Care of Client with

Cerebrovascular Accident
(CVA) and Hypertension
 Anna Cruz is a 52 – year old school principal who was
brought by an ambulance to the hospital yesterday due to spasms
on the right arm and leg, difficulty swallowing, 2 episodes of
vomiting, blurring of vision, and dizziness. During admission her
vital signs revealed: Temp – 38.2 degrees Celsius, Pulse rate – 104
bpm, Respiratory rate – 24 br/min and BP – 160/100 mmHg. She
was responsive but could not immediately answer questions. She
was able to open and close her mouth when instructed.
 She was accompanied by her secretary. The ER doctor
examined her and advised blood tests for CBC, electrolytes and
blood sugar. A cardiac enzyme test was ordered for the following
day. An ECG was taken which showed tachycardia but with normal
sinus rhythm.
 A CT scan of the brain was done a few hours later. The CT
scan result revealed: “mild subdural clot at the right hemisphere
with minimal cerebral edema”. Her ICP was also measured at 17
mmHg. The admitting diagnosis was “Cerebrovascular Accident
CVA/ Stroke, Hypertension”. She was placed in a private room and
was kept under observation with her daughter as the watcher.
 EXECUTIVE SUMMARY
 A stroke or Cerebrovascular accident (CVA) occurs when a
blood vessel in the brain becomes blocked or bursts.
 Symptoms include sudden weakness, paralysis, and numbness
of your face or limbs.
 People who experience stroke may have difficulty thinking,
moving, and even breathing.
 Risk factors : hypertension (high blood pressure), personal or
family history of stroke or transient ischemic attack (TIA),
diabetes, high cholesterol.
This study concluded that chronic stress together with comorbidities

such as hypertension can precipitate the development of CVA.

The ICP of the patient increased and her right arm and leg

experienced spasms due to the interruption of nerve signal

transmission.
Patient was already experiencing tingling sensation on her right

arm, one of the most vulnerable part of her body when the accident

occurred.
Thus, patient A experienced spasm on her right arm and due to the

proximity of the nerves in her right arm to her right leg, the right

leg was also affected.

Orders Upon Admission:

Oxygen 2-3 L/min Nasal Cannula

O2 sat – 4 hrs
Patient is on NGT
Infused with NSS & D5% LR alternately –
2,500 ml/day
Blenderized feeding: Low fat, high caloric
diet
The primary drugs that were given to the patient worked:
Prevented Seizure
Managed the Hypertensive Crisis
Decreased Cerebral Edema
Decreased, Managing the ICP

phenytoin (Dilantin): PRN at 10 mg/kg to infuse IV at 25 mg/min.

nifedipine (Adalat): BID at 20 mg given PO or NGT.
mannitol (Osmitrol): q6, 10% at 1.25 g/kg infused IV over 30

minutes.
alteplase (Activase): infuse first 10% bolus over 1 minute and the

remainder to be infused over 60 minutes, at 0.9 mg/Kg of weight;

 This Case Analysis recommends that Range of Motion
exercises hastens the recovery process and it
prevents complications.
 The patient’s diet must be given emphasis by
coordinating with other members of the health care
team.
 Instruct the significant others which food to provide
and avoid during treatment and after discharge.
 Monitoring of vital signs and administration of
medication, prompt management of signs and
symptoms are also highlighted.
The formulation of NCP and HTP should include

both the patient and significant others.

Nurses should also act as a bridge: refer the

patient’s significant others to private and

government programs/organizations that can

help them with their hospital expenses.

