TOMAS CLAUDIO MEMORIAL COLLEGE College of Nursing

A CASE STUDY OF A CLIENT WITH CEREBROVASCULAR ACCIDENT (CVA)

Presented by: Natividad, Mark Obrero, Lorelie Ocampo, Janina Kyreen Pangandaman, Sittie Naomie Pelicano, Shiela Marie Perez II, Elizabeth Pigtain, Asia Ramirez, Jomel Ramirez, Rossini Repato, Karen Marie Presented to: Mrs. Rommelyne Robles, RN, MAN Clinical Instuctor

I.

INTODUCTION A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. Ischemic stroke is the most common type of stroke and is caused by a blockage of the blood vessels supplying the brain. This may be due to hardening and narrowing of the arteries (atherosclerosis) or by a blood clot blocking a blood vessel. The most severe type of stroke is a hemorrhagic stroke. It occurs when a blood vessel in the brain bursts, allowing blood to leak and cause damage to an area of the brain. There are 2 types: subarachnoid hemorrhage, which occurs in the space around the brain; and an intracerebral hemorrhage, the more common type, which involves bleeding within the brain tissue itself. The symptoms of a stroke usually appear suddenly. Initially the person may feel sick, and look pale and unwell. They may complain of a sudden headache. They may have sudden numbness in their face or limbs, particularly down one side of their body. They may appear confused and have trouble talking or understanding what is being said to them. They may have vision problems, and trouble walking or keeping their balance. Sometimes a seizure (fit) or loss of consciousness occurs. Depending on what function the damaged part of the brain had, a person may lose one or more of the following functions:

ability to perform movements usually affecting one side of the body; speech; part of vision; co-ordination;

balance; memory; and perception Sudden weakness or numbness of the face, arm and leg on one side of the body. Loss of speech, or difficulty talking. Dimness or loss of vision. Unexplained dizziness, especially when associated with any of the above signs. Unsteadiness or sudden falls. Headache (usually severe and of sudden onset). Confusion.

The warning signs are:

Confirmation of diagnosis and initial treatment of strokes usually takes place in a hospital. A computerized CT scan of the brain is done which produces a two or three dimensional pictures of the part of the brain. Another laboratory procedure done is (MRI)or Magnetic Resonance Imaging scan which uses a large magnet, low-energy radio waves and a computer to produce a two or three dimensional pictures of the body. If a stroke has occurred, treatment should begin as soon as the stroke is diagnosed to ensure that no further damage to the brain occurs. Initially, the doctor may administer oxygen and insert an intravenous drip to provide the affected person with adequate nutrients and fluids. In cases of ischemic stroke, it is common to give aspirin to reduce the risk of death or of a second stroke. If the cause of the stroke was a clot, it is possible that the quick administration of certain clot-dissolving drugs, such as alteplase, will prevent some symptoms such as paralysis. However, this is not a suitable treatment for all strokes, and can increase the risk of hemorrhagic stroke, so there are strict guidelines determining the circumstances in which it should be used. Once a stroke has permanently damaged the brain, the damage cannot be undone. However, many symptoms can improve considerably in the days following a stroke, because the areas of brain on the periphery of the stroke can

recover. In addition, your doctor will suggest ways to prevent a future stroke, including modifying your lifestyle to minimize your risks of stroke, and taking medications. Depending on the type and cause of the stroke, anticoagulant drugs (blood thinners) may be prescribed to help prevent new blood clots from forming, in order to prevent a future stroke. Examples include aspirin, aspirin plus dipyridamole (Asasantin), clopidogrel (e.g. Plavix) and warfarin (Coumadin or Marevan). Where there is a blockage in a neck artery, surgery may be performed to remove the build-up of plaque in order to prevent a future stroke. This operation is called a carotid endarterectomy. Men are 25% more likely to suffer strokes than women, yet 60% of deaths from stroke occur in women. Since women live longer, they are older on average when they have their strokes and thus more often killed (NIMH 2002). Some risk factors for stroke apply only to women. Primary among these are pregnancy, childbirth, menopause and the treatment thereof (HRT). The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. Advanced age is one of the most significant stroke risk factors. 95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. A person's risk of dying if he or she does have a stroke also increases with age. However, stroke can occur at any age, including in childhood.

