NCM 105

A Grand Case Presentation

Cereberovascular
Disease, Infarct,
Left Middle
Cerebral Artery
Submitted by:
 ACKNOWLEDGMENT

Our group would like to express our sincere gratitude to the persons who were

behind the success of this case presentation. First, we would like to thank our parents

who recognized our needs in financing the project; who have been supportive in terms

of their experience in the formulation of case studies; to the staff of J.R Borja General

Hospital- Medical Ward for providing a venue for clinical practice and sharing their

knowledge regarding our case; and especially to our clinicfal instructor Sir Jimmy

Boston, RN: who taught us a lot of things and inculcated in our minds the ideal boost for

nursing excellence; and most to our Almighty God who would let all things happen for a

cause—a cause that will make us realize the true value of Nursing practice.
 TABLE OF CONTENTS

I. Introduction

II. General Objectives

III. Specific Objectives

IV. Definition of Terms

V. Patient’s Profile

VI. Nursing Assessment

VII. Anatomy and Physiology

VIII. Pathophysiology

IX. Doctor’s Order

X. Laboratory Results and Diagnostic Tests

XI. Drug Study

XII. Nursing Care Plans

XIII. Discharge Plan

XIV. Prognosis

XV. Evaluation

XVI. References
 INTRODUCTION
Cerebrovascular disease is a group of brain dysfunctions related to disease of
blood vessels supplying the brain. Hypertension is the most important cause that
damages the blood vessel lining endothelium exposing the underlying collagen where
platelets aggregate to initiate a repairing process which is not always complete and
perfect. Sustained hypertension permanently changes the architecture of the blood
vessels making them narrow, stiff, deformed and uneven which are more vulnerable to
fluctuations of blood pressure. A fall in blood pressure during sleep can lead to marked
reduction in blood flow in the narrowed blood vessels causing ischemic stroke in the
morning whereas a sudden rise in blood pressure can cause tearing of the blood
vessels causing intracranial hemorrhage during excitation at daytime. Primarily people
who are elderly, diabetic, smoker, or have ischemic heart disease, have
cerebrovascular disease. All diseases related to artery dysfunction can be classified
under a disease as known as Macrovascular disease. This is a simplistic study by which
arteries are blocked by fatty deposits or by a blood clot. The results of cerebrovascular
disease can include a stroke, or even sometimes a hemorrhagic stroke. Ischemia or
other blood vessel dysfunctions can affect one during a cerebrovascular accident.

CVD is the most disabling of all neurologic diseases. Approximately 50% of

survivors have a residual neurologic deficit and greater than 25% require chronic care.
Cardiovascular disease mortality in the Philippines was studied from the existing vital
statistics for 2000-2008. Death rates from cerebrovascular diseases increased
enormously both in men and women. This increase in mortality was seen in all age
groups. The age-standardized mortality rate in men rose from 33.3 in 2000 to 78.0 in
2005, and that of women from 15.4 to 34.5. The male to female ratios in the age-
standardized death rates increased during this 9-year period. Age-standardized mortality
increased clearly in the male population but decreased in the female population of the
Philippines. This excess mortality in males is mostly due to the increased cardiovascular
disease death rate. This is a clear example of how chronic non-communicable diseases
are becoming major health problems in countries where they previously have not been
prevalent. Immediate preventive measures are needed in order to control cardiovascular
diseases in countries, such as ours, where disease rates are rapidly increasing.

We chose this case as the main subject of this presentation because we were
greatly alarmed with the sudden increase of the number of people having the said
disease. We want to find out what makes it such a horrifying disease. We also wanted
to come up with a thorough study so as to hasten and develop our critical thinking by
utilizing the different nursing theories and principles that we learned from our
discussion. It is then through this case presentation that we will be able to apply the
things we were taught to.
 GENERAL OBJECTIVES
At the end of the 1-hour case presentation, we will be able to develop our nursing

skills in presenting our subject matter; gain new knowledge and understanding about

our clients’ case; identify the proper care to be provided; enhance our positive attitude

and improve our confidence and self-esteem.

