MAHARAJ VINAYAK NURSING COLLEGE JAIPUR

JAIPUR NURSING
COLLEGE JAIPUR

SUBJECT: MEDICAL-SURGICAL NURSING

CASE STUDY

ON

Cerebro vascular accident (CVA)

SUMBITTED BY: SUBMITTED TO:

MR. PRADEEP JAJORIA DR. YOGESH YADAV

MSC NURSING 1st Year MEDICAL & SURGICAL NURSING

JAIPUR NURSING COLLEGE JAIPUR NURSING COLLEGE

JAIPUR JAIPUR

DATE OF SUBMISSION

08-05-2017

1
HISTORY COLLECTION

IDENTIFICATION DATA

NAME OF THE PATIENT : MR. kaluram

AGE : 63 year

SEX : male

DIAGNOSIS : cerebro vascular accident (CVA)

WARD : ICU

OCCUPATION : Retired

DATA OF ADMISSION : 3rd july

IPD NO : 2093356

BED NO : 4

ADDRESS : No 126, vidiyadhar nagar jaipur

DATE OF CARE STATED : 8-052017

DATE OF CARE END : 18-05-2017

ORIENTATION TO UNIT :-

The patient and family member got adequate orientation to hospital policy regarding
smoking policy, visiting policy, toilet and bathroom facilities etc.

 HEALTH PATIENT ASSESSMENT:-

1) HEALTH PERCEPTION /HEALTH MANAGEMENT:

a. CHIEF COMPLAINTS:
Mr.Kaluram was admitted in M.V.G Hospital with chief complain of
numbness into the face and arm and leg, void disturbance, deficiency in
walking, dizziness on toes and imbalance
b. PAST MEDICAL AND SURGICAL HISTORY:
Mr.Kaluram has no past history in hospitalization and illness

2
C. PERSONAL HISTORY:
Mr.Kaluram is moderately build and he doesn’t have the habit of
smoking . The sleeping pattern is disturbed due to hospitalization and
disease condition. The daily activity performance is decrease due to
weakness
c. NUTRITION/ METABOLISM :
Mr.Kaluram takes a mixed type of diet he doesn’t follow any diet pattern.
No nausea and vomiting present but slightly dryness on mucous membrane
due to disease condition he is weak.
d. ELIMINATION :
The client has regular bowel and urine elimination. No bowel sound
abnormal. No abdominal distention.
e. ACTIVITY / TOLERANCE:
CARDIOVASCULAR STATUS:
he is not having any aspiration distress apical phase are audible, S1 S2
heard on auscultation
RESPIRATORY STATUS:
Respiratory rate is 1b breath/mt and his breath sound is normal.
ACTIVITY OF DAILY LIVING:
he is partially dependent to others for performing her daily activities.
f. COGNITIVE/ PERCEPTORS:
LEVEL OF CONSCIOUSNESS:
The patient is conscious and can orient the tunic, place daily activities.

SERLSORIUM:
Eye/ sight : visual disturbance present
Ear /hearing : no abnormalities
Dizziness : present
Skin /touch : normal but numbness on the legs and arm
Pain : no specific pain
COGNITION:
His primary language Hindi language .
g. SLEEP/ REST:
his sleep is disturbed due to the disease condition and hospitalization.
h. SELF PERCEPTION/ SELF CONCEPT
The patient is disturbed due to his hospitalization , his daily activity is
change he want to discharge soon.

i. ROLE / RELATIONSHIPS:
The patient is married and have children he is a bussinessman. he
belong to an average socioeconomic status due to disease condition his
role function is change

3
 j. COPING / STRESS
The patient is anxious regarding his disease condition and manage his
stress by talking his family members.
k. VALUES/ BELIFE:
The patient is hindu religion, his present condition doesn’t in there and
affect his spiritual and religion practice.

