HOLY ANGEL UNIVERSITY

Angeles City
College of Nursing

CerebroVascul
arAccident
Submitted by:

Valarie Agustin
Arianne De Jesus
Leo Cesar Dela Cruz
John Henrick Dingal
Genevieve Gopez
Fritzie Blanca Limiac
Ralp Lauren Lumanlan
Princess Dian Munoz
Irien Nain
Andrei Punzalan
Jenelyn Talavera
Paula Angeli P. Tayag
Alraian Tuazon

Submitted to:

Mr. Nathaniel H. Gaddi RN, MD

March 1, 2010

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INTRODUCTIO
N

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 I. INTRODUCTION

“The only way to keep your health is to eat what you don’t want, drink
what you don’t like, and do what you’d rather not.”
-Mark Twain

A. BRIEF DESCRIPTION OF THE DISEASE CONDITION

Cerebrovascular accident (CVA) is the medical term for what is commonly termed
as stroke. It refers to the injury to the brain that occurs when flow of blood to brain tissue is
interrupted by a clogged or ruptured artery, causing brain tissue to die because of lack of
nutrients and oxygen.

The severity associated with cerebrovascular accident can best be demonstrated by

many facts. It has been noted that CVA is the leading cause of adult disability in the world.
Worldwide, one-quarter of all strokes are fatal. Two-thirds of strokes occur in people over the
age of 65. Strokes affect men more often than women, although women are more likely to die
from a stroke. The incidence of strokes among people ages 30 to 60 is less than 1%. This figure
triples by the age of 80.

The quote says that everything occurring in our lives are the result of our previous
choices- choices that may lead to a good present status or the opposite, especially in health
were most of the conditions met by patients are results of their chosen lifestyle and other health
practices.

Some choices made by certain people may have detrimental health effects that may
progress to a clinical condition. A person’s diet, activity of daily living, health beliefs and others
can result to health illness. Like the case of this study, a person’s way of life, along with other
non-modifiable factors resulted to the occurrence of weakness and slurred speech that lead to a
condition called Cerebrovascular Accident (CVA).

A stroke (sometimes called a cerebrovascular accident (CVA)) is the rapidly

developing loss of brain function(s) due to disturbance in the blood supply to the brain, caused
by a blocked or burst blood vessel. This can be due to ischemia (lack of glucose and oxygen
supply) caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected

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area of the brain is unable to function, leading to inability to move one or more limbs on one side
of the body, inability to understand or formulate speech, or inability to see one side of the visual
field. A stroke is a medical emergency and can cause permanent neurological damage,
complications, and death. It is the leading cause of adult disability in the United States and
Europe. It is the number two cause of death worldwide and may soon become the leading
cause of death worldwide. Risk factors for stroke include advanced age, hypertension (high
blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high
cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important
modifiable risk factor of stroke.

A stroke is occasionally treated with thrombolysis ("clot buster"), but usually with
supportive care (speech and language therapy, physiotherapy and occupational therapy) in a
"stroke unit" and secondary prevention with antiplatelet drugs (aspirin and often dipyridamole),
blood pressure control, statins, and in selected patients with carotid
endarterectomy and anticoagulation.

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases
do not progress further. The symptoms depend on the area of the brain affected. The more
extensive the area of brain affected, the more functions that are likely to be lost. Some forms of
stroke can cause additional symptoms: in intracranial hemorrhage, the affected area may
compress other structures. Most forms of stroke are not associated with headache, apart from
subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral
hemorrhage.

Disability affects 75% of stroke survivors enough to decrease their employability. Stroke
can affect patients physically, mentally, emotionally, or a combination of the three. The results of
stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to
areas in the brain that have been damaged.

Some of the physical disabilities that can result from stroke include paralysis,
numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned
movements), difficulties carrying out daily activities, appetite loss, speech loss, vision loss,
and pain. If the stroke is severe enough, or in a certain location such as parts of the
brainstem, coma or death can result.

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 Emotional problems resulting from stroke can result from direct damage to emotional
centers in the brain or from frustration and difficulty adapting to new limitations. Post-stroke
emotional difficulties include anxiety, panic attacks, flat affect (failure to express
emotions), mania, apathy, and psychosis.

30 to 50% of stroke survivors suffer post stroke depression, which is characterized by lethargy,
irritability, sleep disturbances, lowered self esteem, and withdrawal. Depression can reduce
motivation and worsen outcome, but can be treated with antidepressants.

Emotional lability, another consequence of stroke, causes the patient to switch quickly
between emotional highs and lows and to express emotions inappropriately, for instance with an
excess of laughing or crying with little or no provocation. While these expressions of emotion
usually correspond to the patient's actual emotions, a more severe form of emotional lability
causes patients to laugh and cry pathologically, without regard to context or emotion. Some
patients show the opposite of what they feel, for example crying when they are happy.
Emotional lability occurs in about 20% of stroke patients.

Cognitive deficits resulting from stroke include perceptual disorders, speech

problems, dementia, and problems with attention and memory. A stroke sufferer may be
unaware of his or her own disabilities, a condition called anosognosia. In a condition
called hemispatial neglect, a patient is unable to attend to anything on the side of space
opposite to the damaged hemisphere.

Up to 10% of all stroke patients develop seizures, most commonly in the week
subsequent to the event; the severity of the stroke increases the likelihood of a seizure.

Hippocrates (460 to 370 BC) was first to describe the phenomenon of

sudden paralysis that is often associated with ischemia. Apoplexy, from the Greek word
meaning "struck down with violence,” first appeared in Hippocratic writings to describe this
phenomenon.

The word stroke was used as a synonym for apoplectic seizure as early as 1599, and is
a fairly literal translation of the Greek term.

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 In 1658, in his Apoplexia, Johann Jacob Wepfer (1620–1695) identified the cause
of hemorrhagic stroke when he suggested that people who had died of apoplexy had bleeding in
their brains. Wepfer also identified the main arteries supplying the brain,
the vertebral and carotid arteries, and identified the cause of ischemic stroke [also known
as cerebral infarction] when he suggested that apoplexy might be caused by a blockage to
those vessels. Rudolf Virchow first described the mechanism of thromboembolism as a major
factor.

B. REASONS FOR CHOOSING THE CASE

The group chose this case for their study because the group found it interesting. The
student nurses wanted to learn more about the disease condition, its causes, symptoms and
interventions that the student nurse need to know as they become future health care providers.
In line with this, the group was able to enhance their knowledge and skills as nurses in order to
render effective nursing care.

C. STATISTICS

Global Statistics
According to the World Health Organization, 15 million people suffer stroke worldwide
each year. Of these, 5 million die and another 5 million are permanently disabled.
High blood pressure contributes to over 12.7 million strokes worldwide.
Europe averages approximately 650,000 stroke deaths each year.
In developed countries, the incidence of stroke is declining - largely due to efforts to lower
blood pressure and reduce smoking. However, the overall rate of stroke remains high due
to the aging of the population.

Sources: World Health Report - 2007, from the World Health Organization; International
Cardiovascular Disease Statistics (2007 Update), a publication from the American Heart
Association.

UK
Stroke is a major cause of mortality in the UK, accounting for around 53,000 deaths every year
(around 9% of all deaths). As a single cause of death, stroke is second only to coronary heart

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disease as the biggest killer in the UK. Stroke is also a major cause of premature mortality,
responsible for over 9,500 deaths every year in people under the age of 75, about one in twenty
of all deaths in this age group.

There are a number of different forms of stroke, including subarachnoid haemorrhage,

haemorrhagic stroke and ischaemic stroke. It is often difficult for medical practitioners to identify
the particular stroke subtype without access to evidence from autopsy or a brain scan.
Therefore a large number of stroke mortalities are recorded as either ‘unspecified stroke’ or
‘other cerebrovascular disease’. Because of this, it is not possible to know exactly how many
deaths are caused each year by the individual stroke subtypes.
(http://www.heartstats.org/datapage.asp?id=8164)

May 2007
The burden of stroke
• Each year 16 million people experience a stroke and 5·7 million die.1
• 87% of global stroke mortality occurs in low- and middle-income countries.1
• Unless there are population-wide interventions, by 2030 there will be 23 million strokes
and 7·8 million deaths each year.1
• Over the next two decades stroke mortality will triple in Latin America, the Middle East,
and sub-Saharan Africa.2
• Globally, stroke is the second leading cause of death above the age of 60 years, and the
fifth leading cause in people aged 15 to 59 years old.3
• Stroke is the third most common cause of death in developed countries, behind coronary
heart disease (CHD) and cancer.3
• Stroke is uncommon in people under 40 years.3
• In many developed countries the incidence of stroke is declining but the actual number is
increasing because of ageing populations.3
(http://www.worldheart.org/press/facts-figures/stroke/)

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LOCAL STATISTICS
MORTALITY
MORTALITY: TEN LEADING (10) LEADING CAUSES
Number and rate/100,000 Population Philippines
5-Year Average (2000-2004) & 2005

5 Year Average
2005*
Cause (2000-2004)

Number Rate No. Rate

1. Diseases of the Heart 66,412 83.3 77,060 90.4

2. Diseases of the Vascular system 50,886 63.9 54,372 63.8

3. Malignant Neoplasm 38,578 48.4 41,697 48.9

4. Pneumonia 32,989 41.4 36,510 42.8

5. Accidents 33,455 42.0 33,327 39.1

6. Tuberculosis, all forms 27,211 34.2 26,588 31.2

7. Chronic lower respiratory diseases 18,015 22.6 20,951 24.6

8.Diabetes Mellitus 13,584 17.0 18,441 21.6

9. Certain conditions originating in the

14,477 18.2 12,368 14.5
perinatal period

10. Nephritis, nephrotic syndrome and

9.166 11.5 11,056 3.6
nephrosis
Note: Excludes ill-defined and unknown causes of mortality
(R00-R99) n=23,235
* reference year
** External Causes of Mortality
Last Update: June 29, 2009

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 TEN LEADING (10) CAUSES OF MORTALITY AMONG MALES
Number and Rate/100,000 Population
Philippines, 2005

Cause No. Rate

1. Diseases of the Heart 43,809 102.1

2. Diseases of the Vascular system 30,531 71.2

3. Accidents 27,281 63.6

4. Malignant Neoplasms 21,993 51.3

5. Tuberculosis, all forms 18,229 42.5

6. Pneumonia 18,145 42.3

7. Chronic lower respiratory diseases 14,450 33.7

8. Diabetes Mellitus 8,912 20.8

9. Certain conditions originating in the perinatal

7,385 17.2
period

10. Nephritis, nephrotic syndrome and nephrosis

6,548 15.3

Last Update: June 30, 2009

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 TEN LEADING (10) CAUSES OF MORTALITY AMONG FEMALES
Number and Rate/100,000 Population
Philippines, 2005

Cause No. Rate

1. Diseases of the Heart 33,251 78.5

2. Diseases of the Vascular system 23,841 56.3

3. Malignant Neoplasms 19,704 46.5

4. Pneumonia 18,365 43.3

5. Diabetes Mellitus 9,529 22.5

6. Tuberculosis, All Forms 8,359 19.7

7. Chronic lower respiratory diseases 6,501 15.3

8. Accidents 6,046 14.3

9. Certain conditions originating in the perinatal period 4,983 11.8

10. Nephritis, nephrotic syndrome and nephrosis 4,508 10.6

Note: Excludes ill-defined and unknown causes of mortality (R00-R99) for males (n=11,840)
and females n=11,395
** External Causes of Mortality
Last Update: June 30, 2009
(http://www.doh.gov.ph/kp/statistics/leading_mortality.html)

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CURRENT TRENDS

Breakthrough for fast 3D stroke imaging

Cerebrovascular diseases (for example, ischemic stroke) are the second leading cause of death
worldwide and this trend is expected to continue and even grow until 2030 [1]. Unfortunately,
most people with stroke symptoms still do not get to the hospital in time. This hinders them from
being considered for time-dependent treatments that can reduce disability or death. Such
incidents show that the system of care for stroke victims can be improved. In the first 3 hours
after a suspected cerebrovascular accident (CVA), non-contrast head computed tomography
(CT) is the primary imaging modality for the differential diagnosis of acute stroke. However, the
latest research shows significantly improved clinical outcomes in patients with acute stroke after
lysis therapy with Alteplase even in the range of three to four and a half hours after the first
stroke symptoms [2]. Based on these results we expect that using perfusion CT in addition
could be even more beneficial in order to reduce serious adverse events and predict a beneficial
outcome for these patients by looking at the relation between core infarct and tissue at risk. This
has been not performed in this study and has to be proven in future studies.

Faster stroke diagnosis

CT perfusion imaging with syngo® Volume Perfusion CT Neuro can be used to diagnose acute
ischemic stroke in the emergency department quicker than with magnetic resonance imaging
(MRI), according to results of a large single-center study [2]. The study shows that CT perfusion
had 100 percent accuracy for detecting the acute ischemic stroke (AIS). If adopted, the
researchers say that this advancement in stroke detection will mean dramatically faster

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diagnosis times - less than half the time of MRI screening - and enable physicians to provide
more accurate and targeted care, thereby avoiding potentially life-threatening complications that
can occur when thrombolytic drug therapy is used inappropriately. The study also reveals that
within five minutes of the patient getting on the CT scanner table, results can be achieved, as
opposed to MRI, which takes half an hour. The study also reveals that the widespread use of
CT perfusion is a practical way to help busy emergency departments to significantly save time in
acute stroke diagnosis, target treatment, and reduce the risks of inappropriate thrombolytic use.
According to the researchers, it is remarkable that the average time between an emergency
room neurological exam and CT scan was only 35 minutes. They confirmed that CT perfusion
imaging is very effective for diagnosing acute stroke and concluded that their result could
change national stroke triage protocols.

Precise information
Apart from the speed advantage, dynamic perfusion CT has become an increasingly accepted
examination for the differential diagnosis of acute stroke patients. Multislice CT, with a
continuously increasing number of detector rows, has quickly made high-resolution CTA of the
cerebral vasculature a clinical routine examination. It has, however, not really overcome the
limitations with respect to traditional CT perfusion imaging, which is restricted to the detector
width. Innovative technology such as the unique Adaptive 4D Spiral mode of the Siemens
SOMATOM® Definition family overcomes the limitations of static detector designs and now
allows volume perfusion imaging of the whole brain in clinical routine.

