I. INTRODUCTION Cerebrovascular accident: The sudden death of some brain cells due to lack of oxy en !

hen the blood flo! to the brain is im"aired by blocka e or ru"ture of an artery to the brain. # C$# is also referred to as a stroke. %ym"toms of a stroke de"end on the area of the brain affected. The most common sym"tom is !eakness or "aralysis of one side of the body !ith "artial or com"lete loss of voluntary movement or sensation in a le or arm. There can be s"eech "roblems and !eak face muscles& causin droolin . Numbness or tin lin is very common. # stroke involvin the base of the brain can affect balance& vision& s!allo!in & breathin and even unconsciousness. # stroke is a medical emer ency. #nyone sus"ected of havin a stroke should be taken immediately to a medical facility for dia nosis and treatment. The causes of stroke: #n artery to the brain may be blocked by a clot 'thrombosis( !hich ty"ically occurs in a blood vessel that has "reviously been narro!ed due to atherosclerosis ')hardenin of the artery)(. *hen a blood clot or a "iece of an atherosclerotic "la+ue 'a cholesterol and calcium de"osit on the !all of the artery( breaks loose& it can travel throu h the circulation and lod e in an artery of the brain& "lu in it u" and sto""in the flo! of blood, this is referred to as an embolic stroke. # blood clot can form in a chamber of the heart !hen the heart beats irre ularly& as in atrial fibrillation, such clots usually stay attached to the inner linin of the heart but they may break off& travel throu h the blood stream& form a "lu 'embolus( in a brain artery and cause a stroke. # cerebral hemorrha e 'bleedin in the brain(& as from an aneurysm 'a !idenin and !eakenin ( of a blood vessel in the brain& also causes stroke. The dia nosis of stroke involves a medical history and a "hysical examination. Tests are done to search for treatable causes of a stroke and hel" "revent further brain dama e. # C#T scan 'a s"ecial -.ray study( of the brain is often done to sho! bleedin into the brain, this is treated differently than a stroke caused by lack of blood su""ly. # C#T scan also can rule out some other conditions that may mimic a stroke. # sound!ave of the heart 'echocardio ram( may be done to look for a source of blood clots in the heart. Narro!in of the carotid artery 'the main artery that su""lies blood to each side of the brain( in the neck can be seen !ith a sound!ave test called a carotid ultrasound. /lood tests are done to look for si ns of inflammation !hich can su est inflamed arteries. Certain blood "roteins are tested that can increase the chance of stroke by thickenin the blood. %troke look.alikes: 0ust because a "erson has slurred s"eech or !eakness on one side of the body does not necessarily mean that "erson has had a stroke. There are many other nervous system disorders that can mimic a stroke includin a brain tumor& a subdural hematoma 'a collection of blood bet!een the brain and the skull( or a brain abscess 'a "ool of "us in the brain caused by bacteria or a fun us(. $irus infection of the brain 'viral

ence"halitis( can cause sym"toms similar to those of a stroke& as can an overdose of certain medications. Dehydration or an imbalance of sodium& calcium& or lucose can cause neurolo ic abnormalities similar to a stroke. Treatment of a stroke: 1arly use of anticoa ulants to minimi2e blood clottin has value in some "atients. Treatment of blood "ressure that is too hi h or too lo! may be necessary. '3o!erin elevated blood "ressure into the normal ran e is no lon er recommended durin the first fe! days follo!in a stroke since this may further reduce blood flo! throu h narro!ed arteries and make the stroke !orse.( The blood su ar lucose in diabetics is often +uite hi h after a stroke, controllin the lucose level may minimi2e the si2e of a stroke. Dru s that can dissolve blood clots may be useful in stroke treatment. Oxy en is iven as needed. Ne! medications that can hel" oxy en.starved brain cells survive !hile circulation is reestablished are bein develo"ed. Rehabilitation: *hen a "atient is no lon er acutely ill after a stroke& the aim turns to maximi2in the "atient4s functional abilities. This can be done in an in"atient rehabilitation hos"ital or in a s"ecial area of a eneral hos"ital and in a nursin facility. The rehabilitation "rocess can involve s"eech thera"y to relearn talkin and s!allo!in & occu"ational thera"y for re ainin dexterity of the arms and hands& "hysical thera"y for im"rovin stren th and !alkin & etc. The oal is for the "atient to resume as many of their "re.stroke activities as "ossible.

