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INTRODUCTION Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke. Symptoms of a stroke depend on the area of the brain affected. The most common symptom is weakness or paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm. There can be speech problems and weak face muscles, causing drooling. Numbness or tingling is very common. A stroke involving the base of the brain can affect balance, vision, swallowing, breathing and even unconsciousness. A stroke is a medical emergency. Anyone suspected of having a stroke should be taken immediately to a medical facility for diagnosis and treatment. The causes of stroke: An artery to the brain may be blocked by a clot (thrombosis) which typically occurs in a blood vessel that has previously been narrowed due to atherosclerosis ("hardening of the artery"). When a blood clot or a piece of an atherosclerotic plaque (a cholesterol and calcium deposit on the wall of the artery) breaks loose, it can travel through the circulation and lodge in an artery of the brain, plugging it up and stopping the flow of blood; this is referred to as an embolic stroke. A blood clot can form in a chamber of the heart when the heart beats irregularly, as in atrial fibrillation; such clots usually stay attached to the inner lining of the heart but they may break off, travel through the blood stream, form a plug (embolus) in a brain artery and cause a stroke. A cerebral hemorrhage (bleeding in the brain), as from an aneurysm (a widening and weakening) of a blood vessel in the brain, also causes stroke. The diagnosis of stroke involves a medical history and a physical examination. Tests are done to search for treatable causes of a stroke and help prevent further brain damage. A CAT scan (a special X-ray study) of the brain is often done to show bleeding into the brain; this is treated differently than a stroke caused by lack of blood supply. A CAT scan also can rule out some other conditions that may mimic a stroke. A soundwave of the heart (echocardiogram) may be done to look for a source of blood clots in the heart. Narrowing of the carotid artery (the main artery that supplies blood to each side of the brain) in the neck can be seen with a soundwave test called a carotid ultrasound. Blood tests are done to look for signs of inflammation which can suggest inflamed arteries. Certain blood proteins are tested that can increase the chance of stroke by thickening the blood. Stroke look-alikes: Just because a person has slurred speech or weakness on one side of the body does not necessarily mean that person has had a stroke. There are many other nervous system disorders that can mimic a stroke including a brain tumor, a subdural hematoma (a collection of blood between the brain and the skull) or a brain abscess (a pool of pus in the brain caused by bacteria or a fungus). Virus infection of the brain (viral

encephalitis) can cause symptoms similar to those of a stroke, as can an overdose of certain medications. Dehydration or an imbalance of sodium, calcium, or glucose can cause neurologic abnormalities similar to a stroke. Treatment of a stroke: Early use of anticoagulants to minimize blood clotting has value in some patients. Treatment of blood pressure that is too high or too low may be necessary. (Lowering elevated blood pressure into the normal range is no longer recommended during the first few days following a stroke since this may further reduce blood flow through narrowed arteries and make the stroke worse.) The blood sugar glucose in diabetics is often quite high after a stroke; controlling the glucose level may minimize the size of a stroke. Drugs that can dissolve blood clots may be useful in stroke treatment. Oxygen is given as needed. New medications that can help oxygen-starved brain cells survive while circulation is reestablished are being developed. Rehabilitation: When a patient is no longer acutely ill after a stroke, the aim turns to maximizing the patient's functional abilities. This can be done in an inpatient rehabilitation hospital or in a special area of a general hospital and in a nursing facility. The rehabilitation process can involve speech therapy to relearn talking and swallowing, occupational therapy for regaining dexterity of the arms and hands, physical therapy for improving strength and walking, etc. The goal is for the patient to resume as many of their pre-stroke activities as possible.

OBJECTIVES:

General Objective: To be able to acquire knowledge on how to deal or manage a patient with Cerebrovascular Accident.

Specific Objective: 1. 2. 3. 4. 5. To thoroughly assess the clinical manifestations of patient with CVA based on the patients history. To formulate comprehensive nursing diagnosis for a client with CVA. To formulate a plan of care for patients with CVA. To formulate appropriate nursing interventions that can be applied for a patient with CVA. To evaluate the plan of care for a patient with CVA.