PHYSICAL EXAMINATION
GENERAL EXAMINATION

Level of consciousness : Conscious

Orientation : Orientation to time

Grooming : adequately

ANTHROPOMETRIC MEASUREMENTS

Height : 151cms

Weight : 65 kg

VITAL SIGN:

Temperature : 98.6. F

Pulse : 64beats/ min

Respiration : 14 breath/ min

Blood pressure: 160/ 120 mm of hg

HEAD TO TOE EXAMINATION

HEAD

Colure of the hair : White & perish

Distribution : Equally

Scale in scalp : Absent

Dandruff : Absent

EYES

External discharge : absent

4
Eye brows : present

Pupil size : normal

Sclera : normal

Conjunctiva : normal

Vision : blurred vision and decreased vision

EARS

External discharge : absent

Lifting of ear lobes : absent

Hearing : Normal

NOSE

External discharge : absent

Sepal deviation : absent

MOUTH

Gums : normal

Teeth : normal

External discharge : absent

FACE

Scar : absent

Lesion / rash : absent

Puffiness : absent

SKIN

Scar : absent

Lesion/ rash : absent

Texture : tight

Moisture : dry

5
NECK

Range of Motion : Possible/Painful/absent

Lymph Nodes : Not enlarged/enlarged/Painful

Lesion/ rash : absent

Thyroid gland : Not enlarged/enlarged/ removed

UPPER EXTREMITIS

ROM : passive

Balanced coordination: negative

Scar : absent

Lesion /rash : absent

Lunar phase : present

CHEST

INSPECTION :

Scar : absent

Lesion / rash : absent

Puffiness : absent

Organ enlargement : absent

PALPATATION

Tenderness : absent

PERCUSSION

Fluid collection : absent

AUSCULTATION:

Breath sound : S1&S2

ABDOMEN:

INSPECTION :

Scar : absent

Lesion / scar : absent

6
Organ enlargement : absent

PALPATION

Tenderness : absent

PRECUSSION

Fluid collection : absent

AUSCULTION:

Bowel sound : normal

BACK:

Spinal curvature :normal

Scar : absent

Lesion / rash : absent

Pressure sore : absent

LOWER EXTREMITIS:

ROM : passive but weak on left side

Balance and coordination: negative

Scar : absent

Lesion / rash : absent

Femoral, potential.

INTERFERANCE:

Mr.Kaluram is not having any physical defects. But balance and co-ordination of
both examination are negative and the left limb is found to weak and ROM is passive.

7
LAB INVESTIGATIONS

S.
Name of the Investigation Patient value Normal value Inference
No.

1. Hemoglobin 10 – 9 qm/dl 14 -16 gm/dl Decreased

2. Bleeding time 1 -8 sec 1 -2 sec Normal

3. Clotting time 3 sec 2 – 4 sec Normal

4. RBC 5 million 4.5 – 5.5 Normal

cell/mm3 million cell /
mm3
6000
5. WBC Normal
cells/mm3 4000 -11000
cells/ mm3

MEDICATIONS

S. Name of the Nursing

No. Drug Dose Route Action Side effect responsibility

1. Inj. 2ml IV/IM A third equitation Candidiasis , Check vital

Cefotaxime cephalosporin that mild diarrhea, sign
sodium binds to bacterial abdominal
cell wall/ cramping , maintain intake
membranes and allergic output chart
inhibit cell wall reaction check for
synthesis A complication
NSAID that
inhibit
prostaglandin

8
 2. Inj. synthesis. Also
Diclofenac centrists the iris
2ml IV/IM speincter may Headache observe for
specific inmate complication
Abdominal
angiogenesis by cramps maintain intake
initiating out put chart
substances or Constipation
angiogenesis check vital
Nausea sign.
effect of
prostaglandins Dyspepsia

ANATOMY & PHYSIOLOGY

The central nervous system is controlling various system of the body. Central nervous system
is composed of brain and spinal cord. The CNS is responsible for the integrations of all
nervous activities. The nerve is dividing into

 Central nervous system

o Brain
o Spinal cord
 Peripheral nervous system
o 12 pairs of cranial nerve
o 31 pair of spinal nerve
 Cranial nerve system enclosed by
o Dura meter
o Arachnoids matter
o Diameter

FUNCTION OF BRAIN

 Basal ganglia control the extra pyramidal motor pathway, which the motor
pathway which influence the lower motor nervous of brain steam and spinal
cord .
 Through its connect with cerebral cortex moderate the motor activities and
avoid abnormal involuntary movement.
 Brain act an information gathering data analyzing and decision making
decision
 Useful information is reformed as memory.

