Identification profile:

 Name of the patient: Mrs. Malina Saha

 Age: 57 years
 Sex: Female
 Address: Putia Boxanagar, shipahijala.
 Religion: Hinduism
 Educational status: 5th pass
 Marital status: Married
 Occupation: Housewife
 Date of admission: 5/10/2023
 Time: 10:05 am
 Ward: Emergency ward
 IP number: 20230101555
 Bed number: 8
 Diagnosis: Cerebrovascular accident (CVA)
 Under the treatment of: Dr. Arindam Majumder
 Date & time of surgery: No surgery had undergone

Chief complain:

 Hemiplegia in right side of the body

 Vertigo since today morning
 Slurred speech since today morning
 Vomiting tendency and chest pain from yesterday night

History of present illness:

My patient Mrs. Malina Saha was admitted on 5/10/23 at 10:05 am in TMC & Dr. BRAM teaching
hospital in emergency ward with the complains of Hemiplegia in right side of the body, vertigo
since today morning, slurred speech since today morning, vomiting tendency and chest pain from
yesterday night.

History of past illness:

 HTN from last 18 years and under irregular medication

 T2DM from last 11 years and under medication

Family history of illness:

There was no significant history of any communicable disease, chronic disease, congenital or
psychological problems among the family members.
Family history:

 Family tree –

Lt. kamal kanti saha Lt. Lalita saha

Mr. Badal saha Mrs. Malina saha

Mr. Debhasish saha Mr. Litan Saha

 Detail history of family members:

Sl. Name of the family Age Sex Relationship Educational Occupation Health
No. member (years) with the status status
patient
1 Mr. Badal Saha 65 M Pt. husband 8th passed Car driver Healthy
2 Mrs. Malina saha 57 F Pt. self 5th passed housewife Unhealthy
3 Mr. debhasish saha 29 M Pt. son Graduated Prvt. job Healthy
4 Mr. litan saha 25 M Pt. son Graduated Prvt. job Healthy

Socio-economic status:

This family belongs to an middle-class family. Mr. Badal Saha is the head of the family. Family’s
monthly income is nearly about Rs. 45000/month. House is made up of bricks and cement. There are
proper facilities lighting, ventilation and drainage system available. Source of drinking water is tube
well. They have maintained good IPR with their neighbours.
Personal history:

Mrs. Malina Saha is non-vegetarian. She had no history of chewing pan, addiction of any drug,
smoking and alcohol consumption. Her elimination pattern is regular.

Physical Examination:

Date: 5/10/23

Time: 11:30 am

1. General appearance
 Nourishment – nourished
 Body built – thin
 Activity – dull
2. Mental status
 Consciousness – semiconscious
 Look – depressed
 Orientation – well oriented to date, place and person
3. Posture
 Body curves – normal
 Movement – hemiplegia in right side of the body

4. Height – 5 ft. 4 inch

5. Weight – 48 kg
6. Vital sign:

Date Time Body Pulse Respiration Blood pressure

temperature
05/10/23 10:30 98.8-degree F 58 beats/min 22 breaths/min 182/94 mm Hg
am
7. Skin condition
 Colour – brown
 Texture – dry
 Temperature – normal
 Lesions – absent
8. Head
 Cleanliness – clean
 Condition of hair – normal
 Pediculosis – absent
9. Face – depressed & anxious
10. Eye
 Vision – hyperopia
 Eyebrow – normally present
 Conjunctiva – pink
  Sclera – white
 Eyeball – black
11. Ears
 External ears – no discharge
 Placement – bilaterally symmetrical
 Hearing – hears the vibration of tuning fork by both ears
12. Nose & Sinus
 External nose – no discharge present
 Nostrils – NG tube in left nostril
 Nasal septum – normal
13. Mouth & throat
 Odour – absent
 Lips – dry
 Teeth – all teeth are not present
 Tongue – pale and dry
 Gums – normal
14. Neck
 Lymph node – normal
 Thyroid gland – normal
15. Thorax
 Chest inspection – symmetry of expansion
 Palpation – no abnormalities detected
 Auscultation – no abnormalities detected
16. Cardiovascular system
 S1-S2 sound – loud S2 sound
17. Abdomen
 Inspection – no abnormalities detected
 Palpation – no abnormalities detected
 Auscultation – bowel sound not heard
18. Extremities
 Any lesion – absent
 Range of motion – hemiplegia in right side of the body
 ABOUT THE DISEASE

