic

Sick sinus syndrome

CNS: headache, dizziness, nausea, lethargy

GI: abdominal discomfort, cramps, dyspepsia

CV: palpitation, tachycardia, bradycardia

SKIN: rashes, urticaria

> Check for the patient’s blood pressure status.>Before administration of medicine check for the right patient, right medication, right dose, right time and right route.> Assess for any adverse reaction.> Assess hydration and fluid status.> Monitor blood pressure.


Side Effects Nursing Consideratio

n

Generic name:Mecobalamin

Brand name:Cobal

Dosage, frequency, route:500mcg TID PO

Classification:Central Nervous System Drug(Vitamin)

Stock dose:1500mcg

Helps maintain a healthy nervous system. And to treat deficiency in vitamin B12

Peripheral neuropathy, diabetic neuropathy

GI: anorexia, nausea and vomiting

SKIN: rashes

> Before administration of medicine check for the right patient, right medication, right dose, right time and right route.


Side Effects Nursing Consideratio

n

Generic name:Ranitidine

Brand name:Zantac

Dosage, frequency, route:50mg q 8° TIV

Classification:Gastrointestinal drug

Inhibits gastric secretions

Used in management of various GI disorders such as dyspepsia, gastro-esophageal reflux disease (GERD) and peptic ulcer

Hypersensitivity CNS: dizziness, headache, hallucination, depression, insomia

GI: nausea, vomiting, abdominal discomfort, diarrhea, constipation

Right patient, right medication, right dose, right time, and right routeTaken with foodMonitor adverse reaction

Drug Name Action Indication Contraindication Side Effects Nursing consideratio

n

Generic name:Losartan

Brand name:Angiocard

Dosage, frequency, route:50mg OD PO


To reduce blood pressure

For hypertension, in heart failure and myocardial infarction

Hypersensitivity to other Sulfonamide derived drugs

CNS: orthostatic hypotension, dizziness, severe migraine

RENAL: impaired renal function

Right patient, right medication, right dose, right time, and right routeMonitor VSMonitor drug reaction


Side Effects Nursing Consideration

Generic name:Osmofundin 20%

Brand name:Mannitol

Dosage, frequency route:100cc q 8° IV

Classification:Fluids/Electrolytes

To reduce Intra cranial pressure

Reduction of increased ICP associated with cerebral edema.

Hypersensitivity and severe renal disease

CNS: headache, dizziness, fever

GI: diarrhea, vomiting, nausea, thirst

GU: urine retention, marked diuresis

RESPIRATORY: Thrombophlebitis

CV: Heart failure, tachycardia

Obtain history of patient’s blood pressure before starting therapy and reassess regularly.Before administration of medicine check for the right patient, right medication, right dose, right time and right route.Monitor renal status.Assess neurologic status of the patient.


Side Effects Nursing consideratio

n

Generic name:Clonidine

Brand name:Catapress

Dosage, frequency, route:150mg

Classification:Cardiovascular drug

To decrease blood pressure.

Management of all kinds of hypertension

Hypersensitivity to clonidine

CNS: drowsiness, dizziness, headache, fatigue, anxiety

GI: constipation

SKIN: local skin irritation, allergic contact dermatitis, hypo and hyper pigmentation of the skin

Before administra-tion of medicine check for the right patient, right medication, right dose, right time and right route.Check for the patient’s blood pressure before and after drug administra-tion


Side Effects Nursing consideratio

n

Generic name:Simvastatin

Brand name:Altovast

Dosage, frequency, route:20mg HS PO


To reduce cholesterol

Treatment of hypercholesterolemias in patient with ischemic heart disease.

Patients with acute liver disease or unexplained persistently raised serum amino transferase concentrations

CNS: headache, dizziness, nausea,

GI: abdominal pain, constipation,Flatulence

Before administration of medicine check for the right patient, right medication, right dose, right time and right route.Assess patient’s nutrition or dietMonitor cholesterol baseline


Side Effects

Nursing consideration

Generic name:Lactulose

Brand name:Dufalac

Dosage, frequency, route:30cc

Classification:GI drugs or Laxatives

To soften or loosen stool for easy excretion.

Treatment of constipation

Galactosemia and bowel obstruction

CNS: nausea and vomitting

GI: diarrhea and flatulence

Before administration of medicine check for the right patient, right medication, right dose, right time and right route.Assess patient’s conditionMonitor for possible adverse GI reaction.Monitor fluid and electrolyte status

CUES PROBLEM SCIENTIFIC EXPLANATION INTERVENTION

RATIONALE EVALUATION

Subjective:“Meron sugat na namamaga sa parting pwet nya sa kaliwa” as verbalized by the relative of the patient. Objective:Disruption of skin surface at the left gluteal area

Skin Impairment

Pressure, Skin Force and Friction: The compression of the tissues when patient remains in a single decubitus position for a lengthy period causing ischemia and tissue necrosis

Source: Oxford Medical Dictionary

Keep the area clean/dry, carefully dress wounds to prevent infection.

