INTRODUCTION

A cerebrovascular accident (CVA), or stroke, occurs when a sudden decrease in cerebral

blood circulation as a result of thrombosis, embolus, or hemorrhage leads to hypoxia of brain

tissues, causing swelling and death. When circulation is impaired or interrupted, an area of the

brain becomes infracted and this changes membrane permeability, resulting in increase edema

and intracranial pressure (ICP). The clinical symptoms may vary depending on the area and

extent of the injury.

Thrombosis of small arteries in the white matter of the brain account for the most

common cause of strokes. A history of hypertension, diabetes mellitus, cardiac disease, vascular

disease, or atherosclerosis may lead to thrombosis, which may cause ischemia to the brain

supplied by vessels involved.

Embolism is the second most common cause of CVA, and happens when a blood vessel

is suddenly occluded with blood, air, tumor, fat, or septic particulate. The embolus migrates to

the cerebral arteries and obstructs circulation causing edema and necrosis.

When hemorrhage occurs, it is usually the sudden result of ruptured aneurysms, tumors,

or AV malformations, or involves problems with hypertension or bleeding dyscrasias. The

cerebral bleeding decreases the blood supply and compresses neurons, leading to a loss in

function and death of neuronal tissue. Hypertensive intracranial hemorrhage occurs most often in

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

the basal ganglia, cerebellum, or the brain stem, but can affect other more superficial areas in the

brain. Hemorrhage can account for as much as 25% of all strokes.

Patients who have strokes frequently have had prior events, such as TIAs ( transient

ischemic attacks ) with reversible focal neurologic deficits lasting less than 24 hours, or RIND’s

( reversible ischemic neurologic deficits ) lasting greater than 24 hours but leaving little, if any,

residual neurologic impairment.

In addition to the disease processes discussed earlier, cardiac dysrhythmias, alcohol use,

cocaine or other recreational drug use, smoking and the use of oral contraceptives may

predispose patient to strokes.

Strokes may cause temporary or permanent losses of motor function, thought processes,

memory, speech, or sensory function. Difficulty with swallowing and speaking, hemiplegia, and

visual field effects are also related complications of this disease. Treatment is aimed at

supporting vital functions, ensuring adequate cerebral perfusion, and prevention of major

complications or permanent disability.

Objective of the Study

This study is conducted by a student of NCM501202 Cluster 2 for the following

purposes:

 Trace the disease process of the of the patient’s medical status

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

  Recognize the medical care of the client and identify the significance of the medical

management rendered

 Formulate and implement an effective nursing care plan specially designed for the

client’s problems as identified in the nursing assessment.

Scope and Limitations

The scope and limitation of this case study are as follows:

 Patient’s history and background

 Overview of the disease

 Predisposing and precipitating factors of the aforementioned disease condition

 Anatomy, Physiology, and Pathophysiology of Cerebrovascular Accident

 Nursing and Medical management administered during the confinement period

 Discharge plan, referrals and recommendations pertinent to the disease condition

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Patient’s Profile

Name: Abecia, Teodoro Q.

Age: 77 years old

Sex: Male

Occupation: Retired DPWH Worker

Civil Status: Married

Name of Spouse: Eufrocina Abecia

Birthday: May 20, 1929

Height : 5 feet, 7 inches

Birth Place: Camiguin Province

Address: Cabilto St. Gingoog City

Nationality: Filipino

Religion: Roman Catholic

Contact number : 09104285495

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Developmental Stages

Developmental stage theories related to individuals categorize a person’s behaviors or

tasks into approximate age ranges or in terms that describe the features of an age group. The age

ranges of the stages do not take into account individual differences; however, the categories do

describe characteristics associated with the majority of individuals at periods when distinctive

developmental changes occur and with the specific tasks that must be accomplished. Because

human development is highly complex and multifaceted, developmental stage theories describe

only one aspect of development, such as cognitive, psychosexual, psychosocial, moral, and faith

development. Stage theories emphasize a definite, predictable sequence of development that s

orderly and continuous.

