INTRODUCTION:

A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in
death oI an area oI brain tissue (cerebral inIarction) and causing sudden symptoms.
O Most strokes are ischemic (usually due to blockage oI an artery), but some are
hemorrhagic (due to rupture oI an artery).
O Transient ischemic attacks resemble ischemic strokes except the symptoms
resolve within 1 hour.
O Symptoms occur suddenly and can include muscle weakness, paralysis, abnormal
or lost sensation on one side oI the body, diIIiculty speaking, conIusion, problems
with vision, dizziness, and loss oI balance and coordination.
O Diagnosis is based on symptoms, but imaging and blood tests are also done.
O Recovery aIter a stroke depends on many Iactors, such the location and amount oI
damage, the person's age, and the presence oI other disorders.
O Controlling high blood pressure, high cholesterol levels, and high blood sugar
levels and not smoking help prevent strokes.
O Treatment may include drugs to make blood less likely to clot or to break up clots
and sometimes surgery.
A stroke is called a cerebrovascular disorder because it aIIects the brain (cerebro-) and
the blood vessels (vascular).
OB1ECTIVES:
The case presentation aims to knowledge to the expectators with regard CVA.
And, that they will be able to:
a) DeIine CVA
b) Determine etiologic Iactors with its rationale
c) Determine symptomatology with its rationale
d) Determine management strategies to the patient with CVA
e) Relate on the disease process in its pathophysiology
I) Make comprehensive care and nursing interventions Ior each problem identiIied
g) IdentiIy diagnostic procedures Ior CVA
h) Picture out the Anatomy and Physiology oI organ involved in CVA

II. ASSESSMENT:

PHYSICAL ASSESSMENT:
A. BIOGRAPHIC DATA
1. NAME : ALSONADO TONIZLA
2. ADDRESS : TABOK, HINDANG LEYTE
3.AGE : 91 YEARS OLD
4. SEX : FEMALE
5. RACE : FILIPINO
6. MARITAL STATUS : MARRIED
7. OCCUPATION : NONE
8. RELIGIOUS ORIENTATION : ROMAN CATHOLIC
9. HEALTH CARE : NONE

B. CHIEF COMPLAINT OR REASON FOR VISIT
~ IN BECAUSE OF ELEVATED BP
~ HAD NO PREVIOUS STROKE ATTACKS

C. HISTORY OF PRESENT ILLNESS

~ Patient was diagnosed oI having CVA, it was her 1
st
time to have attacks and
it caused her to have leIt-sided paralysis. She is at present unable to converse due
to slurring oI speech.

D. PAST HISTORY

~ Patient`s health was diminishing due to her old age.

~ Patient had previous incidents oI hypertension

~ patient wasn`t certain on the immunizations received.

~ no allergies noted

~ accidents and injuries were related to playing during his childhood years and his
work Ior past 6 years.

~ had previous hospitalizations beIore due to her hypertension

~ maintained anti-hypertensive drugs such as Captopril















E. FAMILY HISTORY OF ILLNESS




F. GORDON`S FUNCTIONAL HEALTH PATTERN

1.HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

~ Health is decreasing because oI her old age. She is unable to converse and is
now gone to her '2
nd
childhood She presently has leIt-sided paralysis.

2. NUTRITIONAL AND METABOLIC PATTERN

~ beIore her attack, she had soIt diet and sometimes Iish but at present, she is still
Ior NGT Ieeding. She is poorly nourished upon assessment and is kept NPO due to the
risk oI aspiration. Water is not an exception Ior she gags even iI a very small amount oI
water is given.

DM
HPN
CVA

DM,
HPN

DM

DM

3. ELIMINATION PATTERN

~ DeIecates twice a day with semi - Iormed stools. Urinates 2 3 times a day. No
proIused sweating is present according to S.O.

4. ACTIVITY EXERCISE PATTERN

~ Patient no longer does exercises since her stamina is lessened and is usually on
bed due to weakness and due to the risk oI elevation oI her BP

5. SLEEP REST PATTERN

~ Sleeps 7 hours a day and is usually disturbed. OIten takes naps in the aIternoon.

6. COGNITIVE PERCEPTUAL PATTERN

~ Physical and mental status are greatly diminishing. Physical strength is
weakening and mental state is becoming like oI an inIant, is very stubborn and moody.
She no longer listens to instruction which irritates her S.O.

7. SELF PERCEPTION AND SELF CONCEPT PATTERN

~ Patient is easily agitated and is very resistive to care. Does not listen to simple
instructions.

