A CASE PRESENTATION OF

CEREBROVASCULAR ACCIDENT

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Royce Jen Valerie V. Beluan

Ena Katherine F. Canono
Carmel Ray A. Enriquez

March 2020
 TABLE OF CONTENTS

PAGES

I. TITLE PAGE i

II. TABLE OF CONTENTS ii

III. LIST OF TABLES iii

IV. LIST OF FIGURES iv

V. OBJECTIVES 1

VI. DEFINITION OF TERM 2

VII. INTRODUCTION OF THE CASE 3

VIII. VITAL INFORMATION 7

IX. NURSING HEALTH HISTORY 8

X. GENOGRAM 9

XI. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM 10

XII. GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT 16

XIII. NORMAL ANATOMY AND PHYSIOLOGY 18

XIV. DIAGNOSTIC TESTS 19

XV. PHARMACOLOGY MEDICATIONS 25

XVI. CONCEP MAP 28

XVII. NURSING CARE PLAN 31

XVIII. DISCHARGE PLAN 36

XIX. REFERENCES 42

ii
LIST OF TABLES

PAGE

I. CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS 3

AGE 18 AND OLDER

II. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM 10

III. GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT 16

VI. NORMAL ANATOMY AND PHYSIOLOGY 18

V. DIAGNOSTIC TESTS 19

VII. MEDICATION THERAPY FOR HYPERTENSION 24

VI. PHARMACOLOGY MEDICATIONS 25

VII. NURSING CARE PLAN 31

iii
 LIST OF FIGURES

PAGE

I. GENOGRAMS 9

II. CONCEPT MAP 28

iv
 OBJECTIVES

General Objective:

At the end of one hour of case presentation, the participants will be able to demonstrate

knowledge regarding the general health and disease process of the patient with Cerebrovascular

Accident and its management.

Specific Objective:

At the end of an hour of case presentation, the participants will be able to:

1. The nature of the disease, its signs and symptoms, diagnosis and treatment;

2. Understand the pathophysiology and etiology of case presented;

3. Create a concept map of the Cerebrovascular Accident;

4. Efficiently provide appropriate and proper nursing diagnosis in line with the client’s

condition;

5. Skillfully formulate nursing care plan for the problems identified ; and

6. Construct discharge plan.

1
 DEFINITION OF TERMS

 Arteriovenous malformations – It is an abnormality in embryonal development that

leads to tangle of arteries and veins in the brain that lacks a capillary bed

 Atherosclerosis – It is the hardening of the arteries. It is the most common disease of

the arteries

 Brain Aneurism – Is a dilation of the walls of a cerebral artery that develops as a result

of weakness in the arterial wall.

 Diabetes Mellitus – It’s a group of metabolic diseases characterized by hyperglycemia

resulting from defects in insulin secretion, insulin action, or both.

 Hypertension – Is defined by the American Society of Hypertension and the

International Society of Hypertension as a systolic blood pressure (SBP) of 140mm Hg

or a diastolic blood pressure of 90 mm Hg or higher.

 Intracerebral Hemorrhage – It is bleeding inside the brain. Degenerative changes from

these diseases cause rupture of the blood vessel.

 Subarachnoid Hemorrhage – There is bleeding between the brain and skull or

bleeding within the subarachnoid space.

 Transient ischemic attack – It is a neurologic deficit typically lasting for 1 to 2 hours.

A TIA is manifested by a sudden loss of motor, sensory, or visual function.

2
 INTRODUCTION

Cerebrovascular accident (CVA) also known as a stroke is described as a group of

conditions involving the death of brain tissue due to disruption of its vascular supply. According

to Hinkle, Cheever (2018), a stroke is a sudden loss of function resulting from disruption of the

blood supply to a part of the brain. Strokes can be divided into two major categories: ischemic

(approximately 87%) and hemorrhagic (13%). Ischemic stroke, being the most common type of

the two results when arteries supplying brain tissue are blocked. It is often caused by cerebral

thrombosis and cerebral embolism. Usually the plaque consists of cholesterol, calcium, fat, and

cellular waste products. For hemorrhagic strokes, it results from bleeding of arteries supplying

brain tissue.

Hemorrhage strokes accounts for 13% of strokes. As stated by Hinkle and Cheever

(2018), it is primarily caused by intracranial and subarachnoid hemorrhage. Intracerebral

hemorrhage, or bleeding into the brain tissue, is most common in patient with hypertension and

cerebral atherosclerosis. A subarachnoid hemorrhage may occur as a result of arteriovenous

malformations, intracranial aneurysm, trauma, or hypertension. The most common cause is

leaking in the area of the circle of Willis and a congenital AVM of the brain.

According to Who (2016), cerebrovascular accidents are the second leading cause of

death and the third leading cause of disability. Globally, 70% of strokes and 87% of stroke-

related deaths and disability-adjusted life years occur in low- and middle-income countries. In

the Philippines, stroke second leading cause of death. It has a prevalence of 0·9%; ischemic

stroke comprises 70% while hemorrhagic stroke comprises 30%. Age-adjusted hypertension

prevalence is 20·6%, diabetes 6·0%, dyslipidemia 72·0%, smoking 31%, and obesity 4·9%. The

neurologist-to-patient ratio is 1:330·000, with 67% of neurologists practicing in urban centers.

3
Health care is largely private, and the cost is borne out-of-pocket by patients and their families.

Challenges include delivering adequate support to the rural communities and to the

underprivileged sectors.

The risk factors predisposing of stroke are heart diseases, age and gender, race and

ethnicity, personal or family history of stroke or transient ischemic attack, and brain aneurysm or

arteriovenous malformations. The precipitating factors of stroke are hypertension, diabetes

mellitus, smoking, falls and alcoholic. Signs and symptoms of CVA is Face drooping, Arm

weakness, Speech difficulty, and Time to call

The purpose of this study is to instill knowledge to the listeners about cerebrovascular

accident or stroke particularly about hemorrhagic strokes. With this information, the listeners

will be able to recognize different types of cerebrovascular accidents along with its sign and

symptoms and its management.

4
 VITAL INFORMATION

Code Name: Mama

Age: 86 years old

Gender: Female

Civil Status: Widow

Date of Birth: January 6, 1934

Place of Birth: Raya, Balindong
Race: Asian
Cultural or Ethnic Background/Group: Maranaw
Primary Language: Maranaw
Secondary Language: Bisaya
Religion: Islam
Highest Educational Attainment: College level
Occupation: Housewife
Usual Health Care Provider/s: Dr. Camiliam
Date of Admission: February 19, 2020
Date of Discharge: February 26, 2020; expired
Source/s of History: 90% SO, 10% chart
Reason/s for Seeking Health Care: unconscious
Primary Attending Physician: Dr. Manticayan, internal medicine and co-management with Dr.
Daya, Neurosurgeon
Initial Impression/Diagnosis: Cerebrovascular Accident to consider bleed
To consider intracranial bleed
Hypertensive urgency
Final Diagnosis: Cerebrovascular accident, bleed
Left temporal, left parietal and bilateral
Linear fracture in the bilateral skull
CAP - MR

5
 NURSING HEALTH HISTORY

PRESENT HEALTH CONCERN

According to the daughter of Mama, 6 hours prior to the admission, after their last prayer

session the client went to the bathroom to cleaned her body but she was found by her family

unconscious in the ground and was brought to the hospital after the incident.

