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I.

INTRODUCTION
A Cerebrovascular Accident is the medical term for a stroke. A stroke is when
blood flow to a part of your brain is stopped either by a blockage or a rupture of a blood
vessel. There are important signs of a stroke that you should be aware of and watch out
for. A left-side stroke happens when the blood supply to the left side of the brain is
interrupted. Without oxygen and nutrients from blood, the brain tissue quickly dies. The
cerebrum is the largest part of the brain. It is made of a left and a right hemisphere. In
most people, the left hemisphere is in charge of the functions on the right-side of the
body. It is also involved in abilities such as the ability to speak, or use language. There
are two main types of stroke: ischemic and hemorrhagic.
Hemorrhagic stroke accounts for about 13 percent of stroke cases. It results from
a weakened vessel that ruptures and bleeds into the surrounding brain. The blood
accumulates and compresses the surrounding brain tissue. The two types of
hemorrhagic strokes are intracerebral (within the brain) hemorrhage or subarachnoid
hemorrhage.
Globally, measurements undertaken by the WHO revealed an up to ten-fold
difference in age-adjusted and sex-adjusted mortality rates and burden (measured in
disability-adjusted life year loss rates (DALYs)) among countries. Both were
considerably higher in low-income countries (North Asia, Eastern Europe, Central Africa,
and South Pacific) compared to high-income countries (Western Europe, North
America). 795,000 new or recurrent strokes occur per year in the US, accounting for
approximately 1 in 18 deaths. In Europe, the incidence of stroke varies from 101.1 to
1

239.3 per 100,000 in men and 63.0 to 158.7 per 100,000 in women. Within 5 years of a
stroke, over half of patients aged 45 years will die: 52% of men and 56% of women.
Stroke is the second leading cause of death above the age of 60 years, and the
fifth leading cause of death in people aged 15 to 59 years old. Every year, 15 million
people worldwide suffer a stroke. Nearly six million die and another five million are left
permanently disabled. Stroke is the second leading cause of disability, after dementia.
Disability may include loss of vision and / or speech, paralysis and confusion. Stroke is
less common in people under 40 years, although it does happen. In young people the
most common causes are high blood pressure or sickle cell disease. In many developed
countries the incidence of stroke is declining even though the actual number of strokes
is increasing because of the ageing population. In the developing world, however, the
incidence of stroke is increasing. In China, 1.3 million people have a stroke each year
and 75% live with varying degrees of disability as a result of stroke. The predictions for
the next two decades suggest a tripling in stroke mortality in Latin America, the Middle
East, and sub-Saharan Africa.
Nationally, according to the latest WHO data published in April 2011 Stroke
Deaths in Philippines reached 40,245 or 9.55% of total deaths. The age adjusted Death
Rate is 82.77 per 100,000 of population ranks Philippines #106 in the world.
Locally, there are no records of incidence of stroke published online for Davao
Del Norte. However, in Davao City, Councilor Rene Elias Lopez said stroke is now the
top cause of morbidity in the city, with 1,800 people dying from the disease in 2008.

OBJECTIVES
The study aims to present all the information we have gathered about the case of
our patient who has an admitting diagnosis of T/C Cerebrovascular accident; CAP-MR.
Moreover, this intends to share the knowledge based on information gathered to the
patient, the significant others and to our fellow nursing students.
Specifically, this study intends to:

Obtain sufficient and relevant information regarding our patients condition.


Present personal data of our patient.
Trace the past medical history affecting the patients present health condition.
Present factual information by conducting a thorough head-to-toe assessment

with our chosen subject serving as our baseline data.


Show and discuss the anatomy and physiology of the involved organ and system

basing from our patients diagnosis.


List down the actual laboratory results of our patient.
Present the medical interventions done to the patient including the different drugs

ordered with their action in alleviating the underlying causes of present condition.
Identify the needs of the patient and formulate effective nursing care plans

appropriate for the patients case.


Impart suitable and realistic health teachings to the patient himself and to his

significant others (watcher).


Evaluate the outcome of the condition of the patient.

II. ASSESSMENT
A Biographical Data
Name: Patient Magandang Buhay
Age: 62 years old
Birthdate: June 05, 1958
3

Birthplace: Pindasan, Compostella Valley Province


Sex: Female
Status: Widow
Address: Seminary Drive, Magugpo East, Tagum City, Davao del Norte
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: February 03, 2015
Time admitted: 9:52 pm
Attending Physician: Dr. Dejan
B Chief Complaint
Dizziness
C History of present illness
Patient Magandang Buhay was admitted on February 03, 2015 at Bishop
Joseph Regan Memorial Hospital. Few minutes prior to admission, she had
sudden onset of dizziness associated with vomiting. Patient claimed shes unable
to see. Naa man gud koy igsuon nga nagpakamatay 2 years ago maam. Grabe
iyang kaguol jud atong mga panahona. Mao to, ginatabangan namo siya maam
para dli na to niya mahinumduman, kadugayan naka recover ra man pud siya.
Pero

naabot

man

gud

gahapon

ang

amigo

sakong

igsuon

maam.

Nahinumduman na pud guro ni mama tong nahitabo, kay pagkahuman ato,


ningkalit ra man siyag kalipong tapos sige siyag ingon na dli daw siya kakita, as
verbalized by the watcher. During my first encounter with the patient, she was
stuporous, has decreased level of consciousness, asleep most of the time and
was only responsive to verbal stimulation; Has sluggish pupil reaction at left with
a gauge of 1mm and fixed pupil reaction at right with a gauge of 3mm; Has weak
handgrip but moderate leg movement; has spontaneous eye opening to speech,
oriented verbal response, and obeying motor response, which gives her an
overall GCS score of 14. During the rounds of Dr. Dejan, the watchers asked her
a question, Doc, nganong sige ra man siyag katulog? Usahay ra jud niya ibuka

iyang mata tapos wala daw siyay makita. Then, Dr. Dejan explained to them,
that the cause maybe of that manifestation is that stroke has affected the frontal
lobe of the brain of the patient.
D Past Medical History
Dili ni mao ang una nga giaatake siya ug stroke maam, kadaghan na man. Ang
pinaka bago lang katong pagkamatay sakong igsuon. Grabe man gud jud iyang
kaguol ato, dli jud niya madawat ang nahitabo. Pero naka recover na pud bia na
siya maam kay gipa therapy man namo na siya tapos naa pud siya gina
maintain na tambal, mga para sa highblood, stroke ug diabetes, as verbalized
by the patients watcher.
E Personal, Family and Socio-Economic History
Patient Magandang Buhay belongs to a middle class family. Currently, she
doesnt have a job and is living with his youngest daughter, since her other children
already have their own family. But despite that fact, they still continue to support the
patient in all her needs, especially when it comes to her health. The patients father
was hypertensive and died also because of Stroke. The patient has five siblings and
two of them were also Hypertensive. The patient doesnt have any vices according
to the watchers verbalization.
F Patient Need Assessment
Date: February 04, 2015
Name of patient: Patient Magandang Buhay
Age: 62 years old

Sex: F

Status: Widow

Date/ Admission Time: February 03, 2015 9:52 pm


Arrived on Unit by: Stretcher From: Emergency Room
5

Admitting weight/VS: Weight: 70kg.Temp: 36 C BP: 190/100 mmHg


RR: 20cpm PR: 77 bpm O2 sat: 94%
Clients Reason for Admission: Naa man gud koy igsuon nga nagpakamatay 2
years ago maam. Grabe iyang kaguol jud atong mga panahona. Mao to,
ginatabangan namo siya maam para dli na to niya mahinumduman, kadugayan
naka recover ra man pud siya. Pero naabot man gud gahapon ang amigo
sakong igsuon maam. Nahinumduman na pud guro ni mama tong nahitabo, kay
pagkahuman ato, ningkalit ra man siyag kalipong tapos sige siyag ingon na dli
daw siya kakita, as verbalized by the watcher.
How was problem been managed by client at home? Maintenance drugs
(Antihypertensive and Antidiabetic); Patient was immediately brought to the
hospital after such manifestations mentioned above.
Allergies: No known allergies to food and drug
Medication (at home): Maintenance drugs (Antihypertensive and Antidiabetic)
Physiologic Needs
I.

Oxygenation: BP = 120/80 mmHg; PR =74bpm; RR = 20cpm (regular


respiration).
Lungs (per auscultation: sound, character, chest pain): With symmetrical
chest expansion upon inhalation and distress not noted upon assessment.
With crackles heard upon lung auscultation.
Cardiac Status (per auscultation: sound, character, chest pain): With
normal cardiac sound of Lubb dubb heard upon auscultation and no
complains of chest pain upon assessment.
Capillary Refill: With capillary refill of 2 seconds upon blanching.

