case stud on cva

7/30/2019 Case Stud on CVA

1/36

Case study on CVA

rehabilitation

Area: Male Medicine ward

Topic: Cerebro vascular accident

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HISTORY COLLECTION

Introduction:

As a part our medical surgical nursing II clinical posting I got posting in NIMHANSBangalore. I was posted in male rehabilitation ward I selected Mr. Ramegowda for writing

case study. He diagnosed as cerebro vascular arrest. I started care on 18/3/09 and ended on

20/3/09.

Demographic data:

Name Age Sex Religion Education Occupation Marietal

status

Date & time

of Admission

Mr.

Ramegowda

55yrs male Hindu 8th

standard

agriculture Married 15/3/09

Date and time of history collection 18/03/2009

Informant : Patient himself, Patient relatives and case sheet.

Ward: male medicine ward

IP No 768453

Address: door no.23

Siddartha layout

Mysore

Diagnosis: Cerebro vascular arrest with right side hemiplegia

Present history of illness

Mr. Ramegowda is admitted on 15/3/09 with complaints of sudden onset of fever and cough and

breathing difficulty since 10 days. Mr. Ramegowda developed fever 10 days before and fever was

intermittent and moderate grade. The fever will more during night. Along with fever he got cough

also. While coughing sputum is not expectorate. Sputum is thick and mucoid and not having any

foul smell. At the time of admission his SPO2 WAS 89% Muscle strength wasRT LT

Upper limb: 2/5 5//5

Lower limb 2/5 5/5

Deep tendon reflexes were BJ TJ SJ KJ AJ

RT 3+ + ++ 0 +

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LT ++ ++ + ++ + +

Patient had crackles on auscultation, swallowing difficulty. Patient had slurring of speech.

Later patient diagnosed as CVA with right side hemiplegia.

At present he is on nasogasrtic tube feeding. He is having fever, headache andcough and he is on oxygen supply. He is not able to move his right side limbs. He is

on urinary catheter.

Past history of illness

He had history of hypertension about 1year and on treatment. He is taking tablet aten 50mg BD.

He had a history of CVA since 1 year. He did not have any history of Diabetes Mellitus, Epilepsy,

Bronchial Asthma etc. in the past. He had history of hospitalization in the past for the same

problems..

Family history

Mr. Ramegowda is living with his wife and son.T here is no history of any illness like

Diabetes Mellitus, Hypertension, Tuberculosis and Asthma in the family.

Key

- Male Patient

- Male

- Female

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Socio economic history

He belongs to a middle class family. He is a agriculturist. After he got CVA, he was not

doing any work. But son is earning Their monthly income is about Rs 5000/-. He is having good

relationship with family members and neighbours.

Life style, habits and beliefsMr. Ramegowda is moderately built and moderately nourished. He believes in god.

He takes mixed diet. His bowel pattern is normal and he is on urinary catheter. He is having good

exposure to mass media. He had the habit of, smoking and alcoholism since 10 years. He used to

smoke I packet beedies per day. He used to drink every day. He is not having the habit of doing

exercises. If he suffered from any disease he used to go local clinics and takes medication.

History of any allergy

Mr. Ramegowda is not having any allergy towards dusts, drugs, spores, foods and

medications.

PHYSICAL EXAMINATION

General Examination

Body built - Moderately built

Nourishment - Moderately nourished

Hygiene - Good

Temperature -1020F

PR -86 beats/minRR - 26breaths/min( on ventilator)

BP - 130/90 mm of Hg

Subjective data Objective data

Head

Mr. Ramegowda says that, I have headache

Vision

Mr. Ramegowda says that, I can see you properly

Inspection

- Hairs are equally distributed

- Guarding the fore head

- No dandruff

- No lesion

Palpation:

- No lesion/ wound

- VAS 7/8

Inspection:- External Eye structures are normal.

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Hearing

Mr. Ramegowda says that, I can hear you properly

Speech and orientation

Mr. Ramegowda says that, I cant speak properly

Respiratory system

Mr. Ramegowda says that, I have cough but sputum

is not comming

Cardio-vascular system

Mr. Ramegowda says that, I dont have chest pain

- No signs of any infection of eye,

- Normal pupillary reaction

- No discoloration of sclera

- No discharge or periorbital odema

Palpation:- No lesion

- Eye opens while calling her name

Webers test =positive

Rinnies test= positive

He is having slurring of speech and he is

oriented to time, place and person

Posterior thorax

Inspection: Size, shape, configuration is

normal and either side of the chest is equally

expands..Secretions present. Thick and

yellow color secretions

Palpation: Absence of lesions,

Thorasic expansion =2cm

Percussion: dullness on right side of the

chestAuscultation: crackles sound heard

Anterior Thorax

Inspection: Size, shape and configuration is

normal

Palpation: Absence of lesions.

Percussion: dullness

Auscultation:

crackles sound heard

Inspection

Temparature- 1020F

BP- 130/90 mm of Hg

- Absence of clubbing, cyanosis and

there is no signs of peripheral

vascular disease

- Iv canula present on Left hand

- Neck vessels-Not distended

Palpation:

PR-86 beats/mt

Capillary refill is 2sec

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Gastro intestinal system

Mr. Ramegowda says that, I am having swallowing

difficulty

Lymphatic system

Mr. Ramegowda says that, I dont have enlargement

in my neck

Renal system

Mr. Ramegowda says that, I am passing urine

through pipe

Musculo skeletal system

Mr. Ramegowda says that, I cant walk

Peripheral pulses are palpable

Auacultation:

S1 and S2 heard.

