EXAMPLE of case study abute cerebrovascular accident

1. Case Study
Introduction:
A.H. is a male Pt., 76 years old, living in DAIR AMMAR; his house
is composed of4 rooms. He is Muslim and he was married with two wifes
and he is sitting at home without working. He admitted to the
RAMALLAH hospital in 27/04/2004 at 6pm with his sons as emergency
situation because of signs & symptoms:
(loss of consciousness, hyperthermia {39˚c axillary}, drowsy, fatigue,
dilated pupils, facial paresis, dyspnea, shortness of breath, tachypnoea {38
breath/minute}) due to second CVA; because the pt was suffer from old
CVA in the right side of the brain that mean abasia in the left side of the
body. The medical team took lab tests and x-rays examination to his chest
and his head, and ct-scan for his head, and they found that there was
Brain ct-Multiple cerebral infarction & Brain Atrophy
Health History:
1- Chief Complain/s:
The Pt. was suffering from loss of consciousness hyperthermia {39˚c
axillary}, drowsy, fatigue, dilated pupils, facial paresis, sweating,
dyspnea, shortness of breath, tachypnoea {38 breath/minute} due to
CVA.
2- History of present illness:
The pt was suffering before admission to the hospital from
hyperthermia for 3 days {38˚c axillary} and in the fourth day the
temperature raised to {39˚c axillary}, and the pt felt of drowsy, fatigue
then he felled down and he lost his consciousness, so the family called
the Dr, when the Dr came the pt was suffering from dyspnea, shortness
of breath and tachypnoea {38 breath/minute}, when the Dr examined
the pt, he found all the signs and symptoms above and he examined his
pupils and they were dilated. Then the Dr talled the family that the pt
must go to the hospital as quickly as possible. And so the pt admitted to
the hospital as emergency condition with his sons in 27/04/2004 at
6pm, and he admitted to the emergency room which the medical teem

2. there apply IV solution and did suction for the respiratory tract and took
x-ray for his chest.
In the second day in the hospital the Dr wrote order to examine his head
by ct-scan, and the ct-scanwas taken and the Dr found that there was a
clot close completely the major artery feed the left side of the brain and
there was brain atrophy in the right side of the brain related to old CVA
in the right side of the brain.
3- Other current health problems:
The Pt. suffered from diabetes {300mg/dL} for 40 years, but after the
pt admitted to the hospital the level of glucose in the blood decreased
gradually to {130mg/dL}, diabetic foot since 1999, hypertension for 30
years {150-180/70-90mmHg}, but when the pt admitted to the hospital
the blood pressure decreased to {100/60mmHg}.
4- Operation and present admission / date performed:
There was no operation for the pt but there were lab tests like CBC,
electrolytes tests and chest x-ray and brain ct-scan.
5- Past medical history & operations:
1) Influenza every two years.
2) Amputation for the left leg before 1 year related to diabetic foot.
3) Amputation for the big toe in the right leg before 5 months related to
diabetic foot.
4) He took all vaccines when he was child.
6- Family History:
The family was composed ofthe father and two wives and 6 sons and 5
daughters.
Three of his sons were smoking, and all of his sons and daughters were
married.
The pt. mother's and father's were suffering from hypertension and
hyperglycemia, so the pt. and 4 of his children were suffering from
hypertension and hyperglycemia.
His house was composedof4 rooms, the electricity was good and it
wasn't been cut off, the water was good too and it wasn't been cut off,
there wasn't a telephone in the house, the ventilation was good because
there were two windows in each room.d