PAST HEALTH HISTORY

Based on the information of the family, the Mama experienced mumps, chicken pox and

strep throat in her childhood days. She had not completed her immunization when she was

young. Way back to 2005, the Mama undergone cholecystectomy and it was performed by Dr.

Eustique Jr. T. Oliverio, General Surgeon at Iligan Medical Center. The client did not experience

any injuries or accidents in the past. It was stated by the daughter that the client was admitted

many times that it cannot be counted by fingers. She was admitted at Medical Community Center

either due to cough or hypertension was confined for 2-3 days. Last 2019 in September 4, 2019

at 7:45 PM, she was admitted due to mild stroke at Adventist Medical Center-Iligan (AMCI).

Based on the previous chart it was recorded that 4 hours prior to the admission, Mama started

having involuntary movement at the left side of her body associated with headache and the

symptoms persisted thus the family decided to send the patient to the hospital at AMCI. The

admitting diagnosis at the time is Transient Ischemic Stroke and the final diagnosis results are

Alzheimer’s Dementia, Post-Stroke Epilepsy and Hypertensive Cardiovascular Disease. The

attending physician at the time is Dr. Diamla a Neurologist. Dr. Diamla ordered to performed CT

scan to Mama on September 5, 2019 and the result is old infarctive changes in the right parietal

lobe white matter with malacic changes – as a sequela from previous history of cerebral bleed.

6
The medications that was given to Mama for parenteral are Pantoprazole (pantopraz) 40 mg IV

which is a proton pump inhibitor that decreases the amount of acid produced in the stomach,

Kepra 500 mg + 90 mL PNSS to run for 1 hour then every 12 hours x 2 more doses is used to

treat partial-onset, myoclonic, or generalized tonic-clonic seizure in patients with epilepsy and

diazepam 5 mg IV. For oral medications are Depakote 1 tablet is to prevent migraine headaches,

Pantoprazole 40 mg 1 tablet once a day after meals, this is used to treat certain stomach and

esophagus problems (such as acid reflux) and Levocetirizine 5 mg 1 tablet, an antihistamine used

to relieve allergy symptoms. She was discharge in September 6, 2019 at 11:30 AM. The last

check-up of her vision was last 2019 she was prescribed with eyeglasses by Dr. Salma

Gandamra, Ophthalmologist. In 2013 she had her pap smear by Dr. Saavedra, Gynecologist at

Amai Pakpak Medical Center and Mama is practicing Breast Self-Examination stated by the

daughter. She is allergic to seafoods. The current medications she took are B complex vitamins

and amlodipine. She delivered 6 babies and all of them are full term babies without any

complications. In 2015 was her last travel in Manila.

7
 GENOGRAM

PATERNAL MATERNAL

unrecalled unrecalled unrecalled unrecalled

unrecalled unrecalled

86 Y.O ? ? ? ? ? ? ?
HPN HPN HPN HPN HPN HPN HPN HPN
CVA
LEGENDS:
- MALE HPN - HYPERTENSION

- FEMALE CVA - CEREBROVASCULAR ACCIDENT

- CLIENT ? - UNRECALLED AGE

8
 Physical Examination and Review of Systems
Table 2

Areas Examined Findings Problems Identified

1. General Health a) Body proportions are normal. Arm a) Ineffective tissue

Survey span (distance between fingertips perfusion r/t
a. Physical with arms extended) is approximately secondary to
development and equal. hypotension
body build b) Sexual development is appropriate b) Ineffective
b. Gender and sexual for gender and age. breathing pattern
development c) Client appears to be his stated as evidenced by
c. Apparent age as to chronologic age. the assessment
compared to d) Color is even without obvious lesions c) Altered body
reported age and her condition is gradually temperature:
d. Skin color and deteriorated. hyperthermia
condition e) She is dress in the appropriate setting d) Risk for
e. Dress and hygiene and has a good hygiene. aspiration r/t
f. Level of f) Unconscious and unresponsive. tachypnea
consciousness Glasgow Coma Scale (GCS) is 5-6
g. Vital Signs g) Vital Signs:
 T – 37.8˚C – 39.3 ˚C
 P –62 bpm
 R –17-30 bpm
 BP – 70/40 mmHg
 O2 - 82%

9
2. Integumentary  Warm to touch  Impaired Skin
System  Senile turgor Integrity
 IV line attached at metacarpal vein at  Altered body
the right and left hand temperature:
 Has thickened nails hyperthermia

 Nails are clean

 Capillary refill less than 2 seconds
 There is normally a 160-degree angle
between the nail base and the skin.
 Febrile; T - 37.8˚C – 39.3 ˚C

3. HEENT HEAD and FACE  Risk for

a. Head and face  Hair is thin, white, course, dry aspiration r/t
b. Eyes and evenly distributed tachypnea
c. Ears  No swelling or tenderness noted
d. Nose upon palpation
e. Oral cavity EYES
 Lids close symmetrically; skin
intact, no discharges and no
discoloration noted
 Eye constrictions and dilations
are delayed
EARS
 Symmetrical; auricle aligned to
outer canthus of the eye
 External pinna was firm and non-
tender
 No discharges, tenderness,
masses or swelling noted upon
inspection and palpation
NOSE

10
  NGT attached
 Breather mask attached with 15
L/min.
ORAL CAVITY
 Lips were dry and pale
 Removed dentures
 Front teeth are missing
 Saliva accumulated in the mouth
4. Neck  Symmetrical and proportional to head No problem
and shoulder identified
 No lumps, mass, and tenderness
noted upon palpation

5. Respiratory System  Respiratory rhythm is irregular  Risk for

 RR – 17-30 bpm aspiration r/t
 Breather mask attached with 15 tachypnea
L/min
 There is equal bilateral chest
expansion of 1 to 2 inches.
 Nasal flaring is not observed.
 The client has evenly colored skin
tone, without unusual or prominent
discoloration.
 Chyne-stokes

6. Cardiovascular  The jugular venous pulse is not  Ineffective tissue

System normally visible with the client perfusion r/t
sitting upright secondary to
 No blowing or swishing or other hypotension
sounds are heard.