Key Benefits of syngo Volume Perfusion CT Neuro

• Whole brain and 3D tissue at risk evaluation with dynamic information*
• All perfusion parameters at hand: cerebral blood flow (CBF), cerebral blood volume
(CBV), time to peak (TTP) and mean transit time (MTT)
• Auto Stroke: therapeutic decision without complex user interaction ready for 24/7 use.
• Increased confidence: integrated automated motion corrections compensates for patient
movement

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 • * Requires Adaptive 4D Spiral
___________
[1] World Health Statistics 2008
[2] The Role of CT Perfusion Imaging in Acute Stroke Diagnosis: A Large Single-Center
Experience, Rai et al., The Journal of Emergency Medicine, Volume 35, Issue 3, Pages 237-
354, October 2008)

The antidepressant Lexapro may help protect key thinking functions if taken soon after a
stroke, U.S. researchers said. People who took Forest Laboratories Inc's (FRX.N) Lexapro, or
escitalopram, after a stroke recovered more of their thinking, learning and memory skills than
others who had counseling-type therapy normally used to treat depression or who were given a
placebo. It is not clear why Lexapro helped, but they said there is increasing evidence that
antidepressants cause changes in key brain structures needed for memory and thinking --
including the visual cortex, hippocampus and cerebral cortex -- that may help explain the
memory improvements.

New research finds that one out of 12 people who have a stroke will likely soon have
another stroke, and one out of four will likely die within one year. Researchers say the findings
highlight the vital need for better secondary stroke prevention. These findings suggest that
South Carolina and possibly other parts of the United States may have a long way to go in
preventing and reducing the risk factors for recurrent strokes.

Eating chocolate may lower your risk of having a stroke, according to an analysis of
available research that will be presented at the American Academy of Neurology's 62nd Annual
Meeting in Toronto April 10 to April 17, 2010. Another study found that eating chocolate may
lower the risk of death after suffering a stroke. Chocolate is rich in antioxidants called
flavonoids, which may have a protective effect against stroke, but more research is needed. The
first study found that 44,489 people who ate one serving of chocolate per week were 22 percent
less likely to have a stroke than people who ate no chocolate. The second study found that
1,169 people who ate 50 grams of chocolate once a week were 46 percent less likely to die
following a stroke than people who did not eat chocolate.

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D. NURSING OBJECTIVES

After 2 days of Nurse-Patient Interaction the student nurse will be able to:

Cognitive:

• Identify specific theoretical causes and clinical manifestations, and trace the
pathophysiology of the involved disease entity;
• Identify nursing problems and construct nursing care plans specifically;
• Understand the normal anatomy and physiology of the affected organs that are affected
by the underlying disease condition;

Affective:

• describe predisposing and precipitating factors that could possibly contribute to the
occurrence of the disease;

Psychomotor:

• Accurately gather nursing history

• Enumerate ways of preventing the occurrence of the disease or problem

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 NURSING
ASSESSMENT

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 II. NURSING ASSESSMENT

Personal History

Mr. CVA is 62 years old and is married. He was born on April 26, 1947 at San Pedro,
Mexico, Pampanga. He resides with his family at Mexico, Pampanga. He was admitted last
February 23, 2010. Mr. CVA lives with his wife and children.

His children are responsible for the welfare of their parents since both of their parents
are not working anymore. Their family is a Baptist Christian. They don’t necessarily believe in
the so-called manghihilot. They rely much on doctors when it comes with their health status.
The family of Mr. CVA lives at Sapang Makulangut. The place where they live is known for
many “tambays”. Mrs. CVA dVerbalized description of their community as “Ay! Nuko, ding tao
Karin pag alduk da ing emperador…”. It is also seen to have many street vendors who sell
street foods such as barbeque, quail eggs and fried chicken skin.

Mr. CVA eats his meal on a regular basis (breakfast, lunch and dinner). He even has
snacks in between his meals approximately three times a day. They usually eat pork, rice and
vegetables. He often buys street foods such as isaw, chicken skin, chicken feet, fish ball, halo
halo, turon and quail eggs. Mr. CVA is fond of drinking coffee and softdrinks. According to his
wife he can consume a liter of softdrinks in one sitting. This persists even after he was
diagnosed with diabetes.

He is also an occasional alcohol drinker and a smoker. Whenever he is engaged with

situations wherein he is forced to drink he can consume an average of 4 bottles of Red Horse.
He smokes for like 2-3 sticks per day since his mid-20 (with a pack years of 6.3 pack years). His
sleep cycle goes from around 7pm-4am.

He takes his breakfast around 8am while reading his daily newspaper. He usually eats
pandesal and coffee for breakfast. After eating, he takes a 30 minute nap. Upon awakening, he
eats a meryenda such as turon where he buys at a store in front of their house accompanied by
another cup of coffee. For lunch, he often eats meat and rarely eat vegetables as his ulam with
an average of 2-3 cups of rice as his meal. For his afternoon meryenda, he eats street foods
available nearby their house accompanied with softdrinks. And for his dinner, it is usually the
same with his lunch preference. He doesn’t have any forms of exercise. His forms of usual

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activities for the day are watching tv, reading newspaper and sleeping. His wife even said,
“Sarap ng buhay niyan, kain at tulog lang”

Computation for Pack Years: (# of sticks per day (3 sticks)/ 20) X 42 years

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Family Health Illness History

Mr. CVA

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 It is very evident that Mr. CVA is at high risk of developing Cerebrovascular Accident
(CVA). One of his grandparents experienced of having CVA and the other two grandparents
have the factors that contribute to occurrence of CVA such as Diabetes Mellitus (DM) and
Hypertension. His mother inherited DM for his grandfather while his father had a history of CVA
and hypertension. His Aunts and Uncles in both sides had hypertension. Two of his siblings died
from CVA, and the other one had a hypertension. Based from his family history, it is very
apparent on how Mr. CVA developed hypertension and DM that made him at risk for CVA.

History of Past Illness

Mr. CVA was never hospitalized and had no history of chickenpox, mumps and measles.
Usually, according to his wife, Mr. CVA only experience common coughs, fever and colds due to
weather changes. He self-medicates with Paracetamol for fever, Robitussin for common
coughs and Neozep for colds. There was an instance wherein he was brought to a clinic for
severe stomach ache due to hyperacidity last 2007. The doctor who checked him told Mr. CVA
that his fondness of drinking softdrinks contributed to his hyperacidity. He was asked to take
antacids as his medications.

History of Present Illness

It was around 2006 when Mr. CVA was diagnosed by the doctor with DM Type II. And
around mid-2008, Mr. CVA was first hospitalized for his first attack of stroke. According to Mr.
CVA’s wife, he was brought to the hospital that time because the patient was complaining of
slurred speech and dizziness while he was watching tv. From then on he was taking
maintenance drugs for his DM which is Metformin (taken every evening) and Insulin (25 units
during morning and another 15 units during evening). According to his wife, oftentimes it is Mr.
CVA who injects insulin to himself. Another maintenance drug for his hypertension is Bascorten
which he takes 10mg of it every day. Whenever he experiences hypertension his BP is around
140-200 for the systole and 90-110 for the diastole.

Few days before his symptoms occurred, he complained to his wife a feeling of being
nervous when he found out that their neighbor died because of DM and having the same
disease condition this triggered him to be anxious, this feeling manifested the day before he was
admitted to the hospital (February 22, 2010). According to Mr. CVA’s wife, it was around

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3:00pm of February 23, 2010 when her husband felt something uncommon. Around 9:00 am of
February 23, 2010 he was feeling slight light-headedness while he was taking his breakfast. He
just lay down thinking that he would feel okay after doing so. This feeling persisted for about 2
hours as verbalized by the patient’s wife. And around 2:00pm, while he was taking his lunch,
the patient was asking for a glass of water to his wife but he could not speak clearly. All they
could hear were a bit of groaning and slurd speech. Some of the words the patient tries to say
weren’t that clear. The wife of Mr. CVA immediately got worried thinking that these symptoms
were the same as with his first episode of stroke. Mr. CVA’s wife also noticed that when they
asked him to walk he was having difficulty because of his dizziness and that he is also
complaining that he can’t move properly the right side of his body especially his arms and legs.
Immediately after that, they rushed him to the hospital and around 3:00pm later that day Mr.
CVA was admitted. His chief complaint was slurd speech and right sided weakness.

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 PHYSICAL
ASSESSMENT

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 III. PHYSICAL ASSESSMENT

Physical Assessment as lifted from the chart: (February 23, 2010)

Head Eyes Ears Nose Throat- Pinkish palpebral conjunctiva; anecteric sclera
Chest and Lungs- Equal chest expansion, clear breath sounds, absence of rales,
absence of wheezes
Cardiac- dynamic heart sounds, normal respiratory rate and rhythm, absence of
murmur
Abdomen- soft, normal active bowel sounds, non-tender
Extremities- strong pulses, absence of cyanosis

February 23, 2010

1st day of Nurse-Patient Interaction

Vital Signs:
BP: 140/100mmHg
Temperature: 37.1 C/axilla
PR: 97bpm
RR: 29bpm
1. GENERAL SURVEY
 Wears reading glasses
 Approximately two weeks prior to the incident Mr. CVA exhibited
disorientation as evidenced by frequent query of the date
 Absence of chest pain felt and verbalized
 Loss all of his teeth
 Height of 5’8”
 Weight of 70 kilograms
 There is absence of difficulty in urinating reported; absence of discharges,
swelling, ulcerations and nodules in the genital area as verbalized
 Absence of masses felt by Mr. CVA on the rectal lining
 There is absence of verbalized constipation or any difficulty or pain during
defecation

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 2. SKIN
Inspection
 With fair complexion
 The neck area has a ruddy color while the rest of his skin is uniform in
color except areas not exposed to the sun (e.g. axillae) which are slightly
lighter
Palpation
 Has warm temperature at 37.1oC and the skin is warm to touch
 Exhibits a good skin turgor - skin springs back to previous state when
pinched.

3. HEAD AND FACE

Inspection
 The head is slightly tilted to the left which is oval in shape but the right
side is drooping compared to the other side.
 Patient can easily move his head towards his left side but is having
difficulty in other directions
 The hair is thin and is evenly distributed throughout the upper part of the
skull
 Hair is black with white streaks and is slightly greasy in texture when
touched

a. Eyes
Inspection
 Symmetrically aligned and is able to focus properly
 The iris is symmetrical and are brown in color
 Pupils are black and equally round and reactive to light and
accommodation
 Sclera is anicteric
 Has pale pink palpebral conjunctiva
 Able to close and open the left upper eyelids

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  The right eyelid is able to close properly but exhibits weakness upon
opening
 There is a red, nodular lump in his right eyelid which has a yellowish spot;
absence of discharges noted but the eyes are moist
 Lacrimal glands are not enlarged
 Eyebrows are evenly distributed on both eyes
 Eyelashes are evenly distributed on the lids of the eye and are not turning
inward

b. Ears
Inspection
 Exhibits a good sense of hearing as observed upon interrogation, Mr.
CVA responds whenever his name is called
 Has auricles that has the same color as his facial skin, symmetrically
aligned with the outer canthus of the eye
 He has a preauricular pit on the helical root of his right ear
 There is minimal accumulation of brownish waxy cerumen on both ears
Palpation
 Absence of swelling and tenderness

c. Nose
Inspection
 Displays symmetry on both sides of the nose, air moves freely as Mr.
CVA breathes through the nares
 Absence of nasal discharges coming out, absence of tenderness and
inflammation observed
 Septum is equally symmetrical on both sides and there are absences of
deviations seen
Palpation
 Absence of masses palpated from both maxillary and frontal sinuses

d. Oral cavity
Inspection

25
  Upper and lower lips have uniform brown to pink color, absence of cracks
and fissures seen
 Mr. CVA is wearing smooth, intact dentures during the interview
 Gums are pinkish and moist
 The tongue which is slightly deviated to the left is pinkish in color
 Can move freely to the left but movement to the right side is limited
 Absence of difficulty in swallowing
 Uvula is positioned on the midline of the soft palate
 Tonsils are pink and smooth
 Palatine tonsils are pinkish and not inflamed
 Gag reflex is present
Palpation
 Lips are smooth and moist

e. Neck
Inspection
 Head is symmetrically centered above
 Exhibits a limited range of motion having difficulty to tilt head from left to
right

4. CHEST AND LUNGS

a. Chest
Inspection
 Has proportion and symmetry in shape on the thoracic cavity
 Presence of pulsations in the suprasternal notch
 Absence of dynamic precordium
Palpation
 Absence of nodules and lumps
Percussion
 There is a resonant sound upon percussion

b. Lungs
Inspection

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  Exhibits symmetrical respirations at 29 breaths per minute
 With symmetrical chest expansion as observed
Percussion
 There is resonance upon percussion
Auscultation
 Exhibits clear breath sounds upon auscultation

5. HEART
Auscultation
 Absence of murmurs
 With apical pulse of 100 beats per minute
 Radial pulse is palpable with a pulse rate of 97 beats per minute in the
right and 96 beats per minute in the left hand which are noted to be soft
equal pulses
 The posterior tibial pulse is palpable with a pulse of 93 beats per minute
in the right and 98 in the left which are noted to be soft equal pulses
 There is regular heart rhythm and there is a low-pitched and relatively
long “lubb-dub” observed upon auscultation
 Blood pressure is 140/100 mmHg

6. BREAST
Inspection
 Nipples are round, everted, dark brown in color and are symmetrically
positioned on both chest and are equal in size
 Absence of discharges coming out
 Absence of rashes noted
Palpation
 Absence of tenderness palpated and both breasts are firm

7. ABDOMEN
Inspection
 Absence of rashes, lesions or any dilated veins seen
 Absence of abdominal distention noted

27
 Abdomen is neither bulging nor distended
 Umbilicus is not inverted
Auscultation
 With 15 bowel sounds per minute

Palpation
 Has flat and soft abdomen
Percussion
 With tympanic sound upon percussion

8. GENITALS
Inspection
 Mr. CVA is wearing a diaper during the interview

9. EXTREMITIES AND BACK

Inspection
 There is proportionality and symmetry with the four extremities with their
sizes and shape
 The right foot has its second toe crossed over the big toe
 On the left foot there is a 1.5 cm space between the third and the fourth
toe
 Nails are convex in curvature, smooth in texture
 The nail bed is peach in color, intact with the epidermis, dirty and
untrimmed with dirt accumulations on the fingertips
 There is prompt return of pinkish color for about 2 seconds during blanch
test (capillary refill test)
 The spinal column is vertically aligned without any postural defects noted

28
 Upon assessment of the Muscle Strength the right arm scored 2; the left
arm 4; the right leg 3; the left leg 4

2 4

3 4

Muscle strength
5- Normal strength. Muscle is able to move through a full range of motion
(ROM) against gravity and applied resistance
4- Muscle is able to move through a full ROM against gravity but with
weakness to applied resistance
3- Muscle is able to move actively against gravity alone
2- Muscle is able to move with support against gravity
1- Muscle contraction is palpable and visible
0- Muscle contraction or movement is undetectable

29
 10. NEUROLOGIC EXAMINATION
a. Mental Status
 Patient is conscious and disoriented about the date and time although he
is aware of the place and the person accompanying him
 He is able to respond with yes or no questions
 Unable to completely verbalize a sentence
 Speech is limited to one word
b. Intellect: Memory, Judgment and Reasoning, Thought Process
 Short attention span, there is a frequent need to repeat instruction
 He is unable to provide information when asked about his diet during the
last 24 hours and other questions regarding his past because of speech
difficulties
 Assessment was limited about new learning and judgement because Mr.
CVA could neither verbalize nor write his answer.