Skin Character and Color: Brownish skin complexion, warm to touch and
dry. Good skin turgor noted.
Life Supporting Apparatus: With O 2 inhalation @ 3LPM via nasal cannula.

II.
III.

With IVF #2 PNSS 1L @ KVO rate infusing well @ cephalic vein.


Other Observations: No other observations
Temperature Maintenance
Temperature: 37.7o C
Skin Character: Brownish, warm to touch, dry and with good skin turgor.
Nutritional Fluid
Height: 55
Weight: 70 kg.
Amount of Food Consumed: Patient was ordered NPO temporarily during
the first 2 days of her admission. On the third day, she can already have
soft diet as ordered by her AP, but was only able to consume half of the
meal served. Because according to her watcher, Dili man gud daw siya
ganahan sa lugaw maam.
Prescribed diet: NPO (1st 2 days); Soft Diet (3rd day onwards)
Eating pattern: On the first 2 days, since she was ordered NPO, the
patient really wasnt able to eat or drink anything. On the 3 rd day, she can
already 3 x a day, but with minimal to half amount of food consumed.
Eating problems: Needs assistance and aspiration precaution should be
considered.
IVF/Fluid Intake: IVF- 100cc, Water None on the first day of assessment,
because she was still on NPO; 50 cc on the 2nd day, because the diet has

IV.

already been changed to soft diet.


Elimination
Last bowel movement: February 3, 2015 in the morning, while the patient
was still at home.
Normal pattern: Kaisa sa isa ka adlaw, kada buntag jud, as verbalized by

V.

the watcher.
Urination: Able to urinate250-450 cc amber-colored urine within the shift.
Other observations: With Foley catheter attached to urobag
Rest and Sleep
7

Bed time: Sige ra man na siyag katulog maam. Kapoy daw, as


verbalized by the watcher.
Waking up: Usahay ra na siya magmata, gawas kung pukawon jud ug
tuyo, as verbalized by the watcher.
Sleep (pattern, amount of sleep): Able to sleep at long intervals and wakes
VI.

up only through verbal stimulation.


Pain Avoidance
Rate of pain (using scale 0-10): No complains of pain upon assessment;
No signs that the patient is currently experiencing pain. The patient is
stuporous, asleep most of the time and has decreased level of

VII.

consciousness.
Character: N/A
Location: N/A
Frequency: N/A
Duration: N/A
Behavior: N/A
Other Observations: None
Stimulation/ Activity
Work: She currently doesnt have a work and is already dependent; shes
living with her youngest child, since her other children already have their
own family.
Recreation or past time: Hes doing household chores.
Hobbies or vices: Wala jud na siyay bisyo maam. Magtanaw ra na siyag
TV sa balay kung walay ginabuhat, as verbalized by the watcher.
Safety Security needs
Neuro VS: score of 14 out of 15
Mental status: She was stuporous, has decreased level of consciousness,
asleep most of the time and was only responsive to verbal stimulation.
Emotional Problems: None
Other objective cues: Has sluggish pupil reaction at left with a gauge of
1mm and fixed pupil reaction at right with a gauge of 3mm; has weak
handgrip but moderate leg movement; has spontaneous eye opening to
speech, oriented verbal response, and obeying motor response
8

VIII.
IX.

Love and belonging


Self- esteem

X.

Self-actualization

Ericksons Developmental Task


Erickson envisions life as a sequence of levels of achievement. Each stage
signals a task that must be achieved. The resolution of the task can be complete,
partial, or unsuccessful. Erickson believes that the greater the task achievement, the
healthier the personality of the person: failure to achieve a task influences the persons
ability to achieve the next task. These developmental tasks can be viewed as a series of
crises, and successful resolution of these crises is supportive to the persons ego.
Failure to resolve the crises is damaging the ego.

Generativity vs. Stagnation


Patient Magandang Buhay, 62 years old, falls under the Mid Adulthood from 3565 years old which has the central task of Generativity versus Stagnation. This stages
major task is creativity, productivity and concern for others. Self-indulgence, selfconcern, lack of interests and commitments are the indicators of negative resolution. In
the case of our patient, Patient Magandang Buhay, he attained the Generativity for he
was able to achieve and realize the major task successfully by showing concern to his
family especially to his children despite of the condition she has. She always thinks of
whats best for his family, willing to give the excellent care and love that she can.
9

PHYSICAL ASSESSMENT
General Survey
Patient Magandang Buhay, 62 years old, male, stands 5 feet and 5 inches tall
and weighs 70kg. With the following VS as monitored and recorded upon admission
Temp = 36o C; BP= 190/100 mmHg; PR = 77 bpm; RR = 20cpm. With IVF bottle # 1
PNSS 1L @ KVO rate infusing well. She was stuporous, has decreased level of
consciousness, asleep most of the time and was only responsive to verbal stimulation.
Vital Signs Monitoring Sheet
Name: Patient Magandang Buhay

Sex: F

Ward: St. Joseph

Room/Bed: 309

Date/Shift

Time

12/07/201

6:25 PM

Age: 62 Y.O

Temperatur

Blood

Respirator

Card3iac

e
35.7

Pressure
260/130

y Rate
22

Rate
88

39.3
36.8

180/100
180/190
200/140

21
22

87
96

200/110
180/100
150/80
150/100
150/80
150/100

25
28
25
25
24
20

98
96
97
98
86
90

4
311
12/08/201

6:30 PM
8:00 PM
12:00 AM

4
117

12/08/201

1:00
2:00
2:30
3:00
4:00
8:00

AM
AM
AM
AM
AM
AM

36.7
36
37
37

10

4
73

12/08/201

10:00 AM
12:00 NN
1:00 PM
4:00 PM

37.3

140/90
150/100
170/100
140/90

6:00 PM
8:00 PM
12:00 MN

37.4
36.5
36.7

150/90
150/90
150/90

21
22
22

87
83
88

4:00 AM
6:00 AM
8:00 AM

37.1
36.8

160/100
180/90
150/80

22
22
20

80
89
86

10:00 AM
12:00 NN
2:00 PM
4:00 PM

36.6
37.1
37.3
37

180/100
140/100
190/90
160/90

21
20
20
22

84
85
81
76

8:00 PM
12:00 MN

37.4
37

160/80
180/100

20
20

75
76

4:00 AM
8:00 AM

37
36.9

160/90
160/100

20
21

78
90

10:00 AM
12:00 NN
2:00 PM

36.8
37.2
37.1

170/100
130/100
160/90

20
20
21

91
88
89

37.1

19

89

21

86

4
311
12/09/201
4
117
12/09/201
4
73

12/09/201
4
311
12/10/201
4
117
12/10/201
4
73

11

REVIEW OF SYSTEMS
Integumentary System
Generally, patient Magandang Buhay has brownish skin that is warm to touch,
with the presence of hair, with good skin turgor and capillary refill of 2 seconds after
blanching.
HEENT
HEAD

Head is normocephalic, can lift head fully and turn them from side to side. Hair is
short, thick and evenly distributed. No dandruff, head and scalp lesions not
noted.

EYES

Eyes are symmetrical and black in color; No eye discharges noted. The patient
sluggish pupil reaction at left with a gauge of 1mm and fixed pupil reaction at
right with a gauge of 3mm when diverted to light; Pale and palpebral conjunctivae
not noted, with white and anicteric sclera. Eyelashes are equally distributed.

EARS

Both symmetrical; with no discharges noted within both ears. There were no
lesions, wounds or discoloration noted upon inspection, and there were no
problems in hearing.

NECK
12

Short and mobile. Able to perform the different neck ROM exercises or
maneuvers. No tracheal deviations felt upon placing a finger along one side of
the trachea, noting the space and comparing with the opposite side. No swollen
lymph nodes upon palpation.

THROAT

Gums are in good condition. Tongue midline and mobile with visible papillae.
Tonsils are not inflamed. Pinkish hard and soft palate. Gag reflex is present.

Pulmonary System

With crackles heard upon auscultation; regular breathing pattern and symmetrical
chest expansion. Theres an equal rise and fall of the chest with normal depth of
respiration.

Cardiovascular System

Normal lubbdubb heard upon auscultation and apical pulse heard per
auscultation. No heaves and thrills heard. No murmurs, regular cardiac rate and
rhythm heard upon auscultation.