11
  The radial and apical pulse rates are
identical
 Normally no murmurs are heard
 BP – 70/40 mmHg
 PR – 62 bpm
 Chest X-ray results:
 Minimal cardiomegaly
 Atherosclerotic Aorta
7. Breast and axilla  No masses should be palpated. No problem
 No palpable nodes identified

 No swelling, nodules, or ulceration

should be detected.

8. Gastrointestinal  Abdomen is free of lesions or rashes. No problem

System and  Umbilicus is midline at lateral line identified
Abdomen  Abdomen is flat
 Abdomen is symmetric
 Abdomen does not bulge when client
raises head.
 Abdominal respiratory movement
maybe seen
 A slight pulsation of the abdominal
aorta, which is visible in the
epigastrium
 No palpable masses are present.
9. Lymphatic/Hematolo CBC results: Risk for infection
Results Interpretation
gic System 2/21/20 related to
RBC 3.25 Decrease

HEMATOCRIT 0.32 Decrease

12
 HEMOGLOBIN 100.0 Decrease

WBC 21.76 Increase

SEGMENTERS 0.93 Decrease

LYMPHOCYTE
S 0.05 Decrease

STABS 0 Decrease

MONOCYTES 0.02 Decrease

EOSINOPHILS 0 Decrease

BASOPHILS 0 Decrease
20. Endocrine system FBS(FASTING BLOOD SUGAR)
result:
Result Interpretation

10.03 Increase

23. Nervous System  Unconscious and unresponsive. Ineffective tissue

 Glasgow Coma Scale (GCS) is 5-6 perfusion (cerebral)

 CT scan results: r/t bleeding

 Acute parenchymal hemorrhages
in the left temporal left parietal
and bilateral lobes with
perilesional edema, mass and
intraventricular hemorrhagic
extension.
 Left to right subfalcine
herniation of 0.7 cm.
 Acute subdural hematoma and
subarachnoid hemorrhage as

13
 described.
 Linear fracture in the bilateral
parietal bones traversing the
sagittal suture.
 Atherosclerotic bilateral internal
carotid and vertebral arteries.

GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT

Table 3

Health Pattern Before Hospitalize During Hospitalization

1. Health Perception and The reason Mr. Mama was Her condition gradually
Health Management admitted because unconscious. deteriorated and still
Pattern According to the family she was unconscious and

14
 admitted for many times that he unresponsive.
cannot remember the numbers.
Mama’s appetite decreases. She Because Mama is still
would ate ½ cup of rice that the unconscious, they attached
food is being served. She is NGT to feed her food and
allergic to seafood and does not PNSS is attached according
eat pork based of their religion to doctor’s order.
2. Nutrition and being a Muslim. She drinks 5
Metabolism Pattern glasses of water/day and drinks
coffee 3x a day. Eat 3x a day.
She likes to eat vegetables,
fruits and fish. They would eat
at the restaurant every twice a
week.
Defecating once a day and She was wearing diaper and
3. Elimination Pattern every time she drinks water she would defecate once a day.
would urinate.
Every day she had a routine that She was currently lying on
4. Activity and Exercise every morning upon woke up to bed because of her current
Pattern swipe the floor and attending condition.
prayer session.
She always woke up at 6 in the She is still unresponsive and
morning and sleeps at 9 in the unconscious.
5. Sleep and Rest Pattern evening. She sometimes had
some naps in the afternoon.
She is not drinking alcohol but No particular habit in
6. Personal Habits she had smoke in her teens and drinking alcohol and
stop after 2 years. smoking.
She had not taken some illegal Not taking illegal drugs.
7. Street Drugs drugs in her life.

8. Intimate partner She did not maltreat her She is widow.

violence husband when he was alive.

9. Occupational health She is a housewife. No work or job.

The last check-up of her vision Currently unconscious.
was last 2019. She is wearing
10. Cognitive and eye glasses. She would
Perceptual Pattern experience headache and
dizziness when her blood
pressure increases.
11. Roles and Relationship She had good relationship with Have harmonious

15
 Patter her family relationship with her family.

12. Sexuality and Her menopausal started in the Not applicable.

Reproductive Pattern
13. Self-Perception Pattern
age of 50.
She felt worse and experiencing Not applicable.
pain from her joints and affects
his whole body to the point she
would cry because of the pain.

14. Coping and Stress
tolerance Pattern
15. Values and Beliefs
Pattern
She would cry when she is in
stress situations.
She believed that Allah gave
her years to live and be with her
family. She happy that all her
children is successful in their
careers.
Not applicable.
According to the daughter
that her mother believes that
their Allah is always with
them.

NORMAL ANATOMY AND PHYSIOLOGY OF CARDIOVASCULAR SYSTEM

Table 4

ANATOMICAL STRUCTURE/S DESCRIPTION AND FUNCTIONS

16
1. Heart Blood pressure in the arteries is generated by
contraction and relaxation of muscles of the
heart’s ventricle walls. Systolic pressure
(systolic) measures the pressure in the arteries
when the heart beats (when the left ventricle
contracts). Diastolic pressure (diastole)
measures the pressure in the arteries between
heart beats (when the left ventricle release and
refills with blood).
2. Elastic Arteries The largest arteries closest to the heart. These
are the aorta and its largest branches and the
pulmonary trunk with their large pulmonary
arteries.
3. Tunica Media Made mostly of elastic fibers, the tunica media
stretches under systolic pressure and recoils
during diastolic. The recoil helps push blood
away from the heart and into smaller arteries.
4. Arteries/ Capillaries Arterioles are the smallest of all arteries,
eventually terminating into capillaries. The
middle layer of arterioles consists of tiny rings
of smooth muscle which act as sphincters. If
these rings stay constricted, pressure backs up
into the other arteries and the heart.

ANATOMICAL STRUCTURE/S DESCRIPTION AND FUNCTIONS

a) Brain Brain accounts for approximately 2% of the

total body weight; in an average young adult,
the brain weights approximately 1400 g,
whereas in an average older adult, the brain
17
 weights approximately 1200 g (Hickey, 2014).
The brain is divided into three major areas: the
cerebrum, the brain stem and the cerebellum.
The cerebrum composed of two hemispheres,
the thalamus, hypothalamus and basal ganglia.
The brain stem includes the midbrain, pons and
medulla. The cerebellum is located under the
cerebrum and behind the brain stem.
b) Cerebrum Thick band of fibers that connects the left and
right brain hemispheres

a) Frontal Lobe a) The largest lobe, located in front of the

brain. It is also responsible in large part
for a person’s affect, judgement,
personality and inhibitions.
b) Parietal Lobe b) A predominantly sensory lobe posterior to
the frontal lobe. This lobe analyzes
sensory information and relays the
interpretation of this information to other
cortical areas and essential to a person’s
awareness of body position in space, size
and shape discrimination, and tight-left
orientation.
c) Located inferior to the frontal and parietal
c) Temporal Lobe lobes, this lobe contains the auditory
receptive areas and plays the roles in
memory of sound and understanding of
language and music
d) Occipital Lobe d) Located posterior to the parietal lobes, this
lobe is responsible for visual interpretation
and memory.
c) Brain Stem It is consisting of the midbrain, pons and

