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Case Presentation
On
Cerebrovascular Accident
Group J
Marco Paul Velasco
Precious Jane Parungao
Rod Lambert de Leon
Carla Aleja Abijay
Mylene Narag
Jenalin Quilang
Krizzia Marie Palce
Jessica Datul
General Objective :
•
Cerebral Embolism
•Occurs when a wondering clot ( embolus ) or
some other particle forms in a blood vessel
away from the brain , usually in the heart .
The clot then travels and lodges in an
artery leading on the brain .
Cerebral Hemorrhage
•Occurs when a defective artery in the brain
busts .
Subarachnoid Hemorrhage
•Occurs when a blood vessel on the surface of
the brain ruptures and bleeds into the space
between the brain and the skull .
•
The World Health Organization ( WHO )
definition of stroke is “ rapidly developing
clinical signs of focal ( or global ) disturbance
of cerebral function , with symptoms lasting 24
hours or longer or leading to death , with no
apparent cause other than of (1) Non -
communicable disease . WHO Geneva ( 2 ) vascular
origin ” (3) By applying this definition
transient ischemic attack ( TIA ), which is
defined to less than 24 hours , and patients
with stroke symptoms caused by subdural
hemorrhage , tumors , poisoning , or trauma , are
excluded .
Based from the data gathered from TCGPH
records section , there were 10 reported cases
of CVA as of January 2009 until December 2009
comprises of 2 mortality cases and 8 morbidity
cases .
Why this case?
•We have chosen this case as our topic during
the case presentation because we would like
that we , student - nurses , to be aware about CVA
and also to broaden our knowledge about the
management and treatment of this disease .
•Having awareness and gaining more knowledge
about CVA would enhance our skills and
attitudes in handling patients suffering from
this disease .
•This case serves as a challenge for us
student - nurses to be committed and dedicated
health professionals for in the next days , we
will take care of the health of the citizens .
•
•
PATIENT ’ S PROFILE
Name : I.M.
Age : 80 y / o
Gender : Female
Civil Status : Widower
Birth date : Dec . 24 , 1928
Nationality : Filipino
Religion : Roman Catholic
Address : Ugac Norte , Tuguegarao City
Educational Background : College Graduate
Occupation : Retired Teacher
Date of admission : November 19 , 2009
Time of admission : 6 : 45 pm
Chief complaint : Loss of consciousness
Admitting diagnosis : HPN t / c CVA
Final Diagnosis : CVA recurrent
Sepsis secondary to Pneumonia
NIDDM
Attending Physician : Dr . Valeriano Combate , Jr .
Dr . Marlene Cinco
Dr . Gerardo Pagaddu
Source of information : SO
Patient ’ s chart
Record ’ s section
Gordon’s 11 Functional
Pattern
Health Perception - Health Management
Pattern
Before
• Hospitalization During Hospitalization
According to the SO, According to the SO, she
her mother has been stated that her mother is
pampered starting when she not in good condition. She
was diagnosed with believes that doctors,
Alzheimer’s disease 5 years nurses and other medical
ago. When she suffered from members will help her
the sickness, they treated mother to recover. SO also
her immediately by taking added that they obediently
OTC drugs for cough, colds follow all the orders of
and fever. With regards to the doctors.
her maintenance drugs to
her hypertension, they give
it at right time as
prescribed.
Nutritional - Metabolic Pattern
•
Before Hospitalization During Hospitalization
According to the SO, Upon admission, the
her mother eats everything patient was inserted NGT
she wants and sees. She has and was ordered with PNSS
no preference diet. She 1liter to run for 8 hours.
eats 3 times a day with mid The diet was osteorized
afternoon snacks. She feeding with SAP.
drinks 6-8 glasses of water
a day. She has no
difficulty in swallowing
and has no allergy with any
type of food.
Elimination Pattern
Before Hospitalization During Hospitalization
According to the SO, Upon admission, the
•her mother eats everything patient was inserted NGT
she wants and sees. She has and was ordered with PNSS
no preference diet. She 1liter to run for 8 hours.
eats 3 times a day with The diet was osteorized
mid afternoon snacks. She feeding with SAP.
drinks 6-8 glasses of water
a day. She has no
difficulty in swallowing
and has no allergy with
any type of food.
Activity Exercise Pattern
•
Before During
Hospitalization
According to the SO, Hospitalization
The patient is in
the patient is like a comatose state.
child. She plays with Student-nurses and SO
her neighborhood. initiated passive range
Sometimes walking of motion for her to
around their house. exercise.
About her hygiene, they
see to it that
cleanliness must
maintain to her.
Sleep - Rest Pattern
Before During
Hospitalization
According to the SO, Hospitalization
Patient is comatose
her mother sleeps at but can respond to
around 8 in the evening physical stimuli.
and wakes up at around
5 in the morning. She
takes naps at
afternoon. She has no
rituals before sleeping
she added.