II.

OBJECTIVES GENERAL OBJECTIVES This study aims to present information that discussed the Cerebrovascular Accident (CVA) and possible complications that may arise and interface with regards to the condition of the client. And to develop, implement and evaluate plans for health promotion, using professional effective nursing care with direct nursing activities. To arrive at this point at which decision can be made. And to help client in terms of physical adaptation. SPECIFIC OBJECTIVES Establish rapport and gain the trust and cooperation of the patient and immediate family members. Perform and obtain thorough and complete physical assessment using the assessment techniques following the cephalocaudal approach; obtain complete medical, socio-cultural, and family history related to the patients current health condition. Analyze and prioritize problems based from the gathered pertinent data to come up with the correct nursing diagnoses. Plan the appropriate nursing interventions to address the patients health needs. The interventions should address not only the physical well being of the patient but also her emotional, social, and mental welfare. Implement the planned nursing interventions to meet the desired outcomes and help improve patients condition. Impart useful health teachings to the patient and immediate family members to prevent further development of the patients condition and other related complications, and for the patient to be able to adjust well and continue with her normal life after being discharged from the hospital

III.

DATA BASE A. Patients Profile Name Age Address Gender Civil Status Date of Birth Nationality Religion : : : : : : : : Mr. M 59 years old P. Sta. Maria St. Brgy. Balibago, Cardona, Rizal Male Married February 7, 1951 Filipino Roman Catholic

B. Admission Data Date of Admission Time of Admission File Record Number Hospital Chief Complaint Admitting Diagnosis Attending Physician : : : : : : : February 1, 2011 8:41a.m. 11020002 Queen Mary Help of Christian Hospital Inc. Right sided body weakness HCVD(Hemorrhagic Cerebrovascular Disease) Alexander Abe

IV.

HISTORY OF PAST AND PRESENT ILLNESS PAST HEALTH HISTORY His right eye was hit by a bamboo streaks that leads into blindness during his adolescence. The patient underwent herniorrhaphy and her wife stated that the patient is not hypertensive or diabetic.

PRESENT HISTORY Last February 1,2011 two hours PTA the patient was found at the living room experiening dizziness and complaining for right sided body weakness. He was brought to QMCHI the same day at 8:41a.m. to seek for medical assistance. He was drowsy but easily arouse. The strength of his right upper and lower extremities were 1 out of 5, and 5 out of 5 on the left extremities. His neurovital signs were E4V4M6 with a total score of 14 in Glasgow Coma Scale. His left pupil were 3mm reacted to light. He has a negative Babinski Reflex. He was seen by Dr.Alexander Abe and has an admitting diagnosis of CVA and has a final diagnosis of HCVD last February 2, 2011. His admitting vital signs reveal the following: Blood pressure Cardiac Rate Respiration Rate Temperature FAMILY HISTORY OF DISEASES During assessment, the patients wife stated that his husbands two brothers have history of hypertension and diabetes mellitus. However, he was not diagnosed having even the two diseases. 170/120 mmHg 62bpm 24cpm 36.6 C

V.

13 AREAS OF ASSESSMENT I. Social Status Mr. M is a 59 years old, married and was born on February 7, 1951. He is currently residing at P. Sta. Maria St. Brgy. Balibago, Cardona, Rizal. He is a high school graduate, a fisherman and they owned a fish pen. He is affiliated in the Roman Catholic Religion and has one child. He is a smoker; he can consume one pack of cigarette every day and he drinks occasionally. According to Erik Eriksons stages of Psychosocial Development, the patient was in the stage of Generativity vs. Stagnation, wherein the patient was in positive development, his wife said that his husband has mentioned in one of their conversation that he is happy and contented with what he and his family have. II. Mental Status During assessment, we have observed that the patient is alert, and oriented to the persons around him. He was also aware that he is in the hospital. The patient was cooperative and evidenced by answering questions through sign language (examples of questions are: How many? Does it hurt? And those questions answerable by yes or no.); he was also able to maintain an eye-to-eye contact and could follow simple directions such as placing his hands above his head and holding the nurse hand. His eyes opens spontaneously, oriented and obeys command. His neurovital sign was E4V5M6 with a total score of 15 in Glasgow Coma Scale. He was not also able to speak. Hindi n siya mkapag salita mula nung inatake sya as stated by his wife. III. Emotional Status Whenever Mr. M had problems, he consulted to his wife and other relatives to seek for some advices. He is optimistic and does not show any signs of hopelessness and helplessness. He is willing to fight for his recovery. IV. Sensory Perception Vision Eyes are black and are almond in shape. He was able to follow the six cardinal gazes. Left eye was reactive to light and accommodating well and his pupil was round. PERRLA assessment was not applicable on right eye

