Cerebrovascular Accidents (CVAs)

• Cerebrovascular Accidents (CVAs) result from insufficient blood supply to the brain.
• A stroke involves the infarction of a brain area due to inadequate blood supply.
• A stroke can be caused by the obstruction of brain-feeding vessels or hemorrhage.
• The affected blood vessels determine the extent of infarction.

Number of Cases/Statistics of the Disease

• Stroke has a high mortality risk and can lead to vision/speech loss, paralysis, and confusion.
• People who have had strokes are at higher risk for subsequent episodes.
• 15 million people worldwide suffer a stroke annually; 5 million die, and 5 million are left disabled.
• Strokes are less common in people under 40, mainly caused by high blood pressure, but also occur in 8% of children with sickle cell disease.

Local Statistics

• Stroke remained the second leading cause of death and one of the top five leading causes of disability in the Philippines from 2009 to 2019.
• Stroke prevalence estimates range from 0.9% (2005) to 2.6% (2017) in the Philippines.
• 7 out of 10 stroke cases are ischemic; the other 3 are hemorrhagic.

Current Trends Regarding the Disease

• Anticoagulant Therapy: Anticoagulants like warfarin or direct oral anticoagulants (DOACs) are used in atrial fibrillation or cardiac conditions to prevent clot formation.
• Blood Pressure Management: Medications like diuretics and angiotensin-converting enzyme (ACE) inhibitors maintain optimal blood pressure due to hypertension being a significant risk factor for stroke.
• Lifestyle Modifications: A heart-healthy diet, physical activity, quitting smoking, and limiting alcohol reduce stroke risk.

Latest Equipment for Treating

• Carotid Endarterectomy: Plaque buildup is removed from the carotid arteries to prevent future strokes, especially in patients with significant carotid artery narrowing.
• Endovascular Thrombectomy: A blood clot gets removed from a blocked artery to restore brain blood flow.
• Angioplasty: A balloon is used to widen narrowed arteries for enhanced blood flow.

Reasons for Choosing Such Case

• Student nurses need to be aware about CVAs in order to broaden their knowledge of the management and treatment of this disease.
• Increasing awareness enhances the handling of patients suffering from CVA.

Patient Information

• Name: Assa Balani Gulang
• Age: 74
• Sex: Female
• Marital Status: Widow
• Birthplace: Tampalan Malamawi, Isabela City Basilan
• Birthdate: June 9, 1950
• Address: Tampalan Malamawi, Isabela City Basilan
• Nationality: Filipino
• Chief Complaints: Headache and Restlessness
• Admission Date/Time: January 8, 2025
• Admitting Diagnosis: Hypertension Type II with Transients ischemic attack
• Informant: Daughter

Family History

• The patient has a family history of hypertension.
• The patient's husband died due to stroke.

History of Past Illness

• The patient was admitted on August 23, 2017, with a diagnosis of hypertension.
• The patient was admitted on December 21, 2024, with the same condition.
• Prescribed medications: Losartan and Amlodipine.

History of Present Illness

• The patient is experiencing a cerebrovascular accident (CVA), commonly known as a stroke.
• Symptoms began on the morning of January 8, 2025 (Wednesday).
• Experienced severe pain in the right brachial region.
• Experiencing severe headache while doing chores.
• Felt numbness on the left side of the body after resting.
• Non-smoker and does not drink alcohol.

