I.

INTRODUCTION
Definition:
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.
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
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.

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
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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 Stroke
Statistics
Stroke is the Philippines' second leading cause of death. It has a prevalence of 09%;
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ischemic stroke comprises 70% while hemorrhagic stroke comprises 30%. Age-adjusted
hypertension prevalence is 206%, diabetes 60%, dyslipidemia 720%, smoking 31%,
and obesity 49%.
Complication
A stroke can sometimes cause temporary or permanent disabilities, depending on how
long the brain lacks blood flow and which part was affected. Complications may include:

Paralysis or loss of muscle movement. You may become paralyzed on one

side of your body, or lose control of certain muscles, such as those on one side
of your face or one arm. Physical therapy may help you return to activities
hampered by paralysis, such as walking, eating and dressing.

Difficulty talking or swallowing. A stroke may cause you to have less control
over the way the muscles in your mouth and throat move, making it difficult for
you to talk clearly (dysarthria), swallow or eat (dysphagia). You also may have
difficulty with language (aphasia), including speaking or understanding speech,
reading or writing. Therapy with a speech and language pathologist may help.

Memory loss or thinking difficulties. Many people who have had strokes
experience some memory loss. Others may have difficulty thinking, making
judgments, reasoning and understanding concepts.

Emotional problems. People who have had strokes may have more difficulty
controlling their emotions, or they may develop depression.

Pain. People who have had strokes may have pain, numbness or other strange
sensations in parts of their bodies affected by stroke. For example, if a stroke
causes you to lose feeling in your left arm, you may develop an uncomfortable
tingling sensation in that arm.

People also may be sensitive to temperature changes, especially extreme cold

after a stroke. This complication is known as central stroke pain or central pain
syndrome. This condition generally develops several weeks after a stroke, and
it may improve over time. But because the pain is caused by a problem in your
brain, rather than a physical injury, there are few treatments.

Changes in behavior and self-care ability. People who have had strokes may
become more withdrawn and less social or more impulsive. They may need
help with grooming and daily chores.
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Vital Information
Name: DJ
Room Number: 258-2
Age: 63
Gender: Male
Civil Status: Married
Date of Birth: February 20, 1953
Birthplace: Iligan City
Cultural group: Iliganon
Primary Language: Cebuan/Bisaya
Religion: UCCP
Highest Educational Attainment: Elementary Level
Occupation: Farmer
Usual Health Care Provider: Physician
Reason for Seeking Health Care: Body Weakness, Slurring of Speech
Date of Confinement: February 9, 2016/ 8:40AM
Source of History: Daughter 80%, Wife 10%, Chart 10%
Attending Physician: Dr. Nestor Estrada
Impression/Final

Diagnosis/Chief

Complaints:

To

Consider

Cerebrovascular

Accident
Description of Patient: asleep in supine position, with patent IVF of PNSS @
10gtts/min, with no signs of inflammation or infiltration on IV site, with NGT on right
nare, right sided body weakness, lethargic but can follow simple commands, receiving
oxygen inhalation at 2L/min via nasal cannula, indwelling urinary catheter with dark
yellow urine output, skin warm to touch, afebrile, BP- 130/90.

Nursing History
Chief Complaints
Slurring of Speech, Right sided Body Weakness

History of Present Illness

One day prior to admission, patient had onset of headache, with pain and
numbness all over the body especially on the right side of the body, with dropping of
facial features and slurring of speech. The patient opted for admission at Kolambugan
Hospital. Hours prior to admission, patient transferred to AMC-Iligan upon request
hence the admission.

History of Past Illness

According to the patients wife, the patient is allergic to eggplant and squid. The
patient is completely immunized as claimed by the wife. He has not undergone any
major or minor surgeries. He was diagnosed to have hypertension in the year 2000 and
Diabetes Mellitus in year 2013. He takes Citicoline, Estudgeron, Mipraz, and Cardiocyl.
He does not take any medications for his DM

HEALTH PERCEPTION PATTERN

BEFORE HOSPITALIZATION
The client experienced weakness on the right side of his body when he does some
household task like gardening. He manages it by having a period of rest in bed. He is
still uncomfortable with his state of health because it greatly affects his daily activities.
He cannot perform the things he 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. He does not perform
testicular 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 has right sided body weakness that is progressive
NUTRITIONAL AND METABOLIC PATTERN
PRIOR TO HOSPITALIZATION
The clients typical food intake is composed of rice, meat, and fish. Occasionally
he eats vegetables and fruits. Hes fond of eating processed food like corned beef,
anything with preservatives, tocino, chicharon and fried dish (porkchop, chicken). He
used a lot fish sauce, MSG when cooking. His appetite was good and drinks 6 glasses
of water daily.