No abnormal heart sounds

Inspection

Well nourished and well built

Maintaining good oral hygiene but dental

caries present on left molar

Lips are dry

No loss of teeth

No gum bleeding

Normal in size and shape, of abdomen

no scar present

NGT present

Auscultation Bowel sounds present at the

rate of 10 /min

Palpation:

Absence of hepatosplenomegaly

No lesions

Percussion:

Dullness heard

No lymph nodes are enlarged

Urine colour is amber yellow,

he is on urinary catheter

, Intake/Output = 2000/1700= +300ml

Albumin nil

Sugar - nil

Pus nil

Inspection:

he is not able to walk, because his right side

is paralysed.

No odema,

Patient is able to move the left limbs

Palpation:

Muscle size is symmetrical in both sides

rigidity or spasticity present on right limbs

ROM is possible on all joints in the left side

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Nervous system

Mr. Ramegowda says that, I cant hold the objects

Muscle strength:

RT LT


Lower limb 2/5 5/5

MSE

- GCS= E4M5V6

- Appearance and behaviour:

groomed, worried and anxious

- Oriented to time, place and person

Speech: slurring of speech resentr

- Judgment and abstract thinking :

present

- Calculation is able to perform

- General information; he is having

good knowledge in agriculture.

Cranial Nerves

Olfactory nerve(CN I): He is able to

smell coffee powder with each

nostrils.

Optic (CN II):

1) vision: 20/20

2) visual acuity: patient is able to

identify the picture on the wall

3) visual field : possible in each side

Occulomotor, Trochlear,

Abducens(CN III, IV, VI):

1) Pupils are equally reacting to

light

2) EOEM are present in both

eyes. Trigeminal Nerve (CN V):

While clenching the teeth, patient has

normal strength. Sensation on frontal,

Maxillary and mandibular area is normal

Facial Nerve (CN VII) :

Smiles normally. Identifies taste of sugar

and salt in the anterior 2/3rd of the tongue.

Vestibulo-Cochlear Nerve (CNVIII):.,

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Webers test =positive

Rinnies test= positive

Glosso pharyngeal and Vagus(x):

Patient is having difficulty inswallowing food

Spinal accessory: is not able to elicit

on right side of the body

Hypoglossal nerve:

Protrudes and move tongues normally

Assessment of sensation

- Sensation to the cold, pain, hot and

vibration is not present on right side

- Position sence, graphesthesia andsteriognos is not

- Present on right side.

Assessment of motor function

- Muscle tone- rigidity on right side

- Muscle size is less in right side of the

body

- Muscle strength:

RT LT


Lower limb 2/5 5/5

-

Reflexes

- Superficial reflexes

Corneal-normal

- Abdominal-normal

- Plantar-normal

Deep tendon reflexes RtLt

- Biceps- 1+

2+

- Triceps- 1+

2+

2+ Bracheo-Radialis- 1+

-

- Patellar- 1+2+

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Integumentary system

Mr. Ramegowda says that, I have fever

Rest and sleep

Mr. Ramegowda says that, I am sleeping properly at

night time after taking tabletPsycho social aspect

Mr. Ramegowda says that, I have good relationship

with other family members

- Achilis- 1+

2+

Assessment of cerebellar function :

- Finger to Nose test: not able to elicit on

right side- Pronation-Supination test: is not able to

elicit

- Gait- Not able to test

- Finger to finger test: not able to elicit on

right side

patting test, Rebound test, and Dexterity

test is not able to elicit

Inspection

Body temperature is 1020F

Hairs are equally distributed.

Nails are normal shape

No lesions on body

Palpation

Body is warm

Skin turgor is reduced

No drooping of eyelids

Mr Ramegowda is having good relationship

with family members and health team

members

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CLINICAL DATA

Name of the test Patients value Normal value EvaluationBlood

Hb%

TLC

ESR

RBS

Blood Urea

S. Creatinine

S.Phosphorous

Total ProtienGlobulin

A/G Ratio

Total Bilirubin

Alkaline Phosphatase

SGOT

SGPT

Creatinine Kinase

Sodium

Potassium

Urine

Albumin

Sugar

Pus

12 mg/dl

10400cells/Cumm

10mm/hr

90 mg/dl

38mg/dl

1mg/dl

4mg/dl

6.gm/dl1gm/dl

1.8g/dl

0.8mg/dl

128u/l

32u/l

28u/l

329u/l

136meq/l

4.meq/l

Nil

Nil

Nil

132 mg/dl

4000 -11000cells/Cumm

0- 10mm/hr

70-150 mg/dl

20-40mg/dl

0.8-1.4mg/dl

2.5-5mg/dl

6-8g/dl2-3g/dl

1.2-2.5

0.1-1mg/dl

37-147u/l

0-40u/l

0-40u/l

250-400u/l

135-145meq/l

3.5-4.5meq/l

Nil

Nil

Nil

Normal

leucocytosis

Normal

Normal

Normal

Normal

Normal

NormalNormal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

SPECIAL INVESTIGATIONS

Apart from the above investigation patient under gone special investigations like

1. CT Scan: hypodense lesion on left side of the brain

2. Chest X ray: With in normal limit

3. MRI: frontal infraction

4. ultra sound : normal

5. ECG: With in normal limit

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PLAN OF TRAETMENT

NAME OF THE

DRUG

DOSE ROUTE FREQUENCY ACTION SIDEEFFECTS NURSES

RESPONSIBILITY

INJ M-20

(Mannitol)

100ml IV Tid It is an osmotic diuretic that

increases the osmotic pressure

of the glomerular filtrate and

thus inhibiting tubular

reabsorption of the water andelecTrolytes. It elevates

plasma osmolalty, resulting in

enhanced water flow to extra

celIular fluid.