because it is blind, reported by his wife. No discharges found during inspection. Smell Mr. Ms nose is symmetrical in shape. He can identify smell. No further assessment was done due to oxygen therapy via nasal cannula. Hearing Ears are symmetrical in terms of size and shape. There is no presence of earwax and no discharges found during inspection. We assessed his hearing ability by asking him to close his eyes and identify the sound made by tapping of a ball pen and a coin in the side rails of his bed and by making a sound of a crumpled paper. He was able to hear the sounds made at a specific distance. He was able to identify the sound that he hears by asking him to point out which of the two (ball pen or paper) he hears first and last. Taste He had pale, dry and cracked lips. When we inspect his teeth, he had no cavities and had dentures on the upper part of his teeth. No further assessment was done due to having an NGT. Touch He reacted through facial mask of pain when his skin was tested intradermally on his left arm. When we asked him if he feels any pain, he pointed his head and rates it as one from a pain scale of 1-10. He reported feeling of numbness on the right upper and lower extremities V. Motor Ability He cannot move his right upper and lower extremities, but his left upper and lower extremities can move fully. Have proper symmetry between left and right upper and lower extremities. There is no presence of deformities. He cannot turn to his left side because he cannot move his right upper and lower extremities. He also feels numbness on the affected part. On assessment last February 07, 2011 the patients muscoskeletal strength on the right extremities improved. He can now move his right arm but only limited range of motions were performed. He

VI.

Temperature Mr. Ms temperature as of February 01, 2011 at 7:00 p.m. is 36.8C taken at the left axilla, using a digital thermometer and marked as normal. His skin was warm to touch.

VII.

Circulatory Mr. Ms blood pressure was taken and recorded as 160/90 mmHg. His pulse rate was 65 bpm, and is within normal range of 60-100 for an adult as of February 1, 2011 at 7:00 p.m. There was no presence of edema with a capillary refill ranging from 1-2 seconds taken at the left index finger.

VIII.

Respiratory Respiratory rate was taken and recorded as 20cpm on Feb.01, 2011 at 7:00p.m. His chest is symmetrical in shape. There is no presence of phlegm and abnormal breath sounds. The patient uses oxygen therapy via a nasal cannula regulated at 2-3lpm. On assessment last February 07, 2011 wheezes are heard upon auscultation. The patient also had a cough as stated by his wife. He is still on oxygen therapy. Umuubo siya saka may plema kaya lang hindi niya nailalabas as stated by his wife.

IX.

Nutritional Status Before hospitalization: He eats 2 cups of rice and drinks 2 glasses of water every meal. He eats vegetable, fish, and chicken. During hospitalization: Hirap syang makakain, hindi nya kayang lumunok as stated by his wife. He has an NGT and has a diet of have a low salt low fat diet. As of February 7,2011 he has an IV fluid of D5NaCl 1 L at the level of 800cc regulated at 20-21gtts/min.

X.

Elimination Prior to hospitalization: Mr. M defecates once daily and voids more than 5 times a day. During hospitalization: As of February 01, 2011 Mr. M does not defecate yet. He has an indwelling folley catheter and his urine output within 3 hours is 1100cc. His urine appears yellow in color. On assessment last February 07, 2011 his wife reports that Mr.M had defecate once daily and releases a semi-solid stool. He was also on a bladder training every 2hours.

XI.

Reproductive He underwent a surgical procedure in the 1980s due to hernia. He only had one child.

