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A Closer Look on:
CEREBROVASCULAR
ACCIDENT
Prepared by:
Jacqueline y. pineda
Staff nurse, surgery ward
DEMOGRAPHIC DATA
Name: Mr. X
Age:89
Gender: Male
Case Number: 167947
Diagnosis: CVA, ARF, Pneumonia,
NSTEMI, DVT, Subacute Pulmonary
Edema, DM II, Parkinson’s Disease
PHYSICAL ASSESSMENT
General Appearance:
Bedridden
Conscious
Weak-looking
Pale in appearance
Thin
PHYSICAL ASSESSMENT
Vital Signs:
 Blood Pressure: 130/80
 Pulse Rate: 89
 Respiratory Rate: 23
 Temperature: 36.8
Skin:
 Intact
 Warm
 Poor skin turgor
 Wrinkly
 Scaly
PHYSICAL ASSESSMENT
Head and Neck:
Skull is smooth, no depression.
Loss of hair on scalp.
Neck veins are slightly distended.
Thorax:
Symmetrical though the ribs are prominent.
Abdomen:
Rigid, with active peristalsis.
PHYSICAL ASSESSMENT
Genital Area:
Minimal pubic hair. No hernia noted.
Upper limbs:
Nail beds are thick and dry.
Lower limbs:
With non-pitting edema on both feet,
grade 1 to 2.
PATIENT HISTORY
I. PAST MEDICAL HISTORY
With history of Parkinson’s disease,
CVA, Hypertension, transferred to our
hospital from another hospital where he
was intubated due to acute respiratory
failure and sepsis.
PRESENT MEDICAL HISTORY
CVA, ARF, Pneumonia, NSTEMI, DVT,
Subacute Pulmonary Edema, DM II,
Parkinson’s Disease
Nursed in ward with:
Limb and chest physiotherapy
NGT Feeding of Jevity 250ml plus 100ml
water every four hours with strict
aspiration precaution.
Nebulization, suctioning and changing of
position
Tracheostomy tube with oxygen support
at 3 liters per minute
Foley catheter connected to urine bag
MEDICATIONS:
MEDICATIONS
INVESTIGATIONS:
PATHOPHYSIOLOGY
TOPIC PRESENTATION
INTRODUCTION:
A
stroke,
or
cerebrovascular
accident (CVA), is the rapid loss of brain
function due to disturbance in the blood
supply to the brain.
ANATOMY AND PHYSIOLOGY
Blood Flow Blockage. The brain receives about 25% of
the body's oxygen, but it cannot store it. Brain cells
require a constant supply of oxygen to stay
healthy and function properly. Therefore, blood
needs to be supplied continuously to the brain
through two main arterial systems:
The carotid arteries come up through either side of
the front of the neck. (To feel the pulse of a carotid
artery, place your fingertips gently against either
side of your neck, right under the jaw.)
The basilar artery forms at the base of the skull from
the vertebral arteries, which run up along the
spine, join, and come up through the rear of the
neck.
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ETIOLOGY
 Ischemic stroke. About 85 percent of strokes are ischemic strokes.
The most common ischemic strokes include:
 Thrombotic stroke.
 Embolic stroke.
 Hemorrhagic stroke. Hemorrhagic stroke occurs when a blood
vessel in your brain leaks or ruptures..
 Transient ischemic attack (TIA). A transient ischemic attack (TIA)
— also called a ministroke — is a brief episode of symptoms similar
to those you'd have in a stroke. A transient ischemic attack is caused
by a temporary decrease in blood supply to part of your brain. TIAs
often last less than five minutes.
ETIOLOGY
CT Scan of brain without contrast:
FINDINGS: The brain is morphologically
normal. No acute hemorrhage.
IMPRESSION: Diffuse cerebral atrophy with
small periventricular white matter chronic
ischemic changes.
SIGNS AND SYMPTOMS
Trouble with walking.
Trouble with speaking and understanding.
Paralysis or numbness of the face, arm or
leg.
Trouble with seeing in one or both eyes.
Headache.
INTERVENTION
Nursing Intervention includes:
Monitor Vital Signs, especially the blood
pressure
Monitor the Neurovascular Status
Refer any untoward change in sensorium.
Give stat medications immediately as
ordered
Give due medications on time
Institute safety and aspiration precautions
TREATMENT
Thrombolysis
Hemicraniectomy
COMPLICATIONS
 Aspiration pneumonia
independently
 Decubitus ulcers
 Urinary incontinence
 Dementia
 Bowel incontinence
 Disability:
 Memory loss
Difficulty speaking
 Muscle spasms
Difficulty swallowing  Osteoporosis
Arm weakness

Chronic
pain
(unilateral)
 Recurrent stroke
Leg weakness
(unilateral)
 Tremor
Facial weakness
 Inability to live
PRIORITIZATION OF NURSING
PROBLEMS
BREATHING
 Ineffective Airway Clearance
 Ineffective Breathing Pattern
ACTIVITY AND REST
 Disturbed Sleep Pattern
 Impaired Physical Mobility
 Risk for Activity intolerance
FATIGUE
 Ineffective Breathing Pattern
 Decreased Cardiac Output
 Risk for Decreased Cardiac Tissue Perfusion
 Self Care Deficit
PRIORITIZATION OF NURSING
PROBLEMS
NUTRITION
 Imbalanced Nutrition Less Than Body Requirement
 Risk for Electrolyte Imbalance
 Deficient Fluid Volume
ELIMINATION
 Risk for Urinary Incontinence
 Impaired Urinary Elimination/Urinary Retention
 Bowel Incontinence
 Risk for Constipation
 Impaired Gas Exchange
PRIORITIZATION OF NURSING
PROBLEMS
PERCEPTION/COGNITION
 Disturbed Sensory Perception
 Impaired Memory
 Impaired Verbal Communication
SAFETY
 Risk for Infection
 Risk for Aspiration
 Risk for Injury
 Risk for Impaired Skin Integrity
 Ineffective Thermoregulation – Hyperthermia/Hypothermia
THERAPEUTIC
 Effective Therapeutic Regimen Management
NURSING HEALTH TEACHING
Family health teaching is an important role of the nurse
which includes the following:
 Maintaining skin care
 Adequate hydration
 Feeding with aspiration
 Scheduled and strict positioning
 Monitoring vital signs such as temperature, pulse, and
blood pressure
 Strict compliance to rehabilitation – physical therapy,
occupational therapy and speech-language pathology
PRESSURE ULCER
MANAGEMENT
Strict turning every two hours.
Keeping prominent areas dry, clean and
free from pressure.
Applying creams/ointments as
prescribed.
Dressing wound/bed sores.
PAIN MANAGEMENT
Pain Medications as ordered.
Promoting rest and sleep.
Instituting comfort measures.
MORSE FALL RISK ASSESSMENT
GLASGOW COMA SCALE
NCP: INEFFECTIVE AIRWAY
CLEARANCE
NCP: IMPAIRED SKIN INTEGRITY
NCP: IMPAIRED SKIN INTEGRITY
CONCLUSION
CVA is a medical emergency which can be
prevented if the risk factors are reduced. In
case of stroke, the patient must be instantly
brought to the hospital and be given
immediate
interventions.
Some
complications can be avoided if the patient is
closely monitored and given due attention
and care. The manifestations and recovery
depend on the location and severity of the
damage or bleeding in the patient’s brain.
THANK YOU FOR
LISTENING 