CNS: seizures, head ache,

Fever

CVS:Edema,

thrombophlebitis, HTN,

Tachy cardia, Heart failureENT: Blurred vision

GI: Thirst, dry mouth

GU:Urine retension

- Warm bottle to prevent

crystallization

- Give 60-90 minutes

properly

- Monitor vital signs andCVP, I/O hourly, serum

sodium and potassium and

for signs of dehydration

and electrolyte imbalance.

- Give frequent mouth care

to relieve thirst

- Dont give electrolyte

free mannitol solutions

with blood. If blood is

given simultaneously, add

atleast 20 meq of sodium to

avoid pseudo agglutination

INJ Rantac

(Rannitidine)

2ml IV TID Completively inhibits action

of histamine on the H2 at

receptor sites of parietal cells,

decreasing gastric acid

secretion.

CNS: Vertigo, Malaise and

head ache

EENT: Blurerred Vision

Hepatic:Jaundice

Others: Itching and

blurring in the incision site

Use cautioly in patient with

hepatic dysfunction

Assess patient for

abdominal pain

Instruct the patient to take

without regard to meals

because absorption is not

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affected by food.

Urge patient to avoid

cigarette smoking because

it will increase gastric

secretions

INJ. C-tax

(Ceftriaxon)

1gm IV Bd A third generation

cephalosporin that inhibits cellwall synthesis and promoting

osmotic instability, usually

bactericidal.

CNS: Fever, Head ache,

DizzinessCVS: Phlebitis

GU: Genital Pruritis

Heamatologic:

Eosinophilia, Thrombocy-

tosis

Skin: Pain, induration

Use cautiously in patients

hypersensitive to PencillinAnd to pregnant and

lactating Woman

Obtain specimen for

culture and sensitivity

Monitor PT and INR in

patient with poor Vitamin

K synthesis

Tell patient to report

adverse reaction promptly

Tab. Amlo at

(amlodepine and

atenolol)

50mg NGT tid

Beta blockers and ca2+

channel blockers.

Antihypertensive. Atenolol is

a cardioselective beta blocker.

CNS: Ataxia, slurred

speech, dizziness,

insomnia, nervousness,

twitching, head ache,

mental confusion

CVS: Periarteritis nodosa

GI: Gingival hyperplasia

- Use cautiously in patients

with hepatic dysfunction,

hypotension, Myocardial

insufficiency, DM and

elderly

- reduce if alt level is

increases

- Stop drug if rashes

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Heamatologic:

Thrombocytopenia,

agranulocytosis and

pancytopenia

Skin: Pupuric dermatitis

appears

- Monitor drug level in

blood

- Monitor CBC and

calcium level in every 6

months

- Teach the patient about

side effect and tell to report

if any.- Advise to avoid Alcohol

- Advise for good oral

hygiene and regular dental

examination to prevent

excess gum deposition.

- Caution patient that drug

may colour urine pink, red

or recdish brown.

Tab. pacimol

(paracetamol)

500mg NGT sos It is an antipyretic and

anagelsics in nature in action

with weak anti inflammatry

action which may due to

inhibition of PG

Blood dyscariasis. Nausea,

vomiting, allergeic

reactions, hepatic necrosis

- Use cautiously in patients

with hepatic dysfunction,

hypotension, Myocardial

insufficiency, DM and

elderly

- Give with meals to

prevent GI irritation

- Stop drug if rashes

appears

- - Monitor CBC

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- Teach the patient about

side effect and tell to report

if any.

- Advise to avoid Alcohol

-..

SPECIAL TREATMENT:

1. IVF on flow 40 ml/hr2. Physiotherapy

3. Nasogasrtic tube feeding

4. O2onflow 5.)Nebulization

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CEREBRUM

The brain is divided into mainly 3 parts , cerebrum, brain stem and cerebellum.

Cerebrum is composed of both right and left hemispheres. Both hemispheres can be further divided

into four major lobes.

1. frontal lobe

2. parietal lobe

3. temporal lobe

4. occipital lobe

Gray matter is the outer covering of the cerebrum. Each lobes have different functions.

The basal ganglia, thalamus, hypothalamus and limbic system are also located in the

cerebrum. The basal ganglia are a group of paired structure located central to cerebrum and

mid brian. It helps in execution and completion of involuntary movements. Thalamus lies

directly above the brain tem. it is mainly sensory canter. Hypothalamus lies below the

thalamus and it regulates Mans. In the inner surface of the cerebrum, limbic system

present. It concerned with emotion, feeding behaviour, and sexual response.

Circle of Willis

The circle of Villis which is located in the base of the skull, is devided in to anterior (carotid

portion) and posterior (Vertebro basilar portion) circulation. The components of the each portion

involve: Middle cerebral arteries, the anterior cerebral arteries and the anterior communicating

artery which connects the two anterior cerebral arteries

Two posterior cerebral areteries, two posterior communicating arteries connect the

middle cerebral arteries with the posterior cerebral arteries, thus uniting the internal

carotid system with the vertebral-basilar system

The circle of Willis encloses a very small area that is little more than one square inch in diameter

or approximately 6 cm2. Functionally the carotid circulation and the posterior circulation usually

remain separate.

Venous DrainageUnlike venous drainage in other parts of the body, which closely follows the arterial pattern, the

cerebral venous drainage is chiefly managed by vascular channels created by the two dural sinuses.