Physical Assessment

• Hair: Evenly distributed, black, thick, clean, well-groomed, and no signs of thinning.
• Skin: Intact, no pressure ulcers, bruising, or breakdown.
• Head and Face: Noticeable left-sided facial asymmetry, slight ptosis, and mild drooping of the left corner of the mouth.
• Eyes: Left eyelid drooping slightly (ptosis) and reactive pupil to light. Patient cannot open her eyes spontaneously or in response to commands.
• Ears: Normal, no deformities, abnormalities, or discharge.
• Nose: Symmetrical, no deformities or bleeding, and intact nasal patency bilaterally.
• Mouth and Throat: Mild drooping on the left side of the mouth; unable to completely close lips.
• Tongue slightly deviates to the left when extended
• Neck: No swelling, masses, or deformities; no jugular venous distention; mild left-sided weakness with neck flexion
• Heart: Heart rate within normal limits (82 bpm), no murmurs, gallops, or abnormal heart sounds.
• Chest: Symmetrical chest movement during respiration, with clear lung sounds bilaterally without issues.
• Upper Extremities: Decreased strength and muscle tone, with the left hand and arm unable to move.
• Abdomen: Soft, non-tender, and non-distended, with active bowel sounds in all quadrants.
• Lower Extremities: Mild weakness with limited movement in the left leg, edema on the left ankle and lower leg and reflexive movement present in the left foot.
• Musculoskeletal: Significant weakness and paralysis on the left side, unable to move without assistance (due to left-sided weakness).
• Neurological System: Left-sided hemisphere with paralysis on the left side of the body, including facial weakness. Left side sensory loss and decreased sensation in the left hand and forearm.

Anatomy and Physiology

• The brain controls thought, memory, emotion, touch, motor skills, vision, breathing, temperature, hunger, and body processes.
• The brain and spinal cord make up the central nervous system (CNS).
• Weighing about 3 pounds in the average adult, the brain is about 60% fat, with the remaining 40% being water, protein, carbohydrates, and salts.
• The brain contains blood vessels, nerves, neurons, and glial cells, and relies on neurons (nerve cells).

Main Parts of the Brain

• Cerebrum: The cerebrum comprises gray matter (the cerebral cortex) and white matter at its center. The cerebrum initiates and coordinates movement and regulates temperature.
• Cerebellum: Located at the back of the head, below the temporal and occipital lobes, it coordinates voluntary muscle movements and maintains posture, balance, and equilibrium.
• Brainstem: The brainstem connects the cerebrum with the spinal cord and includes the midbrain, the pons, and the medulla.
• Midbrain: The complex structure with neuron clusters, neural pathways, and other structures.
• Pons: The connection between the midbrain and the medulla.
• Medulla: Located at the bottom of the brainstem, it meets the spinal cord and is essential to survival.
• Spinal Cord: Supported by the vertebrae, the spinal cord carries messages to/from the brain to the rest of the body.

Protective Covering of The Brain

• Meninges: Three layers of protective covering called Meninges, surround the brain and the spinal cord.
• Dura Mater: The outermost layer, is thick and tough with two layers: the periosteal and meningeal layers.
• Arachnoid Mater: The arachnoid mater is a thin, weblike layer of connective tissue.
• Pia Mater: The pia mater is a thin membrane that hugs the surface of the brain and is rich with veins and arteries.

Lobes

• Frontal Lobe: The frontal lobe is located in the front of the head and is involved in personality, decision-making, and movement, contains broca's area associated with speech.
• Parietal Lobe: The parietal lobe is the middle part of the brain, helps a person identify objects and understand spatial relationships, and houses Wernicke's area which helps the brain understand spoken language.
• Occipital Lobe: The Occipital Lobe is also located in the back of the brain and is involved with vision.
• Temporal Lobe: The Temporal Lobe is located on the sides of the brain and is involved in short-term memory, speech, musical rhythm, and smell recognition.

Blood Supply for The Brain

• Vertebral Arteries: Two sets of blood vessels supply blood and oxygen to the brain.
• Carotid Arteries: Branches into the skull, and the external and the internal arteries follow the spinal column into the skull, where they join together at the brainstem and form the basilar artery to supply blood to the rear portions of the brain.

Cranial Nerves

• Cranial nerves are 12 nerves, are inside the cranium (the dome of the skull).

Pathophysiology of CVA

• Atherosclerosis can lead to a temporary reduction in blood flow (TIA).
• Hypertension accelerates plaque development and vessel rupture.
• Blockage of blood flow in a cerebral artery leads to cerebral hypoperfusion.
• Cellular starvation leads to cell death in the brain, causing stroke symptoms.
• Prolonged deprivation causes irreversible damage.