8. ROLE RELATIONSHIP PATTERN

~ Lives with her Iamily, is currently dependent to care Irom others. Is considered
an inIant due to her present mental state.

9. SEXUALITY REPORDUCTIVE PATTERN

~sexual practices is no longer present

10. COPE STRESS TOLERANCE PATTERN

~patient just tend to rest and sleep when tired and stressed.

11. VALUE BELIEF PATTERN

~ patterned on Christian teachings





GENERAL INFORMATION
AGE : 91 years old
SEX : Iemale


VITAL SIGNS
TEMP : 36.6 C
PULSE RATE : 63 bpm
RESPI RATE : 19 cpm
BLOOD PRESSURE : 130/90 mmHg


GENERAL APPEARANCE

LEVEL OF CONSCOIUSNESS : conscious
COHERENCE : incoherent
NUTRITIONAL STATE : poorly nourished
EMOTIONAL STATE : agitated and is not talking



HEAD
CONFIGURATION : symmetric, normal
FACIAL MOVEMENTS : no Iacial movement
FONTANELS : closed
SCALP : Ioul smelling, dry, no presence oI lice

SKIN
GENERAL COLOR : Ilushed skin, slight rubor
TEXTURE : rough
TEMPERATURE : is cool with a temp oI 36.6
TURGOR : very poor turgor
MOISTURE : skin is dry


EYES
LIDS : normal, presence oI discharges
PERIORBITAL REGION : normal
CONJUCTIVA : slightly pale
SCLERA : normal, white in color
CORNEA AND LENS : normal, symmetric
PUPILS : leIt eye is less sensitive to light
PERIPHERAL VISION : intact



EARS
EXTERNAL PINNAE : slightly moist
EXTERNAL CANAL : slight cerumen
GROSS HEARING : symmetrical

NOSE
NASOLABIAL FOLD : normal
SEPTUM : midline
MUCOSA : moist
PATENCY : is patent
GROSS SMELL : not assessed
SINUSES : not inIlamed, moist, not tender

MOUTH
LIPS : dry, slightly pale MUCOSA : pale
TONGUE : midline
GUMS : dark in color SPEECH : absent


NECK
TRACHEA : midline CERVICAL LYMPH NODE : not enlarged
UVULA : moist., midline MUCOSA : moist
TONSILS : not imIlammed POSTERIOR PHARYNX : normal

CHEST AND LUNGS
BREATHING PATTERNS : regular, 19 CPM
SHAPE OF CHEST : not barrel chest, normal
LUNG EXPANSION : uniIorm rise and Iall
PERCUSSION : resonant sound
BREATH SOUNDS : slight crackles noted


BREAST AND AXILLAE
SIZE : small SHAPE : Ilat
COLOR : dark SURFACE : dry




ABDOMEN
GENERAL : normal, dry
CONFIGURATION : normal, symmetric
BOWEL SOUNDS : hyperactive
PERCUSSION : tympanitic
PALPATION : no tenderness


BACK AND EXTREMITIES

PERIPHERAL PULSES : palpable and present
NAILS AND NAIL BEDS : nails are short but dirty
ROM : ROM on leIt side is absent
MUSCLE TONE AND STRENGTH : leIt side is paralysed
SPINE : midline
EXCRETO URINARY SYSTEM
EXTERNAL GENITALIA MALE

VAGINA : no discharges, lacerations


DEVELOPMENTAL TASK
THEORY/ TASK BASIC ACTUAL
ERIKSON`S 8 STAGES
OF LIFE

INTEGRITY VS DESPAIR
(OLD AGE)
SuIIers loss oI status and
Iunction such as thru illness
She is currently paralyzed
and is dependent on others,
she has loss her Iunction
and is being cared oI.

HAVIGHURST
DEVELOPMENTAL
TASK

LATE ADULT OR OLD
AGE

~Later maturity

~Adjusting to decreasing
physical strength and
health.

~adjusting to retirement and
reduced income.

~patient no longer works
because oI her decreasing
strength and because oI the
risk oI hypertension. She is
being cared Ior and very
dependent due to her
paralysis.