XII.

State of Physical Rest and Comfort Before admission: According to his wife, the client spend his time at night by watching television and used to sleep at midnight, and wakes up at 3:00am because he needs to woke up early to go to their fish pen. He also takes nap in the afternoon for one hour. During Hospitalization: According to his wife the patient completed an eight hour sleep at night. The client takes nap in the afternoon and sometimes become irritable when the hospital gets hot.

XIII.

State of Skin and Appendages Mr. M has dry, dark and warm skin. The skin turgor is poor. There is no reported history of skin disease or allergy. She had thick, black, curly hair and was fully distributed; he has a healthy scalp as evidenced by absence of dandruff and lice. His nails are found to be properly trimmed and no traces of dirt are noted.

VI.

LABORATORIES

CLINICAL CHEMISTRY DATE: February/01/2011 Examination SGPT (ALT) BUN Creatinine Sodium Potassium Result 10U 3.8mmol/L 87mmol/L 131mmol/L 3.6mmol/L Normal Values 4-36 U 3.2-7.1mmol/L 71-133mmol/L 136-145mmol/L 3.5-5.1mmol/L Significant Findings Normal Normal Normal Indicates kidney failure Normal

URINALYSIS DATE:February/02/2011 Result Color Transparency pH Sp. Gravity Sugar Protein Microscopic: Puss Cell RBC Bacteria Epithelial Cell Yellow Slightly turbid 5.0 1.010 (-) Trace 2-3hpf 10-12hpf Few Moderate Normal Values Clear Straw/amber 4.6-8.0 1.005-1.030 Negative Negative None 0-2 none Small amount Significant Findings Dehydration Infection Normal Normal Normal Due to HPN infection due to BPH infection infection

HEMATOLOGY

Examination Hemoglobin Hematocrit WBC Segmenter: Neutrophil Lymphocytes Monocytes

Result 133g/L 0.39% 11.110/L 0.90mmol/L 0.07mmol/L 0.03mmol/L

Normal Values 149-170g/L 0.24-0.51% 5.0-10.010/L 0.42-0.75mmol/L 0.20-0.51mmol/L 0.02-0.09mmol/L

Significant Findings Due to O2 decrease due to infection infection infection Normal

CLINICAL CHEMISTRY DATE:February/02/2011

Examination Blood Sugar (FBS) Cholesterol Triglyceride HDL cholesterol LDL cholesterol

Result 4.5mmol/L 5.61mmol/L 1.08mmol/L 1.11mmol/L 4.01mmol/L

Normal Values 4.4-5.9mmol/L <5.20mmol/L <1.69mmol/L 0.91mmol/L <3.36mmol/L

Analysis Normal Associated with atherosclerosis Associated with atherosclerosis Associated with atherosclerosis Associated with atherosclerosis

February 02, 2011 CT SCAN REPORT:

Plain axid cranial CT scans show subtle wedge shaped, hypodense lesion in the left posterior parietal lobe. Cortical sulci, cisterns and ventricles are prominent. Midline structure are undisplaced. Posterior fossa structures are unremarkable. Intimal calcifications are seen in the basilar and internal carotid arteries. Calcifications are seen in the right orbit. Bony calvarium, petromostoids and paranasal sinuses are intact. Impression: Subtle, wedge-shaped, hypodense lesion in the left posterior parietal lobe. Suggest follow up contrast enhanced CT scan to rule out acute infarction. Cerebral atrophy. Atherosclerotic basilar and internal carotid arteries. Calcifications in the right orbit.

RADIOLOGICAL REPORT DATE: February 02, 2011 PROCEDURE: PA ADULT There is suspicious soft tissue density in the midthoracis region cavity slight (right) deviation of the trachlear air column to the right. Heart is enlarged. Aorta is tortuous and calcified Hemidiaphragm and Costrophrenic sinuses are intact. Impression: Suspiscious mass suggest right lateral view. Cardiomegally Atheromatous Aorta

DATE: February 07, 2011 There is fullness of the anterior and posterior mediastinal area seen in lateral view. Impression: The right hemidiaphragm is elevated. The aorta is tortuous Other findings remain unchanged Suggest clinical correlation and CT- scan Correlation for further evaluation

VII.