Cerebrovascular accident (CVA)

Definition: A stroke is an interruption of the blood supply to any part of the brain resulting in a
sudden loss of brain function. A stroke is sometimes called a "brain attack." It occurs when blood
flow to a part of the brain is suddenly stopped and oxygen cannot get to that part. This lack of
oxygen may damage or kill the brain cells. Death of a part of the brain may lead to loss of certain
body functions controlled by that affected part. Blood flow can be compromised by a variety of
mechanisms.

CAUSES OF CEREBROVASCULAR ACCIDENT:

Stroke may result from either interrupted delivery of blood and oxygen to the brain (ischemic stroke)
or abnormal bleeding in the brain (haemorrhagic stroke).

1. Transient Ischemic Attack: TIA or 'mini-stroke' is a short-term stroke that lasts for less than 24
hours. The oxygen supply to the brain is quickly restored and symptoms disappear. A transient
stroke needs prompt medical attention because it indicates a serious risk of a major stroke. TIAS
occur before almost 30% of ischemic strokes.
2. Cerebral Thrombosis: Cerebral thrombosis is when a blood clot (thrombus) forms in an artery
that supplies blood to the brain. Blood vessels that are furred up with fatty deposits (atheroma)
make a blockage more likely. The clot prevents blood flowing to the brain and cells are starved
of oxygen. Certain medical conditions can also cause platelets or red blood cells to become
stickier or cause increased blood viscosity, leading to formation of a thrombus. These conditions
include polycythemia, multiple myeloma, sickle cell anemia, protein C deficiency, and protein S
deficiency.
3. Cerebral Embolism: Cerebral embolism is a blood clot that forms elsewhere in the body before
traveling through the blood vessels and lodging in the brain. In the brain, it starves cells of
oxygen. An irregular heartbeat or recent heart attack may make prone to forming blood clots.
Examples of an embolus include a thrombus that has broken away from the wall of the blood
vessel, heart, or valve; a piece of plaque; or a clump of bacteria.
4. Cerebral Haemorrhage: Cerebral haemorrhage is when a blood vessel bursts inside the brain and
bleeds (haemorrhages). With a haemorrhage, blood seeps into the brain tissue and causes extra
damage. The blood vessel may rupture because of high blood pressure (hypertension), increased
tendency toward bleeding, an abnormal weakness in the wall of a blood vessel (aneurysm), or
abnormal communication between arteries and veins (arteriovenous malformation).

RISK FACTORS:

The following factors may put you at a higher risk of having a CVA:

 Hypertension
 Diabetes mellitus
 Heart disease, such as coronary artery disease
 Congestive heart failure
  Atrial fibrillation
 History of transient ischemic attacks and cerebrovascular disease
 A family history of stroke
 Cigarette smoking, cocaine use, or drinking too much alcohol
 Diabetes (high blood sugar)
 Atherosclerosis or fatty cholesterol deposits on artery walls
 High blood cholesterol (fat)
 Kidney disease, especially when dialysis is needed
 Blood clotting disorders
 Rheumatoid arthritis, systemic lupus erythematosus, vasculitis, and ulcerative colitis

Related anatomy & physiology:

Anatomy:
Physiology:
Pathophysiology:

Clinical manifestation:

According to book According to patient

Headache
Numbness
Weakness
Confusion or loss of memory
Difficulty in swallowing Present
Aphesis
Loss of motor ability Present
Vision loss affecting one or both eyes
Difficulty in speaking Present
Personality, mood, or emotional changes
Dizziness Present
Diagnostic studies:

According to book:-

A stroke is a medical emergency. Anyone suspected of having a stroke should be taken to a medical
facility immediately for evaluation and treatment.