OBJECTIVES:

General Objective: To be able to ac+uire kno!led e on ho! to deal or mana e a "atient !ith Cerebrovascular #ccident.

Specific Objective: 5. 7. 8. 9. :. To thorou hly assess the clinical manifestations of "atient !ith C$# based on the "atient6s history. To formulate com"rehensive nursin dia nosis for a client !ith C$#. To formulate a "lan of care for "atients !ith C$#. To formulate a""ro"riate nursin interventions that can be a""lied for a "atient !ith C$#. To evaluate the "lan of care for a "atient !ith C$#.

SIGNIFICANCE OF THE STUD The case study re ardin "atient !ith colon tumor "rovides a!areness and kno!led e re ardin the disease and its !arnin si ns that can be used as a tool for further mana ement of the disease and its "revention.

NU!SING HEA"TH HISTO!

A# BIOG!A$HIC DATA Na%e: ;rs. # < A&&re'': %an 0ose <aombon /ulacan A(e: :7 yrs old Se): = !ace: =ili"ino *arital Stat+': ;arried Occ+pati,n: >ouse!ife !eli(i,+' Orientati,n: Roman Catholic Healt- Care Financin(: <hil health CHIEF CO*$"AINT ?Nan hina an kali!a baha i n akn kata!an@& as verbali2es by the "atient HISTO! OF $!ESENT I""NESS One day "rior to admission& the "atient felt !eak on the left side of her body& she also has hi h blood "ressure that day& so they decided to o to the hos"ital for further mana ement and treatment $AST HISTO! The client received 7 immuni2ations only '/CA and D<T( because the family is not a!are of its im"ortance. The client commonly had cou h and fever. The childhood diseases that she ac+uired are mum"s& measles& and chicken "ox and sore eyes .There !ere no kno!n food or medication aller y. Client has no history of accidents or inBuries. %he does not smoke or drink alcohol FA*I" HISTO! OF I""NESS The clients father and mother has a history of hy"ertension.

B# C#

D#

E#

F#

HEA"TH $E!CE$TION $ATTE!N BEFO!E HOS$ITA"I.ATION The client ex"erienced !eakness on the left side of her body !hen she does some household task like ardenin . %he mana es it by havin a "eriod of rest in bed. %he is still uncomfortable !ith her state of health because it reatly affects her daily activities. %he cannot "erform the thin s she likes and usually do. Client believed that "ro"er diet& exercises& and ade+uate financial su""ort are the thin s needed to maintain "ro"er health diet and no vices are factors of havin a healthy body. %he does not "erform self.breast examination. *hen si ns and sym"toms arise they sou ht medical consultation. The client also believed in ?albularyo@ and use herbal medicines such as la undi& uava leaves& "ito."ito 'C different kinds of leaves(. DU!ING HOS$ITA"I.ATION The client still feels left sided body !eakness

G#

NUT!ITIONA" AND *ETABO"IC $ATTE!N $!IO! TO HOS$ITA"I.ATION The client6s ty"ical food intake is com"osed of rice& meat& and fish. Occasionally she eats ve etables and fruits. %he6s fond of eatin "rocessed food like corned beef& anythin !ith "reservatives& tocino& chicharon and fried dish '"orkcho"& chicken(. %he used a lot fish sauce& ;%A !hen cookin . >er a""etite !as ood and drinks D lasses of !ater daily. Client !ound heals !ell and she !ears com"lete u""er and lo!er dentures but this doesn6t affect her food intake.

H#

E"I*INATION $ATTE!N BEFO!E HOS$ITA"I.ATION Client usually defecates at least 7.8 times of soft and !atery stool consistin of small amounts !hich is li ht bro!n color !ith "resence of blood 'fresh blood(& !ith discomfort or difficulties and ex"erienced excessive s!eatin . Client urinates Dx a day !hich is yello!ish. oran e color !Eout any discomfort.