CRANIAL NERVES ASSESSMENT

Nerve Classification Major Assessment

functions

Have patient sniff a Mr. CVA was able to

familiar scent (alcohol distinguish alcohol
and perfume) with eyes but failed to identify
I Olfactory Sensory Smell closed then was asked the scent of the
to open his eyes and perfume, he
point out the scent. classified it as the
scent of alcohol.

II Optic Sensory Vision Have patient read from Mr. CVA was not
a card or newspaper, able read but
one eye at a time. Test confirmed that he
visual fields by having can see the object
patient cover one eye, handed infront of him
focus on the examiner’s through squeezing
nose, and identify the the examiners hand.
number of fingers held

30
 up in each of four visual
quadrants.

Check pupillary Both pupils constrict

responses by shining a upon exposure to
bright light on each direct light from the
pupil; both pupils penlight. There is
Eyelid should constrict. To also constriction as
elevation; check accommodation, the examiners finger
most move one finger toward move toward Mr
III Oculomotor Motor EOMs; Mr CVA’s nose; the CVA’s nose.
pupil size pupils should constrict
and and converge. Check Mr. CVA was able to
reactivity EOMs by having patient look up, down, upper
look up, down, laterally, left, lower left but
and diagonally (cardinal unable to look right,
positions of gaze). lower right and upper
right

Extraocular Check EOMs by having Mr. CVA was able to

eye patient look up, down, look up, down, upper
movement laterally, and diagonally left, lower left but
(turns eye (cardinal positions of unable to look right,
downward gaze). lower right and upper
and right
IV Trochlear Motor
laterally)

V Trigeminal Sensory Chewing; Palpate temporal and Mr. CVA was not
facial and masseter muscles teeth able to bite down or
Opthalmic branch mouth clenched chew. Although Mr.
sensation; CVA was able to

31
 corneal identify the cotton
reflex wisp in his forehead,
(sensory) chin and both

Somatic cheeks.

sensations The right cheek is

Maxillary branch
Sensory of face, oral Test corneal reflex, drooping compared

cavity, touch forehead, to the left side.

Mandibular
teeth cheeks, and chin with
branch
cotton wisp
Somatic
sensation
Sensory and Symmetrical
lower face
Motor comparisons
and
Bite down or chew
mastication

Have patient move the Mr. CVA was able to

eyes from side to side. move his eyes to the
left easily but
Lateral eye
VI Abducens Motor showed some
movement
restriction upon
turning to the right
side.

Ask patient to smile, Mr. CVA was not

frown and puff cheeks. able to perform a
Have patient identify smile, frown or even
Facial
salt or sugar placed on puffing of his cheeks.
expression
Sensory and the tongue(N/A Mr. The taste test was
VII Facial Taste,
Motor CVA was placed on not applicable at that
anterior 2/3
under nothing per orem time because he was
tongue
(NPO)) placed under nothing
per orem(NPO) by
the doctor.

VIII Acoustic Sensory Hearing; Observe balance and Mr. CVA can only
equilibrium hearing acquity. Hold hold his left arm up

32
 up one finger and have and was unable to
Mr. CVA quickly and point the examiner’s
repeatedly move his finger precisely. Mr.
finger back and forth CVA could not
from the examiner’s precisely touch his
finger to his nose. Then nose with his left
have him alternately index finger with or
touch his nose with his without his eyes
right and left index closed
fingers. Finally, have
him repeat these tasks
with his eyes closed.
The movements should
be precise and smooth

Identifies taste The taste test was

Gagging Test gag reflex with not applicable at that
and tongue depressor, note time because he was
swallowing rise of uvula with placed under nothing
IX Sensory and (sensory); “ahhhh” per orem(NPO) by
Glossopharyngeal Motor taste, the doctor. Gag
posterior reflex was present
1/3 of and there is a rise of
tongue the uvula with
“ahhhh”

X Vagus Sensory and Sensation Identifies taste The taste test was
Motor in pharynx, Test gag reflex with not applicable at that
larynx, and tongue depressor, note time because he was
external ear rise of uvula with placed under nothing
Swallowing “ahhhh” per orem(NPO) by
the doctor. Gag
reflex was present
and there is a rise of
the uvula with

33
 “ahhhh”

Push chin against Mr. CVA was unable

Shoulder hand, shrug shoulder to push his chin
XI Spinal movement; against the
Motor
accessory head examiners hand. He
rotation could not also shrug
his shoulders

Move tongue side to Mr. CVA has

side against a tongue difficulty in
depressor articulation; the word
Assess articulation. “oo” is barely
understandable. The
tongue can only
move towards the
Tongue
left side against the
XII Hypoglossal Motor movement;
tongue depressor; he
speech
was unable to move
his tongue upward,
downward and to the
ride side, with or
without the pressure
from the tongue
depressor.
GLASGOW COMA SCALE

34
 Measure Response Score
Opens spontaneously 4
Opens to verbal command 3
Eye Response
Opens to pain 2
No response 1
Reacts to verbal command 6
Reacts to painful stimuli
Identifies localized pain 5
Motor Response Flexes and withdraws 4
Assumes flexor posture 3
Assumes extensor posture 2
No response 1
Is oriented and converses 5
Is disoriented but converses 4
Verbal Response Uses inappropriate words 3
Makes unintelligible sounds 2
No response 1

35
February 24, 2010
2nd Nurse Patient Interaction
BP: 130/80mmHg
Temperature: 37.3 C/axilla
PR: 97bpm
RR: 25bpm

1. GENERAL SURVEY
> Changed diaper 2 times
2. SKIN
Palpation
 Has warm temperature at 37.3oC and the skin is warm to touch

3. HEAD AND FACE

Inspection
 The head is slightly tilted to the left which is oval in shape but the right
side is drooping compared to the other side.
 Patient can easily move his head towards his left side but is having
difficulty in other directions
a. Eyes
Inspection
 Presence of yellowish rheum in both eyes
 The right eyelid is able to close properly but exhibits weakness upon
opening
 There is a red, nodular lump in his right eyelid which has a yellowish spot;
absence of discharges noted but the eyes are moist
b. Ears
Inspection
 presence of white flakes and scaly skin on the auricles
c. Nose
d. Oral cavity

36
 Inspection
 Lips are dry and the presence of cracks are noted

 The tongue has a thin bluish coating

 The tongue which is slightly deviated to the left is pinkish in color

 Can move freely to the left but movement to the right side is limited
e. Neck
Inspection
 Exhibits a limited range of motion having difficulty to tilt head from left to
right

4. CHEST AND LUNGS

a. Chest
Inspection
 Presence of pulsations in the suprasternal notch

b. Lungs
Inspection
 Exhibits symmetrical respirations at 25 breaths per minute

5. HEART
Auscultation
 With apical pulse of 99 beats per minute
 Radial pulse is palpable with a pulse rate of 97 beats per minute in the
right and 98 beats per minute in the left hand which are noted to be soft
equal pulses
 The posterior tibial pulse is palpable with a pulse of 95 beats per minute
in the right and 96 in the left which are noted to be soft equal pulses
 Blood pressure is 130/80 mmHg

6. BREAST

7. ABDOMEN

37
 With 17 bowel sounds per minute

8. GENITALS

9. EXTREMITIES AND BACK

38
 Upon assessment of the Muscle Strength the right arm scored 3; the left
arm 4; the right leg 3; the left leg 4

2 4

3 4

Muscle strength
5- Normal strength. Muscle is able to move through a full range of motion
(ROM) against gravity and applied resistance
4- Muscle is able to move through a full ROM against gravity but with
weakness to applied resistance
3- Muscle is able to move actively against gravity alone
2- Muscle is able to move with support against gravity
1- Muscle contraction is palpable and visible
0- Muscle contraction or movement is undetectable

39
 10. NEUROLOGIC EXAMINATION
a. Mental Status
 Mr. CVA is conscious and still disoriented about the date and time
although he is aware of the place and that he is accompanied by his wife

 He is able to respond with yes or no questions

 Still unable to completely verbalize a sentence

 Speech is limited to two to three words

b. Intellect: Memory, Judgment and Reasoning, Thought Process

 Mr. CVA was able to follow directions and maintain eye contact
throughout the interview

 He is unable to provide information when asked about his diet during the
last 24 hours and other questions regarding his past because of speech
difficulties
 Assessment was limited about new learning and judgment because Mr.
CVA could neither verbalize nor write his answer.

CRANIAL NERVES ASSESSMENT

Nerve Classification Major Assessment

functions

Have patient sniff a Mr. CVA was able to

familiar scent (alcohol distinguish alcohol
and perfume) with eyes but failed to identify
I Olfactory Sensory Smell closed then was asked the scent of the
to open his eyes and perfume, he
point out the scent. classified it as the
scent of alcohol.

III Oculomotor Motor Eyelid Check pupillary Mr. CVA was able to
elevation; responses by shining a look up, down, upper
most bright light on each left, lower left but
EOMs; pupil; both pupils unable to look right,

40
 should constrict. To lower right and upper
check accommodation, right
move one finger toward
Mr CVA’s nose; the
pupil size
pupils should constrict
and
and converge. Check
reactivity
EOMs by having patient
look up, down, laterally,
and diagonally (cardinal
positions of gaze).

Extraocular Check EOMs by having Mr. CVA is still

eye patient look up, down, unable to look right,
movement laterally, and diagonally lower right and upper
(turns eye (cardinal positions of right
IV Trochlear Motor downward gaze)
and
laterally)

V Trigeminal Chewing; Palpate temporal and Mr. CVA was not

facial and masseter muscles teeth able to bite down or
Opthalmic branch mouth clenched chew.
Sensory sensation; The right cheek is
Maxillary branch corneal drooping compared
reflex to the left side.
Mandibular (sensory)
branch Sensory Somatic
sensations
of face, oral Test corneal reflex,
cavity, touch forehead,

teeth cheeks, and chin with

41
 Somatic cotton wisp
sensation
Sensory and
lower face Symmetrical
Motor
and comparisons
mastication Bite down or chew

Have patient move the Mr. CVA was able to

eyes from side to side. move his eyes to the
left easily but
Lateral eye
VI Abducens Motor showed some
movement
restriction upon
turning to the right
side.

Ask patient to smile, Mr. CVA was able to

frown and puff cheeks. perform a smile and
Have patient identify frown but not puffing
Facial
salt or sugar placed on of his cheeks. The
expression
Sensory and the tongue(N/A Mr. taste test was not
VII Facial Taste,
Motor CVA was placed on applicable at that
anterior 2/3
under clear liquid diet) time because he was
tongue
placed under clear
liquid diet by the
doctor.

VIII Acoustic Sensory Hearing; Observe balance and Mr. CVA can only
equilibrium hearing acquity. Hold hold his left arm up
up one finger and have and was unable to
Mr. CVA quickly and point the examiner’s
repeatedly move his finger precisely. Mr.
finger back and forth CVA could not
from the examiner’s precisely touch his
finger to his nose. Then nose with his left
have him alternately index finger with or
touch his nose with his without his eyes
right and left index closed

42
 fingers. Finally, have
him repeat these tasks
with his eyes closed.
The movements should
be precise and smooth

Push chin against Mr. CVA was unable

Shoulder hand, shrug shoulder to push his chin
XI Spinal movement; against the
Motor
accessory head examiners hand. He
rotation could not also shrug
his shoulders

Move tongue side to Mr. CVA has

side against a tongue difficulty in
depressor articulation; the word
Assess articulation. “oo” is barely
understandable. The
tongue can only
move towards the
Tongue
left side against the
XII Hypoglossal Motor movement;
tongue depressor; he
speech
was unable to move
his tongue upward,
downward and to the
ride side, with or
without the pressure
from the tongue
depressor.

43
 GLASGOW COMA SCALE

Measure Response Score

Opens spontaneously 4
Opens to verbal command 3
Eye Response
Opens to pain 2
No response 1
Reacts to verbal command 6
Reacts to painful stimuli
Identifies localized pain 5
Motor Response Flexes and withdraws 4
Assumes flexor posture 3
Assumes extensor posture 2
No response 1
Is oriented and converses 5
Is disoriented but converses 4
Verbal Response Uses inappropriate words 3
Makes unintelligible sounds 2
No response 1

44
45
DIAGNOSTIC
AND
LABORATORY
PROCEDURES

46
47
 IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/Laboratory Date Indication or Results Normal Values Analysis and

Procedures ordered/Date Purpose Interpretation of
result in the result
Chest X-ray Ordered Mr. CVA There are no A normal chest x The results show
February 23, undergone chest x- pulmonary ray will show that Mr. CVA’s
2010 ray to check if there infiltrates, cardiac normal structures heart is not
are pulmonary size and for the age and enlarged.
Result infiltrates, check configuration are medical history of
February 24, the cardiac size normal. the patient.
2010 and configuration The diaphragm, Findings, whether
dynamic sulci and ribs are normal or
precordium was intact. abnormal, will be
noted upon provided to the
admission which is referring physician
an indicator of in the form of a
enlarged heart. written report.
Nursing Responsibilities:
Prior :
• Explain the procedure to the pt why it is indicated.
• A chest x-ray examination itself is a painless procedure
After:
• Explain to pt that the results of a chest x-ray can be available almost immediately for review by the physician
Diagnostic/ Date ordered/Date Indication or Results Normal Analysis and

48
 Laboratory result in Purpose Values Interpretation of
Procedures the result
CT scan February 23, 2010 Mr. CVA Plain multiple axial views of the N.A. The test indicates
undergone CT head using incremental CT that there is
scan to have reveals a small hypodense Foci presence of an
multiple axial on the anterior limb on the left infarct at left lobe of
views of the internal capsule and the left the brain explaining
head to putamen. right sided
distinguish the weakness
cause of the There is also a hypodense focus
signs and on the left parietal cortex.
symptoms
present. The ventricles and cistern are not
dilated The middle line structures
are not displaced.

The sella furica posterior fossal

and basal skull structures are
intact.

Impression: Acute infarct, anterior

limb or left internal capsule left
putamen and left parietal cortex.

Nursing Responsibilities:

49
• Explain the procedure to the pt. and why it is indicated.
• Explain that this test is done to take excellent pictures of the brain to locate any problem areas if they exist.
• Assess the client for allergies to iodine, seafood and contrast medium.
• Evaluate the client for restlessness. Clients unable to remain still 30-90 minutes during the scan may need a sedative.
• Ensure an informed consent has been obtained if contrast medium is used.
• Remove metal objects such as jewelries, glasses, and dental bridges from the head and neck before the procedure.
• Restrict food and fluids for 8 hours before the scan if contrast medium is injected.
• Do not restrict food, fluids, or medications when contrast medium is not used for scan.