Lastly, this case study concludes that thorough

assessment and individualized treatment always

works.
 INTRODUCTION
IDENTIFICATION THE FOCAL
PROBLEM
 A stroke also known as cerebrovascular accident (CVA)
occurs when a blood vessel in the brain becomes blocked
or bursts.
 The brain depends on a network of blood vessels to supply
it with oxygen-rich blood. A loss of blood flow causes
surrounding nerve cells to be cut off from their supply of
nutrients and oxygen during a stroke.
 Stroke can be divided into two major categories:
Hemorrhagic in which there is excavation of blood into the
brain or sub arachnoid space, and Ischemic in which
vascular occlusion and significant hypo perfusion occur.
Ischemic stroke is due to a clot in the
blood supply to the brain
When brain cells begin to die as a result
of the reduced blood flow. Symptoms
occur in the part of the body that those
brain cells control.
The majority of people who had their first
stroke had high pressure or hypertension.
High blood pressure causes weakened
arteries in the brain, which adds much
higher risk for stroke — which is why
controlling blood pressure is critical in
lowering the risk of getting a stroke.
Primary hypertension and Secondary
Hypertension are two types of
Hypertension.
 SIGNIFICANCE OF THE STUDY
This study will be great benefit to the following:
Patient: Optimize the patient's level of functioning and independence

through making the patient understand the disease process and

management of the cerebrovascular disease.

Patient Family: For them to develop effective ways to manage the

needs of patient and provide support to enrich their relationship for

being the support system.

Nursing Students: Enhance the knowledge, skills and attitude in

providing quality and evidence based nursing care to patients with

similar conditions and use this study as a basis for further

development.
ANATOMY AND PHYSIOLOGY
BRAIN
The brain receives information through
our five senses: sight, smell, touch, taste,
and hearing – often many at one time. It
assembles the messages in a way that has
meaning for us, and can store that
information in our memory. The brain
controls our thoughts, memory and
speech, movement of the arms and legs,
and the function of many organs within
our body.
NERVOUS SYSTEM

The nervous system is a complex

network of nerves and nerve cells
(neurons) that carry signals or
messages to and from the brain
and spinal cord to different parts
of the body. It is made up of the
central nervous system and the
peripheral nervous system.
HEART

The cardiovascular system is a closed

system if the heart and blood vessels. The

heart pumps blood through a closed

system of blood vessels. Blood vessels

allow blood to circulate to all parts of the

body. Arteries usually colored red because

oxygen rich, carry blood away from the

heart to capillaries within the tissues.

Veins usually colored blue because oxygen

poor, carry blood to the heart from the

capillaries. Capillaries are the smallest

vessels within the tissues where gas

exchange take place.

REVIEW OF RELATED LITERATURE
Stroke is the world’s second leading cause of

death and the third leading cause of

disability. About 25% of strokes are

recurrent, the annual risk of recurrence is

about 4% and the mortality rate after a

recurrent stroke is 41% (Wajngarten, 2019).

 Strokeis divided into hemorrhagic and ischemic
strokes. The majority (87%) of strokes are
ischemic, although the relative burden of
hemorrhagic versus ischemic stroke varies
among different populations.

Ischemic 87%
Hemorrhagic
13%

4th Qtr
Johnson et al, (2016) stated that stroke
has risk factors that are similar to
coronary heart disease and other vascular
disorders. Targeting the main modifiable
factors of hypertension, elevated lipids,
and diabetes are all effective preventive
strategies. Comorbidities are a hallmark of
stroke that both increase the incidence of
stroke and worsen outcome.
Modifiable and nonmodifiable risk factors for

ischemic stroke have been identified and

include age; gender; race/ethnicity; heredity;

hypertension; cardiac disease, particularly atrial

fibrillation; diabetes mellitus;

hypercholesterolemia; cigarette smoking; and

alcohol abuse. The most important modifiable

risk factor for ischemic stroke is hypertension,

and antihypertensive treatment is critical for

Symptoms of stroke of depend upon the
affected region of brain, which in turn is
defined by the arterial anatomy involved.
During a stroke, elevated blood pressure
is completely possible, with 60–80 percent
of patients reporting a systolic blood
pressure (Systolic blood pressure) of
>140 mm Hg.
Lifestyle modification is appropriate at all
levels of intervention. Good lifestyle
campaigns, such as salt reduction and
increased physical activity, as well as
infographics on stroke and its risk factors,
must be expanded. Despite advances in
stroke prevention strategies and
treatments, stroke recurrence is still the
major threat to any stroke survivor.
 PATHOPHYSIOLOGY