3. Physical Assessment:
1- General Appearance:
The hair was white and short and there was a **** in the partial part of
his head, he was thin, there were wrinkles in his skin, the color of the
skin was frumentaceouse (‫)حنطي‬, his face was pale related to the facial
paralysis and the poorcirculation in the face, and there was bad smell
from the pt. because he didn't get bathing since 2 days.
2- Skin:
There were wrinkles in the hands and the legs and on his face, the skin
was dry , the color of the skin was frumentaceouse (‫)حنطي‬, there were
no masses, there were bedsores at the lower back ,there were no rash or
scares, there was no redness, there was bad smell from the pt. because
he didn't get bathing, the nails was been cuted.
3- Head & Neck:
-Head:
The pt couldn't move his head, there were no trauma in his head, the
pt. didn't suffer from hydrocephaly, there were no wounds in his
head, there was a **** in the partial part of his head, the skin of the
head was moist and clean.
-Hair:
The pt's hair was white and short, there was a **** in the partial part
of his head, there were no dandruff, and there wasn't alopecia.
-Neck:
The pt couldn't move his neck, there were no masses or node
enlargement, and there was neither swelling nor tenderness.
-Eyes:
There was no responsefor vision, the pupils were dilated, the two
eyes were symmetric, there was no excessive tearing, there was no
glaucoma nor discharge, the pt. wasn't use glasses before his
disease, his eyes didn't have any allergies from any thing, his eyes
color was black, he didn't use lens, his eyebrows and eyelashes were
thin.

4. -Ears:
There was no responsefor hearing, there were no discharge from his
ears, there were no waxes nor bleeding in his ears, he didn't use
hearing aids, the two ears were symmetric.
-Nose:
There was no responsefor smelling, there were no discharge from
the nose, his nosewas clean, his nose was symmetric with his face,
and there was NG tube within his nose for feeding and given orally
medications through it.
-Mouth:
There was no responsefor tasting, pt. wasn't use dentures, his teeth
were clean, there were no infections in the gums, no food's remains
between his teeth, his mouth was dry, his lips were pink and dry,
and he could distinguish between different tastes.
4- Breast & Axillary:
Because the pt. was female, he refused to let me to examine his chest,
but he tolled me that there were no masses in his chest, there were no
infections in his chest, his breasts were symmetric, he examined his
breasts in the home, and there were no infections in his axilla.
5- Respiratory:
The rate of respiration was 30/minute, the respiration wasn't deep, the
pt. suffered from unproductive coughing, the respiration was irregular,
the pt. feel difficulty in breathing, there was fluid in the plural cavity as
I saw in the results of the examinations, so the pt. suffer from dyspnea.
6- Circulatory:
The pulse was 84b/m, the pulse was regular, the BP was 180/ 70
mmHg, the pt. suffered from hypertension, the pt. suffered from
hyperglycemia (diabetes), there was little cyanosis, there were no
infiltration at the site of the IV solution.
7- Abdomen:

5. The pt. suffered from abdominal pain when he entered the hospital, but
after he got his medications he didn't suffer from abdominal pain, he
could eat softfood like milk, butter milk, bake, thyme, olive oil, but he
couldn't eat heavy food like banana, apple, egg … etc, there were no
masses in the abdomen, the pt. suffered from vomiting.
8- Diet & Nutrition:
The pt. ate from the hospital food just the soft food like milk, bake,
cheese with little little amount because he was suffering from vomiting,
at normal situation (without vomiting) the pt. couldn't eat heavy food
like banana, apple, egg … etc, because it caused anxiety for the pt., the
pt. didn't have allergy from any kind of food.
9- Elimination:
- Urinary:
The pt. went to the bathroom 7 times a day for urination, and
once every two days or discharge stool, the color of the urine
was straw, the odorwas aromatic, there were no blood cells or
fibers in the urine, the urine was acidic, so the two kidneys
worked good, there were no infections in the pt's urinary
system, there were no masses or enlarge organs in the urinary
system.
- Bowel:
The pt. hadn't pain in the bowel, the pt. didn't suffer from
constipation, were no masses or enlarge organs in the bowel,
there were sounds in the bowel, no rectal bleeding.
10- Reproductive System:
There were no infections in the genital area, the menstruation
was on it's time every month, he didn't suffer when he was
birthing, the deliveries were easy and full term birth, all
deliveries were out of the hospital.
11- Muscles:
The pt suffered from fatigue in all parts of his bodywhen he
admitted to the hospital, but after one day the pt felt better
that he could stand, he could walk, he could change his