DISEASE CONDITION
9
ATAXIA:

Impaired atelicity to co- ordinate movement, often seen as a staging gait or postural
imbalance. As ischemic stroke, cerebrovascular accident (CVA) or what is now being
termed “brain attack” is a sudden loss of brain resulting from disruption of the blood supply
to the part of the brain

ETIOLOGY:

PATIENT PICTURE BOOK PICTURE

Large artery thrombosis  Large artery thrombosis
 Small penetrating thrombosis
 Cryptogenic
 Intracerebral hemorrhage
 Subarachnoid hemorrhage cerebral
aneurysm

CLINICAL MANIFESTATION:

BOOK PICTURE PATIENT PICTURE

 Numbness or weakness of the face arm or  Numbness in the face arm and leg
leg especially on one side of the body.
 Confusion or change in mental status  Visual disturbance

 Trouble speaking or understanding spcese  Dizziness

 Visual disturbances  Loss of balance and co- ordination

 Difficulty walking, dizziness or loss of

balance and co- ordination

 Sudden sever headache

GLASSGOW COMA SCALE:

10
 RESPONSE SCORE RANGE SCORE
Eye opening response Spontaneous 4
To voice 3
To pain 2
None 1

Best verbal response Oriented 5

Confused 4
Inappropriate 3
Incomprehensible 2
Sound 1
none 0

Best motor response Obeys Command 6

Localizes Pain 5
Withdraws 4
Ilex Ion 3
Extension 2
None 1

PATIENT RESPONSE :

Eye opening response to voice 3

Best verbal response oriented 5

Best motor response localizes pain 3

Total = 15

DIAGNOSIS EVALUATION:

BOOK PICTURE PATIENT PICTURE

 Non contrast computed tomography  Non contrast computed tomography
(CT Scan) (CT Scan)
 Carotid angiography
 Digital subtraction angiography
 Occnlopthybmography
 Phonon angiography

MANGMENT:

BOOK PICTURE PATICENT PICTURE

ACUTE TEATENT
1. Support of vital functions , maintain 1. Support of vital function
airway , breathing oxygenation and 2. Maintain patient airway breathing
correlation. oxygenation and circulation
2. Reperfusion and hem dilution with 3. Diuretics treatment reduce cerebra
volume expanses thrombolytic edema

11
 therapy with plasmimogen activator
vasodilatation with memodipine
3. Management of increase ICP
4. Diuretic treatment to reduce cerebral
edema peaks 3- 5 days after in
5. Calcium channel blockers to reduce
blood pressure and prevent cerebral
vasospasm
SUBSEQNENT TEATMET:
1. Anticoagulant after hemoglobin is 1. Physical therapy
ruled out. 2. Speech therapy
2. Ant platelets agent such as ticlopidine
(tictid) or aspirin.
3. Antispasmodic agent for spastic
paralysis
4. A rehabilitation program including
physical therapy occupational therapy
and speech as needed .
5. Treatment of post stroke depression
with antidepressant such as selective
sureteroris receptors intake inheritor
citalopram

PROGRESS REPORT

DAY PROCEDURE
Ist day First day done bed making for the patient history collecting from
the patient and also physical examination has been done and
assisted the patient to do the activity

IInd day Second day had done bad making for the patient vital sign has
been checked and recorded assisted patient to do the activities
health education has been given to the personal hygiene ,
medication and follow up.

IIIrd day Third day done bed making for the patient, vital sign checked
and second assisted patient to do activity medication is
administered as prescribed by the physician .

IVth day Fourth day done bed making for the patient collected blood from
the patient for sugar test.

Vth day Fifth day done bed making for the patient administered
medication as prescribed by the doctors connected IV fluids for
the patient

12
THEORY APPLICATION BASED ON CALLISTA ROY THEORY:

Mr.Kaluram is selected to ruder comprehensive nursing are based on callista roy’s

adaptation theory the patient is diagnosed with the ataxia hemiparesis nursing care based on
this theory will help the client to adapt will be his present sitvation

Physiolgic Mode
Visual Disturbances
Memeber Of Face And
Arm
Anorexia And Weakness
Dizzeness

Self Concept
Role Function COPING Decreased Self
Role Changed
Dependent Role PROCESS Concept , Self
Esteem

Inter Depandance Mode

Dependency Got
Incereased

 PHYSIOLOGIC MODE :