%tool Characteristics Color Consistency %mell =re+uency and amount Urine Characteristics Color %mell =re+uency and #mount

3i ht bro!n =ormed stool =oul odor Once a day

Fello!ish. oran e aromatic D times a day at least 5GGGmlEday

DU!ING HOS$ITA"I.ATION Client usually defecate at least 5.7x a day semi formed stool !ith the "resence of blood !hich is li ht bro!n to bro!n. %he has difficulty in defecation !ith excessive s!eatin . Client urinates 9x a day !hich is yello! in color !Eout any discomfort. %tool Characteristics Color 3i ht bro!n to bro!n Consistency %mell =re+uency and #mount Urine Characteristics Color %mell =re+uency and #mount I# ACTIVIT /E0E!CISE $ATTE!N %emi formed =oul odor 5.7 times a day in small amounts

yello! aromatic D times a day at least 5GGGmlEday

BEFO!E HOS$ITA"I.ATION The client said that her activities at home !ere limited because she has ex"erience hi h blood "ressure. %he s"ends her days !ith minimal cleanin like ardenin and !atchin T$. %he also "layed !ith her rand dau hter and randsons. %he !alks short distances as form of her exercise. DU!ING HOS$ITA"I.ATION Client sho!s tiredness and limited movement. # client doesn6t "erform any routine exercise. In the hos"ital the client instructed to <erform RO; by the health care "rovider. 8.=11DINA 8.AROO;INA 8.TOI31TTINA 8.A1N1R#3 ;O/I3ITF 9.COOHINA 8./1D ;O/I3ITF 9./#T>INA 8.DR1%%INA 9.>O;1 ;#INT1N#NC1 3evel G . =ull self care 3evel 5 . Re+uires use of e+ui"ment or device 3evel 7 . Re+uires assistance or su"ervision from another "erson 3evel 8 . Re+uires assistance or su"ervision from another "erson or device 3evel 9 . Is de"endent and does not "artici"ate J# S"EE$/!EST $ATTE!N BEFO!E HOS$ITA"I.ATION The client slee"s for I.J hours usually from I"m.:am but not continuous because of "rom"t abdominal "ain. %he doesn6t take any slee" medications. %he also does take na"s durin afternoon. The client slee"s inade+uately at ni ht. Clients usually !atch T$ sho!s and "layed !ith her rand dau hter and randsons. DU!ING HOS$ITA"I.ATION The client slee"s is lessen to D hours due to abdominal "ain and interru"ted !hen the health care "rovider ive medication and monitor her vital si ns durin the ni ht. %he takes na"s in the afternoon for about 5 hour. 1# COGNITIVE/$E!CE$TUA" $ATTE!N The client does not have any hearin difficulty and can6t remember "ast events %he has a visual "roblem Kfar.si htedness. Throu h demonstration she could easily learn thin s. #bdominal "ain is the one !hich alters her comfort and she mana es it !ith takin "rescribed medications.

"#

SE"F $E!CE$TION AND SE"F CONCE$T $ATTE!N The client said that her condition !as not im"rove& she still ex"erience left sided body !eakness and hi h blood "ressure. Client feels that she lose some !ei ht. =inancial "roblems and health condition usually makes her !orried. *hen this thin s are encountered the client diverts her attention throu h talkin to a family member and "rayin . *# !O"E/!E"ATIONSHI$ $ATTE!N The client lives in extended family. They live "eacefully even there are hardshi" and difficulties that arrives to their lives. /y means of ood conversation they can easily fixed family "roblems. *hen family ex"erienced difficulty of carin for the client they Bust take it as trials iven by od. They have harmonious relationshi"s !ith the family and their nei hbors. SE0UA"IT /!E$!ODUCTIVE $ATTE!N The client is done in sta e of meno"ausal. There is no sexual activity. #ccordin to the client& decreased sexual activity is not a "roblem because they !ere already old. They s"ent most of their time by takin care of each other and !ith that they are sho!in their love for one another. CO$ING ST!ESS TO"E!ANCE $ATTE!N The client !as observed to be !ithdra!n but the behavior im"roved as evidenced by her sociali2ation !ith other "eo"le. *hen thin s are not so !ell& she finds her husband to be the most hel"ful "erson in talkin thin s over. *hen bi "roblems encountered& she al!ays "rays and ask assistance !ith the 3ord. %ome of the time they failed to attain !hat they !ant and try other alternatives in solvin it. VA"UE/BE"IEF $ATTE!N The client is a Roman Catholics usually o to the church to attend mass every %undays& first =riday of the month and novena. %he is very active in "artici"atin reli ious activities. %he hel"s s"read the !ord of od throu h catechism.