There are no valves in he dural sinuses

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NURSING CARE PLAN

Nursing diagnosis:

1. Ineffective airway clearance related to accumulation of secretions.

2. Ineffective tissue perfusion (cerebral) related to infracted areas in the cerebrum.

3. Hyperthermia related to cerebral infection

4. acute pain (frontal area) related to vasospasam

5. Impaired physical mobility related to weakness of limbs.

6. Impaired verbal communication related to dysfunction of speech center.

7. Impaired family process related to hospitalized sick family member.

8. anxiety related to hospitalization

9. knowledge deficit related to disease process

10. Risk for seizures related to neuronal irritation

11. Risk for fluid electrolyte imbalance related to mannitol therapy

12. Risk for impaired skin integrity (bedsore) related to prolonged bed rest

13. Risk for UTI related to presence of urinary catheter.

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Assessment Nursing

diagnosis

Objective Interventions with rationale Implementation Evaluation

Subjective data

Mr. Ramegowda says that,

I have cough, but sputum

is not able to split out

Objective data

Thick secretions

Crackles on auscultation

Yellow discoloration of

secretions

Thorasic expansion is 2cm

Ineffective

airway

clearance

related to

accumulation

of secretions

Patient

maintains a

patent

airway as

evidenced

by absence

of thicksecretions

- Provide lateral position with head

end elevation- helps to drain the

secretions and prevents aspiration

-- Provide Nebulization- Helps to

soften the secretions

- Provide chest Physiotherapy-Mobilize the secretions and promote

expectoration

- Promote Posturl drainage- Mobilize

the secretions

- maintain fluid intake- Hydration

helps to dilute the secretions

- change the position every 2nd

hourly

do the suctioning helps to remove

the secretions.

Administer medications as per

physicians order helps to reduce the

secretions.

Provided lateral position

Provided nebulization

Provided chest physiotherapy

----------

Promoted fluid intake

Changed the position every 2nd

hourly

Done the suctioning

Patient is

having thin

secretions.

Subjective data

Mr. Ramegowda says that,

I have fever

Objective data

Hyperthermia

related to

cerebral

Patient

maintains

normal

body

Give tapid sponge, reduces

temperature by conduction method.

Maintain adequate hydration

to prevent dehydration.

Given tapid sponge,

Maintained adequate

hydration

Patient,

temperature is

reduced into

990F

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Body is warm

Body temperature is 102oF

Lips are dry

Skin turgor is reduced.

TLC= 10400cell/cumm

infection temperature

as

evidenced

Normal

body

temperature

98.60F

Give cold compress, reduces body

temperature by conduction

Administer medications

as per physicians order

Loosen the clothings

, for comfort

Maintain intake and output chart,

shows dehydration

Given cold compress

Administered medications

Tab. Pacimol 500mg

Loosened the clothings

Maintained intake and outputchart

Objective data:

Patient have CVA

CT Scan: hypodense

lesion on left side of the

brain

Risk for

seizures

related to

neuronal

irritation

The client

remains

free from

seizures as

evidenced

by absence

of signs of

seizures

- Implement seizure precautions:

side rails up and padded- Prevent

injury due to seizures

- Assess keenly for the occurrence of

seizures- Helps to prevent injury

- Administer Dilantin 50mg tid-

Maintain the stability of neural

membrane and prevent seizures

- Take all measure to prevent ICP-

Provide comfortable position with

head end elevated to 300-Reduces the

risk for seizures

- Restrict all activities which will

lead to increase in ICP-like neck

flexion, cluster of activities

Reduction of ICP will reduce the

Implemented the seizure

precautions

Assessed for the occurrence of

seizures

Administered Dilantin 50 mg.

Took the measures to prevent

ICP

Restricted the activities that

will lead to seizures

Patient is not

have any signs

of seizures.

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chance for seizures

Objective data:

Patient have CVA

CT Scan: hypodense


brain

patient is receiving

mannitol therapy

Risk for fluid

electrolyte

disturbance

related to

mannitol

therapy

Patient

maintain

normal

fluid and

electrolytes

as

evidencedby absence

of signs of

dehydration

-Monitor for intake and out put-helps

to identify fluid imbalance

- Assess serum sodium and

Pottasium-Helps in early diagnosis

of electrolyte imbalance

- Assess for signs of dehydration,

hypokalemia and hypo natremia-Helps to prevent complications

- Closely monitor for ECG changes-

Arrythmias can be predisposed by

fluid electrolyte imbalance

Maintain intake out put chart shows

the dehydration

Monitored for intake and out

put

Assessed serum electrolytes

Assessed for signs of dehydration, hypokalemia and

hypo natyremia

Monitored for ECG changes

Maintained intake output chart

Patient is not

having signs of

fluid electrolyte

imbalance

Objective data:

Patient have CVA

CT Scan: hypodense


brain

Rt. Side of the body

hemiplegia

Muscle strength 2/5 in

right side

DTR: Weak

Risk for

impaired

skin integrity

(bedsore)

related to

prolonged

bed rest

Patient will

maintain

normal skin

integrity as

evidenced

by absence

of bedsore.

Change the position frequently every

2nd hourly, prevents bedsore

Give pressure point care to increase

blood supply.

Provide back care every 2nd hourly to

increase blood supply.

Check the signs of bedsore

periodically, shows early signs of

bedsore

Provide comfort devices like pillows

and waterbed , takes pressure

Changed the position

frequently every 2nd hourly

Given pressure point care

Provided back care every

Checked the signs of bedsore

periodically,

Provided comfort devices like

pillows and waterbed

There is no

signs of bedsore

present

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INTAKE AND OUT PUT

Date Intake Output Balance

18/3/09 1950ml 2100ml -150ml

19/3/09 2100ml 2150ml +50ml

20/3/09 2450ml 2550ml -100ml

NUTRITIONAL REQUIREMENT:

As per dieticians advice patient is receiving 2220kcal. The menu plan given by the

dietician is:

Time Diet Quantity

6.30am Rava ganji cooked with milk 200ml

9.30am Vegetable soup 250ml

12.30pm Rava ganji cooked with milk 300ml

3.30pm Milk 100ml

6.30pm Rava ganji cooked with milk 250ml

9.30pm Dhal soup 150ml

12.30am Milk 200ml

Health education needs

Health education on

Hygiene: importance of personal hygiene

Exercises : ROM exercises

Prevention of bedsore: back care, use of comfort devices

Relaxation techniques

Nutrition and hydration: high calorie and high protein

Compliance to the treatment regimen and Follow up

complications and management

Rehabilitation- Promote compliance to the treatment regimen

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- Promote exercises

- Health education

- Follow up

RECENT TRENDS

1. .Upper limb and lower limb neurotic devices are available to rehabilitate the motor

impairement in the CVA patient. This is known as robot assisted therapy. But

practicability is less for this devices.