SIGNIFICANCE OF THE STUDY The case study regarding patient with colon tumor provides awareness and knowledge regarding the disease and its warning signs that can be used as a tool for further management of the disease and its prevention.

NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA Name: Mrs. A P Address: San Jose Paombong Bulacan Age: 52 yrs old Sex: F Race: Filipino Marital Status: Married Occupation: Housewife Religious Orientation: Roman Catholic Health Care Financing: Phil health B. CHIEF COMPLAINT Nanghina ang kaliwag bahagi ng akng katawan, as verbalizes by the patient C. HISTORY OF PRESENT ILLNESS One day prior to admission, the patient felt weak on the left side of her body, she also has high blood pressure that day, so they decided to go to the hospital for further management and treatment D. PAST HISTORY The client received 2 immunizations only (BCG and DPT) because the family is not aware of its importance. The client commonly had cough and fever. The childhood diseases that she acquired are mumps, measles, and chicken pox and sore eyes .There were no known food or medication allergy. Client has no history of accidents or injuries. She does not smoke or drink alcohol FAMILY HISTORY OF ILLNESS The clients father and mother has a history of hypertension.

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HEALTH PERCEPTION PATTERN BEFORE HOSPITALIZATION The client experienced weakness on the left side of her body when she does some household task like gardening. She manages it by having a period of rest in bed. She is still uncomfortable with her state of health because it greatly affects her daily activities. She cannot perform the things she likes and usually do. Client believed that proper diet, exercises, and adequate financial support are the things needed to maintain proper health diet and no vices are factors of having a healthy body. She does not perform self-breast examination. When signs and symptoms arise they sought medical consultation. The client also believed in albularyo and use herbal medicines such as lagundi, guava leaves, pito-pito (7 different kinds of leaves). DURING HOSPITALIZATION The client still feels left sided body weakness

G.

NUTRITIONAL AND METABOLIC PATTERN PRIOR TO HOSPITALIZATION The clients typical food intake is composed of rice, meat, and fish. Occasionally she eats vegetables and fruits. Shes fond of eating processed food like corned beef, anything with preservatives, tocino, chicharon and fried dish (porkchop, chicken). She used a lot fish sauce, MSG when cooking. Her appetite was good and drinks 6 glasses of water daily. Client wound heals well and she wears complete upper and lower dentures but this doesnt affect her food intake. H. ELIMINATION PATTERN BEFORE HOSPITALIZATION Client usually defecates at least 2-3 times of soft and watery stool consisting of small amounts which is light brown color with presence of blood (fresh blood), with discomfort or difficulties and experienced excessive sweating. Client urinates 6x a day which is yellowish- orange color w/out any discomfort.

Stool Characteristics Color Consistency Smell Frequency and amount Urine Characteristics Color Smell Frequency and Amount

Light brown Formed stool Foul odor Once a day

Yellowish- orange aromatic 6 times a day at least 1000ml/day

DURING HOSPITALIZATION Client usually defecate at least 1-2x a day semi formed stool with the presence of blood which is light brown to brown. She has difficulty in defecation with excessive sweating. Client urinates 4x a day which is yellow in color w/out any discomfort. Stool Characteristics Color Light brown to brown Consistency Smell Frequency and Amount Urine Characteristics Color Smell Frequency and Amount I. ACTIVITY-EXERCISE PATTERN Semi formed Foul odor 1-2 times a day in small amounts