Gastrointestinal System

Abdomen is distended, and has the same color as the rest of the body. 5-15 clicks
per minute heard upon auscultation.
Musculoskeletal System

13

Unable to perform ADL alone and assistance is really needed. Has weak handgrip
but moderate leg movement; has spontaneous eye opening to speech, oriented
verbal response, and obeying motor response, which gives her an overall GCS
score of 14.
Genito-urinary System
Was able to urinate 250-450 cc amber-colored urine. With Foley catheter
attached to urobag.

III. LABORATORY AND DIAGNOSTIC EXAMINATION

14

URINALYSIS
February 3, 2015
LABORATORY

RESULT

NORMAL VALUE

UNIT

IMPLICATION

ON
Color

Straw

Light yellow to a -

Normal

Sugar

dark amber color


Negative 0
to
trace -

Normal

Albumin
Reaction

amounts.
Negative Negative
5.0
4.5 - 7.2

Normal
Normal

Sp gravity
Crystlas

1.010
-

1.005 to 1.025
-

Normal
-

Casts

Epithellial cells
Mucous threads
Pus cells
RBC

0-2
6-8

Few
0-2
0-2

hpf
hpf

Normal
Normal
Above

EXAMINATION
S/
DETERMINATI

normal.

The presence of
abnormal
numbers of red
cells is urine due
to

glomerular

damage, tumors
which erode the
urinary

tract
15

anywhere

along

its length, kidney


trauma,

urinary

tract

stones,

renal

infarcts,

acute

tubular

necrosis,
and

upper

lower

urinary

uri
tract

infections,
nephrotoxins,
and
Bacteria
Pus in clumps

hpf

physical

stress.
-

ELECTROLYTES
Paramet
er
Sodium
Potassium
Calcium

Result

Limit

139
4.48
1.10

136-145
3.50-5.00
1.12-1.32

Unit
mmol/L
mmol/L
mmol/L

Interpretation
Normal.
Normal.
Normal.

(ionized)

16

February 4, 2015
BLOOD CHEMISTRY
Paramete
Result

Limit

9.45

4.11-5.89

Unit

Interpretation

r
FBS

mmol/L

Increased.
glucose

High

levels

most

of

frequently

indicate diabetes,

but

many

other diseases and conditions


can also cause elevated blood
glucose. Moderately increased
blood glucose levels may be
seen

in

those

with pre-

diabetes. Left un-addressed,


pre-diabetes increases the risk
of developing type 2 diabetes.
Some

other

diseases

and

conditions that can result in an


elevated blood glucose level
include:
Acute stress

Acromegaly;
(response

to

trauma, heart

attack,

and stroke for

instance);
17

Chronic

kidney

failure;

Cushing syndrome; Excessive


food intake; Hyperthyroidism;
Pancreatic
Creatinine

121.30

45-84

umol/L

cancer;

and

Pancreatitis.
Increased. Generally, a high serum
creatinine level means that your
kidneys aren't working well. Your
creatinine level may temporarily
increase if you're dehydrated, have
a low blood volume, eat a large
amount of meat or take certain
medications.

The

dietary

supplement creatine can have the

SGPT

15

32

Total

276

150-200

u/L

same effect.
Normal.

mg/dL

Elevated Total Cholesterol; Normal

Cholestero

Triglycerides; Normal HDL; Elevated

l
Triglycerid

LDL. A total cholesterol test measures

66

<200

mg/dL

all types of cholesterol in your blood.

es

18

High

63

45-65

mg/dL

The result of this test tells your doctor

Density

whether your cholesterol is too high. If

Lipoprotei

your total cholesterol levels are high,

n (HDL)
Low

your doctor will want to know your

199.80

66-178

mg/dL

LDL cholesterol and HDL cholesterol

Density

levels before deciding whether you

Lipoprotei

need treatment. HDL stands for high-

density

lipoprotein.

It's

also

sometimes called "good" cholesterol.


You want your HDL cholesterol to be
high. Studies of both men and women
have shown that the higher your HDL,
the lower your risk of coronary artery
disease.

This

is

why

HDL

is

sometimes referred to as "good"


cholesterol.
density

LDL stands
lipoprotein.

for
It's

lowalso

sometimes called "bad" cholesterol.


Your LDL level is what doctors watch
most closely. You want your LDL to be
low. Too much LDL is linked to
cardiovascular disease. If it gets too
high, you will need treatment.

HBA1C

6.10

4-6

Elevated. Indicates Diabetes.

HEMATOLOGY
19

LABORATORY

RESULT

NORMAL

EXAMINATIONS/

VALUE

DETERMINATION
Hemoglobin
133

134.00-

Hematocrit
Leukocytes No. of

0.40
9.77

160.00
0.36-0.45
5-

Concen.
Segmenters

0.86

10x10^9
0.40-0.60

UNIT

IMPLICATION

g/L

Normal

Normal
Normal
Elevated.

Segmenters

or

neutrophils are the primary


cells

that

bacterial

respond

to

infection.

High

levels of your neutrophils


usually
ongoing

represent
infection,

inflammation,
stress
Lymphocytes

0.12

0.25-0.40

and

and

an

physical
malignancy,

caused by some drug, etc.


Decreased.
Low
lymphocytes

count

indicates that the body is


low on infection resistance.
This

means the body is

susceptible to infections like


tumors

and

cancer.
20

Low

lymphocytes count can also


lead
Monocytes
Eosinophils
Basophils
Stabs
Thrombocytes

0.01
0.01
288.0

Blood type
Rh type

0.01-0.12
0.01-0.05
0.005
0.01-0.05
150-

to

the

damage

various body organs.


Normal
Normal.
L

Normal.

440x10^9

URINALYSIS
LABORATORY

RESULT

NORMAL VALUE

UNIT

IMPLICATION

ON
Color

Light

Light yellow to a -

Normal

Sugar

Yellow
dark amber color
Negative 0
to
trace -

Normal

Albumin

Trace

EXAMINATION
S/
DETERMINATI

amounts.
Negative

An albumin test
checks urine for
the presence of a
21

of

protein

called

albumin. Albumin
is normally found
in

the blood and

filtered

by

kidneys.

the
When

the kidneys

are

working properly,
albumin

is

not

present

in

the

urine. But when


the kidneys are
damaged,

small

amounts

of

albumin leak into


the urine. This is
called
albuminuria.
However,

trace

albumin

in

urine specimen is
usually

not

significant
22

finding. It means
a

very

amount

small
of

protein shows up
Reaction

6.5

4.5 - 7.2

in the specimen.
Normal

Sp gravity
Crystlas

1.005
-

1.005 to 1.025
-

Normal
-

Casts

Epithellial cells
Mucous threads
Pus cells

Few
8-11

Few
0-2

hpf

Normal
Increased.
Indicates

that

there is presence
RBC

10-15

0-2

hpf

of infection.
Increased.
presence

The
of

abnormal
numbers of red
cells is urine due
to

glomerular

damage, tumors
which erode the
urinary
anywhere

tract
along

its length, kidney

23

trauma,

urinary

tract

stones,

renal

infarcts,

acute

tubular

necrosis,
and

upper

lower

urinary

uri
tract

infections,
nephrotoxins,
and
Bacteria
Pus in clumps

hpf

physical

stress.
-

IV. REVIEW OF ANATOMY AND PHYSIOLOGY


24

NERVOUS SYSTEM

25

The brain is a spongy organ made up of nerve and supportive tissues. It is


located in the head and is protected by a bony covering called the skull. The base, or
lower part, of the brain is connected to the spinal cord. Together, the brain and spinal
cord are known as the central nervous system (CNS). The spinal cord contains nerves
that send information to and from the brain.

The CNS works with the peripheral nervous system (PNS). The PNS is made up
of nerves that branch out from the spinal cord to relay messages from the brain to
different parts of the body. Together, the CNS and PNS allow a person to walk, talk, and
throw a ball and so on.

The brain is the bodys control centre. It constantly receives and interprets nerve
signals from the body and responds based on this information. Different parts of the
brain control movement, speech, emotions, consciousness and internal body functions,
such as heart rate, breathing and body temperature.

The brain has 3 main parts: cerebrum, cerebellum and brain stem.

Cerebrum
The cerebrum is the largest part of the brain. It is divided into 2 parts (halves)
called the left and right cerebral hemispheres. The 2 hemispheres are connected by a
bridge of nerve fibres called the corpus callosum.
26

The right half of the cerebrum (right hemisphere) controls the left side of the
body. The left half of the cerebrum (left hemisphere) controls the right side of the body.

The outer surface of the cerebrum is called the cerebral cortex or grey matter. It
is the area of the brain where nerve cells make connections, called synapses, that
control brain activity. The inner area of the cerebrum contains the insulated (myelinated)
bodies of the nerve cells (axons) that relay information between the brain and spinal
cord. This inner area is called the white matter because the insulation around the axons
gives it a whitish appearance.