2. The incidence of pulmonic complications are more among the CVA patients as compared

with other systemic complications.

APPLICATION OF THEORY

Lidiya Halls Care, core and cure theory is applied in this case study.

This model provides base for nursing care. It consists of interlocking circle the core, cure

and care.

Core circle: refers to the patient, it includes nursing care that resolves around a nurses

therapeutic use of self. It involves developing an interpersonal relationship with a patient,

which allows the patient to express feelings about disease condition.

Care circle: refers to the patients body. It includes nursing care given.

Cure circle: refers to the pathological condition or the disease. It is a collaborative

process and nurses advocate role is coming under this.

Cure: Inj Mannitol, T.

Dilantin and T. Rantac and Inj

Ceftriaxone and T. Dolo were

the medications. Closelymonitor for complications.

Patient improved.

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PROGRESS NOTES

Date Problems of the client Care given Evaluation

18/3/09 fever, headache, cough not

able to move his right side

limbs urinary catheter.

nasogasrtic tube feeding

Head end elevation at

30 degree


every 2nd hourly

Given back care every

2nd hourly

Checked the vital

signs

Maintained I/O chart

Administered

medication

Suctioning done

Send the lab

investigation

Checked theneurological status

His temperature is reduced into

1000F

Core: Mr. Ramegowda 55yrsold

man came with cough, fever and

breathing difficulty. diagnosed as

CVA. Weakness of limb present.Nasogastric tube feeding, fever

present, headache.

Care: -

- Pain management

- Take measures to maintain patentairway

- chest physiotherapy

- Administered medications as

prescribed

- Monitor for complications

Monitor I/O chart

ROM exercise,

Cure: Inj Mannitol, and T. Rantac

and Inj Ceftriaxone and T. Dolowere the medications. Closely

monitor for complications

Rehabilitation

Physiotherapy.

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Provided the cold

compress

Massaged the head



limbs urinary catheter.

nasogasrtic tube feeding

Suctioning done

Checked the

neurological status

Checked the vital

signs


every 2nd hourly

Head end elevation at30 degree

Kept head in neutral

position

Provided back care

Pressure point care

given

Elevated the foot end

Provided comfortable

devices like pillows

Nebulization given

ROM exercise

performed

tapid sponge and cold

compress

His temperature is 101 0F



limbs urinary catheter.nasogasrtic tube feeding

Checked the vital

signs


every 2nd hourly

Head end elevation at

30 degree


position

Suctioning done

Checked the

neurological status

Checked the vital

His temperature is 99.6 0F

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signs


position

Provided back care

Pressure point caregiven

Elevated the foot end

Provided comfortable

devices like pillows

Nebulization given

provided tapid sponge

and cold compress

ROM exercise

performed

PATIENT EVALUATION : After giving 3 days care to the patient, patients condition

improved. Hyperthermia is reduced, rigidity on joints reduced, and cooperates while doing

exercises

SELF EVALUATION : After taking this patient I understood how to give care to patients

with CVA and rehabilitation of CVA patients. I studied regarding the meaning

pathophysiology and clinical features and rehabilitation aspects of CVA.

Bibliography

Text book

1. Joanne v hicky, the clinical practice of neurological and neuro surgical Nursing, 5th

edition, Lippincott,2003 p.438-432

2. Sandra M Netlina. The Lippincott manual of nursing practice.7th edition.

Philadelphia:Lippincott;1996. p.669-674

3. Lewis Heitkemper Dirksen. Medical surgical nursing, Assessment and management of

clinical problem.6th edition. Missouri: Mosby;2004. p.1556-1559

4. Suzannae .c.Smeltzer,Brenda. G Bare. Medical Surgical nursing, 9th edition. Philadelphia:

Lippincott ;2000 p.768-770Website

www. Pubmed.com

www. Google.com

INDEX

SL

No

CONTENT PAGE No

30


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1

2

3

4

5

6

7

8

9

10

Nursing History

Physical examination

Related anatomy and Physiology

Disease condition

Rehabilitation

Nursing care plan

Recent trends

Application of theory

Patient evaluation

Bibliography

CVA REHABILITATION

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Introduction A stroke is the rapidly developing loss of brain function(s) due to a disturbance

in theblood supply to the brain. This can be due to ischemia (lack of blood supply) caused by

thrombosis or embolism or due to a hemorrhage. In the past, stroke was referred to as

cerebrovascular accident orCVA, but the term "stroke" is now preferred.

Definition The traditional definition of stroke, devised by the World Health Organization in

the 1970s,[4]is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours

or is interrupted by death within 24 hours".The traditional definition of stroke, devised by the

World Health Organization in the 1970s. A "neurological deficit of cerebrovascular cause that

persists beyond 24 hours or is interrupted by death within 24 hours".