50
Diagnostic/ Date Indication or Purpose Results Normal Values Analysis and
Laboratory ordered/ Interpretation of the
Procedures Date result result
in
Blood Chem February This test was ordered to monitor BUN 4.76 mmol/L 2.5-7.5 mmol/L This indicates that Mr.
23, 2010 Mr. CVA ’s renal function, CVA ’s renal function is
specifically the ability of the well, specifically
kidney to excrete urea and expressed through the
protein. ability of his kidneys to
excrete urea and
protein.
This test was ordered to monitor Crea 132.6 44.2-150.1 Creatinine level is within
Mr. CVA’s renal function, normal range.
specifically the ability of the This indicates that Mr.
kidney to excrete urea and CVA ’s kidneys are able
protein. to excrete urea and
protein, thus reflects that
his kidneys are in good
condition.

This test was ordered to check for Na 133 137-145 Hyponatremia indicates
Mr. CVA’s water balance. Shift of water from
intracellular
compartment to

51

This test was order to Mr. CVA to
measure acid base balance and
normal muscle activity.
February -This test was ordered to
24, 2010 measure and monitor the amount
of sugar in Mr. CVA ’s blood. This
is a more accurate determinant
than RBS.
This test was ordered to Mr. CVA
to determine the total cholesterol
extracellular
compartment with
resultant dilution of
sodium. This usually
occurs with
hyperglycemia, which is
inherent with Mr. CVA .
K 3.6 3.6-5.0 Potassium is within
accepted range. Results
indicate acceptable acid
base balance and
standard muscle activity.
This test may rule out
Hypokalemia as the
cause of Mr. CVA ’s
weakness.
Glucose 4.22 – 6.11 Fasting plasma glucose
(FBS) 8.90 level above 7.0 mmol/L
indicates that Mr. CVA
has Hyperglycemia
Cholesterol 3.57 Up to 5.16 Mr. CVA’s cholesterol is
within the acceptable
52
in his blood.
- This test was ordered to
Mr.CVA to determine the
triglyceride or the glycerol
esterified with three fatty acids in
the blood
-this is also a test which assesses
the risk of developing heart
disease and stroke
- This test was ordered to
Mr.CVA to determine measures
amount of HDL or good
cholesterol in the body
-To determine risk of developing
heart disease and stroke
range thus this test may
rule out the narrowing of
the blood vessels due to
cholesterol blockage as
the cause of his
condition
Tryglycerides 1.08 0.45 – 1.81 Triglycerides are linked
to the thickening of the
arterial wall caused by
fatty materials
deposition. The result
may rule out
atherosclerosis as the
cause of the Mr. CVA’s
stroke
HDLC 1.02 0.75 – 1. 73 With the help of a form
of cholesterol HDL (high
density lipoprotein),
packets of cholesterol
are formed to help move
cholesterol through the
blood suggesting that
cholesterol formation
and deposition in the
arterial walls are less
53
 likely the cause of
Mr.CVA’s stroke
LDLC 2.06 Less than 3.88 LDL does not aid in the
transportation of
- This test was ordered to
cholesterol out of the
Mr.CVA to determine measures
body, instead it deposits
the amount of LDL or the bad
cholesterol onto the
cholesterol in the blood
vessel wall. This results
-assess the risk of
indicates that Mr. CVA is
developing heart disease and
less likely to form
stroke
deposits of cholesterol
onto his vessel walls.

Nursing Responsibilities:
Prior :
• Explain the procedure to the pt. and why it is indicated
• Inform the patient that fluid and food restriction is required especially for FBS which is a 12 hour fast.
• Inform the patient that a blood sample will be taken.
• Tell the patient that he may experience transient discomfort from the needle pincture
• Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.
• For glucose, do not give their insulin/anitdiabetic agents until blood is drawn.
During the procedure:
• For cholesterol, seat the client at least 5 minutes before the venipuncture is performed to reduce fluctuations in serum levels
associated with postural changes.

54
 • Inform the patient that pain may be felt through prick in the needle
• Instruct the patient to calm down to avoid uneasiness.
After:
• Apply brief pressure to prevent bleeding
• Apply warm compress if Hematoma will develop at the venipuncture site.
• For creatinine, assess fluid and nutritional status of client for clues of renal impairment and other diseases causing changes in
creatinine levels.
• Continuously monitor fluid balance through daily weights and intake and output recordings.
• For glucose, ensure the client receives food promptly in accordance with the ordered diet.

55
 Diagnostic/ Date ordered/Date Indication or Purpose Results Normal Values Analysis and
Laboratory result in Interpretation of
Procedures the result
Hemo Glucose February 23, 2010
Test 5pm Mr. CVA has undergone Blood 374 mg/L blood glucose level A high result in
February 24, 2010 glucose monitoring to identify of less than or HGT show increase
12am intervention to maintain his blood 181 equal to 120 in normal values. It
6am glucose within an acceptable 198 mg/dL. may indicate low
6pm range as determined by their 221 insulin levels.
doctors. This is a more
immediate and convenient way to
test his blood glucose.
Nursing Responsibilities:
Prior :
• Explain the procedure to the pt. and why it is indicated
• Inform the patient that a blood sample will be taken.
• Tell the patient that he may experience transient discomfort from the needle pincture
During the procedure:
• Inform the patient that pain may be felt through prick in the needle
• Instruct the patient to calm down to avoid uneasiness.
After:
• Apply brief pressure to prevent bleeding.
• Observe for signs and symptoms of hyperglycemia or hypoglycemia.

56
Diagnostic/ Date Indication or Purpose Results Normal Values Analysis and
Laboratory ordered/ Interpretation of the
Procedures Date result in result
Hematology February 24, -To evaluate the Mr. CVA’s result is
2010 hemoglobin content (iron within the acceptable
status and O2 carrying range. This could
capacity) of erythrocytes Hemoglobin 15.4 g/dl 11.6 – 15.5 indicate that Mr.
by measuring the no. of CVA’s red blood cells
grams of hemoglobin /dl of freely carry oxygen
blood to the body
Mr. CVA’s result is
within the acceptable
range. A lowered
- Measures the volume of
hematocrit can
RBCs in whole blood
Hematocrit 43.5 % 36.0 – 47.0 indicate hemorrhage
expressed as a
thus the result may
percentage.
indicate that
hemorrhage is not
the cause of his CVA
-Measures the number of RBC 4.80 X10 12/L 4.20 – 5.40 Mr. CVA’s result is
RBCs within the acceptable
range. A decrease in
the RBC’s could
indicate hemorrhage
thus the results may

57
 indicate that
hemorrhage is not
the cause of his CVA
Absence of a
decrease or increase
within the normal
-Measures the number of range could indicate
WBC 8.23 X10 9/L 4.8-10.8
WBCs that Mr. CVA’s body
is not currently
fighting off any
infection
The result is within
the acceptable
-To provide a numeric range. This could
estimate of the client’s Neutrophils 69.9 % 40-74 indicate that his body
immune status. is not currently
fighting off a bacterial
infection
-To determine immune Lymphocytes 24.5 % 19-48 The result is within
function, provides a gross the acceptable
measure in nutritional range. This could
status. indicate that his body
is not currently
fighting off a viral
infection

58
 The result is within
the acceptable

-To provide a numeric Eosinophils 2.4 % 0-7 range. This could

estimate of the client’s Monocytes 3.2 % 3-9 indicate that his body

immune status. Basophils 0.0 % 0-2 is not currently

fighting off a parasitic
infection

The patient is not

-Measures the number of
platelets (Thrombocytes)
per mm3 of blood.
prone to excessive
bleeding or
Platelet 256 X10 9/L 150-400 thrombosis. This may
also indicate that
bleeding is not the
cause of stroke.

Nursing Responsibilities:
Prior :
• Explain the procedure to the pt. and why it is indicated
• Inform the patient that fluid and food restriction is not required
• Inform the patient that a blood sample will be taken.
• Tell the patient that he may experience transient discomfort from the needle pincture
• Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.
During the procedure:
• Inform the patient that pain may be felt through prick in the needle

59
 • Instruct the patient to calm down to avoid uneasiness.
After:
• Apply brief pressure to prevent bleeding
• Apply warm compress if Hematoma will develop at the venipuncture site.
• If BUN levels are >40mg/dl without signs and symptoms of dehydration, monitor intake and output, complete dietary
assessment, and check with health care provider regarding protein restriction.
• Monitor for lethargy, confusion, and change in mental status. Provide necessary safety precautions.
• Observe for signs and symptoms GI bleeding, which is associated with decreased red blood cells.

60
THE PATIENT
AND HIS
ILLNESS

61
 V. THE PATIENT AND HIS ILLNESS
Anatomy and Physiology
Nervous System

The nervous system is the body's information gatherer, storage center and control system. Its
overall functions are to collect information about the body's external/internal states and transfer
this information to the brain (afferent system), to analyze this information, and to send impulses
out (efferent system) to initiate appropriate motor responses to meet the body's needs.
The system is composed of specialized cells, termed nerve cells or neurons that communicate
with each other and with other cells in the body. A neuron has three parts:
1. the cell body, containing the nucleus
2. dendrites, hair-like structures surrounding the cell body, which conduct incoming
signals.
3. the axon (or nerve fiber), varying in length from a millimeter to a meter, which conduct
outgoing signals emitted by the neuron. Axons are encased in a fat-like sheath, called
myelin, which acts like an insulator and, along with the Nodes of Ranvier, speeds
impulse transmission.

62
Typically a given neuron is connected to many thousands of neurons. The specific point of
contact between the axon of one cell and a dendrite of another is called a synapse. Messages
passed to and from the brain take the form of electrical impulses, or action potentials, produced
by a chemical change that progresses along the axon. At the synapse, the impulse causes the
release of neurotransmitters (like acetylcholine or dopamine) and this, in turn, drives the
impulse to the next neuron. These impulses travel very fast along these chain of neurons -- up
to 250 miles per hour. This contrasts with other systems, such as the endocrine system, which
may take many hours to respond with hormones.
The nerve cell bodies are generally located in groups. Within the brain and spinal cord, the
collections of neurons are called nuclei and constitute the gray matter, so-called because of
their color. Outside the brain and spinal cord the groups are called ganglia. The remaining
areas of the nervous system are tracts of axons, the white matter, so-called because of white
myelin sheath. Tracts carrying information of a specific type, such as pain or vision, generally
have specific names. .
Major Divisions of the Nervous System
The nerves of the body are organized into two major systems:
• the central nervous system (CNS), consisting of of the brain and spinal cord,
• the peripheral nervous system (PNS), the vast network of spinal and cranial nerves
linking the body to the brain and spinal cord. The PNS is subdivided into:
1. the autonomic nervous system (involuntary control of internal organs, blood
vessels, smooth and cardiac muscles), consisting of the sympathetic NS and
parasympathetic NS
2. the somatic nervous system (voluntary control of skin, bones, joints, and
skeletal muscle).
The two systems function together, with nerves from the periphery entering and becoming part
of the central nervous system, and vice versa.

63
Brain Structures

The brain, the body's "control central," is one of the largest of adult organs, consisting of over
100 billion neurons and weighing about 3 pounds. It is typically divided into four parts: the
cerebrum, the cerebellum, the diencephalon (thalamus, hypothalamus, sometimes classed
as cerebral structures) and the brain stem (medulla oblongata, pons, midbrain), which is an
extension of the spinal cord.
Cerebrum
The largest division of the brain, the cerebrum, consists of two sides, the right and left
cerebral hemispheres, which are interconnected by the corpus callosum. The two
hemispheres are "twins," each with centers for receiving sensory (afferent) information and for
intiating motor (efferent) responses. The left side sends and receives information to/from the
right side of the body, and vice versa. Various intellectual functions are concentrated in either
the left or right hemispheres.
The hemispheres are covered by a thin layer of gray matter known as the cerebral
cortex. The interior portion consists of white matter, tracts, and nuclei (gray matter) where
synapses occur. Each hemisphere of the cerebral cortex is divided into four "lobes" by various
sulci and gyri: The sulci (or fissures) are the grooves and the gyri are the "bumps" on the brain's
surface.

64
The four lobes perform specific functions:
a) Frontal - controls fine movements (Betz cells)/ upper motor neuron) and smell. Also,
center for abstract thinking, judgment, and language (left hemisphere)
b) Parietal - coordinates afferent information dealing with pain, temperature, form, shape,
texture, pressure, and position. Some memory functions are also found here.
c) Temporal - handles dreams, memory, and emotions. Center for auditory function.
d) Occipital - governs vision
In addition to the four lobes, is the basal ganglia. The basal ganglia aggregates of neurons
(gray matter), constitute the extrapyramidal system. The extrapyramidal system governs
postural adjustment and gross voluntary movements, as opposed to fine movements,
controlled by the frontal lobe. The basal ganglia receive afferent input from the cerebral cortex
and thalamus. Their axons synapse in the brain stem and the spinal cord.
Cerebellum
The cerebellum, the second largest brain structure, sits below the cerebrum. Like the
cerebrum, the cerebellum has an outer cortex of gray matter and two hemispheres. It
receives/relays information via the brain stem. The cerebellum performs 3 major functions, all of
which have to do with skeletal-muscle control:
Function summary:
• Balance/ Equilibrium of the trunk (See also: Vestibular System)
• Muscle tension, spinal nerve reflexes, posture and balance of the limbs
• Fine motor control, eye movement. (Incoming information is transferred from the
cerebral cortex via the pons. Outgoing information goes back to the cortex via the
thalamus.)
Cerebellar disease (abscess, hemorrhage, tumors, and trauma) results in ataxia (muscle
incoordination), tremors, and disturbances of gait and equilibrium. This can also interfere with a

65
person's ability to talk, eat, and perform other self care tasks. Paralysis does not result from
loss of cerebellar function.
Diencephalon
The diencephalon, located between the cerebrum and the midbrain, consists of several
important structures, two of which are the:
• Thalamus: large, bilateral (right thalamus/left thalamus) egg-shaped mass of gray
matter serving as the main synaptic relay center. Receives/relays sensory information
to/from the cerebral cortex, including pain/pleasure centers.
• Hypothalamus: a collection of ganglia located below the thalamus and associated with
the pituitary gland. It has a variety of functions: senses changes in body temperature;
controls autonomic activities and hence regulates the sympathetic and parasympathetic
nervous systems; links to the endocrine system/controls the pituitary gland; regulates
appetite; functions as part of the arousal or alerting mechanism; and links the mind
(emotions) to the body -- sometimes, unfortunately, to the degree of producing
"psychosomatic disease."
Brain-Stem
The medulla oblongata, pons, and midbrain (mesencephalon or cerebral
peduncles) -- often referred to collectively as the brain stem -- control the most basic life
functions. Of these three, the medulla is the most important. In fact, so vital is the medulla to
survival that diseases or injuries affecting it often prove fatal. All functions of the brain stem are
associated with cranial nerves III-XII.
Function summary:
• Breathing/respiration (pons, medulla)
• Heart rate/ action (medulla)
• Blood pressure (vasoconstriction)/ blood vessel diameter (medulla)
• Reflex centers for pupillary reflexes and eye movements (midbrain, pons); and for
vomiting, coughing, sneezing, swallowing, and hiccupping (medulla).
Blood supply
An intricate arterial structure supplies the brain with oxygen-rich blood. At the brain stem, two
vertebral arteries, entering through the first cervical vertebrae, join to form the basilar artery.
The basilar artery along with two internal carotid arteries, entering through holes at the base of
the skull, interconnect at the Circle of Willis. From there, the anterior and middle cerebral
arteries arise; the posterior cerebral artery arises from the basilar system.