The cerebrum is further divided into 4 sections called lobes. These include the
frontal (front), parietal (top), temporal (side) and occipital (back) lobes.

Each lobe has different functions:

The frontal lobe controls movement, speech, behaviour, memory, emotions and
intellectual functioning, such as thought processes, reasoning, problem solving,
decision making and planning.

The parietal lobe controls sensations, such as touch, pressure, pain and
temperature. It also controls spatial orientation (understanding of size, shape and
direction).

The temporal lobe controls hearing, memory and emotions. The left temporal
lobe also controls speech.

27

The occipital lobe controls vision.

Cerebellum
The cerebellum is the next largest part of the brain. It is located under the
cerebrum at the back of the brain. It is divided into 2 parts or hemispheres and has grey
and white matter, much like the cerebrum.

The cerebellum is responsible for:

movement

posture

balance

reflexes

complex actions (walking, talking)

collecting sensory information from the body


Brain stem
The brain stem is a bundle of nerve tissue at the base of the brain. It connects
the cerebrum to the spinal cord and sends messages between different parts of the
body and the brain.

The brain stem has 3 areas:


28

midbrain

pons

medulla oblongata
The brain stem controls:

breathing

body temperature

blood pressure

heart rate

hunger and thirst


Cranial nerves emerge from the brainstem. These nerves control facial
sensation, eye movement, hearing, swallowing, taste and speech.

Other important parts of the brain

Cerebrospinal fluid (CSF)


The cerebrospinal fluid (CSF) is a clear, watery liquid that surrounds, cushions
and protects the brain and spinal cord. The CSF also carries nutrients from the blood to,
and removes waste products from, the brain. It circulates through chambers called

29

ventricles and over the surface of the brain and spinal cord. The brain controls the level
of CSF in the body.
Meninges
The brain and spinal cord are covered and protected by 3 thin layers of tissue
(membranes) called the meninges:

dura mater thickest outer layer

arachnoid layer middle, thin membrane

pia mater inner, thin membrane

CSF flows in the space between the arachnoid layer and the pia mater. This
space is called the subarachnoid space.

The tentorium is a flap made of a fold in the meninges. It separates the cerebrum
from the cerebellum.

The supratentorial area of the brain is the area above the tentorium. It contains
the cerebrum, the first and second (lateral) ventricles, the third ventricle, and glands and
structures in the centre of the brain.

The infratentorial area is located at the back of the brain below the tentorium. It
contains the cerebellum and brain stem. This area is also called the posterior fossa.
Corpus callosum

30

The corpus callosum is a bundle of nerve fibres between the 2 cerebral


hemispheres. It connects and allows communication between both hemispheres.
Thalamus
The thalamus is a structure in the middle of the brain that has 2 lobes or
sections. It acts as a relay station for almost all information that comes and goes
between the brain and the rest of the nervous system in the body.
Hypothalamus
The hypothalamus is a small structure in the middle of the brain below the
thalamus. It plays a part in controlling body temperature, hormone secretion, blood
pressure, emotions, appetite, and sleep patterns.

Pituitary gland
The pituitary gland is a small, pea-sized organ in the centre of the brain. It is
attached to the hypothalamus and makes a number of different hormones that affect
other glands of the bodys endocrine system. It receives messages from the
hypothalamus and releases hormones that control the thyroid and adrenal gland, as
well as growth and physical and sexual development.
Ventricles
The ventricles are fluid-filled spaces (cavities) within the brain. There are 4
ventricles:

The first and second ventricles are in the cerebral hemispheres. They are called
lateral ventricles.

31

The third ventricle is in the centre of the brain, surrounded by the thalamus and

hypothalamus.
The fourth ventricle is at the back of the brain between the brain stem and the

cerebellum.
The ventricles are connected to each other by a series of tubes. The fluid in the
ventricles is cerebrospinal fluid (CSF). The CSF flows through the ventricles, around the
brain in the space between the layers of the meninges (subarachnoid space) and down
the spinal cord.
Pineal gland
The pineal gland is a very small gland in the third ventricle of the brain. It
produces the hormone melatonin, which influences sleeping and waking patterns and
sexual development.
Choroid plexus
The choroid plexus is a small organ in the ventricles that makes CSF.
Cranial nerves
There are 12 pairs of cranial nerves that perform specific functions in the head
and neck area. The first pair starts in the cerebrum, while the other 11 pairs start in the
brain stem. Cranial nerves are indicated by number (Roman numeral) or name.
Types of cells in the brain
The brain is made up of neurons and glial cells:

neurons
These cells carry the signals that make the nervous system work.
They cannot be replaced or repaired if they are damaged.
glial cells (neuroglial cells)
These cells support, feed and protect the neurons.
32

The different types of glial cells are:


astrocytes
oligodendrocytes
ependymal cells
microglial cells

Structure and function of the spine


The spine is made up of:

vertebrae, sacrum and coccyx bony sections that house and protect the spinal

cord (commonly called the spine)


The vertebral body is the biggest part of a vertebra. It is the front part of the vertebra,

which means it faces into the body.


spinal cord a column of nerves inside the protective vertebrae that runs from the

brain to the bottom of the spine


disc a layer of cartilage between each vertebra that cushions and protects the
vertebrae and spinal cord

The spine is divided into 5 sections:

cervical the vertebrae from the base of the skull to the lowest part of the neck

thoracic the vertebrae from the shoulders to mid-back

lumbar the vertebrae from mid-back to the hips

sacrum the vertebrae at the base of the spine

The vertebrae in this section are fused and do not flex.

coccyx the tail bone at the end of the spine


33

The vertebrae in this section are fused and do not flex.


Spinal nerves
The spine relays messages between the body and the brain. These nerve
messages control body functions like movement, bladder and bowel control and
breathing. Each vertebra has a pair of spinal nerves that receive messages from the
body (sensory impulses) and send messages to the body (motor impulses). The spinal
nerves are numbered from the cervical spine to the sacral spine.

Stroke occurs when the


supply of blood to the brain is
either interrupted or reduced.
When this happens, the brain
does not get enough oxygen or
nutrients which cause brain
cells to die.
If the stroke occurs in the
left side of the brain, the right
side of the body will be affected, producing some or all of the following:Paralysis on the
34

right side of the body; Speech/language problems; Slow, cautious behavioral style and
Memory loss.

Hemorrhagic

stroke

accounts

for

about 13 percent of stroke cases. It results


from a weakened vessel that ruptures and
bleeds into the surrounding brain. The blood
accumulates

and

compresses

the

surrounding brain tissue.


V. ETIOLOGY OF THE DISEASE
Etiology
High blood
pressure

Actual

Rationale
Uncontrolled increase of blood pressure can
cause a vessel to explode or burst. Thus,
causes

hemorrhagic

stroke.

(http://www.strokeassociation.org/STROKEORG/
AboutStroke/UnderstandingRisk/Understanding
-StrokeRisk_UCM_308539_SubHomePage.jsp#)
Uncontrolled diabetes can cause increase
Uncontrolle
d diabetes

viscosity

of

blood

in

the

blood

stream.

(http://www.strokeassociation.org/STROKEORG/
AboutStroke/UnderstandingRisk/Understanding
35

-StrokeRisk_UCM_308539_SubHomePage.jsp#)
High
cholesterol

Having high Cholesterol contributes to blood


vessel disease, which often leads to stroke.
(https://www.google.com.ph/?
gfe_rd=cr&ei=qKiOVMEBYSK8Qfw6oD4Bw&gws_rd=ssl#q=high+cho
lesterol+in+CVA)

Smoking

Smoking also nearly doubles the risk of


ischemic stroke. Smoking acts synergistically
with other risk factors, substantially increasing
the risk of CHD. Smokers are also at increased
risk for peripheral vascular disease, cancer,
chronic lung disease, and many other chronic
diseases.
(http://circ.ahajournals.org/content/96/9/3243.f
ull)

Excessive alcohol
intake

The

role

of

alcohol

consumption

as

an

independent risk factor for ischemic brain


infarction has remained unclear. Both mortality
and morbidity from ischemic brain infarction
seem to be increased among heavy alcohol
drinkers.

36

(http://stroke.ahajournals.org/content/30/11/23
07.full)
Race

African-Americans

(opens

in

new

window) have a much higher risk of death from


a stroke than Caucasians do. This is partly
because blacks have higher risks of high blood
pressure, diabetes and

obesity.

