NURSING HEALTH HISTORY

A Case Study of Cerebrovascular Accident

I. INTRODUCTION

BRIEF DESCRIPTION OF THE DISEASE

Definition:

It is characterized by a relatively abrupt onset of persisting neurological symptoms due to the destruction of brain tissue (infarction) cause by ischemia (thrombus or embolism) or hemorrhage resulting from disorders in blood vessels that supply the brain. Also called stroke

Stroke any sudden onset focal neurological deficit

Causes:

Intracerebral hemmorhage (rupture of a blood vessel in the pia mater or brain

Emboli (blood clots)

Atherosclerosis (formation of plaque) of the cerebral arteries.

Risk Factor:

1. Hypertension leading risk factor for coronary heart disease and stroke

treatable and can be controlled.

2. Modifiable by change in lifestyle

a. smoking

b. elevated serum cholesterol

c. obesity

d. heart disease

3. Modifiable by Medical mean

a. Transient Ischemic Attack

b. Asymptomatic carotid bruit

c. Diabetes Mellitus

d. Increased blood viscosity

e. HPN

4. Non modifiable risk factors

a. age

b. sex

c. race

d. previous stroke

Types of Stroke by Etilogy:

1. Hemorrhage stroke (intracranial hemorrhage)

5% of all strokes

two division

a. Intracerebral (10%) due to rupture of weakened vessels within brain parenchyma as result of Hypertension, arteriovenous malformation or tumor

b. Subarachnoid (5%) result from aneurismal rupture of a cerebral artery with blood loss into space surrounding the brain; evolve over 1 2 hours.

2. Ischemic Strokes (remaining 85%)

Large (40%) or small (20%) vessel thrombosis

-most commonly occur in presence of atherosclerotic cerebrovascular disease

-vascular changes or lipohyalinosis found in small deep penetrating arteries as associated with chronic hypertension can lead to small vessel thrombosis.

-rapid or prolonged interval of onset and may lead last many hours

Cerebral embolism (20%)

-usually a cardiac origin

-frequently result of chronic ischemic cardiovascular disease with secondary ventricular wall hypokinessis or artial arrhythmia both conditions increase risk of intracardiac thrombus formation

-quick onset and fully develop in a matter of minutes

Temporal Classification of Stroke

1. Transient ischemic attack (TIA)

neurologic symptoms develop and disappear over several minutes and completely resolve in 24 hours

most frequently associated with atherosclerotic carotid artery disease

2. Reversible Ischemic Neurologic Deficit

etiology unknown

likely the result from small infarctions (Lacunes) of the deep subcortical gray and white matter resulting in only temporary impairment

3. Stroke in Evolution

describe an unstable ischemic event characterized by the progressive development of more severe neurologic impairment

often associated with active occlusive thrombosis of a major cerebral artery.

Once stable called Complete StrokeOBJECTIVES:

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

Specific Objective:

1. To thoroughly assess the clinical manifestations of patient with CVA based on the patients history.

2. To formulate comprehensive nursing diagnosis for a client with CVA.

3. To formulate a plan of care for patients with CVA.

4. To formulate appropriate nursing interventions that can be applied for a patient with CVA.

5. To evaluate the plan of care for a patient with CVA.

NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA

Name: Mrs. Alen SantosAddress: Binalonan PangasinanAge: 52 yrs old

Sex: F

Race: Filipino

Marital Status: Married

Occupation: Tricycle DriverReligious Orientation: Roman Catholic

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

PHYSICAL ASSESSMENT

PSYCHOSOCIALPATHOPHYSIOLOGICAL BASIS

Significant othersThe patient is visited by her daughters and nieces. A very supportive family who shows comfort and care that can relieve stress that is felt by the patient

Coping MechanismInteracting with SO and Laughing trip.Being happy during treatment can contribute to patients fast recovery and interaction with in the family can be a diversion activity thus reducing pain and stress.

ReligionRoman CatholicIt is important to know, for there might be beliefs of a certain religion that has a conflict with a health intervention.

Primary LanguageIbanag/ Ilocano/ TagalogLanguage can be a barrier for an effective nursing intervention thus it is important for a nurse to know what language to use to have an effective communication.

Financial Source of Health CarePatients older sister working in Dubai and patients first cousin working in London.

OccupationBakery Manager

General appearanceLOC: Conscious

GCS:

Eyes 3

Verbal 2

Motor 4 .TOTAL 9

Weak in appearanceBrain damage not that severe.

Due to decreased O2 supply and perfusion in the brain.

Due to illness.