6. position in the bed, there were no masses in the muscles, the
joints worked free without limitation.
12- Neurological:
The pt couldn't hear very well, he could hear the personwho
was near his, the pt couldn't see very well that he could see
the person who was near his, the pt suffered from glaucoma in
his left eye, the pt didn't use glasses, the pt can smell and taste
very well that he could distinguish between different things,
the pt was full conscious, he could orient to person& place &
time, the pt was suffering from anxiety related to the vomiting
and dyspnea, his memory was good that he could remember
clearly.
13- Psychosocial:
The pt was sad because he couldn't stay at the hospital in the
bed for a long time, his family came to see his in the hospital,
the family was composedofthe mother and the father and 4
men and 4 women, but the father was died and one of his sons
died when he was child, and other son died before 2 years
because of Israeli soldiers, his house was composed of3
rooms, the electricity was good and it wasn't been cut off, the
water was good too and it wasn't been cut off, there wasn't a
telephone in the house, the ventilation was good becausethere
were two windows in each room.
14- Social Problems:
The pt didn't have social problems, all of his relationships
were good, his family came to the hospital to see his, and
some of his neighbors came to see his too.
Pathophysiology of Inflammatory Pleuritis – Pleurisy

7. Common causes of inflammatory Pleuritis are pneumonia, tuberculosis,
lung abscess, bronchiectasis, rheumatic fever and systemic lupus
erythematosis.
Pleurisy can be classified as wet or dry. Dry pleurisy is extremely
painful and is associated with an audible pleural rub. It is not associated
with an effusion. Wet pleurisy is associated with development of an
effusion due to the often copious serous exudation that accompanies the
inflammation.
In general, in uncomplicated cases, the effusion consists of a relatively
clear, straw colored fluid, but some particularly those associated, with
carcinoma of the lung, can be mildly to heavily blood stained. If the
effusion is relatively small it may be re-absorbed with complete
resolution. However, these effusions can comprise several liters and
can therefore encroach considerably on lung spacewith accompanying
respiratory distress. Pleural effusions can also be a focal site of
infection due to both the static nature of the condition, and the potential
culture medium for bacterial growth.
- Clinical manifestations:
The severity of these will depend largely on the size of the effusion.
Most are insidious and often asymptomatic. Breathlessness, dyspnea,
and chest pains usually accompany only large effusions.
- Diagnosis ofdisorders of the pleura:
All pleural effusions are diagnosed by chest X-ray. Differential
diagnosis is by aspiration and analysis of pleural fluid.
- Medicaland nursing management:
Inflammatory effusions and hydrothoracies are dealt with by thoracic
aspiration, that is, an aspiration needle is inserted into the pleural cavity
and the fluid is aspirated via a syringe.
Preparation of the pt for thoracic aspiration:
An explanation is given to the pt as his cooperation throughout the
procedureis important. The pt is asked not to sneeze or cough or take a
sudden deep breath without indicating that suchan occurrenceis
imminent. The pt is sat in an upright position with his arms resting on
an overbed table in order to expand the thoracic cavity. An anxiolytic
drug may have been given to help him relax. A local anesthetic is