Cognitive Perceptual Pattern
Before During
Hospitalization
According to the Hospitalization
The patient responds
SO, her mother is a to stimuli by means of
retired teacher, she rubbing her sternum for
uses eyeglasses. She her to wake up.
speaks dialects such as
Ilocano, Tagalog and
English.
lf - Perceptual Pattern
Before During
The patient suffers
Hospitalization Hospitalization
The patient is
from Alzheimer’s comatose.
disease.
Role - Relationship Pattern
•Before Hospitalization During Hospitalization
According to the SO, Due to her condition,
before her mother was her daughter stated that
diagnosed with Alzheimer’s, they will do all their best
she was a loving mother and to take care of their
responsible to her mother. They will make sure
children. She provides to give back the care they
their needs and sees to it have received from her.
that they are comfortable
in their way of life.
Coping - Stress Pattern
•
Before During
Hospitalization
When her mother is Hospitalization
During her present
tired, she sleeps for condition, she is in a
her to rest. stressful state. Her
family is there to
comfort and give her
necessary needs just to
show their love.
Sexual - Reproduction Pattern
The patient has five children and
had her menopause at the age of 50 .
Black
Color Inspection Black w/ white d/t decreased
hairs melanocyte
production
secondary to
aging
NAILS
Color of the nail Inspection Pink transparent Pallor d/t poor arterial
bed circulation
EYES/ Normal
Round
EYEBROWS
Shape Inspection Round Normal
Equal in size
Symmetry Equal in size Normal
Inspection Symmetrical in
movement Symmetrical in
Movement Inspection
movement
Blinks involuntarily d/t decrease activity
& bilaterally of CN V
Ability to blink Inspection Absence of blink
CONJUNCTIVA
Color Inspection Pink - red Pale d / t poor
arterial
circulation
PUPILS
PERRLA Inspection Response to Very slow to d/t
penlight react to compression
( dilates and light of CN III
constricts )
Size of the Inspection
pupil 2mm
EXTERNAL
AUDITORY
CANAL
Hearing Inspection Hears equally Normal
in both ears Hears equally
in both ears
NOSE
Symmetry Inspection Symmetrical Symmetrical Normal
Color Inspection Same color as Same color as Normal
the face and the face and
neck neck
LIPS & MOUTH
Symmetry Inspection Symmetrical Symmetrical Normal
Color ( lips ) Inspection Pink Pale d / t decrease
oxygenation
Moisture Inspection Moist Dry d / t decreased
salivary
production
r / t loss of
vagal
stimulation
NECK
Symmetry Palpation Symmetrical Symmetrical Normal
Appearance Inspection No No Normal
distentions distentions
THORAX
Chest Inspection Normal
contour Symmetrical Symmetrical
Inspection Normal
Clavicle Prominent Prominent
Inspection Normal
Chest wall Full chest Full chest
expansion expansion
Inspection d / t decreased
Breathing Regular Irregular function of
pattern the medulla
K
Date Result Normal Range Analysis
11 - 24 - 09 3 . 0 mmOl / L 3.5-5.5
11 - 29 - 09 4 . 0 mmOl / L mmOl
3 . 5 - 5/.L5 Normal
mmOl / L
CBC
11 - 20 - 09
Parameters Result Normal Analysis
WBC 12 . 4x10 3 /mm 3 Range
3 . 5 - 10 d / t increase
RBC 3 . 83x10 6 /mm 3 3.8-5.8 pyrogens
Normal
Hgb 11 . 4 g / dl 11 . 0 - 16 . 5 Normal
Hct 37 . 0 % 35 - 50 Normal
PLT 188x10 3 /mm 3 150 - 390 Normal
INTAKE AND OUTPUT MONITORING SHEET
12 - 05 - 09
Intake Output
Time Oral Parent Others Total Urine Drainag Others Total
7-3 500 erral
100 600 600 e 600
3-11 1000 430 700 700 700
11-7 660 200 800 800 800
Total : 2890
Total : 2100
12 - 04 - 09
Intake Output
Time Oral Parenterra Othe Total Urine Drainage Othe Total
7-3 720 l100 rs
75 895 200 rs 250
3-11 1000 250 1250 500 500
11-7 600 250 850 200 200
Total :
2995 Total : 950
12-03-09
Intake Output
11-30-09
Intake Output
Time Oral Parenterra Others Total Urine Drainage Others Total
7- 3 600 l340 940 1000 1000
3-11 890 475 1365 1100 1100
11-7 550 200 750 900 900
Total: 2055
Total: 3000
11-29-09
Intake Output
11-28-09
Intake Output
Total: 4510
Total: 3600
11-27-09
Intake Output
11-26-09
Intake Output
Total: 2165
Total: 1750
11-23-09
Intake Output