 Cerebrovascular accident (CVA) is the medical

term for a stroke. A stroke occurs when blood flow to
a part of the brain is disrupted either by a blockage or
the rupture of a blood vessel.CVA refers to a
functional abnormality of the central nervous system
(CNS) that occurs when the blood supply to the brain
is disrupted.
 Strokes can be divided into two major
categories. These are ischemic
(approximately 87%), in which
vascular occlusion and significant
hypoperfusion occur, and hemorrhagic
(approximately 13%), in which there
is extravasation of blood into the brain
or subarachnoid space. Although there
are some similarities between the two
types of stroke, differences exist in
etiology, pathophysiology, disease
management and nursing care.
A transient ischemic attack or TIA is a neurologic

deficit typically lasting 1 to 2 hours. A TIA is

manifested by a sudden loss of motor, sensory, or

visual function. The symptoms result from temporary

ischemia or the process of impairment of blood flow

to a specific region of the brain; however, when brain

imaging is performed, there is no evidence of

ischemia.
A TIA may serve as a warning of impending stroke.
Accordingly, approximately 15% of all strokes are
preceded by a TIA. Lack of evaluation and treatment
of a patient who has experienced previous TIAs
may result in a stroke
and irreversible deficits.
 DISEASE MANAGEMENT
NURSING CARE MANAGEMENT

Other treatment and care modalities include:

 Improving Mobility and Preventing Joint Deformities
 Changing Positions – change patient’s position every 2 hours
 Establishing an Exercise Program – the affected extremities are
exercised passively and put through a full range of motion four or
five times a day
 Preparing for Ambulation – the patient is assisted out of bed and
an active rehabilitation program is started
 Enhancing Self-Care
Assisting With Nutrition

Attaining Bladder And Bowel Control

Improving Thought Processes

Maintaining Skin Integrity

Improving Family Coping

Monitoring And Managing Potential Complications

 PATHOGENESIS
The pathogenesis of essential hypertension is multifactorial and highly

complex. Factors that play an important role in the pathogenesis of

hypertension include genetics, activation of neurohormonal systems such

as the sympathetic nervous system and renin-angiotensin-aldosterone

system, obesity, and increased dietary salt intake. Arterial hypertension is

the condition of persistent elevation of systemic blood pressure (BP).

Cerebrovascular disease includes all disorders in which an area of the

brain is temporarily or permanently affected by ischemia or bleeding and

one or more of the cerebral blood vessels are involved in the pathological

process. Cerebrovascular disease includes STROKE. Thus, Clot formation

(thrombosis), blockage (embolism) or blood vessel rupture (hemorrhage).

Lack of sufficient blood flow (ischemia) affects brain tissue and may cause
PATHOGENESIS

Figure 3. Pathogenesis of the Patient’s Condition

Figure 3.1. Subdural Hematoma
 PATIENT’S PROFILE
Name: Anna Cruz

Sex: Female

Address: Armor Village, Zamboanga City

Birthdate: May 01, 1969

Birthplace: Zamboanga City

Age: 52

Occupation: High School Principal

Religion: Roman Catholic

Civil Status: Widow

Nationality: Filipino

Weight: 60 kgs

Height: 5’6”
 HISTORY OF PAST ILLNESS

According to the daughter of the patient,

The patient was diagnosed with Primary
Hypertension 5 years ago.
Currently taking (Adalat) 20mg PO as
maintenance.
 HISTORY OF PRESENT ILLNESS

The patient CT Scan result revealed: “mild

subdural clot at the right hemisphere with
minimal cerebral edema”.
Upon admission, The patient was
diagnosed of Cerebrovascular Accident
CVA/Stroke, Hypertension.
 GORDON'S 11 FUNCTIONAL HEALTH PATTERNS

Health Perception Health Management Pattern

• Patient was diagnosed with primary hypertension 5 years ago and she was

prescribed of nefedifine (Adalat) 20 mg PO as maintenance.

• She also received blood transfusion when she was 45 year old because of dengue

fever and had a history of UTI 2 years ago with some antibiotics prescribed.