Classification

Ischemic stroke :In an ischemic stroke, blood supply to part of the brain is decreased,

leading to dysfunction of the brain tissue in that area. There are four reasons why thismight happen: thrombosis (obstruction of a blood vessel by a blood clot forming

locally), embolism (idem due to an embolus from elsewhere in the body, see below), [1]

systemic hypoperfusion (general decrease in blood supply, e.g. in shock)[6] and venous

thrombosis.[

Hemorrhagic stroke: Intracranial hemorrhage is the accumulation of blood anywhere

within the skull vault. A distinction is made between intra-axial hemorrhage (blood

inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the

brain). Intra-axial hemorrhage is due to intraparenchymal hemorrhage or

intraventricular hemorrhage(blood in the ventricular system).

Signs and symptomsSigns and symptoms

If the area of the brain affected contains one of the three prominent Central nervous system

pathwaysthe spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus),

symptoms may include:

hemiplegia and muscle weakness of the face

numbness reduction in sensory or vibratory sensation

In addition to the above CNS pathways, the brainstemalso consists of the 12 cranial nerves.

A stroke affecting the brain stem therefore can produce symptoms relating to deficits in these

cranial nerves:

altered smell, taste, hearing, or vision (total or partial)

drooping of eyelid (ptosis) and weakness ofocular muscles

decreased reflexes: gag, swallow, pupil reactivity to light

decreased sensation and muscle weakness of the face

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http://en.wikipedia.org/wiki/Disturbancehttp://en.wikipedia.org/wiki/Blood_supplyhttp://en.wikipedia.org/wiki/Ischemiahttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Embolismhttp://en.wikipedia.org/wiki/Hemorrhagehttp://en.wikipedia.org/wiki/World_Health_Organizationhttp://en.wikipedia.org/wiki/Stroke#cite_note-3%23cite_note-3http://en.wikipedia.org/wiki/Stroke#cite_note-3%23cite_note-3http://en.wikipedia.org/wiki/World_Health_Organizationhttp://en.wikipedia.org/wiki/Stroke#cite_note-Donnan-0%23cite_note-Donnan-0http://en.wikipedia.org/wiki/Shock_(circulatory)http://en.wikipedia.org/wiki/Stroke#cite_note-5%23cite_note-5http://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Stroke#cite_note-Stam2005-6%23cite_note-Stam2005-6http://en.wikipedia.org/wiki/Intra-axial_hemorrhagehttp://en.wikipedia.org/wiki/Extra-axial_hemorrhagehttp://en.wikipedia.org/wiki/Intraparenchymal_hemorrhagehttp://en.wikipedia.org/wiki/Intraventricular_hemorrhagehttp://en.wikipedia.org/wiki/Intraventricular_hemorrhagehttp://en.wikipedia.org/wiki/Neural_pathwayhttp://en.wikipedia.org/wiki/Neural_pathwayhttp://en.wikipedia.org/wiki/Spinothalamic_tracthttp://en.wikipedia.org/wiki/Corticospinal_tracthttp://en.wikipedia.org/wiki/Dorsal_columnhttp://en.wikipedia.org/wiki/Medial_lemniscushttp://en.wikipedia.org/wiki/Hemiplegiahttp://en.wikipedia.org/wiki/Central_facial_palsyhttp://en.wikipedia.org/wiki/Brainstemhttp://en.wikipedia.org/wiki/Brainstemhttp://en.wikipedia.org/wiki/Cranial_nerveshttp://en.wikipedia.org/wiki/Ptosis_(eyelid)http://en.wikipedia.org/wiki/Extraocular_muscleshttp://en.wikipedia.org/wiki/Disturbancehttp://en.wikipedia.org/wiki/Blood_supplyhttp://en.wikipedia.org/wiki/Ischemiahttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Embolismhttp://en.wikipedia.org/wiki/Hemorrhagehttp://en.wikipedia.org/wiki/World_Health_Organizationhttp://en.wikipedia.org/wiki/Stroke#cite_note-3%23cite_note-3http://en.wikipedia.org/wiki/World_Health_Organizationhttp://en.wikipedia.org/wiki/Stroke#cite_note-Donnan-0%23cite_note-Donnan-0http://en.wikipedia.org/wiki/Shock_(circulatory)http://en.wikipedia.org/wiki/Stroke#cite_note-5%23cite_note-5http://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Stroke#cite_note-Stam2005-6%23cite_note-Stam2005-6http://en.wikipedia.org/wiki/Intra-axial_hemorrhagehttp://en.wikipedia.org/wiki/Extra-axial_hemorrhagehttp://en.wikipedia.org/wiki/Intraparenchymal_hemorrhagehttp://en.wikipedia.org/wiki/Intraventricular_hemorrhagehttp://en.wikipedia.org/wiki/Neural_pathwayhttp://en.wikipedia.org/wiki/Neural_pathwayhttp://en.wikipedia.org/wiki/Spinothalamic_tracthttp://en.wikipedia.org/wiki/Corticospinal_tracthttp://en.wikipedia.org/wiki/Dorsal_columnhttp://en.wikipedia.org/wiki/Medial_lemniscushttp://en.wikipedia.org/wiki/Hemiplegiahttp://en.wikipedia.org/wiki/Central_facial_palsyhttp://en.wikipedia.org/wiki/Brainstemhttp://en.wikipedia.org/wiki/Cranial_nerveshttp://en.wikipedia.org/wiki/Ptosis_(eyelid)http://en.wikipedia.org/wiki/Extraocular_muscles


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balance problems and nystagmus

altered breathing and heart rate

weakness in sternocleidomastoid muscle with inability to turn head to one side

weakness in tongue (inability to protrude and/or move from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can

produce the following symptoms:

aphasia (inability to speak or understand language from involvement of Broca's or

Wernicke's area)

apraxia (altered voluntary movements)

visual field defect

memory deficits (involvement oftemporal lobe)

hemineglect (involvement ofparietal lobe)

disorganized thinking, confusion, hypersexual gestures (with involvement of frontal

lobe)

anosognosia (persistent denial of the existence of a, usually stroke-related, deficit)