Each stage is affected by those stages preceding it and affects those stages that follow.

For example, an adolescent who is unable to establish a stable sense of personal identity may

have difficulty in later developmental stages with adult roles and career aspirations.

Developmental stage theories view families as ever changing and growing. Crucial, yet

predictable, tasks occur at each level stage or stage of developmental. Achievement of tasks

appropriate at one level is prerequisite for successfully as achieving the tasks expected at the

next level. A major task of the family, from a developmental perspective, is to create an

environment where the family can master critical developmental tasks. This ensures orderly

progression through the stages of the family life cycle.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Freud’s Psychoanalytic Theory

Sigmund Freud (1856-1939)

He was an Austrian neurologist and the founder of psychoanalysis, offered the first real

theory of personality development. He based his theory of development on his observations of

mentally disturbed adults. He described adult behavior as being the result of instinctual drives

that have a primarily sexual nature (libido) from within the person and the conflicts that develop

between these instincts, reality, and the society. He described child development as being a series

of psychosexual stages in which the child’s sexual gratification becomes focused on a particular

body site.

OLDER ADULTHOOD

The patient has developed sexual maturity and established satisfactory relationships with

the opposite sex. Thus, forming loving relationships or assuming the responsibilities of adult life

may all be seen as symbolic ways of satisfying the drive energy of Freud’s final stage of

Paychosexual development.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Erikson’s Theory of Psychosocial Development

Erik Erickson (1902-1906)

He was trained in psychoanalytic theory but later developed his own theory of

psychosocial development that stresses the importance of culture and society in development of

the personality. He looked at actions that lead to mental health. He describes eight developmental

stages covering the entire life spans.

OLDER ADULTHOOD

Erikson believes that the last interpersonal dimension that emerges during older

adulthood is a sense of “Ego Integrity vs. Despair.” Older adults develops a sense of acceptance

of life as it was lived and the importance of the people and relationships that individual

developed over the lifespan.

The patient had a sense of fulfillment in his life and had a sense of unity with his family

and relatives.

Piaget’s Theory of Cognitive Development

Jean Piaget (1896- 1980)

He was a Swiss psychologist, introduced concepts of cognitive development that are

similar to those of both Freud and Erikson and yet separate from each. He defined four stages of

cognitive development; within each stage are finer units or schema. Each period is an advance

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

over previous one. To progress from one period to the next, the child recognizes his or her

thinking process to bring them closer to reality.

OLDER ADULTHOOD

Persons who reach the formal operation stage are capable of thinking logically and

abstractly. They can also reason theoretically. Piaget considered this the ultimate stage of

development, and stated that although the children would still have to revise their knowledge

base, their way of thinking was as powerful as it would get.

Kohlberg’s Theory of Moral Development

Lawrence Kohlberg (1927-1987)

He was a psychologist, studied the reasoning ability of boys and, based on Piaget’s

development stages, and developed a theory on moral reasoning, or the way that children gain

knowledge of right and wrong.

OLDER ADULTHOOD

In the transition from conventional morality to post-conventional morality the individual

begins to recognize the arbitrary nature of socially dictated ethical principles. If the individual is

able to see that universal principles need to be defined in order to act correctly, they can advance

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

to the third level. Otherwise, they often regress to a level one type of irrationally hedonistic

attitude where rebellion for its own sake is valued.

In the stage of Social Contract, the individual becomes concerned with individual rights

and laws defined within a social context. And with the stage of Principled Conscience, the

individual is guided entirely by his individually defined conscience according to universal moral

principles.

The patient can be responsible for self-care because he views this as a standard of adult

behavior.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Patient’s Past and Present Health Illness

The case of Mr. Teodoro Abecia, a 77 years old, male married retired government

worker, Filipino, a Roman Catholic, who is temporarily residing at Cabilto St. Gingoog City,

was admitted for the second time in Sabal Hospital on January 13, 2007 at around 8:50 am.

Patient has been admitted previously at Sabal Hospital from Stroke last November 2006.