• Patient has been complaining of “tingling sensation” in her fingertips but did not

pay much attention to it.

Nutrition and Metabolic Pattern

• The patient’s daughter said that her mother eat three times a day, her favorite

food is spaghetti and ice cream and her digestive metabolism or bowel movement

were loose at times. Her current body weight is 60 kilograms with a normal BMI.
Elimination Pattern

•Anna has no urine output since admission and she has vomited

once. According to the daughter, Anna’s bowel habits is regular.

Activity and Exercise Pattern

• Anna’s daughter claimed that her mother spend too much time

at work and had less time for leisure activities.

Sleep and Rest Pattern

• Patient works overtime in most cases and hardly has time for

rest. The patient comes home late, sleeps late to finish her office

works, goes to work early and stays in the office even on Sundays.
Cognition and Perception Pattern

• Before the incident, the patient was always alert and oriented, she could

answer questions quickly and correctly.

• Currently the patient is conscious, responsive with signs of confusion, can

follow direction when instructed but cannot recall some personal information.

• She can recognize her daughter and secretary but she cannot remember

the name of her husband.

Self-perception and Self-concept Pattern

• Her daughter said that the patient is a very kind person but strict when it

comes to work. She is organized and sets deadlines in almost all tasks.

Roles and Relationship Pattern

• The daughter claimed that Anna is a principal in a secondary school for 15

years. She is a widow and a mother of only one child.

Sexuality and Reproductive Pattern

• The patient become a widow when she was 45 years old, she

only have one child and she underwent cesarean section when

she was 26 years old.

Coping and Stress Tolerance Pattern

• Patient faces the stress head-on and she works her way to

finish the tasks on the time schedule.

Values and Beliefs Pattern

• The daughter claimed that her mother is a Roman Catholic but

seldom goes to church and prefers to read the Bible alone.

 CEPHALO-CAUDAL ASSESSMENT
General Appearance:

• During the initial contact the patient was wearing a six-buttoned office
uniform, three of which are unbuttoned paired with a semi tight black
pants.

• Appears weak, flushed and distressed, her hair is messy and she was
wearing her eyeglasses.

• Conscious, responsive but could not instantaneously answer the

questions.

• Signs of confusion were also noted.

• Weighs 60 kilograms and her height is 5’6”.

Head

a. Hair, Cranial bones/skull, fontanels, sutures, others.

• Gray hair is completely distributed in the head with presence of dandruff on

scattered areas, no lesions, no scars and no wounds noted.

b. Eyes

• Wears eyeglasses +1.5 (since 30 years old), pupils were reactive to light

and accommodation, corneal blinking reflexes were present, sclerae were

white, complained of “blurring” and cannot correctly identify letters in the

magazine when shown to her.

c. Nose

• Nasal passageways were patent, septum was in place, upon illumination,

the sinuses revealed faint red color, cannot identify the scent of mild soap

when introduced.
d. Ears

• Upon whispering, patient kept asking the nurse to repeat

what she said because she “did not hear” anything. Ears had
intact ear canal with minimal cerumen noted, nor discharges
present.

e. Mouth and Throat

• Mouth was clean, with missing right upper molar 1, left lower
molar 1 and right lower molar 1. No odor noted from the
mouth, uvula was intact, tonsils not inflamed.

• Cannot drink well from a cup, Speech was slurred.

• Drooling noted on one side of the mouth.

Neck
a. Trachea
• Neck was aligned, no complaints of discomfort claimed when
palpated.

b. Thyroid Gland
• The thyroid gland was hardly palpable.

c. Great vessels
• No bruit or abnormal sounds was identified, large vessels were
intact and not swollen, and the carotid pulse rate was 104 b/min.
Anterior Thorax

• Anterior thorax showed no evidence of lesions,

both breasts showed no signs of mass or discharges,

breath sounds were clear, RR -24 br/min.

Posterior Thorax

• Posterior thorax showed no evidence of lesions,

scars or wounds, percussion sounds showed no

abnormal results, no lesions nor masses were

palpated, breath sounds were clear. RR – 24 br/min.