If thecerebellum is involved, the patient may have the following:

trouble walking

altered movement coordination

vertigo and or disequilibrium

Pathophysiology

Ischemic stroke occurs due to a loss of blood supply to part of the brain, initiating the

ischemic cascade. Brain tissue ceases to function if deprived of oxygen for more than 60 to 90

seconds and after a few hours will suffer irreversible injury possibly leading to death of the

tissue, i.e., infarction. Atherosclerosis may disrupt the blood supply by narrowing the lumen

of blood vessels leading to a reduction of blood flow, by causing the formation of blood clots

within the vessel, or by releasing showers of small emboli through the disintegration of

atherosclerotic plaques. Embolic infarction occurs when emboli formed elsewhere in the

circulatory system, typically in the heart as a consequence of atrial fibrillation, or in thecarotid arteries. These break off, enter the cerebral circulation, then lodge in and occlude brain

blood vessels.

Due to collateral circulation, within the region of brain tissue affected by ischemia there is a

spectrum of severity. Thus, part of the tissue may immediately die while other parts may only

be injured and could potentially recover. The ischemia area where tissue might recover is

referred to as the ischemicpenumbra (medicine).

As oxygen or glucose becomes depleted in ischemic brain tissue, the production of high

energy phosphate compounds such as adenosine triphosphate (ATP) fails, leading to failure of

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http://en.wikipedia.org/wiki/Balance_disorderhttp://en.wikipedia.org/wiki/Nystagmushttp://en.wikipedia.org/wiki/Sternocleidomastoid_musclehttp://en.wikipedia.org/wiki/Cerebral_cortexhttp://en.wikipedia.org/wiki/Aphasiahttp://en.wikipedia.org/wiki/Broca's_areahttp://en.wikipedia.org/wiki/Wernicke's_areahttp://en.wikipedia.org/wiki/Apraxiahttp://en.wikipedia.org/wiki/Visual_fieldhttp://en.wikipedia.org/wiki/Temporal_lobehttp://en.wikipedia.org/wiki/Hemineglecthttp://en.wikipedia.org/wiki/Parietal_lobehttp://en.wikipedia.org/wiki/Hypersexualhttp://en.wikipedia.org/wiki/Cerebellumhttp://en.wikipedia.org/wiki/Cerebellumhttp://en.wikipedia.org/wiki/Vertigo_(medical)http://en.wikipedia.org/wiki/Ischemic_cascadehttp://en.wikipedia.org/wiki/Infarctionhttp://en.wikipedia.org/wiki/Embolihttp://en.wikipedia.org/wiki/Anastomosishttp://en.wikipedia.org/wiki/Penumbra_(medicine)http://en.wikipedia.org/wiki/High_energy_phosphatehttp://en.wikipedia.org/wiki/High_energy_phosphatehttp://en.wikipedia.org/wiki/Balance_disorderhttp://en.wikipedia.org/wiki/Nystagmushttp://en.wikipedia.org/wiki/Sternocleidomastoid_musclehttp://en.wikipedia.org/wiki/Cerebral_cortexhttp://en.wikipedia.org/wiki/Aphasiahttp://en.wikipedia.org/wiki/Broca's_areahttp://en.wikipedia.org/wiki/Wernicke's_areahttp://en.wikipedia.org/wiki/Apraxiahttp://en.wikipedia.org/wiki/Visual_fieldhttp://en.wikipedia.org/wiki/Temporal_lobehttp://en.wikipedia.org/wiki/Hemineglecthttp://en.wikipedia.org/wiki/Parietal_lobehttp://en.wikipedia.org/wiki/Hypersexualhttp://en.wikipedia.org/wiki/Cerebellumhttp://en.wikipedia.org/wiki/Vertigo_(medical)http://en.wikipedia.org/wiki/Ischemic_cascadehttp://en.wikipedia.org/wiki/Infarctionhttp://en.wikipedia.org/wiki/Embolihttp://en.wikipedia.org/wiki/Anastomosishttp://en.wikipedia.org/wiki/Penumbra_(medicine)http://en.wikipedia.org/wiki/High_energy_phosphatehttp://en.wikipedia.org/wiki/High_energy_phosphate


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energy-dependent processes (such as ion pumping) necessary for tissue cell survival. This sets

off a series of interrelated events that result in cellular injury and death. A major cause of

neuronal injury is release of the excitatory neurotransmitter glutamate. The concentration of

glutamate outside the cells of the nervous system is normally kept low by so-called uptake

carriers, which are powered by the concentration gradients of ions (mainly Na +) across the cell

membrane. However, stroke cuts off the supply of oxygen and glucose which powers the ion

pumps maintaining these gradients. As a result the transmembrane ion gradients run down,

and glutamate transporters reverse their direction, releasing glutamate into the extracellular

space. Glutamate acts on receptors in nerve cells (especially NMDA receptors), producing an

influx of calcium which activates enzymes that digest the cells' proteins, lipids and nuclear

material. Calcium influx can also lead to the failure of mitochondria, which can lead further

toward energy depletion and may trigger cell death due to apoptosis.

Care and rehabilitation

Stroke rehabilitation is the process by which patients with disabling strokes undergo treatment

to help them return to normal life as much as possible by regaining and relearning the skills of

everyday living. It also aims to help the survivor understand and adapt to difficulties, prevent

secondary complications and educate family members to play a supporting role.

A rehabilitation team is usually multidisciplinary as it involves staff with different skills

working together to help the patient. These include nursing staff, physiotherapy, occupational

therapy, speech and language therapy, and usually a physician trained in rehabilitation

medicine. Some teams may also includepsychologists, social workers, andpharmacists since

at least one third of the patients manifest post stroke depression. Validated instruments such

as the Barthel scale may be used to assess the likelihood of a stroke patient being able to

manage at home with or without support subsequent to discharge from hospital.