18
 medulla oblongata.
a) Midbrain a) It connects to the pons and cerebellum
with cerebral hemispheres. It contains
sensory and motors pathways and serve as
the center of auditory and visual reflexes.
b) Pons
b) Portion of the pons help regulate
respiration.
c) Medulla c) Reflex centers for respiration, blood
pressure, heart rate, coughing, vomiting,
swallowing and sneezing. Reticular
information, responsible for arousal and
the sleep-wake cycle.
d) Cerebellum Located at the posterior to the midbrain and
pons and below the occipital lobe. It controls
fine movement, balance and position (postural)
sense or proprioception (awareness of position
of extremities without looking at them).
e) Structures protecting the brain

a) Outmost layer; covers the brain and spinal

a) Dura mater
cord.
b) Subdural space b) Exist below the dura mater
c) Arachnoid c) The middle membrane; an extremely thin
delicate membrane that closely resembles
a spider web.
d) The arachnoid membrane has
d) Subarachnoid
cerebrospinal fluid (CSF) in the space
below known as subarachnoid space.
e) Pia mater e) The innermost, thin, transparent layer that
hugs the closely and extends into every
fold of the brains surface.
f) Cerebrospinal Fluid It is important in immune and metabolic
functions in the brain. It is produced at a rate of
about 500 mL/day.

19
g) Cerebral Circulation The brain receives approximately 15% of the
cardiac output or 750 mL per minute of blood
flow.
h) Spinal Cord Spinal cord is continuous with the medulla,
extending from the cerebral hemispheres and
serving as the connection between the brain
and periphery. Approximately 45 cm (18
inches) long and about the thickness of a
finger.

20
 DIAGNOSTIC TEST
Table 5

DIAGNOSTIC NORMAL INTERPRETATIO NURSINF

RESULT SIGNIFICANCE
TEST/DATE VALUE N RESPONSIBILITIES
LIPID PROFILE  Explain test
procedure. Explain
2/19/20
that slight discomfort
 CHOLESTEROL 3.5-5.2 mmol/L 5.00 NORMAL may be felt when the
skin is punctured.
 TRIGLYCERIDE 0.68-1.88 mmol/L 0.63 DECREASE  Low fat diet.
 Encourage to avoid
S 0.77-1.83 mmol/L 1.19 NORMAL Hyperthyroidism stress if possible
2.08-5.46 mmol/L 3.52 NORMAL because altered
 HDL (overactive thyroid)
physiologic status
 LDL Malabsorption influences and
changes normal
syndrome
hematologic values.
 Apply manual
pressure and
dressings over
puncture site.
 Monitor the puncture
site for oozing or
hematoma formation.
 Instruct to resume
normal activities and
diet.
 FBS(FASTING  Explain test
BLOOD SUGAR) procedure. Explain
that slight discomfort
2/19/20 3.3-6.6 mmol/L 10.03 INCREASE  Acromegaly may be felt when the
 Acute pancreatitis skin is punctured.
 Acute stress response  Encourage to avoid
stress if possible
 Chronic renal failure because altered
21
  Corticosteroid physiologic status
therapy influences and
changes normal
 Cushing’s syndrome hematologic values.
 Diabetes mellitus  Apply manual
pressure and
 Diuretic therapy
dressings over
 Glucagonoma puncture site.
 Pheochromocytoma  Monitor the puncture
site for oozing or
hematoma formation.
 Instruct to resume
normal activities and
diet.
 Explain test
procedure. Explain
 POTASSIUM 3.5-5.3 mmol/L 2.57 DECREASE
that slight
 SODIUM 135-148 mmol/L 138 NORMAL discomfort may be
felt when the skin is
 CREATININE 53-106 umol/L 88.49 NORMAL
punctured.
 Encourage to avoid
2/19/20 stress if possible
because altered
physiologic status
influences and
changes normal
hematologic values.
 Apply manual
pressure and
dressings over
puncture site.
 Monitor the
puncture site for
oozing or hematoma

22
 formation.
 Instruct to resume
normal activities
and diet.
CBC & PLATELET  Explain test
procedure. Explain
COUNT
that slight
 RBC 4-6 x 10 12/L 3.25 DECREASE  anemia, fluid discomfort may be
overload, or felt when the skin is
hemorrhage beyond punctured.
24 hours.  Encourage to avoid
stress if possible
because altered
 HEMATOCRIT 0.40-0.54 0.32 DECREASE  anemia, physiologic status
hemodilution or influences and
changes normal
massive blood loss. hematologic values.
130-160 g/L 100.0 DECREASE  anemia, recent  Apply manual
 HEMOGLOBIN pressure and
hemorrhage or fluid dressings over
retention causing puncture site.
 Monitor the
hemodilution. puncture site for
5-10 x 10 9/L 21.76 INCREASE  Infection such as an oozing or hematoma
 WBC formation.
0.50-0.65 0.96 INCREASE abscess, meningitis,  Instruct to resume
 SEGMENTERS
appendicitis, normal activities
and diet.
leukemia.

0.25-0.35 0.05 DECREASE  Increased count is

 LYMPHOCTES
0.05-0.10 0 DECREASE often linked to
 STABS
0.03-0.07 0.02 DECREASE allergic diseases and
 MONOCYTES
0.01-0.03 0 DECREASE parasites.
23
 EOSINOPHILS 0.1 0 DECREASE
 BASOPHILS
140-150 x 10 9/L 245 INCREASE  Increase count
 PLATELET indicates carcinoma
COUNT monocytic leukemia
or lymphoma,
collagen vascular
disease