Turn the patient from side to side at least every two hours

Instructed to maintain clean, dry clothes and preferably use cotton fabric

To minimize infection and further swelling

To reduce pressure to avoid aggravation of wound.

Skin friction and rough clothes may cause irritation and increase risk for infection

Goal met. The swelling and skin impairment on the left gluteal area has lessened and healed

NAME: Mrs. REMEDICAL DX: Cerebrovascular AccidentNURSING DX: Impaired Skin Integrity related to physical immobilization as manifested by bed sores on the left gluteal areaSHORT TERM GOAL: At the end of our shift, tissue perfusion will normalize and maintain.LONG TERM GOAL: At the end of the confinement, patient’s skin integrity will display timely healing of pressure sores without complication.

CUES PROBLEM SCIENTIFIC EXPLANATION

INTERVENTION


Advised to provide optimum nutrition by increased protein intake and increased fluid intake Inspect skin on a daily basis, describing wound characteristics and changes.

To provide positive Nitrogen balance for tissue healing and to promote good skin turgor

To monitor progress of wound healing

NAME: Mrs. REMEDICAL DX: Cerebrovascular Accident NURSING DX: Impaired physical mobility related to neuromuscular impairment as evidence by body weakness and limited range of motionSHORT TERM GOAL: At the end of our shift, the patient will be able to practice active and passive range of motion exercises. LONG TERM GOAL: At the end of the hospitalization, the patient will regularly and continuously perform active and passive range of motion exercises even at home.CUES PROBLE

MSCIENTIFIC

EXPLANATION

INTERVENTION RATIONALE EVALUATION

Subjective cues:“Hirap daw syang gumalaw” as verbalized by the patient’s daughter

Objective:Motor deficitContralateral paralysisSensory deficit

Impaired physical mobility

Problems commonly associated with immobility include weakened muscles, joint contracture and deformity. Each joint of the body has a normal range of motion; if the range is limited, the functions of joints are impaired and painful deformities may develop.

Assessed degree of weakness in both upper and lower extremities.

Assessed ability to move and change position, to transfer and walk.

Observed for activities or situations that increase or decrease tone.

There may be differing degrees of involvement on the affected side. Paralysis, paresis and sensory loss are contralateral to the side of the brain affected by the stroke.

Activities that cause spastic response can be postponed until later in recovery.

Goal Met:The patient was able to verbalized understanding in the importance of participating in the activities of daily living.

CUES PROBLEM SCIENTIFIC EXPLANATION

INTERVENTION


Source: Medical and Surgical Nursing by Brunner & Suddarths

Monitored skin integrity for areas of blanching or redness as sign of potential breakdown.

Changed position of patient every two hours.

Performed active and passive ROM exercises in all extremities.

Teach the patient and family about exercises and transfer techniques.

Impaired mobility increases the risk of skin breakdown.

Patient may not feel increases in pressure or not have the ability to change position. To prevent risk for skin breakdown.

Preserves muscle strengths and prevent contractures, especially in spastic extremities.

To promote recovery and prevent injury.

NAME: Mrs. REMEDICAL DX: Cerebrovascular AccidentNURSING DX: Impaired verbal communication related to neuromuscular

impairment as evidence by slurring of speech and use of non verbal cues.

SHORT TERM GOAL: At the end of our shift, the patient will be able to develop techniques of communication.

LONG TERM GOAL: At the end of the hospitalization, the patient will be able to practice her developed techniques of communication to lessen her difficulty and maintain the usual pattern of communication.CUES PROBLEM SCIENTIFIC

EXPLANATION


Subjective cues:“Hindi namin maintindihan yung sinasabi nya” as verbalized by the patient’s daughter

Objective:Slurred speechUse of non-verbal cuesDifficulty maintaining usual communica-tion pattern

Impaired verbal comunica-tion

Decreased, delayed, or absent ability to receive process, transmit, and/or use a system of symbols because of decrease blood flow to the brain. Source:Oxford Medical Dictionary

Assessed speech-language history: determine primary language, ability to read and write and level of education.

Provided, clear simple instructions.

To provide a baseline for developing an individualized teaching plan.

A patient with dysphasia requires direction to be repeated frequently. Tasks needs to be explained in very simple steps and presented one at a time.

Goal Met:The patient was able to practice techniques of communication.

CUES PROBLEM SCIENTIFIC EXPLANATIO

N


Allowed adequate time for patient response.

Provided opportunities for spontaneous conversation.

Provided reality orientation and focus attention, but avoid constantly correcting errors.

Encouraged the family to communicate with the patient more frequently.

If the patient feels rushed, communication problems worsened. The patents need more time to cognitively process information and formulate a verbal response.

This provides the patient a chance to talk without the expectation of desired outcome.

Constant correction increases frustration, anxiety, and anger.

Promotes more effective communication for the patient.

cva presentation

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