BACKGROUND LITERATURE:
DEFINITION:
Cerebrovascular accident: The sudden death oI some brain cells due to lack oI oxygen
when the blood Ilow to the brain is impaired by blockage or rupture oI an artery to the
brain. A CVA is also reIerred to as a stroke.
Cerebrovascular accident (CVA) prevention: In many cases, a person may have a
transient ischemic attack (TIA), a neurological event with the symptoms oI a stroke, but
the symptoms go away within a short period oI time. This is oIten caused by the
narrowing or ulceration oI the carotid arteries (the major arteries in the neck that supply
blood to the brain). II not treated, there is a high risk oI having a major stroke in the
Iuture. II you suspect a TIA, you should seek medical attention right away. An operation
to clean out the carotid artery and restore normal blood Ilow through the artery (a carotid
endarterectomy) markedly reduces the incidence oI a subsequent stroke. In other cases,
when a person has a narrowed carotid artery, but no symptoms, the risk oI having a stroke
can be reduced with medications such as aspirin and ticlopidine (TICLID). These
medications act by partially blocking the Iunction oI blood elements, called platelets,
which assist blood clotting.
Cerebrovascular accident (CVA) is the medical term Ior what is commonly termed a
stroke. It reIers to the injury to the brain that occurs when Ilow oI blood to brain tissue is
interrupted by a clogged or ruptured artery, causing brain tissue to die because oI lack oI
nutrients and oxygen.

ETIOLOGY:
Predisposing
factors
Rationale Actual
Age


Sex(gender)



Geographic
location

Hereditary
(family history)




Prior stroke, or
The chance oI having a stroke approximately
doubles Ior each decade oI liIe aIter age 55.
While stroke is common among the elderly, a lot
oI people under 65 also have strokes.
Stroke is more common in men than in women.
In most age groups, more men than women will
have a stroke in a given year. However, more
than halI oI total stroke deaths occur in women.
At all ages, more women than men die oI
stroke. Use oI birth control pills and pregnancy
pose special stroke risks Ior women.

Strokes are more common in the southeastern
United States than in other areas. These are the
so-called "stroke belt" states.
Your stroke risk is greater iI a parent,
grandparent, sister or brother has had a stroke.
AIrican Americans have a much higher risk oI
death Irom a stroke than Caucasians do. This is
partly because blacks have higher risks oI high
blood pressure, diabetes and obesity.
The risk oI stroke Ior someone who has already











heart attack












Precipitating
factors

hypertension


hypotension







Blockages









Atrial Iibrillation








had one is many times that oI a person who has
not. Transient ischemic attacks (TIAs) are
"warning strokes" that produce stroke-like
symptoms but no lasting damage. TIAs are
strong predictors oI stroke. A person who's had
one or more TIAs is almost 10 times more likely
to have a stroke than someone oI the same age
and sex who hasn't. Recognizing and treating
TIAs can reduce your risk oI a major stroke. II
you've had a heart attack, you're at higher risk oI
having a stroke, too


Hypertension is the main cause oI stroke due to
the increased pressure it imposes on the arteries.
Low blood pressure (hypotension) may also
cause an ischemic stroke, although less
commonly. Low blood pressure results in
reduced blood Ilow to the brain and may
develop as a result oI narrowed or diseased
arteries, a heart attack, a large loss oI blood, or a
severe inIection.
Occluded arteries are a result oI narrowing due
to plaque build up. In the brain, a thrombus that
breaks loose Irom another area oI the body can
travel the vessel pathways to any area oI the
brain and lodge there causing an inIarct (tissue
death), or ischemia in that area. OI course,
ischemia is Iollowed by cell death, leading to
loss oI Iunction in that area oI the body the brain
controlled
Atrial Iibrillation is a prime example oI how a
clot can Iorm and travel to other parts oI the
body. A-Iib is characterized by the rapid
contractions oI the atria oI the heart causing
blood clots to Iorm. A-Iib is treated with
medications to slow the rate and blood thinners
to prevent clots Irom Iorming.An inIarct in the
leIt hemisphere oI the brain aIIects the right side
oI the body, and an inIarct in the right side oI



























surgery





cholesterol








Unhealthy diet and
overweight





Smoking




Excessive alcohol
drinking






diabetes
the brain aIIects the leIt side oI the body. Both
the leIt and right hemispheres communicate
with each other, and the right hemisphere will
take over Ior the leIt, should the leIt suIIer any
damage.
Some surgeries (such as endarterectomy) or
other procedures (such as angioplasty) that are
used to treat narrowed carotid arteries may
cause a blood clot to break loose, resulting in a
stroke.
The substance cholesterol is a component oI cell
membranes and transported in the bloodstream.
It's used within the body to Iorm new cell
membranes. There is good and bad cholesterol.
The bad cholesterol builds up in the blood
vessels within the brain and can cause blockage.
An unhealthy diet promotes the buildup oI bad
cholesterol.
An unhealthy diet can lead to being overweight
and high blood pressure. Again high blood
pressure makes the heart work harder to pump
blood. High blood pressure also causes the
blood vessels in your brain to harden and thin,
increasing the risk oI stroke.