OrientationThe patient still knows where she is, when she was admitted and who are the SO present.An abnormal orientation can be a symptom of brain damage caused by CVA

MemoryPatient still has a good memory thus she recalls diet prescribed her physician and thus still remembers a lot things.Damaged cause by the infarct is not yet that severe to affect the memory of the patient.

SpeechSlurred speechDysarthria resulting from lacunar infarcts, right and left basal ganglia

Non-verbal behaviorSilencePatient expresses his feeling through not speaking especially when she is feeling bad.

ELIMINATION

StoolFrequency: Once a day

Pattern: Every morning

Consistency: Normal Stool

Amount: Approximately 9-10 inches in length, 1.5 in diameter

Color: Light Brown

Odor: Normally foul stool odor

Abdomen: contour palpationRounded, (-) palpable mass

UrineQuantity: 500cc to 1300cc per shift

Pattern: On IFC

Color: Lt. Yellow

Transparency: Sl. Turbid

Spc. Gravity: 1.015Due to oral and IV fluid intake.

Patient is on IFC to decrease BP.

Due to the general liquid diet of the patient.

Due to the general liquid diet of the patient.

Still within normal range.

REST AND ACTIVITY

Current activity levelLie and sit on bed Patient moment varies due to body weakness

Sleep8-9 hours a day during the confinement period

Pain/relief measures

Patient tries to position himself on a comfortable position.

Patient also verbalized that upon having a headache she takes Biogesic.Patient usually positions himself on his back and sometimes lie left laterally or right laterally, depending on patients choice of comfort.

Patient assumes analgesics for pain relief measure in addressing headache.

Sudden headache is one of the s/sx of CVA.

SAFETY

Allergic ReactionSea foods

MedicationsGentamicin 160 mg IV OD

Cefuroxime 750 mg IV q8h

Clonidine 1 tab SL now

Imidapril 1 tab OD/ NGT

Bactoban ointment to wound TIDAntibiotics were administered so as to stop, or if not, lessen infection which caused the disease.

CV agent drugs were ordered to lower the blood pressure of the patient.

Antibacterial ointment was ordered to prevent infection of the wound.

Eye/vision

Glasses:

Pupils: With a 120 reading glass

Right pupil is dilated non-reactive to light. Left Pupil constricted with minimal reaction to light.

Due to an infarct in the brain, vision and normal eye function can be affected.

Hearing/hearing aidPatient has normal hearing

Skin integrity

Lesion scars

Intact Skin

With scars on left handDue to an accident caused by bakery machineries.

Mucus membraneMoist and intact

TemperatureTemperature, via axillary, of the patient varies from 36.0C to 37.4C

OXYGEN

Activity ToleranceCan move minimallyPatient has general weakness

Airway clearance

Nose

MouthWith no secretions

Clear

Respiration rate

Depth

Rhythm

28 cycle per minute

Normal

Regular

Color

Skin

Nails

LipsPale

Pinkish

Somewhat dry

Patient has a low hemoglobin count.

Capillary refill

1-2 secondsNormal Oxygenation of tissue cells

PulsesWithin normal range

Blood pressure140-210/70-110 mmHgPatient is having an elevated BP due to illness.

EdemaNone

Homans SignNegative

NUTRITION

Hospital Diet/Restrictions

OR feeding of 1600 calories in 4 equally divided feeding

IVFs (according to chart)

Site PNSS 1L x 20-21 gtt/min

D5NSS 1L x 20-21 gtt/min

D5W L x 20 gtt/min

Left posterior forearm

Tissue turgor

Good skin turgor

Ability to:

Chew

SwallowAble

Able

Feed selfWith SOs assistanceDue to decreased hand movement accuracy.

Anatomy And PhysiologyThe Brain

BRAIN

Made up of 1000 billion neurons and is one of the largest organs of the body, weighing about 1300 kg (3 lbs).

It is a mushroom shaped

4 Principal Parts

1. Brain Stem

Stalk of the mushroom

Consist of medulla oblongata, pons and midbrain

2. Diencephalon

Consisting primarily of the thalamus and hypothalamus

3. Cerebrum

Spreads over the diencephalons

Constitute about seven-eights of the total weight of the brain and occupies most of the cranium.

4. Cerebellum

Inferior to the cerebrum and posterior to the brain stem

Protection and Coverings

The brain is protected by the cranial bones. Like the spinal cord. The brain is also protected by meninges. The cranial meninges surround the brain are continues with the spinal meaninges and have the same basic structure and bear the same names as the spinal meninges.

1. Dura meter pachymenix, tough fibrous tissue

- outermost covering

2. Arachnoid - together with the pia meter is called Leptomeninges

- middle, delicate thin cob-web like membrane

3. Pia meter - innermost

- soft thin membrane which closely lines brain and spinal cord extending into all fissures and sulci.