yellow aromatic 6 times a day at least 1000ml/day

BEFORE HOSPITALIZATION The client said that her activities at home were limited because she has experience high blood pressure. She spends her days with minimal cleaning like gardening and watching TV. She also played with her grand daughter and grandsons. She walks short distances as form of her exercise. DURING HOSPITALIZATION Client shows tiredness and limited movement. A client doesnt perform any routine exercise. In the hospital the client instructed to Perform ROM by the health care provider. 3-FEEDING 3-GROOMING 3-TOILETTING 3-GENERAL MOBILITY 4-COOKING 3-BED MOBILITY 4-BATHING 3-DRESSING 4-HOME MAINTENANCE Level 0 - Full self care Level 1 - Requires use of equipment or device Level 2 - Requires assistance or supervision from another person Level 3 - Requires assistance or supervision from another person or device Level 4 - Is dependent and does not participate J. SLEEP-REST PATTERN BEFORE HOSPITALIZATION The client sleeps for 8-9 hours usually from 8pm-5am but not continuous because of prompt abdominal pain. She doesnt take any sleep medications. She also does take naps during afternoon. The client sleeps inadequately at night. Clients usually watch TV shows and played with her grand daughter and grandsons. DURING HOSPITALIZATION The client sleeps is lessen to 6 hours due to abdominal pain and interrupted when the health care provider give medication and monitor her vital signs during the night. She takes naps in the afternoon for about 1 hour. K. COGNITIVE-PERCEPTUAL PATTERN The client does not have any hearing difficulty and cant remember past events She has a visual problem far-sightedness. Through demonstration she could easily learn things. Abdominal pain is the one which alters her comfort and she manages it with taking prescribed medications.

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SELF PERCEPTION AND SELF CONCEPT PATTERN The client said that her condition was not improve, she still experience left sided body weakness and high blood pressure. Client feels that she lose some weight. Financial problems and health condition usually makes her worried. When this things are encountered the client diverts her attention through talking to a family member and praying. M. ROLE-RELATIONSHIP PATTERN The client lives in extended family. They live peacefully even there are hardship and difficulties that arrives to their lives. By means of good conversation they can easily fixed family problems. When family experienced difficulty of caring for the client they just take it as trials given by god. They have harmonious relationships with the family and their neighbors. SEXUALITY-REPRODUCTIVE PATTERN The client is done in stage of menopausal. There is no sexual activity. According to the client, decreased sexual activity is not a problem because they were already old. They spent most of their time by taking care of each other and with that they are showing their love for one another. COPING STRESS TOLERANCE PATTERN The client was observed to be withdrawn but the behavior improved as evidenced by her socialization with other people. When things are not so well, she finds her husband to be the most helpful person in talking things over. When big problems encountered, she always prays and ask assistance with the Lord. Some of the time they failed to attain what they want and try other alternatives in solving it. VALUE-BELIEF PATTERN The client is a Roman Catholics usually go to the church to attend mass every Sundays, first Friday of the month and novena. She is very active in participating religious activities. She helps spread the word of god through catechism.

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The Brain
Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. The names of these vesicles and the major adult structures that develop from the vesicles follow (see Table 1 ):

The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia). The diencephalon generates the thalamus, hypothalamus, and pineal gland. The mesencephalon generates the midbrain portion of the brain stem. The metencephalon generates the pons portion of the brain stem and the cerebellum.

The myelencephalon generates the medulla oblongata portion of the brain stem TABLE 1 The Vesicles and Their Components Primary Vesicles Secondary Vesicles Adult Structure Important Components or Features prosencephalon (forebrain) telencephacerebrum cerebral (cerebral hemispheres) cerebral cortex (gray matter): motor areas, sensory areas, association areas prosencephalon (forebrain) telencephacerebrum cerebral (cerebral hemispheres) cerebral white matter: association fibers, commisural fibers, projection fibers prosencephalon (forebrain) telencephacerebrum cerebral (cerebral hemispheres) basal ganglia (gray matter): caudate nucleus & amygdala, putamen, globus pallidus prosencephalon diencephalon diencephalon thalamus: relays sensory information prosencephalon (forebrain) diencephalon diencephalon hypothalamus: maintains body homeostasis prosencephalon (forebrain) diencephalon diencephalon mammillary bodies: relays sensations of smells to cerebrum prosencephalon (forebrain) diencephalon diencephalon optic chiasma: crossover of optic nerves prosencephalon (forebrain) diencephalon diencephalon infundibulum: stalk of pituitary gland prosencephalon (forebrain) diencephalon diencephalon pituitary gland: source of hormones