Good nursing care is fundamental in maintaining skin care, feeding, hydration, positioning,

and monitoring vital signs such as temperature, pulse, and blood pressure. Stroke

rehabilitation begins almost immediately.

For most stroke patients, physical therapy (PT) and occupational therapy (OT) are the

cornerstones of the rehabilitation process, but in many countries Neurocognitive

Rehabilitation is used, too. Often, assistive technology such as a wheelchair, walkers, canes,

and orthosis may be beneficial. PT and OT have overlapping areas of working but their main

attention fields are; PT involves re-learning functions as transferring, walking and other gross

motor functions. OT focusses on exercises and training to help relearn everyday activities

known as the Activities of daily living (ADLs) such as eating, drinking, dressing, bathing,

cooking, reading and writing, and toileting. Speech and language therapy is appropriate for

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http://en.wikipedia.org/wiki/Mitochondriahttp://en.wikipedia.org/wiki/Stroke_rehabilitationhttp://en.wikipedia.org/wiki/Speech_and_language_therapyhttp://en.wikipedia.org/wiki/Physicianhttp://en.wikipedia.org/wiki/Rehabilitation_medicinehttp://en.wikipedia.org/wiki/Rehabilitation_medicinehttp://en.wikipedia.org/wiki/Psychologistshttp://en.wikipedia.org/wiki/Social_workhttp://en.wikipedia.org/wiki/Pharmacisthttp://en.wikipedia.org/wiki/Post_stroke_depressionhttp://en.wikipedia.org/wiki/Barthel_scalehttp://en.wikipedia.org/wiki/Nursing_carehttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Vital_signshttp://en.wikipedia.org/wiki/Physical_therapyhttp://en.wikipedia.org/wiki/Neurocognitive_Rehabilitationhttp://en.wikipedia.org/wiki/Neurocognitive_Rehabilitationhttp://en.wikipedia.org/wiki/Assistive_technologyhttp://en.wikipedia.org/wiki/Wheelchairhttp://en.wikipedia.org/wiki/Orthosishttp://en.wikipedia.org/wiki/Activities_of_daily_livinghttp://en.wikipedia.org/wiki/Speech_and_language_therapyhttp://en.wikipedia.org/wiki/Mitochondriahttp://en.wikipedia.org/wiki/Stroke_rehabilitationhttp://en.wikipedia.org/wiki/Speech_and_language_therapyhttp://en.wikipedia.org/wiki/Physicianhttp://en.wikipedia.org/wiki/Rehabilitation_medicinehttp://en.wikipedia.org/wiki/Rehabilitation_medicinehttp://en.wikipedia.org/wiki/Psychologistshttp://en.wikipedia.org/wiki/Social_workhttp://en.wikipedia.org/wiki/Pharmacisthttp://en.wikipedia.org/wiki/Post_stroke_depressionhttp://en.wikipedia.org/wiki/Barthel_scalehttp://en.wikipedia.org/wiki/Nursing_carehttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Vital_signshttp://en.wikipedia.org/wiki/Physical_therapyhttp://en.wikipedia.org/wiki/Neurocognitive_Rehabilitationhttp://en.wikipedia.org/wiki/Neurocognitive_Rehabilitationhttp://en.wikipedia.org/wiki/Assistive_technologyhttp://en.wikipedia.org/wiki/Wheelchairhttp://en.wikipedia.org/wiki/Orthosishttp://en.wikipedia.org/wiki/Activities_of_daily_livinghttp://en.wikipedia.org/wiki/Speech_and_language_therapy


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patients with problems understanding speech or written words, problems forming speech and

problems with swallowing.

Patients may have particular problems, such as complete or partial inability to swallow, which

can cause swallowed material to pass into the lungs and cause aspiration pneumonia. The

condition may improve with time, but in the interim, a nasogastric tube may be inserted,

enabling liquid food to be given directly into the stomach. Stroke rehabilitation should be

started as immediately as possible and can last anywhere from a few days to over a year. Most

return of function is seen in the first few days and weeks, and then improvement falls off with

the "window" considered officially by U.S. state rehabilitation units and others to be closed

after six months, with little chance of further improvement. However, patients have been

known to continue to improve for years, regaining and strengthening abilities like writing,

walking, running, and talking. Daily rehabilitation exercises should continue to be part of the

stroke patient's routine. Complete recovery is unusual but not impossible and most patients

will improve to some extent : a correct diet and exercise are known to help the brain to self-recover.

Goals

Demonstrate self care skills

Exhibit problem solving skill

Establish a communication system

maintain nutritional and hydration status

Musculoskeletal function:

sitting up in the bed transfer from bed to chair(sit on bed , stand place a strong hand on the far wheel chair

arm and sit down

constraint induced movement therapy. use the weakend extremity by avoiding the

movement of strong extremity.

use of supportive devices eg. cane ,walker

limb ROM

physiotherapy

Nutritional therapy:

PEG is dysphagia persists

speech therapiat and dietician and occupational therapist

use unaffected extremity to eat

removing unnecessary items from tray

effective dietary programme

adequate hydration

Bowel function

high fiber diet

fluid intake 3-4lit/day

bowel programme 30min after breakfast

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stool softeners and dulcolax suppository

Bladder function

assessment of bladder distension

offering bed pan

encourage usual position for urination

fluid intake

catheterization

Communication.

speech therapist consultation

visual cues

magic slate

communication board

short sentences use

patient listening

Sexual dysfunction:

counselling

health education

optional positioning of partners

open communication with partners

case stud on cva

Documents