Abdomen

• Abdomen was soft, no scars and lesions noted, bowel sounds

were heard at 2x per minute in all 4 quadrants, percussion

sounds were tympanic at the epigastric region and dull at the

hypochondriac regions; no masses were palpated, and no

unusual findings noted.

Perineal and Rectal Areas

• Genital area appeared intact, no discharges noted, no

hemorrhoids or any sign of abnormality noted with inspection

and palpation.
Neurologic Assessment

• Cranial nerves revealed: “blurred vision, can’t see the objects in

periphery, cannot identify the scent of mild soap, difficulty

swallowing, speech is understandable and has no dissociation of

thoughts, ICP was measured at 17 mmHg, some stiff neck and

hearing difficulty was noted.

• Gag reflex was elicited prior to admission. Extremities: 2+ scores

in both upper and 3+ scores in both lower areas for resistance.

• Cannot raise arms and legs independently but can identify dull

and sharp stimulations in all 4 limbs. With some “pins and needles”

feelings claimed in fingertips

DRUG STUDY
 COMPREHENSIVE
NURSING CARE PLAN
Table 6: Nursing Care Plan, Priority No.2
Table 7: Nursing Care Plan, Priority No.3
HEALTH TEACHING
PLAN
 Conclusions
The physical and mental stresses brought by her work, her

hypertension and lack of exercise precipitated the development of

CVA.
The brain tissues on the right hemisphere experienced ischemia,

and it led to her collapse.

The ICP increased and spasms developed on the right arm because

of the interruption of signal transmission.

Due to the tingling sensation 3 days before, it made her right arm

vulnerable to the accident. She experienced spasm on the right arm

and due to the proximity of the nerves in her right arm to her right

leg, the right leg was also affected.

Patient A was given immediate attention by her secretary,

as a result, no further damage was manifested on the left

side of the patient.

The patient is farsighted.
Her past admission and surgical operation are not

correlated to her condition. However, her menopausal

phase could have affected her vascular integrity.

(phenytoin) worked in preventing the onset of seizure.
(nifedipine)worked in reducing both the
systolic and diastolic pressure of the
patient.
mannitol) helped in reducing the cerebral
edema and it decreased the patient’s ICP.
(altephase) was used therapeutically to
manage the clot formation and reduce the
ICP from 17 mmHg to 15 mmHg.
The oxygen therapy was ineffective in
providing the patient with good oxygen
supply as evidenced by the result of her
oxygen saturation following the next day.
The activities of daily living of patient A is
affected as the disease condition altered
her motor abilities.
Chances of recovery and restoration of
normal function however, is high if patient
A is admitted for at least a week to further
monitor her neurological status and
prevent any complications.
 Recommendations
The following recommendations basing on Patient a

condition are not just useful for the patient but also to

patients suffering from the same condition.

1. ROM (Range of Motion) exercises must be performed on

both extremities to avoid muscle atrophy and contractures.

2. Encourage to modify diet and coordinate with the

nutritionist and significant other for dietary requirements.

3. Vital signs monitoring every 30 minutes to assess any

significant elevation which can precipitate another attack,

ICP monitoring as ordered and management of fever if

4. Monitor input and output. Note signs of water retention.

5. Observing the scheduled time in administering

medication. If medication does not provide the therapeutic

effect needed, notify physician for possible adjustment of the

dosage or replacement of the drug.

6. Plan a comprehensive health teaching session for the

patients and SO following the SMART standard.

7. Encourage patients and SO to report signs and

symptoms for prompt management.

8. Promote low to moderate aerobic physical

exercises.

9. Early training to promote hand mobility in the

form of grasping and releasing object.

10. Notify physicians about the patient and SO's

concern regarding admission and prepare for

possible referrals (Government Assistance Program).

11. Continuous assessment to the patient’s sensory

perception.

12. Monitor the bowel sound of patients, give stool

softeners if need arises or enforce bowel training

exercises as tolerated. Identify certain adverse effects

of medications that may precipitate constipation.