URINALYSIS  Before the test,

 Low specific gravity make sure to drink
 COLOR Light yellow Yellow NORMAL may be associated plenty of water so
with renal failure, you can give an
 TRANSPARENC Clear Hazy NORMAL pyelonephritis, adequate urine
diabetes insipidus, sample. However,
Y 1.016 – 1.022 20cc acute tubular drinking excessive
necrosis, interstitial amounts of water
 VOLUME 4.5 – 4.7 1.015 DECREASE nephritis, and may cause
excessive fluid inaccurate results.
 SPECIFIC (-) intake.  One or two extra
glasses of fluid,
GRAVITY 6.0 INCREASE  High urine ph, which can include
meaning that it is juice or milk if the
 PH REACTION TRACE more alkaline, it client’s diet allows,
might signal a is all patient need
 PROTEIN (-) medical condition the day of the test.
such as: kidney The client doesn’t
 SUGER (-) stones. urinary tract have to fast or
24
 ACETONE +2 infections (UTIs) change your diet for
kidney-related the test.
 BLOOD disorders.  Ask the patient what
are the medication
OCCULT he is taking.
 Protein in urine may  Asked the client to
MICROSCOPIC <4 cells 2-5 INCREASE indicate kidney obtain a clean catch
disease may let urine sample. The
 WBC - /hpf <3 cells 10-25 proteins such as client should collect
albumin leak from the urine in the
 RBC - /hpf Occasional the blood into the middle of his
urine. Proteinuria can urination. This
also be a result of technique helps
 EPITH-
overproduction of prevent bacteria
(-) proteins by the body. from the penis or
SQUAMOU
vagina from getting
(-)  A high count of red in the sample
 EPITH-ROUND
blood cells in the  Urinate a small
urine can indicate amount into the
 AMORPHOUS infection, trauma, toilet, then collect
(-) tumors, or kidney the sample in the
SED stones. cup.
Occasional  Avoid touching the
 CRYSTALS
inside of the cup so
Occasional you don’t transfer
 CAST bacteria from your
(-) (-) hands to the sample.
 MUCUS  When you’re done,
(-) place the lid on the
 BACTERIA cup and wash your
(-) hands. Label the
 UROBILINOGEN container with the
name of the patient.
 BIRIRUBIN

(BILE)

25
CHEST X-RAY  There is  MINIMAL  Remove all metallic
crowding of the CARDIOMEGALY objects.
lower lung  No preparation is
parenchyma  ATHEROSCLEROT required.
IC AORTA
 The trachea is at
the midline. The  SENILE  Provide appropriate
heart is OSTEOPOROSIS clothing.
minimally
enlarged,
magnified and
transversely
oriented.

 Tortuous aorta
with wall
calcifications.
The hilar vessels
are not dilated.

 The diaphragm
is intact, situated
high. The
costophrenic
sulci are sharp
and distinct.

 Generalized
bone rarefaction

 There is interval  Slight interval  Informed Consent.

CT SCAN OF THE increase in size increase in the Obtain an informed
BRAIN and volume of parenchymal consent properly
parenchymal hemorrhages in the signed.
hemorrhages in bilateral cerebral
26
the left temporal hemispheres, as
lobe and left above detailed, with  Look for allergies.
parietal lobe, brain edema, mass
presently effect and  Get health history.
measuring 6.8 x intraventricular
3.8 x 3.7 cm or hemorrhagic  Check for NPO
50 ml extension. status.
(previously 39
ml) and 6.2 x  Worsening left-to-  Get dressed up.
5.4 x 5.0 cm or right subfalcine
85 ml herniation.
 Provide information
(previously 46 
ml), about the contrast
 Acute subdural
respectively. medium.
hematoma and
Parenchymal subarachnoid
hemorrhage is hemorrhage, as  Inform about the
now identified described. duration of the
in the right procedure.
temporal lobe  Linear fracture in the
measuring 2.6 x bilateral parietal
2.4 x 2.9 cm or 9 bones traversing the
ml. Perilesional sagittal suture.
edema is noted.  Atherosclerotic
Small bilateral internal
parenchymal carotid and vertebral
hemorrhages are arteries.
also seen in the
bilateral frontal  Atherosclerotic
lobes. There is bilateral internal
worsening of the carotid and vertebral
overall mass arteries.
effect as
evidenced by
 Right posterior
compression of
ethmoid sinus
the adjacent
disease.
brain
parenchyma and
27
 left lateral
ventricle with
increase in the
left-to-right
subfalcine
herniation from
0.7cm to 1.4 cm.
Diffuse sulcal
effacement is
noted
predominantly
in the left
cerebral
hemisphere.

 Intraventricular
hemorrhagic
extension is
again seen in
both lateral
ventricles, third
ventricle and
fourth ventricle.
There is no
significant
change in the
subdural
hematomas in
the left
frontotemporal
convexity
(thickness of 0.9
cm) and
posterior
interhemispheric
region
(thickness of 0.5
28
 cm)
Subarachnoid
hemorrhage is
again noted in
the bilateral
cerebral
hemispheres,
more extensive
in the left.

 Linear fracture
in the bilateral
parietal bones is
again noted
traversing the
sagittal suture.

 The bilateral
internal carotid
and vertebral
arteries remain
calcified.

 Densities are
seen in the right
posterior
ethmoid air
cells. The rest of
the visualized
paranasal
sinuses are clear.
The orbits and
petromastoids
are
unremarkable

29
30
 PHARMACOLOGIC MEDICATIONS
Table 7

Route/Frequency/Dos Nursing
Drug name Mechanism of Action Indication Contraindication
e responsibilities
Generic name: Route: IV push Increase osmotic To reduce intraocular Hypersensitivity to
 Monitor v/s esp. BP
pressure, thus or intracranial pressure drug.
Mannitol Frequency: Q 6
inhibiting tubular on cerebral edema.  I &o hourly.
Dose: 150 mL reabsorption of Patients with anuria,
water and severe pulmonary
Brand:
electrolytes. congestion, active
intracranial bleeding,
metabolic edema.
Generic name: Route: Oral Inhibits influx of Hypertension, chronic Sick sinus syndrome;  Assess cardio
calcium ion across stable angina, second or third respiratory status.
Amlodipine Dosage:5mg cell membranes to vasospatic angina degree BP, pulse,
produce relaxation of antrioventricular respiration and
Frequnecy: OD coronary ECG.
vascular smooth
 Assess hydration
muscle. Decrease
and fluid volume
peripheral vascular
status, I & O ratio
resistance of smooth
presence of
muscle (decrease
edema, distended
BP)
neck veins,
adequate pulses
and skin turgor.
Generic Name: Route: IVTT Inhibits cell wall Used to treat moderate Contraindicated to
Piperacillin +  Monitor patient for
synthesis during to severe infections. hypersensitivity to
Tazobactam Dose: 4.5 mg diarrhea.
bacterial drug, other
multiplication. Moderate to severe penicillins,  Serious skin
Frequency : q 8 CAP. cephalosphorins, or reactions can occur.

31
Brand name: beta-lactamase
inhibitors.

Use cautiously to
patients with
bleeding tendencies,
uremia, hypokalemia,
and allergies to other
drugs.
Generic: Route: IV drips The precise Indicated as Hypersensitivity to  Instruct the
Levetiracetam mechanism by adjunctive therapy in levetiracetam. patient to take
which levetiracetam the treatment of partial medication as
Dose: 500mg exerts is anti- onset seizures. directed.
Brand: Keppra epileptic effect is
unknown.  Do not
discontinue
Frequency: Q 12
abruptly; may
hrs
cause increase in
frequency of
seizures
Generic: Route: IV Increase blood flow CVA in acute and Hypersensitivity  Monitor BP,
and oxygen recovery phase. Disorder of Cardiac PR, HR
Citicoline Pacemaker acitivity
consumption in the carefully.
Dose: brain. and conduction
 Assess allergic
reaction like GI
disturbances.
Frequency: Q 8hrs  Give only the
prescribed
dose.