Cigarettes contain high levels oI chemicals that
increase blood pressure and increase the
tendency Ior blood to clot increasing the chance
oI blockage in the blood vessels within the brain

Even though studies have proven some alcohol
may help in reducing chances oI stroke large
consumption oI alcohol has been known to raise
levels oI some Iats within the blood causing a
rise in cholesterol levels. As well consuming
large amounts oI alcohol contributes to elevated
blood pressure.

Diabetes is a disorder that changes the way the
body breaks down and converts Iood into
glucose. With diabetes the risk Ior stroke
increases because oI the amount oI glucose in
the blood harms the blood vessels. This can lead







to blockage oI the blood vessels.

How is stroke diagnosed?
A stroke is a medical emergency, and anyone suspected oI having a stroke should be
taken to a hospital immediately so that tests can be run and the correct treatment can be
provided as quickly as possible.

Physicians have several tools available to screen Ior stroke risk and diagnose an active
stroke. These include:
O Physical assessment - blood pressure tests and blood tests to see cholesterol
levels, blood sugar levels, and amino acid levels

O Ultrasound - a wand waved over the carotid arteries in the neck can provide a
picture that indicates any narrowing or clotting

O Arteriography - a catheter is inserted into the arteries to inject a dye that can be
picked up by X-rays

O Computerized tomography (CT) scan - a scanning device that creates a 3-D image
that can show aneurysms, bleeding, or abnormal vessels within the brain

O Magnetic resonance imaging (MRI) - a magnetic Iield generates a 3-D view oI the
brain to see tissue damaged by stroke

O CT and MRI with angiography - scans that are aided by a dye that is injected into
the blood vessels in order to provide clearer and more detailed images

O Echocardiography - an ultrasound that makes images oI the heart to check Ior
embolus




ANATOMY AND PHYSIOLOGY
Supplying the Brain With Blood

Blood is supplied to the brain through two pairs oI large arteries:
O Internal carotid arteries, which carry blood Irom the heart along the Iront oI the
neck
O Vertebral arteries, which carry blood Irom the heart along the back oI the neck
In the skull, the vertebral arteries unite to Iorm the basilar artery (at the back oI the head).
The internal carotid arteries and the basilar artery divide into several branches, including
the cerebral arteries. Some branches join to Iorm a circle oI arteries (circle oI Willis) that
connect the vertebral and internal carotid arteries. Other arteries branch oII Irom the
circle oI Willis like roads Irom a traIIic circle. The branches carry blood to all parts oI the
brain.
When the large arteries that supply the brain are blocked, some people have no symptoms
or have only a small stroke. But others with the same sort oI blockage have a massive
ischemic stroke. Why? Part oI the explanation is collateral arteries. Collateral arteries run
between other arteries, providing extra connections. These arteries include the circle oI
Willis and connections between the arteries that branch oII Irom the circle. Some people
are born with large collateral arteries, which can protect them Irom strokes. Then when
one artery is blocked, blood Ilow continues through a collateral artery, sometimes
preventing a stroke. Other people are born with small collateral arteries. Small collateral
arteries may be unable to pass enough blood to the aIIected area, so a stroke results.
The body can also protect itselI against strokes by growing new arteries. When blockages
develop slowly and gradually (as occurs in atherosclerosis), new arteries may grow in
time to keep the aIIected area oI the brain supplied with blood and thus prevent a stroke.
II a stroke has already occurred, growing new arteries can help prevent a second stroke
(but cannot reverse damage that has been done).

Anatomy of the Brain: Brain Divisions
The forebrain is responsible Ior a variety oI Iunctions including receiving and processing
sensory inIormation, thinking, perceiving, producing and understanding language, and
controlling motor Iunction. There are two major divisions oI Iorebrain: the diencephalon
and the telencephalon. The diencephalon contains structures such as the thalamus and
hypothalamus which are responsible Ior such Iunctions as motor control, relaying sensory
inIormation, and controlling autonomic Iunctions. The telencephalon contains the largest
part oI the brain, the cerebral cortex. Most oI the actual inIormation processing in the
brain takes place in the cerebral cortex.