(http://www.strokeassociation.org/STROKEORG/
AboutStroke/UnderstandingRisk/Understanding
-StrokeRisk_UCM_308539_SubHomePage.jsp#)
Age (>65)

People aging 65 years old above are at great


risk for CVA. . atrial fibrillation is the direct
cause

of

one

in

four

strokes.

(https://www.google.com.ph/?gfe_rd=cr&ei=9JOVLPoO8uL8QeCyoC4DA&gws_rd=ssl#q=ratio
nale+for+65+years+old+person+with+stroke
)
Family
history of stroke

Your stroke risk may be greater if a parent, grandparent,


sister or brother has had a stroke. Some strokes may be
symptoms of genetic disorders like CADASIL (Cerebral
Autosomal Dominant Arteriopathy with Sub-cortical
Infarcts and Leukoencephalopathy), which is caused by

37

a gene mutation that leads to damage of blood vessel


walls in the brain, blocking blood flow. Most individuals
with CADASIL have a family history of the disorder
each child of a CADASIL parent has a 50% chance of
inheriting

the

disease.

(http://www.strokeassociation.org/STROKEORG/AboutSt
roke/UnderstandingRisk/)

Stress

Stress could increase prolonged exposure to


higher blood pressure and therefore promote
damage to blood vessel walls, increase your
risk of heart disease and atrial fibrillation
(irregular heart beat), and it could predispose
you to atheroma (swelling in an artery wall),
and aneurisms (a bulge in a blood vessel wall)
and

ischemic

stroke.

(http://www.abc.net.au/health/thepulse/stories/
2012/10/09/3605871.htm)

VI. SYMPTOMATOLOGY
Symptoms
Weakness

Actual

Rationale
Numbness

can

occur

from

dysfunction

or numbness of

anywhere along the pathway from the sensory

the face, arm, or

receptors up to and including the cerebral

leg on one side of

cortex.

38

the body

(http://www.merckmanuals.com/professional/n
eurologic_disorders/approach_to_the_neurolog
ic_patient/numbness.html)

Loss of speech,
difficulty talking,

communication deficits are characterized by

difficulty in understanding or producing

or understanding

speech correctly (aphasia), slurred speech

what others are

consequent to weak muscles (dysarthria),

saying

and/or difficulty in programming oral muscles


for speech production (apraxia). These deficits
vary in nature and severity depending on the
extent and location of the damage. Some
individuals may also have difficulty in social
communication, such as difficulty taking turns
in conversation and problems maintaining a
topic of
conversation.http://www.asha.org/public/spee

Loss of vision or

ch/disorders/Stroke/
Vision loss can be both a symptom and result

dimming (like a

of a stroke. Temporary vision loss can be a

curtain falling) in

sign of impending stroke and requires

one or both eyes

immediate medical attention. Learn about


how stroke may affect vision and what to do
about ithttp://www.stroke.org/stroke39

resources/library/stroke-and-vision-loss
Sudden, severe

Pain can also accompany a stroke. Numbness

headache with no

and pain can also alternate in the same area

known cause

as

the

brain

communicating

with

is

having
nerves

in

difficulty
a

certain

area.http://www.healthline.com/health/stroke/
complications

of

Problems with balance are common after

or

stroke. If your balance has been affected, you

unstable walking,

may feel dizzy or unsteady which could lead

usually combined

to a fall or loss of confidence when walking

with

and moving around. Loss of balance can be a

Loss
balance

another

result especially if certain part of the brain is

symptom

affected.
http://www.stroke.org.uk/factsheet/balanceproblems-after-stroke

VII. PATHOPHYSIOLOGY
A Written Pathophysiology
Strokes are divided into two main categories: Ischaemic and Haemorrhagic.
SIGNS AND SYMPTOMS:
-

40

Haemorrhagic strokes are due to the rupture of a blood vessels leading to compression
of brain tissue from an expanding haematoma. In addition, the pressure may lead to a
loss of blood supply to affected tissue with resulting infarction. Intracerebral
haemorrhage is the accumulation of blood anywhere within the brain, i.e.
intraparenchymal haemorrhage, intraventricular haemorrhage. This will form a gradually
enlarging haematoma (blood pool). Intracerebral Haemorrhages can be caused by local
vessel abnormalities (hypertension, vasculitis, vascular malformation) or systemic
factors (drugs, trauma, tumours and sickle cell anaemia/leukaemia). Haemorrhaging
directly damages brain tissue and raises intracranial pressure giving headaches,
vomiting nausea and eventually coma and death. Subarachnoid haemorrhage is the
gradual collection of blood in the subarachnoid space of the Dura. These can be
traumatic or spontaneous. Spontaneous haemorrhages occur through saccular (berry)
aneurysms and through extensions of intracranial haemorrhaging or due to similar
causes. Approximately one third of those who suffer a subarachnoid haemorrhage die.it
is the subarachnoid space which can pathologically fill with blood.

41

B Diagram of Pathophysiology
Predisposing Factors:
-

Family History of Stroke


Age

Precipitating Factors:
- Hypertension
- Stress

Brain sends message to adrenal glands


Produce hormones, including adrenalin and cortisol, that
put you into 'fight or flight' mode and increase your
breathing, heart rate and blood pressure.

The adrenalin you produce when you experience stress can


affect the platelets in your blood and promote clotting,
possibly causing a blockage of arteries in or near the brain.

42

Hemorrhagic- Impaired tissue perfusion

Infarction of cerebral vessels known as stroke

Space-occupying blood clots put more pressure on the brain tissues

The regulatory mechanisms of the brain attempt to maintain


equilibrium by increasing BP and ICP

The ruptured cerebral vessels may constrict to limit blood loss. However,
the vasospasm will result to further ischemia and necrosis of brain tissues.

SIGNS AND SYMPTOMS:


-Loss of Balance
- Sudden or severe headache - Loss of vision
Pharmacological
Management
Complications
-Loss of Speech
-Weakness or Numbness
of face and extremities
Nursing Management:
Furosemide
Loss of Muscle
1.
Reposition client q2
Ceftriaxone
Control/Paralysis
2.
Support dependent body
Citicoline
parts with pillows
Speech Problems
Omeprazole
3.
Provide safety measures
Swallowing Difficulties
including environmental
Amlodipine
management
Losartan
4.
Encourage SOs
Mannitol
involvement in activities &
decision making
5.

Personality and Mood


Changes

Peroform passive range


of motion exercises daily

6.

Cognitive Impairments

Depression

Increase functional
activities as strength
improves
GOOD PROGNOSIS

43
BAD PROGNOSIS

VIII. PLANNING
A NURSING CARE PLAN
Date /
Time
Decem
ber 10,
2014
7-3
shift

Assessment

Need

Subjective cues:
Gi-ubo sya sir,
dili sya
kaginhawa kaau
as verbalized by
the watcher.

P
H
Y
S
I
O
L
O
G
I
C
A
L

Objective cues:
-VS: BP- 160/100
PR- 90
RR- 27
Temp- 36.9
O2 sat= 97%

Need

-productive
cough
-crackles heard
upon
auscultation.
-(+) use of
accessory
muscle when

Nursing
Diagnosis
Ineffective
Breathing Pattern
r/t
tracheobronchial
inflammation and
increased sputum
production
secondary to
CAP-MR

Rationale:

Pneumonia is inf
lammation of the
terminal airways
Oxyg and alveoli
enatio caused by acute
n
infection by
patter various agents.
n
Community
Acquired

Objective
of Care
Within the
shift, will
be able to:
a. Identify
or
demonstra
te
behaviors
to achieve
airway
clearance.
b. Display
patent
airway
with
breath
sounds
clearing.

Nursing
Interventions
-Monitored VS.
R: To monitor
patients condition
and compared with
baseline data.
-Placed on MHBR
position.
R: It promotes
relaxation and helps
in promoting
effective airway
clearance.
-Assisted in turning
to sides every 30
minutes.
R: To promote
circulation as well
as to prevent
further
complications in the
pulmonary system.
-Encouraged to
increase OFI.

Evaluation
Within the
shift, GOAL
PARTIALLY
MET, as
evidenced
by:
a. being able
to
identify/demo
nstrate
behaviors to
achieve
airway
clearance
such as deep
breathing
and coughing
exercises.
b. crackles
lung sound
still heard
44

breathing
- with O2
inhalation @
2LPM via nasal
cannula
-lying flat on bed

Pneumonia
(CAP) is a
disease in which
individuals who
have not recently
been hospitalized
develop an
infection of the
lungs. It is an
acute
inflammatory
condition thats
result from
aspiration of
oropharyngealse
cretions or
stomach contents
in the lungs.
Therefore, airway
clearance is not
effective.