Home medications indicated that Mr. Abecia is hypertensive and a risk for pneumonia. It also

indicated that the patient has no known allergic reaction to food and drugs.

Patient’s family history was marked for positive Diabetes Mellitus and Hypertension.

Patient’s social and personal history showed that he is a past cigarette smoker and alcoholic

beverage drinker.

A few days prior to admission, patient has productive cough associated with fever. There

was no consultation done until a day prior to admission, the patient observed body weakness and

loss of appetite. The concerned family prompted him for admission.

Upon admission, the patient appeared to be stuporous, incoherent but not in respiratory

distress.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Anatomy of Cerebral Circulation

The brain, though representing 2% of the total body weight, it receives one fifth of the
resting cardiac output. This blood supply is carried by the two internal carotid arteries (ICA) and
the two vertebral arteries that anastomose at the base of the brain to form the circle of Willis.

Carotid arteries and their branches (referred to as the anterior circulation) supply the
anterior portion of the brain while the vertebrobasilar system (referred to as posterior circulation)
supplies the posterior portion of the brain.

The brain receives its blood supply from the heart by way of the aortic arch that gives rise
to the brachiocephalic (innominate) artery, left common carotid artery (CCA) and the left
subclavian artery

The left Common Carotid artery arises from the aortic arch while the right arises from the
bifurcation of the innominate artery.

External carotid artery starts at the CCA bifurcation. Its branches supply the jaw, face,
neck and meninges. The bulk of the meningeal circulation is supplied by the middle meningeal
artery, the most important branch of the maxillary artery which is one of the two terminal
branches of the ECA (the other terminal branch is the superficial temporal artery). These two
terminal branches in addition to the occipital artery can serve as collateral channels for blood
supply to the brain in instances of obstruction of the ICA. The ascending pharyngeal artery can
serve as a source of blood in instances of occlusion of the ICA.

Internal carotid artery (ICA) starts at the carotid sinus at bifurcation of CCA at the level
of the upper border of the thyroid cartilage at the level of the fourth cervical vertebra. It ascends
just behind and lateral to the hypopharynx where it can be palpated. It passes up the neck without
any branches to the base of the skull where it enters the carotid canal of the petrous bone. It then
runs through the cavernous sinus in an S-shaped curve (the carotid siphon), then it pierces the
dura (beginning its subarachnoid course) and exits just medial to the anterior clinoid process and
then ascends to bifurcate into anterior cerebral artery and the larger middle cerebral artery.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Physiology of the cerebral circulation

Blood Brain Barrier

This barrier insulates the brain and its extracellular fluid, including the cerebrospinal fluid (CSF),
from many of the body’s blood borne chemical perturbations, such as circulating drugs,
immunogenic antigens and electrolyte changes. The anatomic barrier lies in the intracranial
endothelium, where tight intracellular junctions weld the entire inner vascular surface into a
continuous membranous sheet. As a result, only nonpolar materials that have a small molecular
size, are lipid soluble or are transported across the membrane by specific carrier systems or
pumps transgress the endothelium with any rapidity.

Transient breaches of the barrier occur under a variety of circumstances but have little ill
effect on brain function. Sustained, partial barrier alterations occur in areas of cerebral
neoplasms, inflammation or edema associated with such conditions. Severe damage to barrier
transport mechanisms can intensify brain infarction during ischemia.

Regulation of cerebral blood flow

Cerebral blood flow (CBF) in man is about 50 ml / 100 g of brain / minute. It has been shown
that CBF, cerebral blood volume (CBV) and cerebral energy metabolism measured as cerebral
metabolic rate of oxygen (CMRO2) or of glucose (CMRglu) are all coupled and higher in gray
than white matter. This means that the oxygen extraction fraction (OEF) remains about the same
(approximately forty per cent) throughout the brain, therefore, in normal resting human brain,
CBF (i.e. flow) is a reliable reflection of CMRO2 (i.e. function).