66
Cranial Nerves
There are 12 pairs of cranial nerves. Some bring information from the sense organs to
the brain; some control muscles; others are connected to glands or internal organs.

Cranial Nerves Major Function

I. Olfactory Smell
II. Optic Vision
III. Occulomotor Eyelid and eyeball movement
IV. Trochlear Innervates superior oblique turns eye
downward and laterally
V. Trigeminal Chewing face & mouth touch & pain
VI. Abducens Turns eye laterally
VII. Facial Controls most facial expressions secretion
of tears & saliva taste
VIII. Vestibulocochlear Hearing equilibrium sensation
IX. Glossopharyngeal Taste senses carotid blood pressure
X. Vagus Senses aortic blood pressure slows heart
rate stimulates digestive organs taste
XI. Spinal Accessory Controls trapezius & sternocleidomastoid,
controls swallowing movements
XII. Hypoglossal Controls tongue movements

67
The pancreas is a glandular organ that secretes digestive enzymes (internal secretions) and
hormones (external secretions). In humans, the pancreas is a yellowish organ about 7 inches
(17.8 cm) long and 1.5 inches. (3.8 cm) wide.

The Pancreas
The pancreas (Figs. 1097, 1098) is a compound racemose gland, analogous in its
structures to the salivary glands, though softer and less compactly arranged than those
organs. Its secretion, the pancreatic juice, carried by the pancreatic duct to the
duodenum, is an important digestive fluid. In addition the pancreas has an important
internal secretion, probably elaborated by the cells of Langerhans, which is taken up by the
blood stream and is concerned with sugar metabolism. It is long and irregularly prismatic in
shape; its right extremity, being broad, is called the head, and is connected to the main
portion of the organ, orbody, by a slight constriction, the neck; while its left extremity
gradually tapers to form the tail. It is situated transversely across the posterior wall of the
abdomen, at the back of the epigastric and left hypochondriac regions. Its length varies
from 12.5 to 15 cm., and its weight from 60 to 100 gm.

FIG. 1097– Transverse section through the middle of the first lumbar vertebra, showing the
relations of the pancreas. (Braune.)

68
 FIG. 1098– The duodenum and pancreas

FIG. 1099– The pancreas and duodenum from behind. (From model by His.)

Relations.—The Head (caput pancreatis) is flattened from before backward, and is lodged
within the curve of the duodenum. Its upper border is overlapped by the superior part of the
duodenum and its lower overlaps the horizontal part; its right and left borders overlap in
front, and insinuate themselves behind, the descending and ascending parts of the
duodenum respectively. The angle of junction of the lower and left lateral borders forms a
prolongation, termed the uncinate process. In the groove between the duodenum and the
right lateral and lower borders in front are the anastomosing superior and inferior
pancreaticoduodenal arteries; the common bile duct descends behind, close to the right
border, to its termination in the descending part of the duodenum.

69
Anterior Surface.—The greater part of the right half of this surface is in contact with the
transverse colon, only areolar tissue intervening. From its upper part the neck springs, its
right limit being marked by a groove for the gastroduodenal artery. The lower part of the
right half, below the transverse colon, is covered by peritoneum continuous with the inferior
layer of the transverse mesocolon, and is in contact with the coils of the small intestine.
The superior mesenteric artery passes down in front of the left half across the uncinate
process; the superior mesenteric vein runs upward on the right side of the artery and,
behind the neck, joins with the lienal vein to form the portal vein.

Posterior Surface.—The posterior surface is in relation with the inferior vena cava, the
common bile duct, the renal veins, the right crus of the diaphragm, and the aorta.
The Neck springs from the right upper portion of the front of the head. It is about 2.5 cm.
long, and is directed at first upward and forward, and then upward and to the left to join the
body; it is somewhat flattened from above downward and backward. Its antero-superior
surface supports the pylorus; its postero-inferior surface is in relation with the
commencement of the portal vein; on the right it is grooved by the gastroduodenal artery.
The Body (corpus pancreatis) is somewhat prismatic in shape, and has three
surfaces: anterior, posterior, and inferior.
The anterior surface (facies anterior) is somewhat concave; and is directed forward and
upward: it is covered by the postero-inferior surface of the stomach which rests upon it, the
two organs being separated by the omental bursa. Where it joins the neck there is a well-
marked prominence, the tuber omentale, which abuts against the posterior surface of the
lesser omentum.
The posterior surface (facies posterior) is devoid of peritoneum, and is in contact with
the aorta, the lienal vein, the left kidney and its vessels, the left suprarenal gland, the origin
of the superior mesenteric artery, and the crura of the diaphragm.
The inferior surface (facies inferior) is narrow on the right but broader on the left, and is
covered by peritoneum; it lies upon the duodenojejunal flexure and on some coils of the
jejunum; its left extremity rests on the left colic flexure.
The superior border (margo superior) is blunt and flat to the right; narrow and sharp to
the left, near the tail. It commences on the right in the omental tuberosity, and is in relation
with the celiac artery, from which the hepatic artery courses to the right just above the
gland, while the lienal artery runs toward the left in a groove along this border.
The anterior border (margo anterior) separates the anterior from the inferior surface, and
along this border the two layers of the transverse mesocolon diverge from one another;

70
one passing upward over the anterior surface, the other backward over the inferior surface.
The inferior border (margo inferior) separates the posterior from the inferior surface; the
superior mesenteric vessels emerge under its right extremity.
The Tail (cauda pancreatis) is narrow; it extends to the left as far as the lower part of the
gastric surface of the spleen, lying in the phrenicolienal ligament, and it is in contact with
the left colic flexure.
Birmingham described the body of the pancreas as projecting forward as a prominent
ridge into the abdominal cavity and forming part of a shelf on which the stomach lies. “The
portion of the pancreas to the left of the middle line has a very considerable antero-
posterior thickness; as a result the anterior surface is of considerable extent; it looks
strongly upward, and forms a large and important part of the shelf. As the pancreas
extends to the left toward the spleen it crosses the upper part of the kidney, and is so
moulded on to it that the top of the kidney forms an extension inward and backward of the
upper surface of the pancreas and extends the bed in this direction. On the other hand, the
extremity of the pancreas comes in contact with the spleen in such a way that the plane of
its upper surface runs with little interruption upward and backward into the concave gastric
surface of the spleen, which completes the bed behind and to the left, and, running
upward, forms a partial cap for the wide end of the stomach.

FIG. 1100– The pancreatic duct.

The Pancreatic Duct (ductus pancreaticus [Wirsungi]; duct of Wirsung) extends 1

transversely from left to right through the substance of the pancreas (Fig. 1100). It 5
commences by the junction of the small ducts of the lobules situated in the tail of the
pancreas, and, running from left to right through the body, it receives the ducts of the
various lobules composing the gland. Considerably augmented in size, it reaches the neck,
and turning downward, backward, and to the right, it comes into relation with the common
bile duct, which lies to its right side; leaving the head of the gland, it passes very obliquely

71
through the mucous and muscular coats of the duodenum, and ends by an orifice common
to it and the common bile duct upon the summit of the duodenal papilla, situated at the
medial side of the descending portion of the duodenum, 7.5 to 10 cm. below the pylorus.
The pancreatic duct, near the duodenum, is about the size of an ordinary quill. Sometimes
the pancreatic duct and the common bile duct open separately into the duodenum.
Frequently there is an additional duct, which is given off from the pancreatic duct in the
neck of the pancreas and opens into the duodenum about 2.5 cm. above the duodenal
papilla. It receives the ducts from the lower part of the head, and is known as
the accessory pancreatic duct (duct of Santorini).

Development (Figs. 1101, 1102).—The pancreas is developed in two parts, a dorsal and 1
a ventral. The former arises as a diverticulum from the dorsal aspect of the duodenum a 6
short distance above the hepatic diverticulum, and, growing upward and backward into the
dorsal mesogastrium, forms a part of the head and uncinate process and the whole of the
body and tail of the pancreas. The ventral part appears in the form of a diverticulum from
the primitive bile-duct and forms the remainder of the head and uncinate process of the
pancreas. The duct of the dorsal part (accessory pancreatic duct) therefore opens
independently into the duodenum, while that of the ventral part (pancreatic duct) opens
with the common bile-duct. About the sixth week the two parts of the pancreas meet and
fuse and a communication is established between their ducts. After this has occurred the
terminal part of the accessory duct, i. e., the part between the duodenum and the point of
meeting of the two ducts, undergoes little or no enlargement, while the pancreatic duct
increases in size and forms the main duct of the gland. The opening of the accessory duct
into the duodenum is sometimes obliterated, and even when it remains patent it is probable
that the whole of the pancreatic secretion is conveyed through the pancreatic duct.

72
 BOOKBASED PATHOPHYSIOLOGY
Precipitating Factor

Overweight/
Obesity Stress Smoking

Vaso-
↑Serum ↑Fat on the ↑LDL
Eat Smoke Stimulati constrict
Cholesterol abdomen ↓Oxygen
more more on of ↑RBC
level and hips carry
catechol ↑Carbon
capacity
amines ↑vascular monoxide
of blood
resistance in blood
↑LDL ↑Serum
Cholesterol ↑blood
↑Workload
↓HDL ↑blood thickness
of the heart
↓Tissue?
sugar
perfusion
↓Tissue ↑clot
Accumulate perfusion formation
↑blood ↑BP
of LDL
viscosity
Diet high in Fats, ↑risk of injury
Sodium and to intimal
Cocaine use/
abuse Cholesterol arterial wall
Sedentary Lifestyle

Increase attraction
Accumulation of fatty of water in the Deposits of fatty materials in
Induce Enhance of ↑BP
streaks in the arterial wall blood the arterial walls of arteries
vasospasm tablet activity

Poor Increase in blood

Increases volume Vascular changes
circulation
cardiovascular
disorder
Increase blood cholesterol level and blood pressure
Hypertension
73
 Predisposing Factor
Previous heart Diabetes
Inc workload of the heart Age Gender disease

Uncontrolled ↑blood
Degenerative Male hormones Altered sugar
cardiomegaly changes in the arterial wall
Inc. vascular resistance function of the integrity
heart ↑blood
Heart weakens over
↓HDL viscosity
Inc pressure in cerebral blood vessels time ↑lipid/platelet
↓elastin adherence to
vessel walls ↑BP
Dec. Accumulation
Loss of Dec. cardiac output
Impaired vessel of LDL in the
elaticity cerebral ↓elasticity of
flexibility arterial wall
autoregula the blood Atheroma/ clot ↑workload of
tion vessels formation the heart

Rupture of cerebral blood Hardening

vessel
Atherosclerosis of arterial ↑size of heart
Thrombus
wall formation
Weaker heart
Increased risk
Familial
for vessel
History
injury
↓cardiac output

↑risk for DM , heart ↓tissue perfusion

diseases,
Increased Increased risk hypercoagualable state,
lipid/platelet for rupture hypercholesterolemia Microvascular
adherence to changes
vessel walls
Chronic inc. blood glucose

Altered macrovascular
integrity

74
Thrombotic stroke

Development of
atherosclerosis
of the blood
vessel wall

Plsgues develop
on the inner wall
of the affected
blood vessel

First step Accumulation of LDL within the arterial wall

Undegoes chemical changes

Stimulate methodical cells to adhere to monocytes and feels

Second step Maturation of monocytes into macrophages

Ingest LDL particle

Third step Macrophage ingest a critical mass of LDL

Becomes foam cells

Constitutes fatty streaks on the inner arterial wall

(earliest manifestation of arterial plague)

Fourth step Additional growth of the lesion through influence of

inflammatory molecules

Form a fibrous cover over the liquid core

OVER
75
 Separates it from blood flow through the vessel

Fifth step Plaque rupture

Exposes foam cells to clot-promoting elements in the blood

Clot formation

ISCHEMIC CASCADE Dislodgement

Embolic stroke

If at sufficient size

Ischemia May interrupt blood flow

to the brain tissue implies

Neutroxins
(oxygen free radical nitric
oxide glutamate) released

Local acidosis develop

Membrane depolarization occur

Influx of calcium sodium

Cytoxic edema and Cell death Stroke area or core

Zone of hypoperfusion
(penumbra) becomes prone to neurologic damage
death if circulation is not
restored

OVER
76
Ischemia develop

Embolus dislodgement

Travels to the cerebral arteries via carotid artery or vertebrobasilar system

Lodge in smaller cerebral arteries blood vessel at point of bifurcation or where the lumen narrow

Emboli occlude the vessel

Ischemia develop Ischemic Cascade

If embolus breaks off into fragments If damage to vessel wall is significant

Enters small blood vessels Vessel integrity interrupted

Vasospas
Embolus is Cerebral hemorrhage Hemorrhagic Stroke
absorbed m

Nuchal rigidity
Remission of Headache
s/sx Increase in blood pressure

Decrease Inflammatory Entry of blood to

cerebral perfusion process meningeal space

Ischemic
cascade HYPOXIA Release
Increase
leukocytes in
intracranial
interstitial space
pressure
neurologic damage and neutrophils
Altered level of
for phagocytosis
consciousness
CEREBRAL
COMPRESSION
AND INJURY

coma

death 77
 HYPOXIA

BRAIN TISSUE
INFARCT

NEUROLOGICAL DEFICITS

Middle cerebral artery (MCA) most commonly affected

Internal carotid artery second most frequently affected

Massive infarction of most lateral hemisphere and

deeper structure of the frontal, parietal and temporal
lobes

Sensory
Hemiplegia hemipharesis apraxia Aphasia/ Dysphagia
Deficits
Dysarthia

78
 In a healthy, anatomical structure of the body, the carotid arteries form the main blood
supply to the brain. Following a stroke, voluntary control of the muscles may be lost, depending
on the type of stroke the victim is encountering. Strokes can also result from embolism or due to
a ruptured blood vessel. Embolism blocks small arteries within the brain, causing dysfunction to
occur. Spontaneous rupture of a blood vessel in the brain causes a hemorrhagic stroke.
Another form of cerebrovascular disease includes aneurysms. In females with defective
collagen, the weak branching points of arteries give rise to protrusions with a very thin covering
of endothelium that can tear to bleed easily with minimal rise of blood pressure. This can also
occur with defective capillaries caused by tissue cholesterol deposition especially in
hypertensive subjects with or without dyslipidemia. If bleeding occurs in this process, the
resulting effect is a hemorrhagic stroke in the form of subarachnoid hemorrhage, intracerebral
hemorrhage or both.