Reference:
http://nursingcrib.
com/

R: It helps to soften
and expectoration
of secretions.
-Encouraged to do
deep breathing and
coughing exercises.
R: Deep breathing
exercises facilitate
maximum
expansion of the
lungs and smaller
airways. Coughing
is a reflex and a
natural self-cleaning
mechanism that
assists the cilia to
maintain patent
airways.
-Demonstrated
proper back and
chest tapping to
watchers.
R: It can aid to
mobilization and
expectoration of
secretions.

upon
auscultation.

Dependent:
-Administer meds as
45

prescribed.
R: To continuously
treat underlying
causes and
symptoms.

Date Retrieved:
December 11,
2014

Collaborative:
-Encouraged
watchers to assist
patient in turning to
sides as well as in
performing ADL.
R: To prevent
further
complications and
to prevent accidents
that may lead to
injury.

Date /
Time
Decem
ber 10,
2014
7-3
shift

Assessment

Need

Subjective
cues:
Wala baya jud
kusog iyang
tuo nga parte
sa lawas sir

P
H
Y
S
I
O

Nursing
Diagnosis
Self-care
deficit r/t right
sided body
weakness
secondary to
Cerebrovascul
ar accident

Objective
of Care
Within the
shift, there
will be
demonstrati
on of selfcare, as

Nursing
Interventions
-Established rapport.
R: To gain trust and
cooperation.
-Monitored VS.
R: To have a baseline
data.

Evaluation
Within the shift,
GOAL
PARTIALLY
MET, as
evidenced by:
a. Being
46

as verbalized
by the
watcher.

L
O
G
I
C

Rationale:

Motor deficit
are the most
Objective
obvious effect
cues:
of stroke.
-VS: BPN
Symptoms are
160/100
E
caused by
PR- 90
E
destruction of
RR- 27
D
motor neurons
Temp36.9
Nutrition, in the
-hand grip and clothing pyramidal
pathways
leg movement
and
at the right
eliminati (nerve fibers
in the brain
side of the
on
and passing
body are
through the
absent
spinal cord to
- Inability to
the motor
feed self
tract.) When
independently
this happens,
-Inability to
activities of
dress self
daily living can
independently
be impaired
-Inability to
and even selfperform
care.
toileting task
independently
-total

evidenced
by:

-Assured that the


consistency of the
diet is appropriate for
patients ability to
chew and swallow.
R: Mechanical
problem may prohibit
the patient from
eating.
-Assisted during bed
bath.
R: To give comfort.
-Maintained privacy
during bathing.
R: The need for
privacy is
fundamental for most
patients.
-Assisted in changing
the clothes.
R: To give comfort
and to assess for the
parts which cannot
be move frequently.
-Provided frequent
encouragement and
assistance as needed
with dressing.
R: To reduce energy

unable to
place the
unnecessar
y things at
bedside on
his own.
b. Being able
to change
clothes
with
minimal
assistance.
c. Being
unable
to take a
bath
without
total
assistan
ce.

47

assistance
during ADL like
bathing and
clothing
-

Reference:
http://nursesla
bs.com/cerebr
ovascularaccidentnursing-careplans/.
Date
Retrieved:
December 11,
2014

expenditure and
frustration.
- Provided privacy
while patient is
toileting.
R: Lack of privacy
may inhibit the
patients ability to
evaluate their bowel
& bladder.
-Stretched and
tucked properly the
linens.
R: To prevent the
feeling of being
uncomfortable when
lying in bed.
Dependent:
-Administer meds as
prescribed.
R: To continuously
treat underlying
causes and
symptoms.
Collaborative:
-Encouraged
watchers to assist
48

patient in ADL like


daily bed bathing and
oral hygiene.
R: To help patient
maintain a proper
hygiene and prevent
accidents.

Date/Ti
me
Decembe
r 11,
2014
7-3 shift

Assessmen Need
Nursing
t
Diagnosis
Subjective
S
Activity
cues:
A
Intolerance r/t
Dili kalihok
F
right sided
akong tuo na
E
body
kamot og
T
weakness
tiil, as
Y
secondary to
verbalized.
Cerebrovascul
A
ar accident
Objective
N
cues:
D
Rationale:

Objective of
Care
Long Term Goal:
a Participate
willingly in
necessary/de
sired
activities.
b Use identified
techniques to
enhance
activity

Nursing
Interventions
-Monitored VS.
R: To monitor
patients condition
and compared
with baseline data.
- Ascertained
ability to stand
and move about,
and degree of
assistance

Evaluatio
n
GOAL MET,
as
evidenced
by:
a. Able to
participate
willingly in
necessary/
desired
49

- hand grip
and leg
movement
at the right
side of the
body are
absent
- turns to
sides with
assistance
-needs total
assistance in
ambulation
-unable to
perform ADL
alone

S
E
C
U
R
I
T
Y

The sudden
death of some
brain cells due
to lack of
oxygen when
the blood flow
to the brain is
impaired by
blockage or
rupture of an
artery to the
brain, this can
cause body
weakness or
paralysis of
the one side of
the body,
depending on
the area of the
brain that is
affected. This
will lead the
patient to
have
intolerance to
some
activities.
Reference:

intolerance.

necessary or use
of equipment
R: To determined
current status and
needs associated
with participation
in needed/desired
activities.
- Assessed
emotional and
psychological
factors affecting
the current
situation.
R: Stress or
depression maybe
increasing the
effects of an
illness, or
depression might
be the result of
forced inactivity.
- Increased
exercise or activity
levels gradually.
R: To conserve
energy
- Planned care to
carefully balance

activities.
b. Able to
use
identified
techniques
to enhance
activity
intolerance
.

50

http://www.me
dicinenet.com/
script/main/art
.asp?
articlekey=26
76. Date
Retrieved:
December 11,
2014

rest periods with


activities
R: to reduce
fatigue.
- Assisted with
activities and
provided/monitore
d clients use of
assistive
devices(e.g.,
crutches,
wheelchair)
R: To protect client
from injury.
- Promoted
comfort measures
and provided for
relief of pain.
R: To enhance
ability to
participate in
activities.
- Planned for
maximal activity
within the clients
ability.
R: Promote the
idea of normalcy
of progressive
51

abilities in this
area.
- Planned for
progressive
increase of activity
level/participation
in exercise
training, as
tolerated by the
client.
R: Both activity
intolerance and
health status may
improve with
progressive
training.
- Assisted client in
learning and
demonstrating
appropriate safety
measures.
R: To prevent
injuries
Dependent:
-Administered
meds as
prescribed.
R: For continuous
52

treatment of
underlying cause
and symptoms.
Collaborative:
-Encouraged
watchers to
support the
patient by
assisting in
performing ADL.
R: To provide
safety and avoid
accidents that
may cause injury.

53

B DISCHARGE PLAN
Areas

Objective

Activities
1 Encourage the patient to comply
with the prescribed medication.
This prevents further

Medication

100 % compliance to home


medicines

development of the disease


process and other possible
complication.
2 Encourage the client to take the
medicine into the right time,
right dose, right amount, and
right frequency and take note
the side effects of the medicine.
54

This would enable them to


know what are the drugs and its
desired dosage. The exact
dosage and time are important
to ensure the drugs
effectiveness.
3 Instruct patient to notify
physician if there is any
abnormalities after taking the
medicine.
4 Instruct patient to do not buy
any drugs that does not
prescribed by the physician.
To avoid the ineffectiveness of
the drug prescribed, and to
ensure the safety of the client.
1 Avoid strenuous activities.
2 Encourage patient to have
Exercise

To stabilize the condition of the

activities of daily living.


3 Encourage client to have
55

patient. Encourage to do light

adequate rest periods

exercise and understands its

between activities.

important.
1. Explain the purpose of
the medication that is
Treatment

Understanding the recommended


treatment or lessen underlying
illness.

prescribed by the
physician.
2. Inform the significant of
the treatment others that
they should be involved
in the treatment of the
client.
3. Encourage to take
medications religiously.
1 Instruct to take extra care in
doing daily ADL especially in
ambulation.
2 Instruct the client to have a

Health teachings

To prevent the risk of any

proper diet and hygiene.


3 Encourage client to wash hands
56

complications that may lead to


death.

before and after doing things.