Definition of The Disease

• Cerebrovascular Accident (CVA or stroke): Occurs when there is an inadequate blood supply to the brain, leading to brain tissue damage.
• It can be caused by either the blockage or rupture of blood vessels.

Synthesis of The Disease

• CVA: Happens with a lack of adequate blood flow, leading to neurological emergency.
• CVA Classifications: Ischemic (clot) or hemorrhagic (ruptured vessel).
• Both types impair brain function and depend on the type, location, and treatment.

Risk Factors

• Precipitating Factors: Hypertension, Hyperlipidemia, Diabetes Mellitus, Heart Diseases, Atherosclerosis, Arteriosclerosis, Thrombosis, Severe dehydration.
• Predisposing Factors: Sedentary lifestyle, Alcohol/smoke, Age, Diet, Gender, Heredity, Self-medication.

Signs and Symptoms

• Ischemic Stroke: Sudden weakness or numbness, Difficulty speaking, Vision changes, Dizziness or loss of balance, Sudden severe headache
• Hemorrhagic Stroke: Severe headache, Vomiting, Altered mental status, Seizures, Sudden weakness
• Transient Ischemic Attack (TIA) or "Mini-Stroke": Temporary symptoms, Sudden weakness or numbness, Difficulty speaking, Vision changes

C.C. Complication

• Brain edema
• Physical Complication: weakness or paralysis, difficulty with coordination and balance, spasticity
• Cognitive, emotional and communication issues: cognitive impairment, aphasia, depression and anxiety
• Swallowing difficulties: dysphagia
• Pain and Sensory Changes: central pain syndrome, numbness or tingling, shoulder pain
• Infections: Pneumonia, UTI
• Pressure Ulcers: bedsores
• Seizures
• Vision problems
• Deep Venous Thrombosis (DVT)
• Recurrent Stroke
• Cardiovascular Complication

Diagnostics and Laboratory Procedures

• Complete Blood Count Indication: Detect a wide range of condition including anemia, infections, leukemia and blood disorder.
  • RBC Result: Is 6.10×10^12c cells/L (Increased)
  • Hemoglobin Result: Is 187g/L (Normal)
  • Hematocrit Result: Is 58.1% (Normal)
  • Platelet Result: Is 6.35×10^9 (Normal)

Nursing Responsibilities for ECG

• Explain the procedure to the patient and ensure they remain calm and still during the test.
• Prepare the skin for electrode placement by cleaning and drying the area and Monitor the patient for any signs of discomfort or adverse reactions during the procedure.

Medical Management

• The following are used: IVF, O2 THERAPY, NEBULIZATION and NGT

IVF

• Infusion of PLR (Plain Lactated Ringer's Solution)
  • General Description: Replace water and electrolyte loss, and increases the pH level of the body.
  • Indication/Purpose: To treat dehydration, facilitate IV medication flow during surgery and/or restore fluid balance.
  • Client's Response: Improved hydration, stable vital signs, restored electrolyte balance, enhanced energy levels, and improved circulation.

Oxygen Therapy

- General Description: Device used involves delivering oxygen using devices like nasal cannulas or masks to improve oxygen levels in blood.
- Indication/Purpose: Provide oxygen saturation levels in the patients with respiratory distress.
- Client's Response: Improved breathing, oxygen saturation, and reduced signs of respiratory distress.

Catheterization Procedure

- General Description: Urethral catheterization which is the insertion of a catheter into the urethra to drain urine from the bladder.
- Indication/Purpose: Used to urinary retention, monitoring urine output, post-surgery drainage, incontinence management
- Client's Response: The patient may experience relief from urinary retention and effective management of urine output with proper monitoring for complications.

Nursing Responsibilities

• Monitor and regulate IV infusion rates for Plain Lactated Ringer's Solution; check for signs of fluid overload while recording input and output to track fluid balance.
• Regularly assess oxygen saturation levels; ensure the device is properly positioned and monitor for signs of oxygen toxicity or skin irritation.
• Maintain aseptic technique during urethral catheterization, monitor for signs of infection such as cloudy urine or fever, and ensure the catheter and drainage system are secured and unobstructed.