Mr.Kaluram has decreased in ROM and numbness in arm legs. The patient is anorexia and

The patient also have dizziness and visual disturbances

13
  COPING PROCESS:-
o Frequently assessed patient sensorial monitor patient neurological status
maintain GCS score chart.
o Provide a calm and quite and safety environment for the client
o Assist the client in pre forming any ADL’s
 SELF CONCEPT:
o Her present condition influenced his self concept her confidence is decrease
and also the self esteem
 COPING PROCESS:-
o Proper health education give to the client and instructed not to skip meal and
to increased knowledge to increased the confidence and self esteem.
o Provide a psychological support to the client
 INTERDEPENDENCE MODE:-
o Her dependency got increased her ADL’s is decreased she cannot do or
performed ADL without an assistance by other she is disturbed . her routine
was change.
 COPING PROCESS:-
o All her hygienic need are meet
o Teaches her relatives how to performed or how to quit self care activities.
o Provide psychological support.
o Demonstrate hygienic care procedures to her relative .
 ROLE FUNCTION:
o Her all habitual activities was changed. She is disturbed. Now her role has
been changed she has dependent role.
 COPING PROCESS:-
o Her education has given to them regarding her present condition, treatment
modifies and prognosis .
o Help the client to adopt to the situation to make positive activity towards life
his/her present condition.

NEEDS AND PROGR ESS:

PROBLEMS NEEDS
1. Number of the lower extremities 1. Promote activity
2. Conversion to changes mental status 2. Improve mental status
3. Difficulty to speaking 3. Improve communication
4. Visual disturbances 4. Improve visual activity

NURSING DIAGNOSIS

1. Impaired physical motility related to loss of balance and coordination.

2. Disturbed thought process related to brine damage.
3. Altered nutritional status less than body requirement related to loss of appetite.
4. Knowledge deficit regarding disease condition and treatment

14
 5. Disturbed sleep pattern to hospitalization.

HEALTH EUDCATION:-
Health education on
NUTRITION:-
 Advise to include diet rich in protein, vitamin, and mineral.
 Advised to take iodides salt.
 Advised to take more green leafy vegetables and fruits.

PERSONAL HYGINE:-

 Advised to take bath daily.

 Advised to keep the nail short.
 Advised to be washed and properly dried clothes.
 Provided health education regarding importance of health hygine.

ENVIROMENAL SANITATION:-

 Advised to keep the surrounding neat and clear

MEDIACATION:-

 Educated the patient about importance of talking medication

 Advised the patient to be take medication properly at proper time.

FOLLOW UP:-

 Advise to the patient to come regularly for follow up check up.

SUMMARY:-
As a part of my clinical requirement of suspect Medical Surgical Nursing – II critical
care sub specialty. I was posted in medical ward male in M.V.G.hospital. From
there I selected with ataxic hemi paresis for my nursing care after providing care I
given health education regarding the diet, personal hygiene and follow up of the
patient. The patient guide some benefit from the nursing care provided .

15
BIBLIOGRAPHY:-

1. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Sidharth's Textbook of
Medical-Surgical Nursing, 11th Edition. 11th Ed. Lippincott Williams & Wilkins; 2006.
2. Springhouse. Handbook of Medical-Surgical Nursing. Fourth. Lippincott Williams &
Wilkins; 2005.
3. Sommers M. Diseases and Disorders: A Nursing Therapeutics Manual. 4th Ed. F.A. Davis
Company; 2010.
4. Nettina SM. Lippincott Manual of Nursing Practice. Ninth, North American Edition.
Lippincott Williams & Wilkins; 2009.
5. Doenges M, Moorhouse M, Murr A. Nursing Care Plans: Guidelines for Individualizing
Client Care across the Life Span. 8th Ed. F.A. Davis Company; 2009.
6. Krapp KM. The Gale Encyclopedia of Nursing and Allied Health. 1st ed. Thomson Gale;
2001.
7. Williams LS. Understanding Medical Surgical Nursing. 3rd Ed. F. A. Davis Co.; 2007.
8. A&ECert(Oxford) MWPBRPD, PGCE ACMBRDDAS. Watson's Clinical Nursing and
Related Sciences. 7th Ed. Bailliere Tindall; 2007.

16