N#

O#

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The Brain
Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. The names of these vesicles and the major adult structures that develop from the vesicles follow (see Table 1 )

The telencephalon generates the cerebrum (which contains the cerebral corte!, white matter, and basal ganglia). The diencephalon generates the thalamus, hypothalamus, and pineal gland. The mesencephalon generates the midbrain portion of the brain stem. The metencephalon generates the pons portion of the brain stem and the cerebellum. The myelencephalon generates the medulla oblongata portion of the brain stem
TABLE 1 The Vesicles and Their Components Primary Vesicles prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon Secondary Vesicles telencephacerebrum telencephacerebrum telencephacerebrum diencephalon Adult Structure Important Components or Features

cerebral (cerebral hemispheres) cerebral cortex (gray matter): motor areas, sensory areas, association areas cerebral (cerebral hemispheres) cerebral white matter: association fibers, commisural fibers, projection fibers cerebral (cerebral hemispheres) basal ganglia (gray matter): caudate nucleus & amygdala, putamen, globus pallidus diencephalon thalamus: relays sensory information

Primary Vesicles prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon (forebrain) prosencephalon (forebrain) mesencephalon (midbrain)

Secondary Vesicles diencephalon diencephalon diencephalon diencephalon diencephalon diencephalon mesencephalon

Adult Structure diencephalon diencephalon diencephalon diencephalon diencephalon diencephalon brain stem

Important Components or Features hypothalamus: maintains body homeostasis mammillary bodies: relays sensations of smells to cerebrum optic chiasma: crossover of optic nerves infundibulum: stalk of pituitary gland pituitary gland: source of hormones epithalamus: pineal gland midbrain: cerebral peduncles, sup. cerebellar peduncles, corpora uadrigemina, superior colliculi pons: middle cerebellar peduncles, pneumotaxic area, apneustic area sup. cerebellar peduncles, middle cerebellar peduncles, inferior cerebellar peduncles medulla oblongata: pyramids, cardiovascular center, respiratory center

rhombencephalon (hindbrain) metencephalon rhombencephalon (hindbrain) metencephalon rhombencephalon (hindbrain) myelencephalon

brain stem cerebellum brain stem

Primary Vesicles

Secondary Vesicles

Adult Structure

Important Components or Features

Primary Vesicles

Secondary Vesicles

Adult Structure

Important Components or Features

.
" second method for classifying brain regions is by their organi#ation in the adult brain. The following four divisions are recogni#ed (see $igure 1 ).

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part
of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions

" gyrus (plural, gyri) is an elevated ridge among the convolutions. " sulcus (plural, sulci) is a shallow groove among the convolutions. " fissure is a deep groove among the convolutions.
The deeper fissures divide the cerebrum into five lobes (most named after bordering s%ull bones)&the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. "ll but the insula are visible from the outside surface of the brain. " cross section of the cerebrum shows three distinct layers of nervous tissue

The cerebral corte! is a thin outer layer of gray matter. 'uch activities as speech, evaluation of stimuli, conscious thin%ing, and control
of s%eletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas.

The cerebral white matter underlies the cerebral corte!. (t contains mostly myelinated a!ons that connect cerebral hemispheres
(association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection

fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres.

)asal ganglia (basal nuclei) are several poc%ets of gray matter located deep inside the cerebral white matter. The major regions in the
basal ganglia&the caudate nuclei, the putamen, and the globus pallidus&are involved in relaying and modifying nerve impulses passing from the cerebral corte! to the spinal cord. "rm swinging while wal%ing, for e!ample, is controlled here.

The diencephalon connects the cerebrum to the brain stem. (t consists of the following major regions The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. 'ome nerve impulses are
sorted and grouped here before being transmitted to the cerebrum. *ertain sensations, such as pain, pressure, and temperature, are evaluated here also.

The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological cloc%
(sleep+wa%e cycles).