CONCEPTUAL AND THEORETICAL FRAMEWORK Conservation Theory Myra Levine's

It is focused in promoting adaptation and maintaining wholeness using the principles of conservation. The model guides the nurse to focus on the influences and responses at the organismic level. The nurse accomplishes the goals of the model through the conservation of energy, structure, and personal and social integrity METAPARADIGM IN NURSING Person a holistic being who constantly strives to preserve wholeness and integrity and one who is sentient, thinking, future-oriented, and past-aware. Environment Completes the wholeness of the individual. The individual has both an internal and external environment. Internal Environment combines the physiological and pathophysiological aspects of the individual and is constantly challenged by the external environment. External Environment Perceptual environment - is that portion of the external environment which individuals respond to with their sense organs and includes light, sound, touch, temperature, chemical change that is smelled or tasted, and position sense and balance. Operational environment - is that portion of the external environment which interacts with living tissue even though the individual does not possess sensory organs that can record the presence of these factors and includes all forms of radiation, microorganisms, and pollutants. Conceptual environment - is that portion of the external environment that consists of language, ideas, symbols, and concepts and inventions and encompasses the exchange of language, the ability to think and experience emotion, value systems, religious beliefs, ethnic and cultural traditions, and individual psychological patterns that come from life experiences. Health implied to mean unity and integrity and is a wholeness and successful adaptation Nursing The nurse enters into a partnership of human experience where sharing moments in timesome trivial, some dramaticleaves its mark forever on each patient

MAIN CONCEPTS: ADAPTATION Is the process of change, and conservation is the outcome of adaptation. Adaptation is the process whereby the patient maintains integrity within the realities of the environment CONSERVATION Product of adaptation. Conservation describes the way complex systems are able to continue to function even when severely challenged. WHOLENESS/INTEGRITY the unceasing interaction of the individual organism with its environment does represent an open and fluid system, and a condition of health, wholeness, exists when the interaction or constant adaptations to the environment, permit easethe assurance of integrityin all the dimensions of life. KEY CONCEPTS (Conservational principle) Conservation of energy Refers to balancing energy input and output to avoid excessive fatigue. It includes adequate rest, nutrition and exercise. Conservation of structural integrity Refers to maintaining or restoring the structure of body preventing physical breakdown and promoting healing. Conservation of personal integrity Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and self determination. Conservation of social integrity An individual is recognized as some one who resides with in a family, a community, a religious group, an ethnic group, a political system and a nation.

Self-Care Deficit Theory Dorothea Orem Dorothea E. Orem identified three theories of self-care, self-care deficit, and nursing systems. The ability of the person to meet daily requirements is known as selfcare, and carrying out those activities is self-care agency. Parents serve as dependent care agents for their children. The ability to provide self-care is influenced by basic conditioning factors including but not limited to age, gender, and developmental state. Self-care needs are partially determined by the self-care requisites, which are categorized as universal (air, water, food, elimination, activity and rest, solitude and social interaction, hazard prevention, function with social groups), developmental, and health deviation (needs arising from injury or illness and from efforts to treat the injury or illness). The total demands created by the self care requisites are identified as therapeutic self-care demand. When the therapeutic self-care demand exceeds self-care agency, a self-care deficit exists and nursing is needed. Based on the needs, the nurse designs nursing systems that are wholly compensatory (the nurse provides all needed care), partly compensatory (the nurse and the patient provide care together), or supportiveeducative (the nurse provides needed support and education for the patient to exercise self-care). CONCEPTS Nursing client A human being who has "health related /health derived limitations that render him incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care. A human being is the focus of nursing only when a self care requisites exceeds self care capabilities Nursing problem deficits in universal, developmental, and health derived or health related conditions Nursing process a system to determine (1)why a person is under care (2)a plan for care ,(3)the implementation of care Nursing therapeutics deliberate, systematic and purposeful action