Nursing Responsibilities For Drugs

• Name: Citicoline
  • Route Dosage:1gram IVT NOW THEN Q8
  • General Action: Essential compound that plays a critical role in the synthesis of phosphatidylcholine, for brain health and cognitive function.
  • Indication/Purpose: Indicated for neurological and cognitive conditions, as it supports brain cell repair by helping with improving memory, attention, and learning.

Drugs

• Name: Clonidine

  • Route Dosage: 75mg NOW THEN Q4 FOR BP 160/100
  • General Action: Centrally acting alpha-2 adrenergic agonist which reduces sympathetic activity decreasing blood pressure and heart rate for hypertension.
  • Indication/Purpose: Primarily indicated for reducing blood pressure through its central alpha-2 adrenergic agonist action. It is also used in managing withdrawal symptoms from opioids, alcohol, or nicotine, and in treating attention-deficit hyperactivity disorder (ADHD) as an adjunct therapy to improve focus and reduce hyperactivity.

• Name: Losartan

  • Route Dosage:00mg 1TABLET P.O OD
  • General Action: Angiotensin II receptor blocker (ARB) used treat hypertension and reduce the risk of stroke by promoting vasodilation.
  • Indication/Purpose: Primarily indicated in the treatment of hypertension to lower blood pressure and reduce the risk of stroke by helping to protect kidney function and slow the progression of diabetic nephropathy.

• Name: Amlodipine

  • Route Dosage: 50mg 1TABLET P.O OD

• Name: Ketorolac

  • Route Dosage: 30mg IVT ANST x3DOSES

Nursing responsibility for medication

• Includes ensuring that the right medication is properly drawn up in the correct dose, and administered at the right time through the right route to the right patient, limiting administration errors by employing a single-dose system.

Nursing Recommendations For Diet

• The following are the Nursing recommendation for diet: Soft diet, low fat diet, and low sodium diet.

Soft Diet

- General Description: It consists of foods that are gentle on the digestive system, easy to chew, and swallow.
- Indication/Purpose: Helpful for individuals with conditions like stroke, brain injury, or have difficulty eating regular foods.
- Specific Foods Taken: Soft grains such as Cooked rice, mashed potatoes, Tender proteins such as Ground meat, scrambled eggs, Cooked vegetables such as Soft-cooked carrots, squash and Soft fruits such as Ripe bananas, applesauce, mashed avocados and dairy.
- Client’s Response: He/she may be able to eat more easily with assistance.

Low Fat Diet

- General Description: Consists of moderate to high carbohydrates, moderate protein and low fat.
- Indication/Purpose: Beneficial role in the recovery and long-term health of patients who have experienced a stoke.
- Specific Foods Taken: Vegetables, leafy greens such as spinach, beans and legumes, egg white, fish, sweet potatoes, fruit, quinoa, milk, yogurt.

Low Sodium Diet

- General Description: Its a dietary plan that restricts the amount of sodium consumed for individuals experiencing cerebrovascular accident (CVA) or stoke.
- General Description: Its a dietary plan that restricts the amount of sodium consumed. It's often recommended for individuals with certain health conditions, such as high blood pressure, stroke, heart disease.
- Indication/Purpose: May play a significant role in the recovery and management of patient who have.
- Specific Foods Taken: Fruits and vegetable such as apples, grapes, mushroom, potatoes.
- Clients response: The patient may experience better blood pressure control and a reduced risk of complications, supporting stroke recovery and long-term health management.

Nursing Recommendations For Activity:

• The following are the Nursing recommendation for activity: physical therapy, speech therapy, and cognitive stimulation.

Physical Therapy

- General Description: Exercises and physical techniques that are aimed at improving mobility, strength, and balance.
- Indication/Purpose: Help individuals regain or improve physical function, prevent further injury, and increase independence in daily activities.
- Client’s Response: The client may show improved physical movement, strength, balance, and coordination, leading to greater independence in performing activities of daily living.