Primary Vesicles prosencephalon (forebrain) mesencephalon (midbrain)

Secondary Vesicles Adult Structure diencephalon diencephalon mesencephalon brain stem brain stem cerebellum brain stem

Important Components or Features epithalamus: pineal gland midbrain: cerebral peduncles, sup. cerebellar peduncles, corpora quadrigemina, superior colliculi pons: middle cerebellar peduncles, pneumotaxic area, apneustic area sup. cerebellar peduncles, middle cerebellar peduncles, inferior cerebellar peduncles medulla oblongata: pyramids, cardiovascular center, respiratory center

rhombencephalon (hindbrain) metencephalon rhombencephalon (hindbrain) metencephalon rhombencephalon (hindbrain) myelencephalon

A second method for classifying brain regions is by their organization in the adult brain. The following four divisions are recognized (see Figure 1 ).

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most

visible part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions:

A gyrus (plural, gyri) is an elevated ridge among the convolutions. A sulcus (plural, sulci) is a shallow groove among the convolutions. A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain. A cross section of the cerebrum shows three distinct layers of nervous tissue:

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and

control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas.

The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres

(association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres.

Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in

the basal gangliathe caudate nuclei, the putamen, and the globus pallidusare involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here.

The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions:

The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses

are sorted and grouped here before being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also.

The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological

clock (sleep-wake cycles).

The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion,

behavior, hunger, thirst, body temperature, and the biological clock. It also produces two hormones (ADH and oxytocin) and various releasing hormones that control hormone production in the anterior pituitary gland. The following structures are either included or associated with the hypothalamus.

The mammillary bodies relay sensations of smell.

The infundibulum connects the pituitary gland to the hypothalamus. The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye cross

over to the cerebral hemisphere on the opposite side of the brain.

The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter

fiber tracts surrounding a core of gray matter. The brain stem consists of the following four regions, all of which provide connections between various parts of the brain and between the brain and the spinal cord. (Some prominent structures are illustrated in Figure 2 ).

Figure 2 Prominent structures of the brain stem.

The midbrain is the uppermost part of the brain stem. The pons is the bulging region in the middle of the brain stem. The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum.

The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain

regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one component of the reticular formation, is responsible for maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the

surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by comparing actual skeletal movements to the movement that was intended. The limbic system is a network of neurons that extends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to behaviors, experiences, and memories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and encircles the inside border of the cerebrum. The following components are included:

The hippocampus (located in the cerebral hemisphere) The denate gyrus (located in cerebral hemisphere) The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate nucleus of the basal ganglia) The mammillary bodies (in the hypothalamus) The anterior thalamic nuclei (in the thalamus) The fornix (a bundle of fiber tracts that links components of the limbic system)

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) warning sign of impending stroke 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.

Labaoratory Result Blood Chemistry

RESULT Glucose Uric acid CHL Tryglycerides Directhol LL VLDL Alanine Amino Transferase 110mg/dl (high) 5.9 mg/dl 269 mg/dl (high) 169mg/dl ( high) 63 mg/dl (high) 173 mg/dl (high) 34 115 U/L (high)

Fasting Blood Glucose Result Crea Alanine Transferase Na K 113 mg/dl 0.9mg/dl 151mg/dl 4.2mmol/L

DRUG STUDY

Name of Drug, Generic,Brand name

Generic Name: Mannitol Brand Name: Osmitrol Drug Classification: Diuretics

Dosage, Route, Frequency

Action

Indication

Contraindication

Adverse Reaction

Nursing Responsibility

75 ml, q6

Increase osmotic pressure of glomerular filtrate, inhibiting tubular reabsorbption of water and electrolytes, drug elevates plasma osmolality, increasing water flow into exracellular fluid

to reduce - contraindicated to -Seizure intraocular or patient -Edema intracranial hypersensitive to -Heart Failure pressure drugs -Urine retention -Blurred Vision -chills

-monitor vital sign -to relieve thirst give frequent mouth care -dont give electrolyte free solution with blood