ELIMINATION PATTERN
BEFORE HOSPITALIZATION
Client usually defecates at least 1-2 times of soft and brownish stool, 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
brownish
Consistency

Formed stool

Smell

Foul odor

Frequency and amount

Once a day

Urine Characteristics
Color

Yellowish- orange

Frequency and Amount

6 times a
1000ml/day

day

at

least

DURING HOSPITALIZATION
Client has not defecated and has an indwelling urinary catheter with dark yellow color
of the urine output.

ACTIVITY-EXERCISE PATTERN
BEFORE HOSPITALIZATION
His activities are gardening and going to their land in one of the barangays of
Kauswagan.
DURING HOSPITALIZATION
The client cannot do any activities during the hospital stay, he is confined to bed
because of his present situation.
SLEEP-REST PATTERN
BEFORE HOSPITALIZATION
The client sleeps for 8-9 hours usually from 8pm-5am. He also does take naps during
afternoon. The client sleeps adequately at night.
DURING HOSPITALIZATION
The client usually sleeps the whole day.
COGNITIVE-PERCEPTUAL PATTERN
The client does not have any hearing difficulty and can remember past events. Through
demonstration he could easily learn things.
SELF PERCEPTION AND SELF CONCEPT PATTERN
The client said that his condition has not improved, he still experience right
sided body weakness and high blood pressure. According to the wife the patient lose
some weight. Financial problems and health condition usually makes him worried.
When this things are encountered the client diverts his attention through talking to a
family member and praying.
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
There is no sexual activity. 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 his
socialization with other people. When things are not so well, he looks for his wife to be
the most helpful person in talking things over. When big problems are encountered, he
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 member of the United Church of Christ in the Philippines (UCCP) usually
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go to the church to attend religious activities.

Physical Examination (IPPA-Cephalocaudal Approach)
Physical Examination:

General : conscious, coherent

Skin: (-) pallor, (-) cyanosis

HEAD - HEENT: (-) colds

Chest/Lung: CBS

Musculoskeletal: (+) weakness

ADMITTING IMPRESSION: To consider Cerebrovascular Accident

Review of systems:

General: No at loss

Skin: (-) rash

HEENT: (-) colds

Musculoskeletal: (+) weakness, (-) edema

Respiratory: (-) cough

Cardiovascular: (-) chest pain

GI: (-) LBM

SKULL AND FACE

normocephalic shape skull with absence of nodules or masses upon

palpation

symmetrical facial features and facial movements

HAIR AND SCALP

hair is short, black and kinkyt upon inspection
evenly distributed with no lice and dandruff noted
SKIN AND NAILS

warm and moist skin with absence of edema and nodules

fair skin complexion

no presence of lesions

has short fingernails and toenails

no presence of pallor

EYES AND VISION

dark eyebrows are evenly distributed and symmetrically aligned with equal
movements

black pupil

eyelashes are also equally distributed and curled slightly outward and
upward

eyelids close symmetrically with skin intact and no discharge or

discoloration

bulbar conjunctiva is transparent and sclera appears white

without pale palpebral conjunctiva

lacrimal ducts have no edema or tearing upon palpation

cornea is transparent, shiny and smooth with visible details of iris

pupils are equally round and reactive to light accommodation

no discharges noted upon inspection

EARS AND HEARING

no tenderness behind the ears

auricles are same as the color of facial skin

aligned with outer canthus of eyes

not tender and recoil after being folded

left and right ear can hear clearly a normal voice tones

NOSE AND SINUSES

symmetrical and straight

no discharges or flaring

has uniform color and not tender

nasal septum is intact and in midline

facial sinuses are not tender

no lesions

MOUTH AND OROPHARYNX

dry and pale lips

with dental caries

tongue is at the center and pinkish in color with no lesions, no tenderness

noted and moves freely
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NECK
muscles equal in size
head centered
can move his head smoothly and with no discomfort
lymph nodes are not palpable
trachea is in the midline of the neck
thyroid gland is not visible upon inspection and ascends during
swallowing upon palpation
carotid artery and jugular veins are not distended or visible
THORAX AND LUNGS
chest symmetric volume
no tenderness noted
no masses noted
full and symmetric chest expansion
breathing is rhythmic, quiet and effortless

no adventitious breath sounds upon auscultation

spine is vertically aligned

HEART
normal heart rate
regular in rhythm
peripheral pulses are symmetrical with that of the apical pulse
ABDOMEN
uniform in color, flat, soft
non-tender and no masses
UPPER EXTREMITIES and LOWER EXTREMITIES
muscles are equal in size
no contractures
no tremors
no bone deformities
no tenderness palpated
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can sense sharp and blunt objects

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