OREMS GENERAL THEORY OF NURSING A. Theory of Self Care Self care practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being Self care agency is a human ability which is "the ability for engaging in self care" conditioned by age developmental state, life experience sociocultural orientation health and available resources Therapeutic self care demand "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions" Self-care requisites Action directed towards provision of self-care. 3 categories of self care requisites are Universal Universal self-care requisites Developmental self-care requisites B. Theory of self-care deficit Specifies when nursing is needed Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited in the provision of continuous effective selfcare. Orem identifies 5 methods of helping: 1. Acting for and doing for others 2. Guiding others 3. Supporting another 4. Providing an environment promoting personal development in relation to meet future demands 5. Teaching another C. Theory of Nursing Systems Describes how the patients self care needs will be met by the nurse , the patient, or both Identifies 3 classifications of nursing system to meet the self care requisites of the patient:o Wholly compensatory system o Partly compensatory system o Supportive educative system

VIII.

ANATOMY AND PHYSIOLOGY

The supply of freshly oxygenated blood from the heart to the brain is delivered via the carotid and basilar arteries. Carotid Arteries The carotid arteries run up both sides of the neck, and supply oxygen to the "carotid territory" of the brain. The carotid territory includes the frontal and temporal lobes. Strokes in the carotid territory, the "front" of the brain, are referred to as anterior strokes. Anterior strokes produce the most common stroke symptoms. Anterior strokes can be caused by blood clots or narrowing in the carotid arteries as well as in smaller arteries within the brain. Speech difficulties, vision problems, tingling, and paralysis may result from an anterior stroke. Basilar Arteries The basilar arteries are part of the vertebrobasilar circulation system, located at the base of the skull. The two vertebral arteries connect to form a single basilar artery that provides the "vertebrobasilar territory" of the brain with oxygen. This territory includes the brain stem, cerebellum, and occipital lobes. A stoke in this region of the brain is referred to as a posterior stroke (meaning the stroke affects the back of the brain). Posterior strokes cause some of the less

common stroke. Strokes in the basilar territory can sometimes affect both sides of the body. Posterior strokes may also cause headaches, visual disturbances, speech problems, nausea, difficulty swallowing, and weakness in the legs or arms. Circle of Willis The Circle of Willis (also called Willis' Circle, cerebral arterial circle, arterial Circle of Willis, and Willis Polygon) is a circle of arteries that supply blood to the brain.

The Circle of Willis comprises the following arteries: Anterior cerebral artery (left and right) Anterior communicating artery Internal carotid artery (left and right) Posterior cerebral artery (left and right) Posterior communicating artery (left and right)

The basilar artery and middle cerebral arteries, though they supply the brain, are not considered part of the circle 1. The anterior cerebral arteries (ACA) are a pair of arteries on the brain that supply oxygen to most medial portions of frontal lobes and superior medial parietal lobes. The 2 anterior cerebral arteries arise from the internal carotid artery and are part of the Circle of Willis.The left and right anterior cerebral arteries are connected by the anterior communicating artery. The anterior communicating artery is a blood vessel of the brain that connects the left and right anterior cerebral arteries. The internal carotid arteries are major arteries of the head and neck that supply blood to the brain The posterior cerebral artery (PCA) is one of a pair of blood vessels that supplies oxygenated blood to the posterior aspect of the brain (occipital lobe) in human anatomy The posterior communicating artery is one of a pair of right-sided and left-sided blood vessels in the circle of Willis

2. 3. 4.

5.

IX.

PATHOPHYSIOLOGY CEREBROVASCULAR DISEASE (HEMORRHAGIC STROKE)

Predisposing Factors: Age Heredity Sex Precipitating Factors: Hypertension Cigarette Smoking Undesirable cholesterol Poor diet levels of

Atherosclerosis

Formation of Plaque deposits Thrombosis Occlusion by major vessel Hypertension

Lysed or moved thrombus from the vessel

Vascular wall becomes weakened and fragile Sx:, headache, unconsciousness, nausea/vomiting, visual disturbances

Leaking of blood from the fragile vessel wall

Cerebral Hemorrhage

Mass of blood forms and grows

Blood seeps into the ventricles Obstruction of CSF passageway Accumulation of CSF in the ventricles Ventricles dilate behind the point of obstruction Increased ICP