Generic: Route: IVTT Valproic acid is Sole and adjunctive Contraindicated with  Give drug with
Valproic Acid sometimes used therapy in simple and hypersensitivity to food to prevent
Dosage: 500 mg together with other complex absence valproic acid, GI upset.
Brand name: seizure medications. seizures; acute hepatic disease, or
32
 depacon Frequency: Valproic acid is also treatment of manic significant heaptic  Monitor ammonia
Q 12 used to treat manic episodes associated impairment. levels and
episodes related to with bipolar discontinue if
bipolar disorder disorder; prophylaxis there is clinically
(manic depression), of migraine significant
and to prevent headaches; elevation in level.
migraine headaches. adjunctive therapy
 Monitor serum
for multiple seizure
levels of valproic
disorders.
acid and other
anti-epileptic
drugs given
concomitantly,
especially during
the first week of
the therapy.
 Monitor CBC,
platelet count and
bleeding time.

Generic: Route: IVTT Gastric acid-pump Short-term treatment Contraindicated  Arrange for
inhibitor: suppresses of active duodenal with further
Omeprazole
gastric acid secretion ulcer; first line therapy hypersensitivity to evaluation of
Dose: 40mg by specific inhibition in omeprazole are its patient after
of the hydrogen components 8weeks of
Brand: treatment
potassium ATP as therapy for
Omenol Frequency: OD enzyme system at the gastroesophageal gastro reflux
secretory surface of reflux disorders; not
the gastric parietal intended for
cells. disease (GERD).  maintenance
therapy.

 Take the drug

before meals.
33
  Administer
antacids with
omeprazole, if
needed.
Generic: Route:IV Produce analgesia by Relief mild pain or Contraindicated in  If there is fever,
blocking generation fever patients with assess patient’s
Paracetamol
of pain impulses, hypersensitivity to for fever or pain.
Frequency: probably by the drug.
 Avoid giving
inhibiting
Brand: RTC aspirin or aspirin-
prostaglandin like analgesics
Napre synthesis in the CNS. because it inhibits
platelet
x Dose: 300 mg
aggregation.
 Teach client/SO
warning signs that
needs immediate
attention of the
physician.
 Evaluate
therapeutic effect.

34
 CONCEPT MAP

NON-MODIFIABLE FACTORS:
MODIFIABLE FACTORS:
 AGENON-MODIFIABLE
(86 Y.O) FACTORS:
 FAMILY HISTORY
 DIET (MEAT EATER)
VASOCONSTRICTION (HYPERTENSION, STROKE)
 RACE (ASIAN)

INEFFECTIVE TISSUE Blockage of the blood Citicoline 1g IV q 6

PERFUSION vessels
Mannitol 150 ml IV push q 6

Lack of oxygen and

nutrients supply

Cerebral ischemia Hypoxia

Hematocrit = 0.32 Altered cerebral

Hemoglobin = 100.0 metabolism
IMPAIRED PHYSICAL
MOBILITY

Intracerebral Decreased cerebral

hemorrhage perfusion SELF-CARE DEFICIT

RISK FOR
SEIZURE Lactic acidosis
INJURY pH level = 6.0

Valproic Acid 500 mg IV q 12

Aneurysm rupture LOSS OF CONSCIOUSNESS

Ischemic SUBARACHNOID Large artery small artery embolic

Venous stroke
stroke HEMORRHAGE stroke stroke stroke

35
 BRAIN TISSUE
PARALYSIS NECROSIS DEATH

Small artery
Embolic strokes
stroke

↑ BODY
TEMPERATURE

NURSING DIAGNOSIS:
 Ineffective breathing pattern
 Impaired Skin Integrity
 Altered Body Temperature :
Hyperthermia
 Risk for Aspiration
MEDICATIONS:
 Amlodipine 5 mg OD
 Piperacillin + Tazobactam 4.5
mg q 8
LEGEND:
 Levetiracetam 500 mg IV q 12
 Omeprazole 40 mg IV OD - PATHOPHYSIOLOGY
 Paracetamol 300 mg IV RTC
 Tolilac 125 mg IV bolus q 4 - DIAGNOSTIC TESTS

DIAGNOSTIC TESTS: - NURSING DIAGNOSIS

 CT SCAN OF THE BRAIN - MEDICATIONS

 CBC
 POTASSIUM - MANIFESTATIONS
 Chest X-ray

36
 NURSING CARE PLAN
Table 8

Planning
Nursing Nursing
Assessment (Desired or Expected Rationale Evaluation
Diagnosis Interventions
Outcomes)
Objective Data: Ineffective After 8 hours of nursing Independent: After 8 hours of
 Breather mask Breathing interventions the client will a) Assess and record a) The average rate of nursing intervention
attached with Pattern r/t be able to: respiratory rate respiration for adults is the client was able
15L /min unknown cause a. Patient maintains an and depth at least to:
10 to 20 breaths per
 Cheyne-Stokes effective breathing every 4 hours.
pattern, as evidenced minute. It is important Remains free of
by relaxed breathing to take action when injuries.
Vital Signs at normal rate and there is an alteration in
 PR: 62 bpm depth and absence of the pattern of breathing Explains methods to
 RR:17-30 bpm dyspnea. to detect early signs of prevent injury.
 BP:70/40 mmHg b. Patient’s respiratory respiratory
 O2Sat: 82% rate remains within Identifies factors
compromise.
established limits. that increase risk for
injury.
b) Observe for b) Unusual breathing
breathing patterns patterns may imply an Relates intent to
underlying disease practice selected
process or dysfunction. prevention
Cheyne-Stokes measures.
respiration signifies
Patient increases
bilateral dysfunction in
daily activity, if
the deep cerebral or feasible.
diencephalon related
with brain injury or
metabolic
abnormalities
c) Assess for use of
37
 accessory muscle. c) Work of breathing
increases greatly as
lung compliance
decreases.
d) Utilize pulse
oximetry to check
d) Pulse oximetry is a
oxygen saturation
helpful tool to detect
and pulse rate.
alterations in
oxygenation initially

e) Evaluate skin
color, temperature, e) Lack of oxygen will
capillary refill; cause cyanosis coloring
observe central to the lips, tongue, and
versus peripheral fingers. Cyanosis to the
cyanosis. inside of the mouth is a
medical emergency!