- extends around blood vessels throughout the brain.

Main Sulci and Fissures of Cerebral Cortex1. Lateral or Sylvian Fissure

Divided the temporal lobe from the frontal and parietal lobe

Buried under the posterior part of the SYLVIAN FISSURE is the TRANSVERSE TEMPORAL gyri which contains the AUDITORY RECEPTIVE AREA.

2. Rolandic or Central Sulcus

Separates the frontal lobe from the parietal lobe

It separates the precentral gyrus from the Postcentral gyrus, thus separating the motor from the somasthetic area.

3. Longitudinal Cerebral Fssure

Divides the cerebral hemispheres into right and left halves.

4. Parietooccipital Fissure

Separates the parietal lobe from the occipital lobe.

5. Calcarine Sulcus

This sulcus is surrounded by the visual receptive area.

Lobes of Cerebral Cortex and Brodmanns Classification

The function of the cerebral cortex has been mapped out into areas by Broadmann. These two major types of cortical areas are:

1. Primary Cortical Area regions directly related to a specific function

2. Secondary Cortical Area/ Association Area these lie adjacent to the primary area and are concerned with a higher level of organization and integration.

The Major Primary and Association Areas1. Frontal Lobe

Area 4

- primary motor area

Area 6

- premotor area

Area 8

- frontal eye movement and papillary change area

Area 44

- motor speech (Brocas Area)

2. Parietal Lobe

Area 3, 1, 2

- primary sensory areas

Area 5, 7

- sensory association areas

Area 39 40

- Wernickes area

Area 5, 7, 39 40- Gnostic area

Area 43

- primary gustatory area

3. Occipital Lobe

Area 17

- primary visual cortex

Area 18 29

- visual association areas

4. Temporal Lobe

Area 41

- primary auditory cortex

Area 42 & 22

- auditory association areas

AREA 4: PRIMARY MOTOR AREA

Location : precental gyrus and paracentral lobule

Function : contralateral voluntary motor activity

Clinical findings when damaged:

Irritative lesions will present with convulsive seizures

Gross lesions will result in flaccid paralysis and areflexia

AREA 6: PREMOTOR AREA

Location: Superior Frontal Gyrus (lateral aspect)

Function: Sensorially guided movements this refers to voluntary motor activity dependent on sensory, inputs; these movements are activated in response to visual, auditory and somatosensory stimuli.

SUPPLEMENTARY MOTOR AREA

Location: Medial aspect of Area 6

Function: Programming and planning of motor activities and perhaps their imitation.

Has presentation for both right and left sides as well as proximally and distally.

AREA 8: FRONTAL EYE FIELD AREA

Location: Frontal lobe

Function: Center of voluntary movements of the eye INDEPENDENT of visual stimuli such as the conjugate eye movements.

All three areas with motor function (4, 6 & 8) receive inputs from the thalamus, cerebellum, other cortical regions and other peripheral receptors.

AREA 17: PRIMARY VISUAL AREA

Location: OCCIPITAL LOBE specifically along the lips of the calcarine sulcus; this is called the visual or striate area.

Function: vision

Clinical findings when damanged:

an irritative lesion will present with visual hallucinations

a destructive lesion will cause contralateral homonymous defects of visual fields and visual disorganization.

Area 18 & 19 secondary visual areas

AREA 41: PRIMARY AUDITORY AREA

Location : TEMPORAL LOBE specifically at the transverse gyri

Function: hearing

Clinical findings when damaged:

irritative lesion will cause buzzing and roaring sensation

unilateral destructive lesion will lead to a mild hearing loss

bilateral destructive lesion will lead to a complete hearing loss

SECONDARY AUDITORY AREA: AREA 42 & 22, HESCHIL AREA

The auditory association area is involved in the comprehension of language and lesions in this area results in auditory agnosia or the inability to recognize what he hears but patient has intact hearing).

FRONTAL LOBE: additional notes

lie interior to the central sulcus and lateral fissure

main function: motor, cognition, speech, affective behavior

PREFRONTAL CORTEX (Area 9, 10, 11, 12) is essential for abstract thinking, foresight and judgement

A lesion in the prefrontal cortex results in behavior at changes and changes in cognitive function.

Functions of Principal Parts of the BrainPARTSFUNCTION

BRAIN STEM

Medulla 1. Relays motor & sensory impulses between other parts of the brain and the spinal cord.

2. Reticular formation (also in pons, midbrain and diencephalons) functions in consciousness and arousal)

3. Vital reflex centers regulate heartbeat, breathing (together with pons) and blood vessel diameter.

4. Nonvital reflex centers coordinate swallowing, coughing, sneezing and hiccupping.

5. Contains nuclei of origin for CN 8, 9, 10, 11 and 12.

6. Vestibular nuclear complex helps maintain equilibrium.

Pons1. Relay impulses with in the brain and between parts of the brain and spinal cord.