Ischemia is the loss of blood flow to the focal region of the brain. The beginning process
of this is quite rapid. The duration of a stroke is usually two to fifteen minutes. One side of the
face, hand, or arm may swell up. During this time, the person may lose conscious control and
faint. Brain deficits may improve over a maximum of 72 hrs. Deficits do not resolve in all cases.
The neurological recovery period includes stable, to improving, brain function. Stable is the
period by which neither nutrient supply is regained, nor is it lost. Improving, depending on a
hospital code, generally means that the arteries gain control and blood flow functions
consistently within the brain. The cartoid arteries connect to the vertebral arteries. These branch
off into the cerebellar and posterior meningenial arteries, which supply the back of the brain.
Also, during ischemia, interneurons weaken, causing an insufficient amount to perform vital
functions to be present. The neuroglis become congested or maintain loss during a
cerebrovascular accident. If impulse amount ceases, then life itself will cease and the victim
may enter the stage of clinical death. Neural pathways weaken, therefore decreasing action
potential. The neural arc, which in general consists of sensory and motor neurons, weaken as
well. The muscles become paralyzed, in some cases for life. Paralysis also includes the
weakening of the receptors in the body, unless improvement is made. Cerebrovascular damage
to the brain is what makes it difficult for receptors to receive the impulse and transmit it of a
neuron. This chemical reaction is then transmitted creating a poor reflex to the body. The
meninges that also protect the brain and spinal cord are deeply weakened, allowing the victim to
suffer vast transmission of diseases or unstable growth or maintenance if the victim is not in
resting position.

79
During the stage of paralysis, the spinal tracts do not have much to do with the enduring
condition of cerebrovascular disease, either, in time may shorten the life of a victim who is
suffering because the nutrient supply is weakened in transmission during cerebrovascular
disease. Descending and ascending tracts will generally be cut off during cerebrovascular
disease, which conducts impulses down from the cord of the brain. This is known as anesthesia
in a minor case.

PREDISPOSING FACTORS:
Age (above 60 years old) — the chance of having a stroke about doubles for each decade of
life after age 55. While stroke is common among the elderly, over 25 percent of people who
have strokes are under age 65. Increasing age causes degenerative changes to the blood
vessels thus increasing the risk for arterial wall injury.
Gender -- Stroke is more common in men than in women. In most age groups, more men than
women will have a stroke in a given year. At older ages, the incidence is higher in women than
in men. Overall, more women than men die of stroke. Female hormones decrease LDL levels
and Increase HDL level while male hormones does otherwise.
Familial disposition-chance of stroke is greater in people who have a family history of stroke
Previous heart disease-- A diseased heart increases the risk of stroke. The percentage of
people with a first myocardial infarction who will have a stroke within five years at ages 40–69 is
4 percent of men and 12 percent of women. At age 70 and older, 6 percent of men and 11
percent of women will have a stroke after having a heart attack. Atrial fibrillation (the rapid,
uncoordinated quivering of the heart’s upper chambers), in particular, raises the risk for stroke.
Heart attack is also the major cause of death among stroke survivors
PRECIPITATING FACTORS:
Diet
Cigarette smoking — Cigarette smoking is an important risk factor for stroke. The nicotine and
carbon monoxide in cigarette smoke damage the cardiovascular system in many ways.
Physical inactivity — An inactive lifestyle is a risk factor for coronary heart disease. Regular,
moderate-to-vigorous physical activity is important in preventing heart and blood vessel disease.
Even moderate-intensity physical activities are beneficial if done regularly and long-term. More
vigorous activities are associated with more benefits. Physical activity can help control blood
cholesterol, diabetes and obesity, as well as help lower blood pressure.
High blood pressure — High blood pressure increases the heart’s workload, causing the heart
to enlarge and weaken over time. It also increases the risk of stroke, heart attack, kidney failure

80
and heart failure. When high blood pressure exists with obesity, smoking, high blood cholesterol
levels or diabetes, the risk of heart attack or stroke increases several times.
Obesity and overweight — People who have excess body fat — especially if a lot of it is in the
waist area — are more likely to develop heart disease and stroke even if they have no other risk
factors. Excess weight increases the strain on the heart, raises blood pressure and blood
cholesterol and triglyceride levels, and lowers HDL (good) cholesterol levels. It can also make
diabetes more likely to develop. Many obese and overweight people have difficulty losing
weight. If you can lose as little as 10 to 20 pounds, you can help lower your heart disease risk.
Stress — Individual response to stress may be a contributing factor. Some scientists have
noted a relationship between coronary heart disease risk and stress in a person’s life, their
health behaviors and socioeconomic status. These factors may affect established risk factors.
For example, people under stress may overeat, start smoking or smoke more than they
otherwise would.
Sickle cell anemia — This genetic disorder mainly affects African-American and Hispanic
children. "Sickled" red blood cells are less able to carry oxygen to the body’s tissues and
organs. These cells also tend to stick to blood vessel walls, which can block arteries to the brain
and cause a stroke.
Certain kinds of drug abuse — Intravenous drug abuse carries a high risk of stroke from a
cerebral embolism (blood clot in the brain). Cocaine use has been closely related to strokes,
heart attacks and a variety of other cardiovascular complications. Some of them have been fatal
even in first-time cocaine users.
Diabetes is an independent risk factor for stroke and is strongly correlated with high blood
pressure. While diabetes is treatable, having it still increases a person’s risk of stroke. People
with diabetes often also have high cholesterol and are overweight, increasing their risk even
more.

81
CLIENT CENTERED PATHOPHYSIOLOGY

Precipitating Factor

Smoking
Diet high in Fats,
Sedentary Sodium and
Lifestyle Cholesterol

Poor ↑LDL Vasoconstriction

Accumulation
of fatty streaks circulation ↓Oxygen ↑RBC
in the arterial Increase attraction Deposits of carry
wall of water in the fatty materials in capacity
blood the arterial walls of blood ↑vascular ↑Carbon
of arteries resistance monoxide
Increases in blood ↑blood
cardiovascular Increase in blood
thickness
disorder volume Vascular changes
↓Tissue
perfusion
Increase blood cholesterol level and ↓Tissue ↑clot
blood pressure perfusion formation
↑BP

↑risk of injury
to intimal
arterial wall

82
 Hypertension Dynamic precordium
140/100mmHg
Predisposing Factor
Diabetes
Inc workload of the Age Gender Previous CVA 37
heart

Uncontrolled ↑blood
Degenerative Male hormones Altered sugar
cardiomegaly changes in the arterial wall
↑ vascular resistance function of the integrity
heart ↑blood
Heart weakens ↓HDL viscosity
Inc pressure in cerebral blood over time ↑lipid/platelet
vessels ↓elastin adherence to
vessel walls ↑BP
Dec. Accumulation
↓ cardiac output vessel of LDL in the
Loss of Impaired ↓elasticity of
elaticity the blood flexibility arterial wall
cerebral Atheroma/ clot ↑workload of
autoregulation vessels formation the heart
Hardening
Atherosclerosis of arterial ↑size of heart
Rupture of cerebral wall Thrombus
blood vessel formation
Weaker heart
Increased risk
for vessel Familial
injury History
↓cardiac output

↑risk for DM , ↓tissue perfusion

heart diseases
Increased Increased risk
lipid/platelet for rupture Microvascular
adherence to changes
vessel walls

Chronic inc. blood glucose

Altered macrovascular
integrity 83
Thrombotic stroke

Development of
atherosclerosis
of the blood
vessel wall

Plaques develop
on the inner wall
of the affected
blood vessel

First step Accumulation of LDL within the arterial wall

Undergoes chemical changes

Stimulate methodical cells to adhere to monocytes and feels

Second step Maturation of monocytes into macrophages

Ingest LDL particle

Third step Macrophage ingest a critical mass of LDL

Becomes foam cells

Constitutes fatty streaks on the inner arterial wall

(earliest manifestation of arterial plague)

Fourth step Additional growth of the lesion through influence of

inflammatory molecules

Form a fibrous cover over the liquid core

OVER
84
 Separates it from blood flow through the vessel

Fifth step Plaque rupture

Exposes foam cells to clot-promoting elements in the blood

ISCHEMIC CASCADE Clot formation

May interrupt blood flow

to the brain tissue implies

Ischemia

Neutroxins
(oxygen free radical nitric
oxide glutamate) released

Local acidosis develop

Membrane depolarization occur

Influx of calcium sodium

Cytoxic edema and Cell death Stroke area or core

Zone of hypoperfusion
(penumbra) becomes prone to
neurologic damage
death if circulation is not
restored

85
 Cerebral Hypoxia

Presence of an infarct at left lobe of the brain

explaining right sided weakness ( CT scan Feb.
23, 2010)

Hemiparesis of Apraxia Dysarthria Sensory

Dysphagia Deficits Dizziness
the right side of Pt
the body as S.O. exhibited @ lunch
observed by assists pt slurring of time, prior to
S.O. in am of in ADLs speech admission
Feb 23 post Mrs. CVA Lack of
stroke Described balance
this as when
‘NAuutal’ walking

Limited
ROM
↓ muscle
strength

right rm:3/5;
right leg:2/5;
left arm: 4/5;
left leg:4/5

86
 THE PATIENT
AND HIS CARE

87
 VI. THE PATIENT AND HIS CARE

1. Medical Management

a. Intravenous Fluid
Client’s
Medical Indication(s) or
General Description Date Ordered Response to the
Management Purpose(s)
Treatment
Plain Normal Saline An aqueous solution Administered to prevent February. 23, Mr. CVA
Solution 1L x of 0.9 percent sodium dehydration for Mr. CVA 2010 verbalized
30gtts/min chloride, isotonic, in who cannot consume difficulty “masakit,
sterile form, as a solvent liquids and nutrients by di ba maalis to?”
for drugs that are to be mouth and use as a
administered solvent for drugs that are
parenterally to replace to be administered
body fluids and is the parenterally
safest fluid to give
quickly in large volumes.

Nursing Responsibilities:
Before:
1. Check the doctor’s order regarding to what type of IVF to be used and also its volume
and rate.
2. Explain the procedure to the patient.
3. Gather all materials needed for the insertion of IVF to save time and not to waste time
for looking for other materials.
4. Wash hands before and after the procedure to prevent contamination from insertion site.
During:
1. Place patient in a comfortable position to facilitate easy insertion of IV line and to
decrease patient’s fear about the procedure.
2. Make sure that we give the proper IV fluid and drop rate accurately because patient may
experience fluid overload or dehydration.
3. Check for its patency by observing the backflow of blood upon insertion.
After:
1. Press the site where the needle was inserted and secure it with micropore.

88
2. Check the site of hand where the needle is inserted if bulging is not visible. If so,
reinsertion is to be undertaken.
3. Advice patient to avoid scratching the site less movement of the hand where the needle
was inserted to keep it in place.
4. Instruct patient and significant others to inform the nurse on duty if bulging of the site is
visible, if there is back flow of blood of if IVF is not infusing well.
5. Observe the IV site at least every hour for signs of infiltration or other complications fluid
or electrolyte overload and air embolism.
6. IVF regulation should be checked and monitored upon receiving patient.
7. Always check the doctor’s order for new orders regarding the IVF supplement of the
patient.
8. Always check if the IVF is infusing well and intact.
9. Monitor the patient’s skin integrity.
10. Provide comfort for the patient.
11. Remove and dispose used items.
12. Report and record as appropriate.

89
 b. Drugs
Generic Name General Action Indication and Date Ordered, Client Response Nursing
and Brand Purpose Date Started, Responsibilities
Name Date Changed
or Discontinue
Citicoline Na Citicoline is a complex Mr. CVA was Ordered: According to Mr. • Cholinerve must
Cholinerve organic molecule that given this type 02/23/10 CVA there were not be
functions as an of medication no noticeable or administered
Doctor’s order: intermediate in the in order to treat Started: unnecessary along with
biosynthesis of cell cognitive 02/23/10 effect happened medications
1 gram/ IV q12 membrane dysfunction while he taking containing
phospholipids. It is and prevent the medication. meclophenoxate.
also known as CDP- further brain After taking the
choline or cytidine damage. medication, the
diphosphate choline GCS of Mr. CVA
(cytidine 5'- did not worsen.
diphosphocholine).
CDP-choline belongs
to the group of
biomolecules in living
systems known as
nucleotides that play
important roles in
cellular metabolism.

90
.

Generic Name General Action Indication and Date Ordered, Client Response Nursing
and Brand Name Purpose Date Started, Responsibilities
Date Changed or

91
 Discontinue

Clonidine HCl Stimulates Mr. CVA was Ordered: According to Mr. • Close
Catapres peripheral alpha- given this type of 02/23/10 CVA this not the monitoring of
adrenergic medication first time that he Blood Pressure
Doctor’s order: receptors in the because upon Started: takes this kind of and Pulse.
CNS to produce admission his 02/23/10 medication. And • Pt. should take
75mg/Tab NOW transient blood pressure is there were no the last dose
vasoconstriction too high that Discontinue: noticeable or immediately
and then needs immediate 02/23/10 unnecessary before bedtime.
stimulates central intervention. effect happened • Watch out for
alpha adrenergic while he taking dizziness and
receptors in the the medication. drowsiness.
brain stem to Mr. CVA blood
reduce peripheral pressure
vascular decreased from
resistance, heart 170/100 to
rate, and systolic 120/80.
and diastolic
blood pressure.

92
 Generic Name General Action Indication and Date Ordered, Client Response Nursing
and Brand Name Purpose Date Started, Responsibilities
Date Changed or
Discontinue
Neutral human Neutral human Mr. CVA was Ordered: Mr. CVA glucose • Drug should be
insulin insulin of given this type of 02/23/10 level decrease given
Humulin R recombinant DNA medication from 374mg/dl to subcutaneously.
origin. A short- because upon Started: 221 mg/dl. • Don’t rub the
Doctor’s order: acting preparation admission his 02/23/10 site after
that may be HGT result is injection.
10 ‘u’ NOW administered by 374mg/dl, Discontinue: • Monitor pt. for
SC or IV injection. because of this 02/23/10 hyperglycemia
Onset of action he needs (rebound
occurs at immediate effect).
approximately 30 intervention to • Check glucose
min, with a decrease the level for
duration of about level of glucose in effectiveness of
5 hrs and peak the body. the drug.
activity at 1-3 hrs.

93
 Generic Name General Action Indication and Date Ordered, Client Response Nursing
and Brand Name Purpose Date Started, Responsibilities
Date Changed
or Discontinue
Nitroglycerin May interact with Mr. CVA was Ordered: According to Mr. • Closely monitor
Nitroglycerin nitrate receptors in given this type 02/23/10 CVA there were no vital signs.
Patch vascular smooth- of medication to noticeable or • Paste in the
muscle membrane. prevent angina Started: unnecessary effect hairless part of
Doctor’s order: This interaction and to manage 02/23/10 happened while the chest.
reduces hypertension patch is pasted in • Patch should be
5 mg NOW nitroglycerin to Discontinue: his chest. After remove before
nictric oxide, which 02/23/10 administering the defibrillation.
activates the medication, Mr.
enzyme guanylate CVA ’s Dynamic
cyclase, increasing heart sound was no
intracellular longer present. Mr.
formation of cGMP. CVA blood
pressure
decreased from
170/100 to 120/80.