 Complete Physical And Neurological Exam: Doctor will check for problems with vision,
movement, sensation, reflexes, understanding, and speaking. Listen for an abnormal sound,
called a “bruit,” when using a stethoscope to listen to the carotid arteries in the neck. A bruit is
caused by turbulent blood flow. Check and assess blood pressure, which may be high.
 Computerized Tomography: In order to help determine the cause of a suspected stroke, a special
X-ray test called a CT scan of the brain is often performed. A CT scan is used to look for
bleeding or masses within the brain that may cause symptoms that mimic a stroke, but are not
treated with thrombolytic therapy with TPA.
 Computerized Tomography with Angiography: Using dye that is injected into a vein in the arm,
images of the blood vessels in the brain can give information regarding aneurysms or
arteriovenous malformations. Moreover, other abnormalities of brain blood flow may be
evaluated. With faster machines and better technology, CT angiography may be done at the same
time as the initial CT scan to look for a blood clot within an artery in the brain.
 Conventional Angiogram: An angiogram is another test that is sometimes used to view the blood
vessels. A long catheter tube is inserted into an artery in the groin or arm and threaded into the
arteries of the brain. Dye is injected while X-rays are taken and information can be obtained
about blood flow in the brain. The decision to perform CT angiography versus conventional
angiography depends upon a patient’s specific situation and technical capabilities of the hospital.
 Carotid Doppler Ultrasound: A carotid Doppler ultrasound is a non-invasive test that uses sound
waves to look for narrowing or stenosis and decreased blood flow in the carotid arteries (the
major arteries in the front of the neck that supply blood to the brain).
 Heart Tests: Certain tests to evaluate heart function are often performed in stroke patients to
search for the source of an embolism. Electrocardiograms may be used to detect abnormal heart
rhythms like atrial fibrillation that are associated with embolic stroke. Ambulatory rhythm
monitoring may be considered if the patient complains of palpitations or passing out episodes
(syncope) and the doctor cannot find reason for it on the EKG. The patient can wear a Holter
monitor for 1-2 days and sometimes longer looking for a potential electrical conduction problem
with the heart. Echocardiograms or ultrasounds of the heart can help evaluate the structure and
function of the heart including the heart muscle, valves and the motion of the heart chamber.
 Laboratory Tests: The following tests are usually ordered: a CBC, blood chemistries for
electrolyte levels (sodium, potassium, and chloride), blood glucose level, and lipid levels (HDL
cholesterol, LDL cholesterol, triglycerides). Cardiac enzymes are evaluated because of the
association between cardiovascular disease and cerebrovascular disease and to rule out a
simultaneous heart attack (myocardial infarction). Coagulation studies (prothrombin time or PT,
partial thromboplastin time or PTT) reveal clotting or bleeding tendencies.
According to patient:-

Date Name of investigation Finding in patient Normal range

05/10/23 Haemoglobin 9.93 mmol/l 12 – 16
Serum sodium 126 mmol/l 135 – 155
Serum potassium 4.6 mmol/l 3.2 – 5.5

Urine reaction Acitic

Urine colour Staw
Urine appearance Clear
Protein in urea Present

Neutrophil 85% 40 – 75
Lymphocytes 13% 20 – 45
Monocyte 0.2% 0.2 – 0.8
Eosinophil 0.3% 0.1 – 0.6

05/10/23 ESR 32 mm 20 – 34

CT-SCAN signs of a middle cerebral

artery stroke with loss of
definition of the gyri and
grey white boundary

Management:

a) Medical Management:-

Sl. Name of drug Dose Route Frequency Action

No.
1. Inj. Xone 1gm IV BD ceftriaxone binds to one or more to the
peniciline binding protein which inhibits
bacterial cell wall synthesis, render cell
wall osmotically unstable, leads to cell
death.

Osmitrol acts by increasing osmolarity of

2. Inj. Manitol 100 ml IV TDS glomerular filtrate, which inhibits
reabsorption of water and electrolyte and
increases urinary output.

inhibits calcium ion influx across cell

3. Tab. Stamlo 5 mg Oral SOS membrane during cardiac depolarization;
produce relaxation of coronary vascular
smooth muscle, peripheral vascular
smooth muscle, dilates coronary vascular
arteries; increase myocardial O2 delivery
in patient with vasospastic angina.
 Labetanol is used to treat high blood
4. Inj. Lebebit 10 mg IV TDS pressure.

potentiates the actions of GABA,

5. Inj. Lopez 2 mg IV SOS especially in the limbic system and the
reticular formation.

b) Surgical Management:- My patient has not undergone any kind of surgery.