8. injected and the aspiration needle is passed between the ribs, through
the intercostals muscles, untie fluid can be withdrawn.
At this stage an artery forcep is clamped onto the needle, at the point of
entry, in order to prevent deeper penetration of the needle. The fluid is
then withdrawn the needle removed, and a small dressing placed over
the puncture site.
Samples of the fluid may be sent for bacteriological, cytological and
biochemical analysis. Following the procedure, the pt's respiratory
symptoms should abate, and often the pt is free to return home.
Thoracic aspiration may be required by some pts on a regular basis.
Pneumothorax caused by needle puncture of the lung is the main
complication of this procedure. Infection is always a possibility whise
an invasive procedure is performed.
Nursing Care Plan
Problem Nursing action Rational Evaluation
Vomiting RT
inflammation in
the chest.
-Assist the color
and the amount
of what did he
vomit.
-relieve all
things that
stimulate the
vomiting.
-let the pt to eat
small amount of
meals and soft
food like milk,
better milk and
more meals,
especially fluids.
-To determine
the cause of the
vomiting.
-to prevent any
thing that
stimulate the
vomiting.
-The vomiting
been stopped.
-The pt felt
better.
Short
Term
Goal
To stop
vomiting during
hospitalization
period.
Long
To stop the
vomiting after

9. Term
Goal
discharge the pt
and promote his
health.
Problem Nursing
action
Rational Evaluation
Anxiety R/T
the length
period of
hospitalization,
vomiting,
anorexia.
-assist the
causes of the
anxiety
reasons.
-keep privacy.
-encourage his
family to talk
with his.
-stop vomiting.
-decrease the
level of
coughing.
-treat the
anorexia.
-let his to see
his family
sitting around
his talking
with his.
-to
determine
the points of
anxiety
reasons.
-to decrease
the level of
anxiety and
make pt feel
comfortable.
-to form
trust with
the pt.
-to
encourage
the pt to talk
about his
problems.
All actions
were done,
and the
level of
anxiety
decreased,
and the pt
felt
comfort.
Short
Term
Goal
To decrease
the anxiety
during
hospitalization,
and prevent it.
Long
Term
Goal
To prevent
anxiety to
happen after
discharge of
the pt.

10. Problem Nursing action Rational Evaluation
Anorexia R/T
length period of
hospitalization,
and a result of
vomiting.
-Assist his
situation about
his diet, about
his weight.
-give the pt
some of his
likely meals.
-give the pt
vitamins as Dr
order.
-give the pt
information
about the
benefits of the
food.
-let the pt to see
his family sitting
around his
talking with his.
-give the pt soft
food as he like.
-determine the
unlike food to
the pt.
-to encourage
the pt to eat
properly.
-to give the pt all
nutrients that he
need.
-to protect the pt
to loose his
weight.
-to balance the
fluid and
electrolytes.
-to prevent the
pt from
hypoglycemia.
-the pt can eat
anything as he
like.
-the pt felt
comfort.
Short
Term
Goal
-To let the pt to
eat properly in
the hospital.
-To keep the
nutrition of the
pt good in the
hospital.
Long
Term
Goal
To keep the pt's
health good
without any
problems or
diseases related
to anorexia after
discharge.

11. Problem Nursing action Rational Evaluation
Difficulty in
breathing R/T
fluids in the
pleural cavity.
-let the pt to sit
in semi sitting
position.
- let the pt to eat
small amount of
meals and soft
food like milk,
better milk and
more meals.
-to sit the pt in
comfortable
position for
breathing that
the airways are
open.
- to prevent the
stomach to press
on the
diaphragm.
The pt can
breath well
without any
efforts.
Short
Term
Goal
To let the pt
breath better and
decrease the
difficulty in
breathing in the
hospital.
Long
Term
Goal
To let the pt
breath properly
without any
effort and
promote his
respiratory
system after
discharge from
the hospital.
Lab Tests
31/12/2003
Test Result Normal Values
WBC 11.6 k/µl (H) 4.1 – 10.9 k/µl
LYM 2.9 0.6 – 4.1
MID 1 0.0 – 1.8
GRAN 7.7 2 – 7.8