Collaborative:
f) Provide
respiratory f) Provide oxygen to the
medications and system.
oxygen, per
doctor’s orders.
Sig: Breather
mask attached
with 15L /min

38
 NURSING CARE PLAN
Table 9

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Objectives Impaired Physical After 8 hours of Independent:
Mobility r/t nursing interventions, a) Establish rapport. a) To promote After 8 hours of
neuromuscular patient will be able to cooperation. nursing
involvement improve and increase b) Monitor vital signs. b) To have a baseline interventions, the
secondary to CVA strength and function data. patient was able to:
infarct of affected body part.
c) Note emotional/ c) To assess functional  Improve and
behavioral responses ability. increased
to problems strength and
of immobility. function of
affected body
d) Determine d) To assess expected part.
readiness to engage level of participation.
in activities.

e) Turning every 2 e) To promote optimal

hours. level of function and
prevent
complications.

f) Provide for safety f) To prevent

measures including occurrence of injury.
fall prevention.

g) Identify energy g) Limits fatigue,

conserving maximizing
technique. participation.

h) Involve SO in care
39
 assisting them to
learn ways
of managing
problems of
immobility.

i) Provide restful
environment for
patient.

40
 NURSING CARE PLAN
Table 9

Planning
Nursing Nursing
Assessment (Desired or Expected Rationale Evaluation
Diagnosis Interventions
Outcomes)
Objective Data: Ineffective After 8 hours of nursing Independent: After 8 hours of
 Capillary Refill (<2 tissue perfusion interventions the client will a) Assess for sign a) Particular clusters of nursing
secs) r/t secondary to be able to: of decreased signs and symptoms intervention the
 Chest X-ray result: hypotension c. Show no further tissue perfusion. occur with differing client was able to:
 minimal worsening/ causes. Evaluation of
cardiomegaly repetition of Ineffective Tissue Remains free of
 atherosclerotic deficits. Perfusion defining injuries.
aorta d. Maintain maximum characteristics
tissue perfusion to provides a baseline for Explains methods
Vital Signs vital organs, as future comparison. to prevent injury.
 PR: 62 bpm evidenced by warm
 RR:17-30 bpm and dry skin, present b) Check rapid b) Electrolyte/acid-base Identifies factors
 BP:70/40 mmHg and strong changes or variations, hypoxia, that increase risk
 O2Sat: 82% peripheral pulses, continued shifts and systemic emboli for injury.
 T: 37.9 vitals within in mental status. influence cerebral
patient’s normal perfusion. In, addition, Relates intent to
range, balanced it is directly related to practice selected
I&O, normal cardiac output. prevention
measures.
c) Assist with c) Gently repositioning
position patient from a supine Patient increases
changes. to a side lying position daily activity, if
can reduce the risk for feasible.
orthostatic BP
changes. Older
patients are more
susceptible to such
drops of pressure with

41
 d) Do not elevate position changes.
legs above the d) With arterial
level of the insufficiency, leg
heart. elevation decreases
arterial blood supply
to the legs.

e) Check mental e) Review trend in level

status; perform a of consciousness
neurological (LOC) and possibility
examination. for increased ICP and
is helpful in deciding
location, extent and
development/resolutio
n or central nervous
system (CNS)
damage.
Collaborative:
f) Administer
medications as f) Medications facilitate
prescribe to treat perfusion for most
underlying causes of impairment.
problem. Note
the response

42
 NURSING CARE PLAN
Table 9

ASSESSMENT NURSING PLANNING INTERVENTIO RATIONALE EVALUATION

DIAGNOSIS N
Objectives Ineffective tissue After 8 hours of Independent After 8 hours of nursing
perfusion nursing interventions a) Respirations, a) Irregularities interventions the client was
CT Scan results: (cerebral) r/t the client will be able noting patterns can suggest able to:
 Acute parenchymal bleeding as to: and rhythm location of a. Display no further
hemorrhages in the (periods of cerebral insult deterioration/recurrenc
evidenced by
left temporal left a) Display no apnea after or increasing e of deficits.
CT scan further hyperventilatio ICP and need b. Reveal stable vital
parietal and
results. deterioration/recu n), Cheyne- for further signs
bilateral lobes with rrence of deficits. Stokes intervention,
perilesional edema, b) reveal stable vital respiration. including
mass and signs possible
intraventricular respiratory
hemorrhagic support.
extension. b) Evaluate
pupils, noting b) Pupil reactions
 Left to right
size, shape, are regulated by
subfalcine equality, light the oculomotor
herniation of 0.7 reactivity. (III) cranial
cm. nerve and are
 Acute subdural useful in
hematoma and determining
subarachnoid whether the
brain stem is
hemorrhage as
intact. Pupil size
described. and equality is
 Linear fracture in determined by
the bilateral balance between
parietal bones parasympathetic
traversing the and sympathetic
43
 sagittal suture. innervation.
 Atherosclerotic Response to
bilateral internal light reflects
combined
carotid and
function of the
vertebral arteries. optic (II) and
e) GCS is 5-6 oculomotor (III)
cranial nerves.
c) Changes in
blood pressure
compare BP c) Fluctuations in
readings in pressure may
both arms. occur because of
cerebral injury
in vasomotor
area of the
brain.
Hypotension
may occur
because of
shock
(circulatory
collapse).
Subclavian
artery blockage
may be revealed
Dependent by difference in
d) Mannitol 150 pressure
mL IV push Q 6 readings
by doctor’s between arms.
order.
d) To reduce
intraocular or
e) Citicoline IV Q i intracranial
gm 6hrs by pressure on
doctor’s oder cerebral edema.

44
 e) CVA in acute
and recovery
phase.

NURSING CARE PLAN

Table 9

NURSING
ASSESSMENT PLANNING
DIAGNOSIS
Objectives Risk for injury related After 8 hours of nursing Independent:
to loss of large or interventions, patient will a) Provide privacy.
Vital signs:
small muscle be able to:
f) T – 37.8 – 39.3 coordination
secondary to seizure  Attain or sustain
no injury during
seizure activity.
b) Keep padded side
 Will adhere with
safety measures
and identifies
hazards of non-
compliance.
 Will verbalize the
importance of
lifestyle changes
to reduce risk
factors and
protect self from
45
NURSING
RATIONALE EVALUATION
INTERVENTIONS
After 8 hours of
a) 'The patient who nursing
has an
interventions, goals
aura/warning of
were fully met as
impending seizure
may have time to evidenced by:
seek a safe,
private place.  The patient
sustained no
b) Minimizes injury
injury during
rails up with bed in should frequent
seizure activity.
lowest position. or generalized
 Adhered with
seizures occur
while client is on safety
bed helps localize measures.
the cerebral area
of involvement
and may be useful
in chronic
conditions in
helping patient
and significant
other prepare
 for or manage
c) Document pre seizure seizure activity.
activity, presence of
aura, or unusual c) Helps localize
behaviour, type of the cerebral
seizure activity, such area of
as location and involvement
duration of motor and may be
activity, and LOC, eye useful in
activity, respiratory chronic
impairment and conditions in
cyanosis, and helping patient
frequency of and significant
recurrence. other prepare
for or manage
d) No attempt should be seizure activity.
made to restrain the
patient during
seizure.
d) Muscular
contractions
are strong and
e) Stay with the client
restrain can
during and after produce injury.
seizure and perform
e) Promotes
neurological and vital
patient safety
signs check post
and reduces
seizure, weakness or
sense of
motor deficits, BP,
isolation during
RR&, PR.
the event.
46
 Document
postictal state 3
Collaborative: time and
Administered medications completeness
as ordered. of recovery to
normal state.
f) Mannitol 150 mL IV
push q6
f) To reduce
intraocular or
intracranial
pressure on
g) Valproic Acid 500mg
cerebral edema.
IVTT q12
g) Sole and
adjunctive
therapy in
simple and
complex
absence
seizures