94
Generic Name General Action Indication Date Ordered, Client Response Nursing
and Brand and Date Started, Responsibilities
Name Purpose Date Changed
or Discontinue
Metabolic anti- Mr. CVA was Ordered: According to Mr. CVA • Watch out for the
Trimetazidine ischemic agent. given this 02/23/10 there were no sign of nausea and
Vastarel Trimetazidine is a type of noticeable or vomiting.
metabolic agent, a medication to Started: unnecessary effect • Monitor Vital Signs.
Doctor’s order: specific and selective treat and 02/23/10 happened while taking
inhibitor of the 3- prevent the medication. He
35 mg/tab BID KAT. This inhibition another also no longer
of β-oxidation allows episode of experienced any
a recoupling of angina. episodes of angina.
glycolysis and an
increase in glucose
oxidation for better
energy production
under ischemic
conditions.

Generic General Action Indication Date Ordered, Client Nursing

Name and and Purpose Date Started, Response Responsibilities
Brand Name Date Changed or

95
 Discontinue

Reduce plasma Mr. CVA was Ordered: According to Mr. • Pt. should be
cholesterol and given this 02/24/10 CVA there were advice to follow
lipoprotein levels by type of no noticeable or a low
Atorvastatin
inhibiting HMG-CoA medication to Started: unnecessary cholesterol diet
Avamax
reductase and cholesterol decrease 02/24/10 effect happened before and
synthesis in the liver and cholesterol while taking the after
Doctor’s
by increasing the number level. medication. medication
order:
of LDL receptors on liver therapy.
cells to enhance LDL
40 mg/tab HS
uptake and breakdown.

Generic General Action Indication Date Ordered, Client Response Nursing

Name and and Purpose Date Started, Responsibilities
Brand Name Date Changed or
Discontinue

96
 Blocks binding of Mr. CVA was Ordered: According to Mr. • Assess pt.
angiotensin II to given this 02/24/10 CVA there were no condition before
receptors sites in many type of noticeable or therapy.
tissues, including medication to Started: unnecessary effect • Assess for heart
Losartan K vascular smooth maintain 02/24/10 happened while he failure.
Lifezar muscle and adrenal blood taking the • Close monitoring
glands. Angiotensin II pressure. medication. Mr. of Blood Pressure
Doctor’s is a potent CVA blood and Pulse.
order: vasoconstrictor that pressure was • Assess pt. renal
also stimulates the maintained at function via
50 mg/tab ½ adrenal cortex to normal status. creatinine and
tab BID secrete aldosterone. BUN levels.
The inhibiting effects of • Pt should avoid
angiotensin II reduce sat substitutes.
blood pressure.

Generic Name General Action Indication Date Ordered, Client Response Nursing
and Brand and Date Started, Responsibilities
Name Purpose Date Changed or
Discontinue
Binds with Mr. CVA was Ordered: According to Mr. CVA • Tell pt. to refrain
adenosine given this 02/24/10 there were no from activities in
diphosphate type of noticeable or which trauma and
Clopidogrel

97
bisulfate receptorson the medication to Started: unnecessary effect bleeding may occur.
Plogrel surface of activated prevent 02/24/10 happened while taking • If bleeding occur.
platelets. This further the medication. Call the physician
Doctor’s order: action bloks ADP, damage that immediately.
which deactivates cause by • Drug may be taken
75 mg/tab OD nearby glycoprotein CVA. without regard to
IIb/ IIIa receptors Specifically meals.
and prevents to reduce
fibrinogen from atherosclero
attaching to sis events.
receptors. Without
fibrinogen, platelet
can’t aggregate and
form thrombi.

Nursing Responsibilities
Prior:
• Check for the doctor’s order and medication chart
• Prepare materials needed
• Check for the Expiration date of the drug.
• Before giving drug ask the patient about allergic reactions to certain drugs. A negative history of the drug allergy is not a
guarantee against a future allergic reaction.

98
 • Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin pending results.
• Check the Vital Signs.
During:
• Remember the 10 R’s in giving medications.
After:
• Tell the patient/ SO to take the entire quantity of the drug exactly as prescribed even after the patient feels well.
• Encouraged patient to increase fluid intake
• Check Vital Signs
• Inform patient to notify prescriber if rash, fever or chills develop. A rash is a most common allergic reaction.

99
c. Diet

Date Client’s response

Type Ordered General Description Indication(s) or and/or reaction to
of Diet Date Purpose(s) the
Started activity/exercise

NPO February. Mr. CVA was instructed It was ordered so Mr. CVA was very
23, 2010 to have Nothing Per as not to alter reluctant to comply
Orem/Nothing Via diagnostic test with his diet. His
Mouth. He is prohibited results. S.O. however
from ingesting food, monitored his food
beverage, or medicine. intake.

Nursing responsibilities:
Prior :
1. Food and fluid intake should be avoided when NPO.
2. Verify doctor’s order
3. Discuss the importance of the ordered diet
During the procedure:
1. Provide comfort measures such as stretching of bed linens and assist the client to a
comfortable position
2. Support the patient if he/she has hard time it taking diet.
After:
1. Monitor client’s reaction
2. Assess for patient’s condition, how he respond to the diet
3. Record procedure done

100
 Date Client’s response
Type Changed General Description Indication(s) or and/or reaction to
of Diet Purpose(s) the
activity/exercise

Clear February. Mr. CVA was instructed It was ordered so Mr. CVA started to
liquid 24, 2010 to have a clear liquid as to prepare his take his medicines
diet diet to help maintain intestines in with “gatorade” and
adequate hydration, resuming to his practice frequent
provide some important normal diet sips of the said
electrolytes when a full beverage.
diet is not
recommended. Clear
liquids might have
color, but you should
still be able to see
through it.

Nursing responsibilities:
Prior :
1. Noodles in the soup and milk products are to be avoided in a clear liquid diet
2. Verify doctor’s order
3. Discuss the importance of the ordered diet
During the procedure:
1. Provide comfort measures such as stretching of bed linens and assist the client to a
comfortable position
2. Support the patient if he/she has hard time it taking diet.
After:
1. Monitor client’s reaction
2. Assess for patient’s condition, how he respond to the diet
3. Record procedure done

101
NURSING CARE
PLANS

102
 NURSING CARE PLANS
Impaired Physical Mobility

Assessment Nursing Scientific Objectives Nursing Rationale Expected

Diagnosis explanation Interventions Outcome
Limitation in After 2 hours of Instruct to change Reduces risk of The patient
S>θ Impaired independent, Nursing positions at least tissue demonstrated
Physical Mobility purposeful Intervention, the every 2 hours and ischemia/injury. techniques that
O > Patient r/t physical patient will placed on affected Helps maintain enable
manifest: neuromuscular movement of the demonstrate side. functional hip resumption of
- weak and pale impairment aeb body or of one technique or Position in prone extension but activities.
appearance slowed more behaviors that position once or may cause
- difficulty in movement extremities. enable twice a day if increase
standing and Due to the resumption of patient can tolerate. anxiety,
sitting patient’s general activities. especially about
- slowed status because ability to breath.
movement of his brain
- limited range damage
of motion secondary to monitor affected Edematous
CVA, patient side for color tissue is more
develops edema, or other easily
weakness due to signs of traumatized and
affectation in his compromised heals more
cerebral artery. circulation. slowly.
This can result in
decrease Support affected To maintain
perfusion and body parts using position of
the development pillows function and
of infarct. The reduce risk of
reflex or pressure ulcers
muscular
strength of a Schedule activities To reduce
particular limb with adequate rest fatigue.
affected periods during the
becomes weak, day
because of its

103
altered control Encourage Enhances self-
and function. participation in self- concept and
Due to the brain care, occupational sense of
affectation, with activities independence.
this prolonged
status on the Identify energy- Limits fatigue,
muscle limb it conserving maximizing
further weakens techniques for participation
the body that ADLs.
may result to
activity
intolerance and
there insufficient
physiological or
psychological
energy to endure
or complete
required or
desired daily
activities.

104
Risk for unilateral neglect
Assessment Nursing Scientific Objectives Nursing Rationale Expected
Diagnosis Explanation Interventions Outcomes
S- O Risk for A Short Term: > Monitor and To obtain Short Term:
O- muscle unilateral cerebrovascular After 15-20 mins assessed vital baseline data The pt shall have
strength neglect r/t accident (CVA) of NI, signs participated in
test of right muscle is a the pt will the
arm:3/5; weakness sudden loss of participate in the > reassess > To note for performance of
right secondary to function resulting performance of patient’s any range of motion
leg:2/5; left CVA from disruption range of motion general abnormality exercises on the
arm: 4/5; of the exercises on the physical extremities.
left leg:4/5 blood supply to a extremities. condition
-needs part Long Term:
assistance of the brain. A Long Term: > Perform PM > To enhance The pt shall have
in stroke After 2 days of Care well-being & increased the
performing is an upper NI, the pt will provide utilization of the
ADLs motor increase the comfort affected
neuron lesion utilization of the extremities with
and affected > Frequently > To note due assistance
results in loss of extremities with monitor vital significant from the SO.
voluntary control due assistance signs changes in
over from the SO as vital signs
motor evidenced by an
movements. increase in the > Perform > To determine
Because the muscle strength muscle muscle
upper test. strength test functioning on
motor neurons regularly the
decussate extremities
(cross), a
disturbance of > Instruct patient > To increase
voluntary motor and significant strength and
control on one others mobility
side of on a passive
the body may range of motion
reflect on
damage to the the right

105
upper extremities
motor neurons
on the > Promot > To promote
opposite side of adequate rest comfort and
the relaxation
brain.
> Assist patient > To prevent
with self-care Injury and
activities fatigue

> Maintain body > To promote

alignment in and stimulate
functional circulation
position

> Shift patient’s > To stimulate

attention and increase
towards the patient’s
affected side awareness on
the affected
side

> Administer due > To treat

meds underlying
medical
condition

106
 Risk for impaired skin integrity
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis explanation Interventions
S>Ø Risk for Pressure ulcers After 1-hour -monitor V/S -gather baseline After 1-hour of
impaired skin develop when soft of Nursing data for further Nursing
O> Patient integrity r/t tissue (skin, SQ tissue intervention, comparison intervention,
manifested: decreased bed and muscle) are the client and the client and
mobility a.e.b compressed between SO will -provide bedside -to give comfort to SO have
>right sided limited/difficulty a bony prominence verbalize and care the patient verbalized
paralysis of movements. and a firm surface for demonstrate and
>limited a prolonged period of understanding -support affected -to maintain demonstrated
/difficulty of time. on the proper body parts using position of function understanding
movements bed pillows and reduce risk of on the proper
positioning pressure ulcers. bed
that can help positioning
reduce risk of -encourage -to avoid that can help
developing adequate fluid dehydration and reduce risk of
pressure intake skin dryness. developing
ulcers. pressure
-change clients bed -to generate blood ulcers.
position every flow and reduce
two(2) hours the risk of
pressure ulcers.

107
 Impaired verbal communication
Assessment Nursing Scientific Objectives Nursing Rationale Expected
Diagnosis explanation Interventions Outcome
S> Ѳ Impaired Infarction in Short term: INDEPENDENT: Short term:
verbal the brain may After 2 hours  Assess  Helps determine The patient
O> The communication lead to of nursing type/degree of area and degree of brain and his SO
patient related to impairment in interventions, dysfunction involvement and difficulty were able to
manifested: neuromuscular hearing and the patient will the patient has with any understand the
 Slurring of impairment speech thus be able to or all steps of the importance of
speech predisposing indicate an communication process. establishing an
 Glasgow the patient to understanding The patient has difficulty alternative
Coma Scale: verbal of the forming words but can method of
verbal impairment. communicatio understand spoken communication
response For this case, n problem words. and stated “Ah,
score of 4 the frontal area and the pwedi ming
out of 5 which is importance of  Listen for  Patient may lose gawan yan.”
 Absence responsible for establishing a errors in ability to monitor verbal
of eye the personality, method of conversation and output and be unaware Long term:
contact behavior, communicatio provide feed back. that communication is not The patient
 Difficulty motor function, n. sensible. Feedback helps was able to
in use of Broca’s area the patient realize why demonstrate
facial (expressive Long term: the health care provider is congruent
expression speech After 2 das of not responding verbal and
center), nursing appropriately and nonverbal
concentration, interventions, provides opportunity to communication
and abstract the patient will clarify content/meaning. to SO and
thought was be able to health care
affected. This demonstrate  Tests for receptive provider.
led to aphasia congruent  Ask patient aphasia
which was the verbal and to follow simple
partial or nonverbal commands (e.g.
complete communicatio “Close your eyes,
inability to use n with the point to the door”);
or comprehend help of his and repeat simple
language family words or sentences.
resulting to  Identifies dysarthria

108
impaired  Have the because motor
verbal patient produce components of speech
communication simple sounds like (tongue, lip movement,
. “ah”, “sh”, cat breath control) can affect
articulation and may/may
not be accompanied by
expressive aphasia

 Provides for
 Provide communication needs
alternative methods and desires based on
of communication: underlying deficit
e.g. writing on a
piece of paper,
magic slate, using
pictures.
 Helpful in
 Anticipate decreasing frustration
and provide when dependent on
patient’s needs others and unable to
communicate desires.

 Reduces confusion
 Talk directly or anxiety at having to
to the patient, process and respond to
speaking slowly and large amount of
distinctly. Use information at one time.
yes/no questions to As retraining progresses,
begin with, advancing complexity of
progressing in communication stimulates
complexity as the memory and further
patient responds. enhances word/idea
association

 The patient is not

necessarily hearing

109
 Speak with impaired and raising
normal volume and voice may irritate him.
avoid talking too Forcing responses can
fast. Give the result to frustration and
patient ample time may cause him to resort
to respond. Talk to “automatic speech” like
with pressing for a garbled speech,
response. obscenities.

 It is important for
family members to
continue talking to the
 Encourage patient to reduce
SO to persist in isolation, promote
efforts to establishment of effective
communicate with communication, and
the patient like maintain sense of
reading mail, connectedness with
discussing family family.
happenings even if
he is unable to
respond  Promotes
appropriately meaningful conversation
and provides
 Discuss opportunities to practice
familiar topics such skill
as job, family,
hobbies.