Speech Therapy

- General Description: Helping individuals enhance their ability to communicate, improve swallowing, and refine language skills.
- Indication/Purpose: Restore or improve speech clarity, understanding, voice control, and swallowing ability, particularly after neurological impairments like a stroke.
- Client’s Response: The client may improve verbal communication skills, better swallowing function, and enhanced interaction of caregivers/family member.

• Cognitive Stimulation
  • General Description: Individuals engage in activities to enhance cognitive functions, including memory, problem-solving, and alertness.
  • Indication/Purpose: Improvement of mental functioning with the help of enhanced memory and problem-solving abilities.
  • Client’s Response: Increased mental clarity and cognitive abilities with a slower progression of decline, better quality of life due to enhanced cognitive abilities.
• Fine Motor Activities
  • General Description: Precision coordination of small muscle movements.
  • Indication/Purpose: Improvement of motor strength, finger movement, and daily activities.
  • Client’s Response: Perform motor tasks effectively with the help of coordination.
• Social Interaction
  • General Description: Communications and social connections between individuals.
  • Indication/Purpose: Improve emotional wellness through engagements with others.
  • Client’s Response: Improved performance of functions and social engagement.

Nursing Responsibilities

• Assess and Evaluate: Monitor the patient's progress in mobility, communication, cognitive function, motor skills, and social interaction.
• Support and Education: Offer emotional support, encourage participation and teach the patient and caregivers about exercises and strategies for improving daily tasks.
• Collaborate and Track Progress: Adjust care plans and document improvements or challenges, ensuring the patient's needs are met.

Assessment/Objectiev

• At the end of intervention, the patient will demonstrate improved verbal communication; expressing himself or herself clearly, using non verbal, alternative communication methods with the use of simple sentences, speaking slowly, and allowing adequate time responses.
  • Interventions: Evaluate patient to express themselves and colloborate with the speech therapist.
  • Rational: Provides tools for frustration that enables improving communication. Assess/Objectiev
• Interventions: Assess motor functions to establish the plan of care. and assist the patient.
  • Outcomes: To demonstrate slight improvement in ROM for paralysis.
  • Rationale: The goal of assisting is to identify.

Nursing Management

• Date/Time: Jan 9, 2025 3:30 PM
  • Focus: Body Weakness
  • Data/Action/Response: Patient in bed with ongoing 02 inhalation via nasal cannula. Body weakness noted, and limited to perform activity of daily living.
• Date/Time: Elevate blood pressure -Focus: elevated blood pressure due to "masakit in ulo niya iban way siya kusug" as verbalized. -Data/action/Response: The patient has fatigue and Check blood pressure every 15 minutes to monitor trends. also given losartan 100mg orally as per doctor's orders. Educated patient and family on medication adherence and instructed patient to rest in a comfortable position to reduce stress. Also notified physician for further evaluation and management.

Functional Health Patterns

• Health Perception-Health Management Pattern: Admtted with chief c/o headache and restlessness with hx of hypertension but med non-adherence. Concerned about their health following stroke but relies heavily on their daughter and siblings for support,
• Nutritional-Metabolic Pattern: Patients used to eat normally 3x/day but currently have difficulty swallowing, so daughter now feeds.
• Elimination Pattern: Urinating 2-3x BDA, no bowel movement today w/ foley catheter to uro bag.
• Activity Exercise Pattern: Daughter reporst that patients gets up early to sell fish at the market and gets adequate rest.
• Sleep/Rest Pattern: Patiens sleep well typically 8-9pm and 6 am, currently having trouble sleeping and cannot differentiate if their asleep.
• Personal Habit: Non-Smoker.
• Perceptual Pattern: Patient is aware with surroundings.
• Self-Perception Pattern: Daughter reports that the family used to be independient and hardworking, currently relies on the kids.
• Role-Relationship: Widow with two daughters and one grandchild, daughter provides healthcare assistance.
• Sexuality-Reproduction: Not sexually active.
• Coping/Stress: As per daughters, their mother seeks comfort form her siblings.
• Values and Belief: Pt belong to the Badjao ethnic group and practice Islam and believe in the ties of family and community.