12. RBC 3.99 m/µl (L) 4.2 – 6.3 m/µl
HGB 12.1 g/dl 14 – 18 g/dl
HCT 35.2% (L) 40 – 52%
MCH 30.3 pg 26 – 32 pg
MCHC 34.4 g/dl 31 – 36 g/dl
RDW 12.7% 11.5 – 14.5%
PLT 278 k/µl 140 – 446 k/µl
MPV 9 fl 0.0 – 99.8 fl
30/12/2003
Test Result Normal Values
WBC 18.8 k/µl (H) 4.1 – 10.9 k/µl
LYM 2 0.6 – 4.1
MID 1 0.0 – 1.8
GRAN 15.1 (H) 2 – 7.8
RBC 4.82 m/µl 4.2 – 6.3 m/µl
HGB 14.4 g/dl 14 – 18 g/dl
HCT 42.1% 40 – 52%
MCH 29.9 pg 26 – 32 pg
MCHC 34.2 g/dl 31 – 36 g/dl
RDW 14.3% 11.5 – 14.5%
PLT 339 k/µl 140 – 446 k/µl
MPV 9.5 fl 0.0 – 99.8 fl
Biochemistry
30/12/2003:
Test Result Normal Values

13. Amylase 29 U/L <90 U/L
Glucose p.p 187 mg/dl (H) 70-140 mg/dl
Bun 23 mg/dl (H) 8-21 mg/dl
Creatinine 1 0.5-1.2
SGOT 376 U/L <42 U/L
SGPT 227 U/L <41 U/L
Alk Phosph 249 U/L 98-279 U/L
Chloride 111 mEq/L 98-107 mEq/L
Na 145 mEq/L 136-145 mEq/L
K 4.3 mEq/L 3.5-5.1 mEq/L
HBAIC 5.1 mEq/L 4.5-7 mEq/L
Pleural Fluid
30/12/2003:
Test Result
Total cells 250/mm
WBC Zero
RBC 250/mm
Protein 2.5g/dL
LDH 357U/L
Glucose 108 mg/dL
Urine Analysis

14. 29/12/2003:
Test Result
Color Straw
PH Acidic 5
Transparency Hazy
Specific Gravity 1.015
Albumen Trance
Sugar Pos +1
Kenton Negative
Bilirubin Negative
Urobilinoyen Normal
Blood Negative
Nitrate Negative
Ultra Sound Report
30/12/2003:
- Liver presents heterogeneous hyperechoic solid lesion of
6.5x5cm of diameter in ITS 8-TH segment.
- GB bed is free.
- Biliary tree is not dilated.
- Pancreas is intact.
- Spleen contains small calcification.
- Renal small cysts, with no definite stones or hydronephrosis.
- Small amount of RT. pleural effusion.
- No pelvic masses or fluid collection.
- CT.SCANmay be helpful.

15. Medications
Name of Drug Route Dose Action Side effects
Trufen P.O 400mg Trufen is used for the
relief of mild to
moderate pain in
conditions such as
rheumatoid arthritis,
osteoarthritis,
dysmenorrhoea,
migraine, postoperative
pain, headache,
toothache, muscular
pain and for the
reduction of fever.
Gastrointestinal
disturbances may
occur(diarrhea,
heartburn, nausea,
abdominal pain).
Rarely: dizziness,
nervousness, skin rash,
pruritis, and
hypersensitivity
reactions.
Cordil P.O 40mg Vasodilators which
prevent angina pectoris
attacks, treatment of
congestive heart failure
(CHF).
Nausea, headache,
dizziness especially
after standing up from
a lying position,
tachycardia, vomiting,
restlessness.
Ratidine I.V 50mg For the treatment of
duodenal and gastric
ulcer, in reflux
oesophagitis and
Zollinger-Ellison
syndrome.
Allergic reactions such
as skin rahes, urticaria,
and angioedema.
Rocephin I.V 1gm Inhibit the cell wall
synthesis of the
bacteria.
Diarrhea, nausea,
vomiting, stomatitis,
glossitis, eosinophilia,
leucopenia, edema,
headache, increase in
liver enzyme, oliguria.
Klaricare P.O 250mg Macrolide Antibiotic. Gastrointestinal
disturbances may
occur(diarrhea,
heartburn, nausea,
abdominal pain)
headache, and skin

16. rahes.