 Assesses
COLLABORATIVE: individual verbal
capabilities and sensory,
 Consult motor and cognitive
with/refer to functioning to identify
speech therapist deficits and therapy

110
needs

111
DISCHARGE
PLAN

112
 DISCHARGE PLAN

Topic: Prevention of Cerebrovascular Disease

Time Allotment: 30 minutes

Venue: Hospital in Angeles City

Objectives Content Time Teaching Expected

Allotment Strategies Outcome
At the end of -Brief description of the 30 minutes -Discussion At the end of
discussion the disease including its risk with Visual discussion:
patient shall have: factors and the common Aids
-The patient
manifestations. would be able
-Question and to participate
by asking
• Identify the -Effects of neglecting the Answer questions and
effects of not affected part and the answering the
questions of
using the complications of stoke the student
affected side. nurse.
-Managements on how - Patient
• Determine to prevent the would be able
possible occurrence of Stroke to Identify the
complications of and their rationale. effects of not
stroke.  Exercise using the
 Weight control affected side.
• Distinguish and  Avoid smoking
follow the means  Avoid too much
-Patient would
to control blood alcohol
be able to
pressure and  Healthy Diet
Distinguish
diabetes mellitus  Enough sleep
and follow the
to decrease the
 Compliance to
means to
risk for the
medications.
control blood
occurrence of
pressure and
stroke or CVA.
diabetes
mellitus to
• Discern
decrease the
importance
risk for the

113
of strict occurrence of
compliance stroke or
to home CVA.
medicines.
-Patient would
be able to
Discern
importance of
strict
compliance to
home
medicines.

114
LEARNING
DERIVED

115
LEARNING DERIVED

Valarie Agustin

"Health is worth more than learning." --Thomas Jefferson

This disease condition is somewhat familiar to me because this was my grandfather’s

illness before he died. So, when the group agreed to take this case as our subject for drug
study, I got a bit excited because I know I can relate to it.

During the study, we have interviewed the wife of the sick. We gathered some data in
order to know about the current condition of the patient. I noticed that the mother doesn’t really
want to participate well with us because he is just answering us without elaborating the
condition of his husband well. I also observed that he looks really tired of taking care of his
husband. It was like she wants to give up. Well, that’s just my opinion. Maybe she felt that way
because I know that it’s really not easy to take care of a Stroke patient. I knew that because I
used to take care of my grandfather when he is still alive. You need to have more patience
because sometimes they’re really moody and hard headed. But in my case I tolerated that
feeling of giving up, because I know that was the only way to show my love for my grandfather
and to thank him for everything he has done for us.

I don’t usually participate during case study preparation but with this I can say that I did
my part. It may not be that much but at least I know I made a help. This study made me realize
that being a caregiver is a very important role. Because when patient’s relatives feels like giving
up on them, we are the next person to show them that they’re still taken cared off and that
there’s always hope as long as you keep fighting.

116
Arianne De Jesus

On our case study, we made mentioned this quote: “The only way to keep your health is
to eat what you don't want, drink what you don't like and do what you'd rather not.” By Mark
Twain. According to this quote, I’ve learned that one of our cherished possessions as a human
being is our own health. On our case study regarding CVA, I’ve learned the complexity of the
disease condition itself. Its complicated pathophysiology and underlying factors which
contributes to the disease triggered us to come out with a very informative study. Our patient
(Mr. CVA) is very cooperative during the assessment phase of this study. Even his wife was
eager enough to answer our questions though sometimes there were some instances when
they are a bit aloof. I know that through this study I did developed the attitude of being intuitive
enough and being able to come out with the best whatever we are doing. This study for sure
would contribute to me as a future nurse.

117
Leo Cesar Dela Cruz

Stroke or cerebrovascular accident (CVA) is one of the common causes of morbidity and
even mortality in the Philippines as well as all around the globe. In the Philippines, it has been a
well-famed topic among elderly and had caused various misled information. Even though there
had been a lot of cases of CVA (a.k.a stroke), the knowledge of the public regarding the
disorder still inadequate. Even those people are of high risk still lack knowledge regarding CVA.
This reflects lack of dissemination of information regarding CVA. Many may think that CVA are
cases that is no longer curable when in fact CVA is being managed today as treatable problem
if recognized early; however, due to the limited knowledge of the public about early warning
signs, many client still suffers from CVA. Some of the disabilities that can result from stroke
include paralysis, cognitive deficits, speech problems, emotional difficulties, pressure sores,
pneumonia, incontinence problems and daily living problems, and pain. If the stroke is severe
enough, coma or death can result. Treatment of the client with strokes carries at maximizing
function and preventing disability. My role as health care providers is indeed important in order
to attain the optimum level of wellness of our client. Suitable care must be carried out and health
teachings must be given to the client and/or relatives so that the needed care of the client is not
only bounded in the hospital rather could also be extended at home.
This case study made me realize the important role in information and health distribution
regarding false ideals. It is through this that they were able to gain enough knowledge to be
equipped for future management of patients with similar case. Through the case handled, I was
able to appreciate the value of preventing the risks that may possibly arise CVA and able to gain
everlasting knowledge the will be sure of great help in rendering effective and therapeutic care
for stroke patient.

118
John Henrick Dingal

I learned to polish my skills such as physical assessment, teamwork and therapeutic

communication. This case study is about CVA. We were able to assess the patient last
February 23 and 24. I was in a small group of when conducting physical assessment and this
strategy is effective because if one student failed to ask a certain question, the other student
may ask the question. The other students were asking for the patient’s wife for the nursing
history.

It is really important to gain the trust by using therapeutic communication so that the
conversation can go smoothly. It is also significant to pay attention to the small detail as well
because data can be extracted from those and can interpret something. We learned that one of
the causes of the patient’s CVA is diabetes.

I was able to gather data from the chart while they were asking further questions. I
learned to improve teamwork. We divided activities to work more efficiently. Being in this field
requires a whole lot of characteristics and attitudes. Being flexible is a must.

We can’t choose our patients nor chose what cases to be handled. Learning how to
adjust is important because every patient is different. The way of initially talking to them can
either make or break the relationship. So to avoid such, reading the chart is necessary before
going so that a small background can be learned and that questions can be formulated than
rather on the spot. Since there are a lot of medications being administered, knowing the
purpose and effect is important.

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Genevieve Gopez

"Tell me and I forget. Show me and I remember. Involve me and I learn." – Anon

In this life, there will be lots of circumstances, problems, obstacles that we will stumble
upon. Some may sway us and make us quit while some pushes us to be strong and confident.
As young as we can be we should learn how to value life and be prepared for a very difficult
path to take. Some may have difficult problems while others go through having serious disease
conditions like for this case study. The quote can be well applied in our chosen field. Tell me
and I forget, like in ordinary classroom discussions, we tend to have “amnesia” as they say.
Show me and I remember, like using videos, pictures, and diagrams can that be recalled easily.
Lastly, involve me and I learn, like for this case study. We were involved in the formulation of
this paper and so we learned.

As we all know, CVA or simply known as stroke is a disease caused by many factors.
One of which is old age. It can also be a complication of other disease conditions. The end
result can be paralysis or even death for severe cases. As statistics states, men are more prone
to this condition but in most cases they can survive and be cured. Women, on the other hand,
are not usually affected by the condition, but they might suffer severe cases when they got
affected.

Knowing the risk factors of CVA can help us in various ways. We, as future health care
providers, can teach our patients to be cautious with their health and we also know how to take
care of ourselves. We know the importance of striving hard to become physically fit, to eat
healthy food and take care of our body and we can share that knowledge to others.

Being involved in this case study made me learn lots of things and gain experiences. It
also enhanced our skills as student nurses. Our ADPIE Nursing process, our critical thinking,
our rational judgment were very much enhanced. It really was like “save the best for last”. We
had the best clinical instructors so nothing more can be asked for. So, for our student nurses’
life, our last case study was the best. The learning’s and experiences will never be forgotten.

Laus Deo Semper!

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Fritzie Blanca Limiac

This case study is perhaps the most challenging I had, but it was one that interests me.
Stroke is probably one of the dreaded conditions. Though not as vivid, I could recall several of
people talking about it, way back then, with faces drowned in hopelessness. Usually, people
have the misconception that stroke is lethal. To a certain degree, this is true; however it is
treatable and preventable. With the advent of nanotechnology, people are can now easily
access information regarding their health. In the completion of this study, we encountered
several sites discussing stroke in a very simple, straightforward manner for the consumption of
the general public. The internet has become a great tool to promote awareness which is vital in
the prevention of stroke or if not, prevention of its further damage. In stroke, every minute
counts, knowledge of the signs and symptoms could help families address the situation
immediately, thus medical care could be initialized.
Awareness is not the only key, however. The success of the medical treatment in
patients with CVA lies in both the healthcare team and the patient. The patient’s willingness to
actively participate in his care means having the battle half won. In this case study, our patient is
very passive, or even, noncompliant. He would rather have it his way. Though his attitude had
repercussions on his health, this helped us develop our therapeutic communication skills. By
employing this, we were able to do a comprehensive assessment of the patient, one that we
usually fail to do due to several unavoidable circumstances.
One that I am most like about the study is that the risk factors were asked to be
explained in detail. That way, they weren’t just words. They were given value.

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Ralp Lauren Lumanlan

‘’In order to gain the heart of a NURSE, You must first become a PATIENT”

In becoming a nurse, one encounters many kinds of diseases that patients experience
and undergoes. So as to educate oneself of these conditions, a nurse must read a lot about
them, their causes , their signs and symptoms and their treatment but doing this case study has
made me realize that reading a condition in a book is totally different from knowing someone
who had experienced the disease and gave their first-hand look on what they have undergone.

This case study had helped me developed my three faculties to become a more
competent nurse. Reading about the patient’s condition and medical management has
enhanced my cognitive skill and my critical skills to think. Listening to the patient’s experience of
the condition, on how they verbalize their anguish or their anxiety to regain their health has
improved my affective skill to feel more and put myself in the shoes of my patient and lastly, the
interventions that we do to relieve the sickness of our patient by applying our theoretical
knowledge into action had developed my psychomotor skill to become a nurse who provide the
best quality care to a patient.

Thus, through all this case study, it had left a mark in my mind that a true nurse must
use his not only his HEAD and HAND in handling his patient but more importantly his HEART.

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Princess Dian Munoz

It was my first time to do CVA case study and I find that case interesting and at the same
time difficult. We had a very thorough patient history taking and physical assessment. We really
assess our patient and made sure that we had gathered all the needed data. The patient was
very accommodating and also her wife. We were asking the wife regarding the nursing history of
the patient since the patient had difficulty speaking. Throughout the interview I had learned that
the patient had diabetes mellitus and I realized that this disease really aggravate CVA. I also
learned that the patient was hypertensive. He had most of the signs and symptoms of CVA. The
patient had a right sided paralysis which indicates that he had a left brain affectation. While
doing the case study we had learned the signs and symptoms of CVA, the predisposing and
precipitating factors and the medications taken by CVA patients.

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Irien Nain

To be have a relative with cerebral vascular accident or stroke is quite difficult. However,
having this disease is much difficult, knowing that you cannot normally move half of your body
due to paralysis or weakness. This situation is like you’re half dead, you cannot do your activity
of daily living, you can’t talk normally, and you can’t see anything on the affected side and
sometimes you cannot understand what the other is saying depending on the part of the brain
affected. At this time, support from a family is really important to assist and care you. But this
doesn’t mean that the patient will be dependent on them. You also need to help yourself. How?
Try not to neglect the affected side so that your body still knows that your affected side is still
functioning.

Stroke is a sudden, localized damage in the brain which can be due to interrupted blood
supply and oxygen in the brain or an abnormal bleeding in the brain. Brain is one of the
essential organs for us to live in this world. Prevention from any head injury or diseases that
causes brain damage is very important. There some time that if a brain injury or damage wasn’t
treated well, it might cause an irreversible functioning of a part of our body and the worst is
death.

It is very vital to prevent the occurrence of this disease if you know that you are one of
the candidates to have stroke. This may also cause some disabilities if not prevented. In our
patient, it is his second incident of Stroke. He also had a history of Hypertension and Diabetes
Mellitus, making hi more vulnerable to get this disease. According to his SO, he was not that
aware of his health, knowing the fact that he had a previous attack of stroke. Discipline is really
needed to prevent this situation. Patient need to become more careful and strictly complies with
the treatment regimen, not just through pharmacological aspect as well as maintaining a healthy
lifestyle.

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Andrei Punzalan

We have accomplished our case study about Cerebrovascular Accident (CVA) for our
last rotation this nursing life. Once again, we had gained new experience, additional knowledge
and had involved ourselves with the conduction of information.

Handling our patient was not difficult. The patient was cooperative during different
procedures done to her. There were six of us who visited him and interviewed his wife and we
did the physical examination to the patient. We had established rapport beforehand and he felt
at ease with us.

We learned about CVA and researched on the signs and symptoms which were proven
evident in the client. Seeing them in reality makes it different learning them from theories and
books. Not only did we gain knowledge but also developed our skills in communication and
performing nursing procedures.

Lastly, in the completion of our case study, we have learned how to value each other’s
presence. Cooperation and participation of each member is highly appreciated. Everyone had
their roles and did well.

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Jenelyn Talavera

A good nurse must be equipped with enough knowledge and competent skills in helping
the clients to achieve an optimum level of functioning. We have chosen this case so that we will
be primed with the knowledge on what cardiovascular is all about, including its signs and
symptoms that the patient may experience. In completing the case study. I've gained a deeper
understanding of the condition, treatment and care of a patient afflicted with CVA. I was able to
determine the cause or the predisposing factors of the patient's condition as maybe related to
his past and present health history by mulling over the patient's profile. I believed that learning
should not only be confined in the four corners of the class room, but it should be derived from
the people we bestow our utmost concerns. The completion of this case study gave me the
opportunity to enhance my understanding and competence.

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Paula Angeli Tayag

When I first heard that our group will be conducting a case study regarding Stroke or
Cerebro Vascular Accident I was kind of intimidated with the topic, since it is a complicated one.
I was able to handle a stroke patient in a Hospital in Angeles City when I was in 2nd yr.
Unfortunately I didn’t learn as much since I was only allowed to take the vital signs then. When I
was performing my nurse-patient interaction the SO was the one answering for the patient,
since the patient was not able to talk at that time. I begun to wonder, what’s with the disease?
Will he be able to talk straight again? Will he be able to return to his work? I had so many
questions in my mind at that time. Time passed and left those questions unanswered. Until
came my 3rd yr and 4th yr my questions are finally answered. I’ve learned that the most essential
element in stroke patients is TIME, that every minute matters. The damage can be controlled or
can progress in just a nick of time. I just hope that our government will provide more information
regarding stroke, so that people can be educated and learn how to prevent and handle this kind
of condition. Everyone needs to be educated even if they’re not in the medical field.

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Alraian Tuazon

One is enough, two is too much

-apparently not for this guy

This case study is truly interesting not only because of the nature of the patient’s disease
but also his attitude towards it. Usually persons who got a first stroke, they take precaution,
preventive measures, making sure that it would never happen again. But he, instead made use
of his time to take pleasure in eating and drinking everything he wanted which somehow
contributed to the reoccurrence of his stroke.

Unlike other case study, this case study is necessary to give information about the
client’s neuro system. It gave opportunity for me, and my other groupmates to harness our skills
in assessing his mental status, cranial nerves, and even use the Glasgow coma scale. This
experience does not often land on our footsteps.

This is the last case study, the last case study presentation, the last cross examination
with a panel, so we are determined to make it our best!

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