The midbrain and the hindbrain together make up the brainstem. The midbrain is the
portion oI the brainstem that connects the hindbrain and the Iorebrain. This region oI the
brain is involved in auditory and visual responses as well as motor Iunction.

The hindbrain extends Irom the spinal cord and is composed oI the metencephalon and
myelencephalon. The metencephalon contains structures such as the pons and
cerebellum. These regions assists in maintaining balance and equilibrium, movement
coordination, and the conduction oI sensory inIormation. The myelencephalon is
composed oI the medulla oblongata which is responsible Ior controlling such autonomic
Iunctions as breathing, heart rate, and digestion.
O Prosencephalon - Forebrain
O Mesencephalon - Midbrain
4 Diencephalon
4 Telencephalon
O Rhombencephalon - Hindbrain
4 Metencephalon
4 Myelencephalon
Anatomy of the Brain: Structures
The brain contains various structures that have a multitude oI Iunctions. Below is a list oI
major structures oI the brain and some oI their Iunctions.

Basal Ganglia
O Involved in cognition and voluntary movement
O Diseases related to damages oI this area are Parkinson's and Huntington's
Brainstem
O Relays inIormation between the peripheral nerves and spinal cord to the upper
parts oI the brain
O Consists oI the midbrain, medulla oblongata, and the pons
Broca's Area
O Speech production
O Understanding language
Central Sulcus (Fissure oI Rolando)
O Deep grove that separates the parietal and Irontal lobes
Cerebellum
O Controls movement coordination
O Maintains balance and equilibrium
Cerebral Cortex
O Outer portion (1.5mm to 5mm) oI the cerebrum
O Receives and processes sensory inIormation
O Divided into cerebral cortex lobes
Cerebral Cortex Lobes
O Frontal Lobes -involved with decision-making, problem solving, and planning
O Occipital Lobes-involved with vision and color recognition
O Parietal Lobes - receives and processes sensory inIormation
O Temporal Lobes - involved with emotional responses, memory, and speech
Cerebrum
O Largest portion oI the brain
O Consists oI Iolded bulges called gyri that create deep Iurrows
Corpus Callosum
O Thick band oI Iibers that connects the leIt and right brain hemispheres
Cranial Nerves
O Twelve pairs oI nerves that originate in the brain, exit the skull, and lead to the
head, neck and torso
Fissure oI Sylvius (Lateral Sulcus)
O Deep grove that separates the parietal and temporal lobes
Limbic System Structures
O Amygdala - involved in emotional responses, hormonal secretions, and memory
O Cingulate Gyrus - a Iold in the brain involved with sensory input concerning
emotions and the regulation oI aggressive behavior
O Fornix - an arching, Iibrous band oI nerve Iibers that connect the hippocampus to
the hypothalamus
O Hippocampus - sends memories out to the appropriate part oI the cerebral
hemisphere Ior long-term storage and retrievs them when necessary
O Hypothalamus - directs a multitude oI important Iunctions such as body
temperature, hunger, and homeostasis
O OlIactory Cortex - receives sensory inIormation Irom the olIactory bulb and is
involved in the identiIication oI odors
O Thalamus - mass oI grey matter cells that relay sensory signals to and Irom the
spinal cord and the cerebrum
Medulla Oblongata
O Lower part oI the brainstem that helps to control autonomic Iunctions
Meninges
O Membranes that cover and protect the brain and spinal cord
OlIactory Bulb
O Bulb-shaped end oI the olIactory lobe
O Involved in the sense oI smell
Pineal Gland
O Endocrine gland involved in biological rhythms
O Secretes the hormone melatonin
Pituitary Gland
O Endocrine gland involved in homeostasis
O Regulates other endocrine glands
Pons
O Relays sensory inIormation between the cerebrum and cerebellum
Reticular Formation
O Nerve Iibers located inside the brainstem
O Regulates awareness and sleep
Substantia Nigra
O Helps to control voluntary movement and regualtes mood
Tectum
O The dorsal region oI the mesencephalon (mid brain)
Tegmentum
O The ventral region oI the mesencephalon (mid brain).
Ventricular System - connecting system oI internal brain cavities Iilled with
cerebrospinal Iluid
O Aqueduct oI Sylvius - canal that is located between the third ventricle and the
Iourth ventricle
O Choroid Plexus - produces cerebrospinal Iluid
O Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the
cerebellum
O Lateral Ventricle - largest oI the ventricles and located in both brain hemispheres
O Third Ventricle - provides a pathway Ior cerebrospinal Iluid to Ilow
Wernicke's Area
O Region oI the brain where spoken language is understood