c) Nursing Management: nursing diagnosis are –

 Impaired physical mobility related to CVA as evidence by hemiplegia right side of the body.
 Imbalance nutrition less then body requirement related to CVA as evidence by dysphagia.
 Anxiety related to hospitalization as evidence by frequent questioning by the patient
Health education:
Summary:

In this case study I discussed about the identification profile of Mrs. Malina Saha, her chief
complaints, history of present illness, history of past illness, his family history, socio economic
status, personal habits, physical examination and also discussed about the definition of CVA ,
aetiology, related anatomy and physiology, pathophysiology, , clinical features, diagnostic studies,
medical management, surgical management, nursing management and health education regarding
CVA.

Conclusion:

Cardiovascular accident (CVA) is an interruption of the blood supply to any part of the brain
resulting in a sudden loss of brain function. A stroke is sometimes called a "brain attack." It occurs
when blood flow to a part of the brain is suddenly stopped and oxygen cannot get to that part. This
lack of oxygen may damage or kill the brain cells. Death of a part of the brain may lead to loss of
certain body functions controlled by that affected part. Blood flow can be compromised by a variety
of mechanisms. Cerebral thrombosis is when a blood clot (thrombus) forms in an artery that supplies
blood to the brain. Blood vessels that are furred up with fatty deposits (atheroma) make a blockage
more likely. The clot prevents blood flowing to the brain and cells are starved of oxygen.

Prognosis:

My patient Mrs. Malina Saha was admitted on 5/10/23 at 10:05 am in TMC & Dr. BRAM teaching
hospital in emergency ward with the complains of Hemiplegia in right side of the body, vertigo
since today morning, slurred speech since today morning, vomiting tendency and chest pain from
yesterday night. Her past illness also HTN from last 18 years and under irregular medication T2DM
from last 11 years and under medication. After the investigation patient was diagnosed CVA. She
was treatment by under Dr. Arindam Majumder and she was not undergone any kind of surgery.

Related research study:

A Study on Stroke and its Outcome in Young adults (15–45 Years) from coastal South India

HN Harsha Kumar, Babusha Kalra, and Nayna Goyal

Indian J Community Med. 2011 Jan-Mar; 36(1): 62–65.

This is a retrospective, record-based study of patients of stroke in the age group of 15–45 years
admitted to two referral hospitals of Kasturba Medical College, Mangalore. The patients were
identified from the medical records, starting from January 1998 to June 2008. Consent was sought
for accessing the medical records. One hundred and nine patients fulfilled the WHO definition of
stroke.(7) Important subtypes of stroke were included (i.e., ischemic, haemorrhagic, embolic).
Patients who presented with drop attacks and loss of consciousness due to other causes were
excluded. The following information was noted in a semi-structured proforma: the socio-
demographic patient characteristics (like age, sex and occupation), presenting symptoms, risk factors
present (like hypertension,(8) diabetes mellitus,(9) smoking, alcoholism, family history, cardiac
disease and dyslipidemias(10)), investigations performed and outcome following stroke.

There were 76 (69.7%) smokers, 53 (48.6%) alcoholics, 59 (54.1%) diabetics and 79 (72.5%)
hypertensives. Family history of stroke was present in 42 (38.5%) patients. Using the body mass
index (≥25) criteria, 53 (48.6%) were overweight, of which 20 (18.3%) were males. Abnormal
platelets and coagulation parameters were found in four cases, all of which had haemorrhagic stroke.
Elevated homocysteine was found in three cases, all of which had ischemic stroke. Single risk factor
was present in 57 (52.2%) patients, two risk factors in 68 (62.4%) and three or more risk factors in
79 (72.5%) patients. Twelve cases did not have any known risk factor. Mortality was lower (8, 7.3%)
than disability (60, 55%), and 41 (37.6%) had good outcome.

Bibliography:

1. Ansari. J. A Textbook of Medical Surgical Nursing-II. 2nd ed. New Delhi (India): pee vee
publication house; 2014. p. 567.
2. Wilam. P. Barbara. L. Woods. N. Shafer’s Medical Surgical Nursing. 7th ed. New Delhi
(India): B.I. Publications pvt ltd; 1996.