4 Patient is advised to avoid
strenuous activities until full
recovery is achieved
5 Encourage significant others to
give total supportive care.
1 Continue prescribed medicines
and its right dosage.
To attain the therapeutic

Out - patient

To maintain quality health and


independence towards self - care.

effect of each medicines


towards the client.
2 Follow up with appointments
with physician.
To evaluate the progress of
the treatment and condition.
3 Encourage the patient to have
adequate rest and sleep
periods.
These aid faster recovery
from the illness and to have
enough strength in performing
57

activities of daily living and


range of motion exercises.
4 Encourage him to comply with
all the modifications and
instructions given to her
In order to have a fast
recovery.
1 Emphasize intake of
nutritious foods.
2 Encourage foods that are
Diet

Decrease intake of fatty and salty


foods as well as those foods that
can irritate the GI tract including
spicy and acidic foods. Include a
variety of vegetables and fruits in

less fatty and salty.


3 Observe proper handling of
foods.
4 Instruct to include variety of
fruits and vegetables in the
diet.

the diet.

58

IX. PHARMACOLOGICAL MANAGEMENT

59

Gener
ic
Name
Furose
mide

Bran
d
Nam
e
Lasix

Classificati
on

Mechanism of
action

Indication

Loop diuretic Furosemide


-Edema
inhibits
associated
reabsorption of with CHF,
Na and chloride cirrhosis,
Gene Brand Classificati mainly
Indication
in the
renal
Action
ric
Name on
medullary
disease
Name
portion of the
-Acute
ascending Loop pulmonary
Ceftri Forgra Cephalospori ofIndicated
Works by
Henle. in
edema
axone m
ns
patients of
with
inhibiting
Excretion
neurologicand
the
potassium
complications,
mucopepti
ammonia
is
carditis
and
de
also
increased
arthritis.
It is
synthesis
while
uric acid
also effective
in in the
excretion
is
Gram negative
bacterial
reduced.
It
infections;
cell wall.
increases
Meningitis,
The betaplasma-renin
Gonorrhea.
levels
and It is lactam
also for Bone
moiety of
secondary
and joint
Ceftriaxone
hyperaldostero
infections,
binds to
nism
may
Lower
carboxypep
result.
respiratory tract tidases,end
Furosemide
infections,
opeptidase
reduces
BP in
middle ear
s, and
hypertensives
transpeptid
asinfection,
well as inPID,
Septicemia and ases in the
normotensives.
Tract
bacterialcyt
ItUrinary
also reduces
pulmonary
oedema before
diuresis has set
in.

Side Effects/
Adverse
Reaction
Fluid and
electrolyte
imbalance.
Rashes,
Side
photosensi
Effects/
tivity,
Adverse
nausea,
Reaction
diarrhoea,
Pain
blurred
Induration
vision,
Phlebitis
dizziness,
Rash
headache,
Diarrhea
hypotensio
Thrombocyt
n. Bone
osis
marrow
Leucopenia
depression
Glossitis
(rare),
Respiratory
hepatic
super
dysfunctio
infections
n.
Hyperglyca
emia,
glycosuria,
ototoxicity.
Potentially
Fatal:
Rarely,
sudden
death and
cardiac
arrest.
Hypokalae
mia and
magnesiu

Time
and
Dosag
e
40mg
OD
IVTT

Nursing
Responsibili
ties

-Reduce
dosage if
given with
other
Time & antihypertensi
Nursing
Dosage ves;
Responsibilit
readjust
dosage
ies
gradually as
1 gram BP
-Assess
responds.
every
patients
12 hours -Administer
Previous
ANST (-) with
sensitivity
food or
IVTT
reaction
milk
to to
penicillin
prevent
GIor
other
upset.
cephalosphori
-Give
early in
ns.
the day so
that increased
-Assess will
urination
patient
for
not
disturb
signs and
sleep.
symptoms
of infection
-Avoid
IV use
before
andis
if oral use
during
the
at
all possible.
treatment
-Obtain C&S
-WARNING:
Do
before
not mix
beginning
parenteral
solution with
highly acidic 60
solutions with
pH below 3.5.
-Do not

infections.

oplasmicm
embrane.
These
enzymes
are
involved in
cell-wall
synthesis
and cell
division. By
binding to
these
enzymes,
Ceftriaxone
results in
the
formation
of
of defective
cell walls
and cell
death.

drug therapy
to identify
if correct
treatment has
been initiated.
-Report signs
such as
petechiae,
ecchymotic
areas,
epistaxis or
other forms
of unexplaine
d bleeding.

61

Generi
c
Name
Citicoli
ne

Bran
d
Nam
e
Choli
nerv

Classificati Indication
on

Action

CNS
stimulant,
Peripheral
Vasolidlator

Citicoline
activates
the biosynthesis
of structural pho
spholipids in the
neuronal
membrane,
increases
cerebral
metabolism and
increases the
level of various
neurotransmitte
rs, including
acetylcholine
and dopamine.
Citicoline has
shown
neuroprotective
affects in
situations
of hypoxia and
ischemia.

Cerebrovasc
ular
Diseases,
accelerates
the recovery
of conscious
ness and
overcoming
motor deficit

Side
Effects/
Adverse
Reaction
citicoline
may exert
a
stimulating
action of
the parasy
mpathetic,
as well as a
fleeting
and
iscretehypo
tensor
effect.

Time & Nursing


Dosag Responsibiliti
e
es
500mg
1 cap
TID

-Watch out
for hypotensive
effects.
-Must not be
administered
along with
medicaments
containing

62

Generic
Brand Classi
Indication
SideSide
Time Time
Nursing
Generi Brand
Classificat
MechanismAction
Indication
Nursing
Name
Name
ficatio
Effects/
and
Responsibilities
c
Name
ion
of action
Effects/
and
Responsibiliti
n
Adverse
Dosag
Name
Adverse
Dosag es
Reaction
e
Reaction
e
Omepraz
Omep Proton
ShortInhibits
term
Suppresses
Diarrhea,
40 mg10mg
-Assess
other
Losarta Cozaar
AntiHypertensi
CNS1 -Monitor
ole
ron
pump
treatment
gastric
nausea,
patient
n
hypertensi
vasoconstricti
on,
dizziness,IVTT tab medications
OD patients
BP.
inhibito
of active
secretion
by fatigue,
maybe-Monitor
taking for
ve
ve and
Nephepatic
asthenia, OD
Generi Brand Classificati
Mechanism
Indication
Side
Time
Nursing
r
duodenalulcer,
constipatio
effectiveness
aldosterone-inhibiting
ally in type
fatigue,
patientsand
who
c Name Name on
of
action
Effects/
and
Responsibilities
gastroesopha
interaction.
secreting hydrogen/p
2 diabeticn, headache,
are also taking
Adverse
Dosag
gealreflux
otassium
vomiting,
-Monitor
therapeutic
action of
patients, to
insomia. CVdiuretics
for
Reaction
e
disease
ATP
as
flatulence,
effectiveness
and
angiotensin II
reduce risk edema,
symptomatic
Amlodip Norvas Calcium
Inhibits the
Alone or
10mg
(GERD),
enzyme
utycaria,
adverse
reaction at
by blocking
of
chest pain.
hypotension.
CNS:
-Monitor blood
ine
c
channel
transport
with other
1 tab
including
dry mouth,
the beginning
angiotensin system
II
CVAinin
EENT-nasal
-Assess
headache,
pressure
and pulse
blocker
of calcium into agents in
OD
erosive
the
gastric
dizziness,
of
therapy
and renal
receptor on
patients
congestion,
patients
dizziness,
before therapy,
myocardial
the
esophagitis
parietal
periodically
the surface of
withcell: headache
sinusitis,
function
during
dose titration,
and vascular
manageme fatigue CV:
and vascular
characterize
throughout
the
hypertensi pharyngitis,
-Tell
patient
to
peripheral
and periodically
smooth muscle nt
symptomatic
as
a
gastric
therapy
.
smooth
on and left sinus
avoid salt
during
cells, resulting of hyperten edema,
GERD.
Long
acid
pump
-Assess
GI system:
muscle and
ventricular disorder.
substitutes
angina, GItherapy.
Monitor EC
in the
sion,
term other tissue inhibitor,
bowel
sounds
8 hrly,
hypertroph Abdominal
bradycardia
G during prolonged
inhibition
angina
treatment
since yit block
abdomen
cells
pain,
nausea,
,
therapy.for pain
of excitation
pectoris
of pathologic
the final
and swelling,
diarrhea,
hypotensio
contraction
and
hypersecretor step of acid
appetite loss.
dyspepsia.M
coupling and
vasospastic n,
y condition: to production.
-Monitor hepatic
usculoskeleta
palpitations
subsequent
angina
maintain
enzymes.
-Monitor intake and
l-muscle
GI: gingival
contraction
healing of
Assess
output ratios and
cramps,
hyperplasia
erosive
knowledge/teach
daily
myalgia,
, nausea
esophagitis.
appropriate
use of this
weight. Assess
for
back
or leg
DERM:
Short term
medication,
signs of CHF
pain.
flushing
(peripheral edema,
treatment
interventions
to
Respiratoryrales/crackles,
of active
reduce
side effects, 63
cough, upper
weight
benign gastric
anddyspnea,
other symptoms
respiratory
gain and jugular
ulcer
to report
infection
venous distention

Generi Brand Classificati


c Name Name on

Mechanism
of action

Indication

Mannito
l

Increases
osmotic
pressure of
plasma in
glomerular
filtrate,
inhibiting
tubular
reabsorption
of water and
electrolytes
(including
sodium and
potassium).
These actions
enhance
water flow
from various
tissues and
ultimately
decrease
intracranial
and
intraocular
pressures

Test dose
for marked
oliguria or
suspected
inadequate
renal
function,
prevent
acute renal
failure
during
cardiovasc
ular and
other
surgeries,
acute renal
failure, to
reduce
intracranial
pressure
and brain
mass,
reduce
intraocular
pressure,
to promote
dieresis in
drug
toxicity,
irrigation
during
transurethr
al resection
of prostate.