The hypothalamus regulates numerous important body activities. (t controls the autonomic nervous system and regulates emotion,
behavior, hunger, thirst, body temperature, and the biological cloc%. (t also produces two hormones ("D, and o!ytocin) and various releasing hormones that control hormone production in the anterior pituitary gland. The following structures are either included or associated with the hypothalamus.

The mammillary bodies relay sensations of smell. The infundibulum connects the pituitary gland to the hypothalamus.

 The optic chiasma passes between the hypothalamus and the pituitary gland. ,ere, portions of the optic nerve from each eye cross over
to the cerebral hemisphere on the opposite side of the brain.

The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber
tracts surrounding a core of gray matter. The brain stem consists of the following four regions, all of which provide connections between various parts of the brain and between the brain and the spinal cord. ('ome prominent structures are illustrated in $igure - ).

Figure 2 !rominent structures of the brain stem.

The midbrain is the uppermost part of the brain stem. The pons is the bulging region in the middle of the brain stem.

 The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum. The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain
regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (."'), one component of the reticular formation, is responsible for maintaining wa%efulness and alertness and for filtering out unimportant sensory information. /ther components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two wingli%e lobes, the cerebellar hemispheres. 0i%e that of the cerebrum, the
surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by comparing actual s%eletal movements to the movement that was intended. The limbic system is a networ% of neurons that e!tends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to behaviors, e!periences, and memories. 1motions such as pleasure, fear, anger, sorrow, and affection are imparted to events and e!periences. The limbic system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and encircles the inside border of the cerebrum. The following components are included

The hippocampus (located in the cerebral hemisphere) The denate gyrus (located in cerebral hemisphere) The amygdala (amygdaloid body) (an almond+shaped body associated with the caudate nucleus of the basal ganglia) The mammillary bodies (in the hypothalamus) The anterior thalamic nuclei (in the thalamus)

 The forni! (a bundle of fiber tracts that lin%s components of the limbic system)

2"T,/2,3'(/0/43

Cerebrovascular accident or stroke (also called brain attac%) results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than -5 hours. 'tro%e are either ischemic, caused by partial or complete occlusions of a cerebral blood vessel by cerebral thrombosis or embolism or hemorrhage (lea%age of blood from a vessel causes compression of brain tissue and spasm of adjacent vessels). ,emorrhage may occur outside the dura (e!tradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance itself (intracerebral). .is% factors for stro%e include transient ischemic attac%s (T("s) 6 warning sign of impending stro%e 6 hypertension, arteriosclerosis, heart disease, elevated cholesterol, diabetes mellitus, obesity, carotid stenosis, polycythemia, hormonal use, (.7., drug use, arrhythmias, and cigarette smo%ing. *omplications of stro%e include aspiration pneumonia, dysphagia, constractures, deep vein thrombosis, pulmonary embolism, depression and brain stem herniation.

0abaoratory .esult )lood *hemistry

.1'80T 4lucose 8ric acid *,0 Tryglycerides Directhol 00 70D0 "lanine "mino Transferase 119mg:dl (high) ;.< mg:dl -=< mg:dl (high) 1=<mg:dl ( high) => mg:dl (high) 1?> mg:dl (high) >5 11; 8:0 (high)

=astin /lood Alucose Result Crea #lanine Transferase Na H 558 m Edl G.Jm Edl 5:5m Edl 9.7mmolE3

D!UG STUD

Na%e ,f Dr+(2 Generic2Bran& na%e

Generic Na%e: ;annitol Bran& Na%e: O'%itr,l Dr+( Cla''ificati,n: Diuretics

D,'a(e2 !,+te2 Fre3+enc4

Acti,n

In&icati,n

C,ntrain&icati,n

A&ver'e !eacti,n

N+r'in( !e'p,n'ibilit4

C: ml& +D

Increase osmotic "ressure of lomerular filtrate& inhibitin tubular reabsorb"tion of !ater and electrolytes& dru elevates "lasma osmolality& increasin !ater flo! into exracellular fluid

. to reduce . contraindicated to .%ei2ure intraocular or "atient .1dema intracranial hy"ersensitive to .>eart =ailure "ressure dru s .Urine retention ./lurred $ision .chills

.monitor vital si n .to relieve thirst ive fre+uent mouth care .don6t ive electrolyte free solution !ith blood