CBF depends on cerebral perfusion pressure (CPP) and cerebrovascular resistance. The
perfusion pressure is the difference between systemic arterial pressure and venous pressure at
exit of the subarachnoid space, the latter being approximated by the intracranial pressure.

Autoregulation

It is a characteristic of the brain to adjust its own blood supply. In normal individuals, CBF
remains constant when the mean arterial pressure is between 60 and 160 mmHg which, in normal
circumstances, when the intracranial venous pressure is negligible, is the same as the CPP.
Whether myogenic, metabolic or neurogenic processes are responsible for this process is
unknown. Autoregulation is impaired or abolished in damaged areas of the brain (e.g. by
ischemia, trauma, etc.) so that CBF becomes pressure passive and follows perfusion pressure.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

 Pathophysiology

Occlusion of major vessel by embolism

Cerebral hemorrhage Other cause of ischemia

Cerebral infarction

Decreased flow of blood to brain

Hypoxia Organs Involved :

Predisposing factors : Brain
Age greater than 60 Family Heart
history of stroke Ischemia Lungs
Smoking Kidneys
Alcohol drinking
Inadequate adenosine triphosphate (ATP) Complications:
Neurotransmitter depletion Pneumonia
Precipitating factors:
Hypertension
Diabetes Mellitus Cerebral edema
Obesity

Vascular Congestion

Compression of tissue

Impaired Function

Anterior Cerebral Artery Middle Cerebral Artery Posterior Cerebral Artery

Confusion Arm paralysis Hemiparesis

Impaired thought Hemianopia Ataxia
Contralateral Paralysis Aphasia Visual Problems
Urinary Incontinence Agnosia Dysphasia
Sensory Deficits Perception deficits Dysphonia

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Evaluation and Implication

After the implementation of nursing interventions, there is a slight improvement on

patency of airway. Range of motion exercises should be performed twice daily for effective

circulation. He have severe disability requiring physical therapist’s care. The patient is left with

a severe deficit on neurologic and respiratory functioning.

Recurrent strokes could occur anytime. In addition, patients that have suffered a stroke

are also at a very high risk for a myocardial infarction (heart attack).

Health Teachings:

 Emphasized the importance of rest, and adequate well-balanced diet and adding fiber to

the diet.

 Encouraged regular range of motion exercises at tolerable intensity.

 Emphasized the importance of low Sodium and low fat diet.

 Discussed the importance of proper hygiene and physical comfort to the family for the

client especially care of indwelled catheter.

 Discussed with the family on the essence of follow up check-ups and laboratory tests.

 Encouraged family support in carrying out discharge orders on home care instructions.

 Provided a written copy of the home care instructions : NGT feeding.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Referral and Follow – up

Instructions were provided to the client’s family as ordered such as maintaining the

airway patency of the client, the support people was given emphasis in doing passive ROM

exercises for the client, providing bedside care to the client to promote comfort, follow home

medications religiously and lastly attend all client’s needs as necessary.

Instructions were also made regarding the client’s follow-up check up with Dr. L. Sabal

one week after discharge in order to monitor the client’s recovery and to determine whether the

care rendered has taken any long term effects.

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Bibliography

1. Medical Surgical Nursing 10th Edition Volume 2 by Suzanne C. Smeltzer and Brenda

G. Bare, Copyright 2004 by Lippincott Williams and Wilkins pp. 1943 – 1945.

2. Microsoft Encarta Encyclopedia

3. Nursing 2007 Drug Handbook 25th Edition, Copyright Lippincott and Wilkins

4. Nurse’s Pocket Guide 9th Edition by Marilynn E. Doenges, Mary Frances Moorhouse

and Alice C. Geissler Murr, Copyright by F. A Davis Company.

5. Delmar’s Critical Care – Nursing Care Plan, 2nd Edition, Sheree Comer

6. http://www.virtualneurocentre.com/diseases.asp?did=823

7. www.emedicine.com

8. http://www.thedoctorslounge.net

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29

Calipayan, Cherrie P. * BS Nursing -3 * Section 325 * Group B29