Osmitr Osmotic
ol
Diuretic

Side
Effects/
Adverse
Reaction
CNS:
dizziness,
headache,
seizures
CV: chest
pain,
hypotension,
hypertension,
tachycardia,
thrombophlebi
tis, heart
failure,
vascular
overload
EENT: blurred
vision, rhinitis
GI: nausea,
vomiting,
diarrhea, dry
mouth
GU: polyuria,
urinary
retention,
osmotic
nephrosis
Metabolic:
dehydration,
water
intoxication,
hypernatremia
, hyponatremi
a,
hypovolemia,
hypokalemia,h

Time
and
Dosag
e
50ml
IVTT
every
6 hrs

Nursing
Responsibilities

-Monitor vital signs.


-Monitor intake and
output.
-Monitor central
venous pressure.
-Monitor pulmonary
artery pressure.
-Monitor signs and
symptoms of
dehydration.

-Monitor signs of
electrolyte
imbalance

64

65

X. SYNTHESES OF CLIENTS CONDITION/STATUS FROM ADMISSION TO


PRESENT
A. Conclusion
Therefore, after we had studied the case, our client has suffered from
Cerebrovascular Accident because of some possible factors that might have contributed
on the development of the condition. Cerebrovascular Accident refers to is the medical
term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by
a blockage or a rupture of a blood vessel. There are important signs of a stroke that you
should be aware of and watch out for. If you think that you or someone around you
might be having a stroke, it is important to seek medical attention immediately. The
more quickly you get treatment, the better the prognosis. When a stroke goes untreated
for too long, there can be permanent brain damage.
The certain condition that the patient is suffering is really considered dangerous.
It is a life-threatening condition especially if the patient will not follow the prescribed
meds and a healthy lifestyle as it would lead to many other complications that may
greatly affect his life as well as his family and eventually may lead to death. Despite of
all that facts, there are treatments and preventive measures that people should do in
order to stop or prevent this condition from getting worst. We conclude that the need for
medical consultations and abiding the medical orders regarding health condition and at
least preventing the worst to happen should be really observed and taken into
consideration by the patient himself and by the significant others as well. Doing right

66

things and sufficient knowledge about the patients conditions can be of great help and
they should know the preventive measures for prevention is always better than cure.

B. Patients Prognosis
Poor

Fair

Good

Duration

Justification
Patient has been
admitted
because of right
sided weakness

and still present


during our 4 day
exposure.
The patient still

Onset

experienced his
chief complaint

Willingnes

during our shift.


The patient has

the willingness
to take all

medications
after the
explanation of
the purpose of
the medicine.
67

Environm

The patient

ent

stayed in a ward

room and was


conducive for
healing and
recovery.
The patients

Diet

diet was more

on salty and
fatty foods.

Computation:
Poor-

1x0=0

Fair-

2x3=6

Good-

3x2=6
12/5 = 2.4 (Fair Prognosis)

C. RECOMMENDATIONS
Giving importance to the health of ourselves and maintaining a healthy lifestyle
as individuals, is highly required to maintain a good and healthy life. It is because
ignoring the health condition could greatly affect life especially when certain conditions
or diseases would develop.
68

It is very important that every person should give importance to his/her health. A
person should promote healthy lifestyle changes that include adequate nutrition, clean
environment, and free from stress. For our patient, it is important to eliminate those
factors that can trigger to his condition.
With this we recommend the following:
1.
2.
3.
4.
5.
6.
7.

Maintain proper hygiene all the time;


Deep breathing exercises to promote relaxation;
Adequate rest and sleep;
Strict compliance to the medical treatment and medical check-up;
Instructed watcher to assist patient in performing ADL;
Instructed watcher not to leave the patient alone;
Follow-up with appointment with the physician.

XI. EVALUATION OF THE OBJECTIVES OF THE STUDY


69

After days of collecting relevant information and sequence of analysis on related


topics of this case study, we are now presenting our evaluation related to our objectives
that have been presented. We have certified that we were able to complete the chosen
case with factual data gathered including the necessary information related to this case.
Within the span of at least of rendering care to Patient Kowowo, we have drawn
together the important and relevant information that serve as the baseline of our study
and were able to identify potential problems. By gaining the patients trust and
cooperation and with the help of the significant others, we were able to assess properly
every single data regarding the patients condition and thoroughly assessed every
system involved. We were able to obtain his past health history that contributed to the
occurrence of the condition. Additionally, we were able to get the complete diagnosis,
able to perform the cephalocaudal physical assessment of the patient, and discussed
firmly the anatomy and physiology of the systems involved. Besides, we were able to
present the pathogenesis of certain conditions included in the admitting diagnosis.
Moreover, we were able to present the factors that affect the patients condition,
comprehensively interpreted the laboratory results, discussed and enumerated the
medications prescribed including the nursing responsibilities and given the interventions
we have planned and implemented for our patient.

We were able to appreciate more the essence of utilizing the nursing process in
the care, service and management of our patient. This case study improves not only our
70

knowledge but also with our skills concerning on providing care for our patient with such
diseases and we can be able to share our learning regarding this study to the significant
people. In addition, it enhances our analysis, research, knowledge and skills on the field
of nursing. It was indeed a hard job on conducting this study yet, it gave a great impact
in our career regarding how useful it is in our chosen profession.

XI.

BIBLIOGRAPHY

Books
71

Brunner and Suddarth's Textbook of Med.-Surg. Nursing 12th ed Copyright


2010 by Lippincott Williams & Wilkins, a Wolter Kluwer business.

Medical - Surgical Nursing 7th ed. by Black Joyce M. and Jane Hokanson Hawks

PorthsEssentials of Pathophysiology 3rd EditionCopyright 2011 by Lippincott


Williams & Wilkins, a Wolter Kluwer business.

Fundamentals of Nursing, 7th ed. by Kozier, Barbara

Medical Surgical Nursing 7th ed. Copyright 2008 by Lewis, et.al. Nurses
pocket guide, 12th ed. by Doenges, Marilynn, et.al.

Nurses Handbook of Health Assessment 6th ed. by Weber, Janet


Daviss Drug Guide for Nurses. TENTH EDITION.
Daviss Nurses Pocket Guide. 12th edition
Internet

http://www.healthline.com/health/cerebrovascular-accident#Overview1 Date

of Retrieval: December 13, 2014


http://www.medicinenet.com/script/main/art.asp?articlekey=2676Date of

Retrieval: December 13, 2014


http://health.cvs.com/GetContent.aspx?token=f75979d3-9c7c-4b16-af56-

3e122a3f19e3&chunkiid=645095Date of Retrieval: December 13, 2014


http://www.world-heart-federation.org/cardiovascular-health/stroke/Date of

Retrieval: December 13, 2014


http://www.strokeforum.com/stroke-background/epidemiology.htmlDate of
Retrieval: December 13, 2014

72

http://www.worldlifeexpectancy.com/philippines-strokeDate of Retrieval:

December 13, 2014


http://emedicine.medscape.com Date of Retrieval: December 13, 2014
http://www.webmd.com/Date of Retrieval: December 13, 2014
http://www.healthline.com/health/Date of Retrieval: December 13, 2014
http://www.mayoclinic.org/Date of Retrieval: December 13, 2014
http://www.livestrong.com/Date of Retrieval: December 13, 2014
http://www.healthcommunities.com/ Date of Retrieval: December 13, 2014
http://emedicine.medscape.com/ Date of Retrieval: December 13, 2014
http://www.ncbi.nlm.nih.gov/Date of Retrieval: December 13, 2014

73

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