2. Contains nuclei of origin of CN 5, 6, 7 & 8

3. Pneumotoxic area and apneustic area, together with the medulla, help control breathing.

Midbrain 1. Relay motor impulses from the cerebral cortex to the pons and spinal cord and relays sensory impulses from the spinal cord to the thalamus.

2. Superior colliculi coordinates movements of the eyeballs in response to visual and other stimuli and the inferior colliculi coordinate movements of the head and trunk in response to auditory stimuli.

3. Contains nuclei of origin for cranial nerves III & IV.

DIENCEPHALON

Thalamus 1. Several nuclei serve as relay stations for all sensory impulses, except small, to the cerebral cortex.

2. Relays motor impulses from the cerebral cortex to the spinal cord.

3. Interprets pain, temperature, light touch, and pressure sensations.

4. Anterior nucleus functions in emotions and sensory.

Hypothalamus 1. Controls and integrates the autonomic nervous system.

2. Receives impulses from viscera

3. Regulates and controls the pituitary gland

4. Center for mind-over-body phenomena

5. Secrets regulating hormones

6. Functions in rage and aggression

7. Controls normal body temperature, food intake and thirst

8. Helps maintain the walking state and sleep

9. Functions as a self-sustained oscillator that drives many biological rhythms.

Cerebrum1. Sensory areas interprets sensory impulses, motor areas function in emotional and intellectual processes.

2. Basal ganglia control gross muscle movements and regulate muscle tone.

3. Limbic system functions in emotional aspects of behavior related to survival.

CEREBELLUM1. Controls subconscious skeletal muscle contractions required for coordination, posture and balance.

2. Assume a role in emotional development, modulating sensations of anger and pleasure.

.

Figure 2

Prominent structures of the brain stem.

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)

Vascular Anatomy

Blood

Transport oxygen, nutrients and other substances for brain functioning

Carries away metabolites

Approximately 18% of total blood volume in brain.

Brain uses 20% of oxygen absorbed in the lungs

Two 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 venous sinuses, meningeal veins (dura) and diploic veins.

CEREBRAL ARTERIES

1. MIDDLE CEREBRAL ARTERY (MCA)

From internal carotid artery

Blood supply to deep structures

Enters lateral fissure sends cortical branches to lateral aspect of FRONTAL, TEMPORAL, PARIETAL, & OCCIPITAL LOBES.

Basal MCA sends small penetrating lenticulo striate arteries to supply internal capsule and adjacent structures.

2. ANTERIOR CEREBRAL ARTERY (ACA)

Also branch of the internal carotid artery

Internal carotid artery to longitudinal fissure to genes of corpus callosum - sends branches to medial frontal and parietal lobes and adjacent cortex, extending posteriorly.

3. POSTERIOR CEREBRAL ARTERY (PCA)

Basilar artery sends branch to medial and inferior surface of the temporal lobe and medial occipital lobe.

Blood supply to choroids plexuses of III & IV ventricles

With calcarine artery and perforating branches to posterior thalamus and subthalamus.

PATHOPHYSIOLOGY

VII. PATHOPHYSIOLOGY

ETIOLOGY

Subacute Infarct, righ basal ganglia and right perventricular white matter region

Lacunar Infarct, left basal ganglia

Sclerotic Mastiod, rightRISK FACTOR

Age

Hypertension

Diet (LDL)

DIC

Deposition of atherosclerotic

Plaque in intima of arteries

Elastic lamina become thin and frayed

Platelet adhere to rough surface

Release of adenosine diphosphate enzyme

Thrombus form

Enlargement of

thrombus

Occlusion of affected

blood vessels Narrowed lumenBreak off

Emboli

Vertebral arteries Vertebrobasilar arteries Internalcarotid arteries

Dysphagia

Numbness Weakness Vertigo

Ataxia HemiparesisParalysis

Lower facial Sensory loss

Dysarthria

Gait problem Headache

Syncope weakness

Numbness

Labaoratory Result

URINALYSIS

Date: August 10, 20015COLORLt. YellowPROTEIN

TRANSPARENCYSl. TurbidSUGAR

PH/REACTION6.5 (4.5-8.0)ACETONE

SPECIFIC GRAVITY1.015 (1.005-1.030)BILE PIGMENTS

CAST/LFPCRYSTALS

Hayline CastAmorp. Urate/PhospatesFew

CELLS/HPFEPITHELIAL CELLS

WBC/Pus Cell3-6 (0-4)SquamousRare

RBC/Red Blood Cell>50 (