Formation of small and large clots

Vasospasm of tissue and arteries

CEREBRAL HYPOPERFUSION Sx: dizziness, confusion, headache Impaired distribution of oxygen and glucose Tissue hypoxia and cellular starvation Lodges unto other cerebral arteries Cerebral Ischemia

Initiation of ischemic cascade

Anaerobic metabolism by mitochondria Production of oxygen free radicals and other reactive oxygen species

Generates large amounts of lactic acid Metabolic Acidosis

Failure production of adenosine triphosphatase Failure of energy dependent process (ion pumping)

Release of excitatory neurotransmitter glutamate Influx of calcium

Damage to the blood vessel endothelium

Activates enzymes that digest cell proteins, lipids and nuclear material

Failure of mitochondria Further energy depletion

Transient Ischemic Attack

Brain sustains an irreversible cerebral damage Release of metalloprotrease (zinc and calcium-dependent enzymes) Break down of collagen, hyaluronic acid and other elements of connective tissue Vascular Congestion Structural integrity loss of brain tissue and blood vessels Breakdown of the protective Blood Brain Barrier Compression of tissue

Cerebral edema

Sx: hemiplegia, unilateral neglect, altered consciousness dysgraphia (inablity to write), aphasia (inability to speech),

Middle Cerebral Artery Lateral hemisphere, frontal, parietal and temporal lobes, basal ganglia

Increased intracranial pressure

Impaired perfusion and function

XII. DISCHARGE PLAN MEDICATION Instruct pt to take prescribed medication and dosage religiously to maintain health improvement. a. b. c. d. e. f. g. h. Zynapse 1g 1 tab 2 x a day Neurobion 1 tab once a day Pantoloc 49mg 1 tab once a day Lactulose 30cc at bedtime Plarexan 75mg/tab 1tab once a day Combizar 50/12.5 1 tab A.M Amlodipine 40mg/tab 1 tab P.M. Levox 750mg/tab 1 tab once a day in one week until February 15, 2011 EXERCISE Instruct and encourage client to balance activities with adequate rest periods and educate client on proper body mechanics to prevent muscle strain and enable client to relax. Instruct the significant others on how to perform active range-of-motion. Also advice to consult to Physical Therapist three times a week. DIET A low salt low fat diet is recommended for patient. And NGT was retained and osteorized feeding was adviced.

HEALTH TEACHING Educated client about the different methods on how to improve health and wellness. Stress the importance of taking medications regularly and report signs to Doctor such as increase in BP. SCHEDULE OF NEXT VISIT Instruct patient to return on February 12, 2011 (Saturday) for follow up check-up. Emphasize importance of follow up check ups.

XIII. EVALUATION Stroke is a term used to describe the neurologic changes caused by an interruption in the blood supply to a part of the brain. The incidence of stroke and stroke mortalities has gradually declined in many industrialized countries in recent years as a result of increased recognition and treatment of risk factors, which may include modifiable risk factors such as hypertension Public education is focused on prevention, recognition of manifestations and early treatment of brain attack. As they say prevention is better than cure. Therefore it is important for each and every one of us to avoid these modifiable risk factors and change sedentary lifestyles to healthy lifestyles. Cholesterol levels should be brought to a normal level, diabetes should be controlled and reducing heavy alcohol consumption. The best intervention is to stop smoking cigarettes. As nursing students, this study showed us the importance of early detection of diseases such as stroke since it may lead to more serious conditions if it is not properly managed or treated. Knowledge of the risk factors and preventive measures can help in reducing the incidence of stroke. Prompt recognition, which allows for early treatment of stroke is recommended to lessen residual deficits and decreased disability. Through this study, may we be able to help others to understand and know more about stroke and ways to prevent and treat its signs and symptoms. The group was able to assess one patient having a case of Cerebral vascular accident and through the study of case the group was able to identify of the causative factors that predisposes the patient in acquiring such disease condition. Furthermore the group was able to identify how was it occurred and how it would be worse if left untreated, with several condition such as this case a lot of problems has occurred that would might permanently affect the lifestyle of the patient. In this study the group was able to be familiarized to medical managements and its benefits and s side effect to patient during therapy