47
 NURSING CARE PLAN
Table 9

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Objectives: Impaired Physical a) Establish a) To promote
Mobility r/t After 8 hours of rapport. cooperation. After 8 hours of
Body immobility neuromuscular nursing interventions, b) Monitor vital b) To have a nursing
involvement patient will be able to signs. baseline data. interventions, the
secondary to CVA improve and increase c) Note emotional/ c) To assess patient was able to:
infarct strength and function behavioral functional ability.
of affected body part. responses to  Improve
problems and
of immobility. d) To assess expected increased
d) Determine level strength
readiness to of participation. and
engage in e) To promote function of
activities. optimal level affected
e) Turning every 2 of function and body part.
hours. prevent
complications.

f) To prevent
occurrence
f) Provide for safety of injury.
measures
including fall
prevention. g) Limits fatigue,
maximizing
g) Identify energy participation.
conserving
technique.
h) Involve SO in
care assisting
them to learn

48
 ways
of managing
problems of
immobility.
i) Provide restful
environment for
patient.

49
 DISCHARGE PLAN

Name: Mama Date of Admission: February 19, 2020

Age: 86 years old Date of Discharge: February 26, 2020; expired
Religion: Islam

OBJECTIVES:

1. To give awareness to the client to religiously take the prescribed medications on time,

and to know its side effects and to follow the instructions given.

2. To have knowledge about the type of food to be eaten and avoided and to aim to have

well-balanced diet;

3. And to avoid unplanned readmission to the hospital by taking note of the instructions

given and following them religiously.

Discharge or Post-Mortem Procedures

Be Respectful

First of all, it should be noted that even though the patient has passed away, they should still be

treated with respect. This is especially true around family members and loved ones. This is

definitely not the time to stick with strictly "business" and not show any compassion and

understanding.

50
The family and loved ones may have customs that you are unfamiliar with. There are many

different cultures with different backgrounds and religious beliefs. They may mourn differently

or do things that seem strange to you.

Do not under any circumstances interrupt them during their practices. The only exceptions would

be if they are disturbing or causing harm to others.

Whenever the time seems right, ask them if they need anything. Make sure they know that you

are available if they do need anything and let them know that they can stay for as long as they

please.

Do not rush them out of the room so you can begin the physical part of the post-mortem care.

What's important right now is that the family is as comfortable as possible. After you are sure

that they have left and are completely done with their visit, you may begin.

Supplies Needed

For post-mortem care, you will need:

 A body bag

 3 name tags (usually included in the body bag)

 3 patient labels

 A fitted and flat sheet

 A hospital gown

 Supplies for a bed bath

Labels and Name Tags Placement

The 3 labels go on each of the three name tags

51
  One of the tags will go on the patient's big toe

 Another will tie the two zippers on the bag together

 The other one will go with the patient's remaining belongings

Post Mortem Care Step by Step

Have another caregiver assist you with this process.

1. If there is a sign that you are supposed to place outside of the door in the hallway, make

sure you do that first.

2. Close the door and pull the curtain.

3. Prepare the water for the bed bath.

4. Raise the bed up and flatten it out.

5. Remove all sheets, blankets, and the gown from the patient.

6. Remove any drains and tubes from them such as IVs and foley catheters, and heart

monitors. If you are unsure of whether something should be removed or this is beyond

your scope of practice, call the patient's nurse for assistance.

7. Dentures and glasses should go in a container and placed to the side. They should later be

placed inside the body bag with the patient.

8. Give the bed bath like you would if the patient was still alive. Just because they can't feel

anything doesn't mean you shouldn't be thorough or should be extra rough on them.

9. Some facilities require you to put a fresh hospital gown on them while others want them

to be placed in the body bag naked. Check your policy or ask your supervisor if you are

unsure which is preferred.

10. You should now tie one of the name tags onto the patient's big toe.

11. You will have to unfold the body bag and unzip it all of the way.

52
 12. Then roll up half of the bag longways.

13. One of you should then turn the patient on their side.

14. The other caregiver should then tuck the old linens underneath the patient and place the

clean fitted sheet on the mattress.

15. Tuck the fitted sheet under the patient as far as possible

16. Now tuck the rolled end of the bag underneath the patient. Make sure the bag is placed in

such a way so the patient will be able to fit. This means the bag should reach past their

head, all the way down past their feet.

17. Then turn the patient onto their other side and finish putting on the fitted sheet and unroll

the rest of the bag.

18. You should then be able to zip up the bag.

19. Don't forget to tie the two zippers together with another name tag.

20. Stretch the flat sheet over the bed completely covering the body bag. Out of respect, you

do not want visitors in the hallways to clearly see the person in a bag while they are taken

to the morgue.

21. Don't forget that dentures and glasses go in the body bag with the patient and the last

name tag should go with the patient's remaining belongings. Make sure the belongings

get to the patient's family.

22.

Rigor Mortis

If the patient has been dead for a few hours, a process called rigor mortis may have set in. This

means that they will be stiff and harder to move around. When this happens, it is still possible to

perform post-mortem care but it is better to take care of them beforehand.

53
If their mouth is wide open, you should gently close it and place a rolled-up towel underneath

their chin. Doing this will prevent their mouth from staying open after rigor mortis sets in.

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 REFERENCES

 Global Health Estimates. Geneva: World Health Organization (2012). Available from:

http://www.who.int/healthinfo/global burden disease/en/[cited 2016 June 1]

 Navvaro, et al. (2014). The real stroke burden in the Philippines.

 International Journal of Stroke.9. 10.1111/ijs.12287

 Hinkle & Cheever (2018). Medical-Surgical Nursing. 14 edition. Wolters Kluwer: New

York.

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