A Case Presentation of a Patient with

Hemorragic
Crebrovascular
Accident

Submitted by:

Filomeno, Gerald V.
Group 9

Submitted to:

Ms. Rosa Reyes RN,MAN

 Introduction

A stroke is damage to part of the brain when its blood supply

is suddenly reduced or stopped. A stroke may also be called a
cerebral vascular accident, or CVA. The part of the brain deprived of
blood dies and can no longer function. Blood is prevented from
reaching brain tissue when a blood vessel leading to the brain
becomes blocked (ischemic) or bursts (hemorrhagic). The symptoms
of a stroke differ, depending on the part of the brain affected and
the extent of the damage. Symptoms following a stroke come on
suddenly and may include: weakness, numbness, or tingling in the
face, arm, or leg, especially on one side of the body trouble walking,
dizziness, loss of balance, or coordination inability to speak or
difficulty speaking or understanding, trouble seeing with one or both
eyes, or double vision, confusion or personality changes, difficulty
with muscle movements, such as swallowing, moving arms and legs,
loss of bowel and bladder control, severe headache with no known
cause, and loss of consciousness.

LEARNING OBJECTIVES:

General Objective

This case presentation aims to increase my knowledge and

skills regarding Cerebrovascular Accident thus enabling me to learn
how to render a quality health care to patient with this kind of
diagnosis.

Specific Objectives

1. To be able to state the significance of laboratory findings to

patient's condition.
2. To be able to discuss the pathology of the disease.
3. To be able to discuss the effects of the drugs taken to the
patient's condition.
4. To be able to formulate effective nursing care plan for the
 patient diagnosed of Cerebro Vascular Accident.

DEMOGRAPHIC PROFILE

Name: J.F.R
Age: 37 y/o
Gender: Male
Civil Status: Married
Date of Birth: June 07, 1975
Place of Birth: Negros Occidental
Citizanship : Filipino
Religion: Roman Catholic
Occupation: Security Guard
Language Spoken: English, Tagalog
Date of Admission: August 02, 2010
Chief Complain: Increase blood pressure
Admitting Diagnosis: CVA bleed
Admitting Physician: Dr. Rustico Jimenez
Final Diagnosis: CVA Hmg, HPN, UTI
Source of Information: Patient and Chart
Past Medical History

The pt was never been hospitalized before and had not

experienced any kind of diseases that needs hospitalization. He was
a known hypertensive but no medications taken.

History of Present Illness

Few hours prior to admission, patient suddenly experienced

dizziness with elevated blood pressure of 200/120mmhg. Patient
also vomited once but he did not loss consciousness. Patient was
initially brought to Olivarez General Hospital and was subsequently
transferred to Medical Center Paranaque with an admitting
diagnosis of CVA bleed under the care of Dr. Rustico Jimenez

Social History

The patient doesn’t smoke and occasionally drink alcoholic

beverages

Family History
Father Mother

(+) allergy to (+) hx of

seafoods hypertension
(+) hx of asthma No history of DM
No hx of DM No hx of asthma
No hx of heart No hx of allergy

PATIENT J.F.R

(+) hx of hypertension
Allergic to Seafoods and
chicken
No history of DM
No hx of asthma
 Physical Assessment

Date assessed: August 09,2010

Vital Signs:
Temperature: 36.4C
Pulse Rate: 64 bpm
Respiratory Rate: 16 cpm
Blood Pressure: 150/100 mmHg

General Appearance:
• The pt. is conscious and coherent
• With IVF of PNSS 1L x 16hrs regulated at 20-21 gtts/min
• With O2 inhalation via nasal cannula
• With Nasogastric Tube inserted.
• With Foley catheter inserted.
• On Osteorized feeding

Area Assessed Findings

SKIN
color Tan
Turgor Skin snaps back immediately
When pinched
Temperature Warm to touch
NAILS
Color of Nail bed Pink and clear
Capillary refill time 2-3 seconds
FACE Tan
Skin color
EYES Anicteric sclera, pink palpebral
conjunctiva
PUPILS Pupils Equally Round and React
Reaction to light to Light Accommodation
Size Equal
Lips
Color Pinkish to slightly brown
NECK
Movement Moves freely
Range of motion Limited ROM
HEART Normal, regular rate

Heart rate 64bpm

THORAX & LUNGS POSTERIOR
 THORAX
Respiratory rate
16cpm
ANTERIOR THORAX
Breathing pattern Breathing is automatic and
effortless, regular and even and
produces no noise
Lung/ breath sounds Clear breath sounds
ABDOMEN
Contour Flat , soft with no tenderness
EXTREMITIES
No gross deformities

Neurological Assessment (August 09,2010)

Glasgow Normal Result Total GCS Interpretati
Coma Values on
Scale
Eyes Spontaneous 4 Total GCS= 8/15 pts.,
-4 15/15 good
To speech- 3 points. prognosis
To pain- 2
None-1 (15 pts. Pt is
Verbal Oriental- 5 5 alert, can
Confused- 4 follow simple
Inappropriat commands
e word- 3 and is
None- 1 completely
Motor Obeys 6 oriented to
command- 6 time, person
Localized and place.)
pain- 5
Flexion pain- (7 or less=
4 pt is
Abnormal comatose.)
flexion- 3
Abnormal (3= indicates
extension- 2 deep coma
Flaccid- 1 and poor
prognosis.z