SPECIFIC OBJECTIVES
At the end of our 2-hour case presentation, under the different areas of learning

we will be able to:

SKILLS

• Properly explain the case of the patient

• Obtain and maintain the interest of the audience in paying attention to the report

• Manage time efficiently and present the case within the allotted time frame

KNOWLEDGE

• Relay accurate, consistent and reliable data in the report

• Gain knowledge on the case of the patient

• Compare the theoretical scheme of the illness to the actual case

ATTITUDE

• Promote cooperation between group member when presenting the case and

answering queries from the panel

• Instill integrity and discipline all throughout the presentation

 DEFINITION OF TERMS
Anaerobic metabolism - The creation of energy through the combustion of
carbohydrates in the absence of oxygen.

Atheroma - an accumulation and swelling (-oma) in artery walls that is made up of cells
(mostly macrophage cells), or cell debris, that contain lipids (cholesterol and fatty acids),
calcium and a variable amount of fibrous connective tissue.

Blood pressure - the pressure of the blood against the inner walls of the blood vessels,
varying in different parts of the body during different phases of contraction of the heart
and under different conditions of health, exertion, etc.

Cerebrovascular disease - is a group of brain dysfunctions related to disease of blood

vessels supplying the brain. Hypertension is the most important cause that damages the
blood vessel lining endothelium exposing the underlying collagen where platelets
aggregate to initiate a repairing process which is not always complete and perfect.

Deep tendon reflexes - A myotatic or deep reflex in which the muscle stretch receptors
are stimulated by percussing the tendon of a muscle.

Dysphagia – difficulty in swallowing

Embolus - a mass, such as an air bubble, a detached blood clot, or a foreign body, that
travels through the bloodstream and lodges so as to obstruct or occlude a blood vessel.

Gag reflex – a normal neural reflex elicited by touching the soft palate or posterior
pharynx; the responses are symmetric evaluation of the palate, retraction of the tongue,
and contraction of the pharyngeal muscle.

Hemorrhagic stroke - involves bleeding within the brain, damaging nearby brain tissue.

Hypertension - elevation of the blood pressure, esp. the diastolic pressure.

Hypoxia – inadequate oxygen tension at the cellular level, characterized by

tachycardia, hypertension, peripheral vascular constriction, dizziness, and mental
confusion.

Infarction - the act of stuffing or filling; an overloading and obstruction of any organ or
vessel of the body.

Ischemia - local deficiency of blood supply produced by vasoconstriction or local

obstacles to the arterial flow.

Metabolic acidosis - a pH imbalance in which the body has accumulated too much
acid and does not have enough bicarbonate to effectively neutralize the effects of the
acid.
Stroke - blockage or hemorrhage of a blood vessel leading to the brain, causing
inadequate oxygen supply and, depending on the extent and location of the
abnormality, such symptoms as weakness, paralysis of parts of the body, speech
difficulties, and, if severe, loss of consciousness or death.

Thrombus - a fibrinous clot that forms in and obstructs a blood vessel, or that forms in
one of the chambers of the heart
 PATIENT’S PROFILE
GENERAL INFORMATION:

Patient’s name: Mr. Strokeman

Address: Talisayan, Misamis Oriental
Birthday: June 4, 1949
Age: 60 years old
Sex: Male
Educational background: High school graduate
Nationality: Filipino
Religion: Roman Catholic
Marital status: Married
Usual occupation: Jeepney driver
Present occupation: Retired
Source of history: Wife
Reliability of historian: Good reliability
Chief Complaints: Admitted due to right sided weakness and slurred speech
Date Admitted: September 20, 2009, 6:30 PM
Diagnosis: Cerebrovascular disease, infarct, at left mid-cerebral artery; hypertensive
cardiovascular disease
Physician: Dr. Mananguete

HISTORY OF PRSENT ILLNESS:

12 hours prior to admission, patient rose from his bed when suddenly he fell on
the floor. He was observed to have right sided weakness with slurred speech, and was
immediately brought to Talisayan District Hospital. Other significant findings include BP
= 160/100 mmHg and positive deviation of nasolabial folds to the right. Patient was
given captopril 25 mg 1 tablet single dose and citicholine drops 1mL PO. For further
management, he was then referred to Northern Mindanao Medical Center, hence
admission.

Vital signs upon admission: BP=150/90 mmHg, T=36.5 C, P=60 bpm, R=20 cpm.
No vomiting, no headache, no change in sensorium noted.
 STAGES OF DEVELOPMENT

With regards to the data drawn together through the assessment, the patient is
classified under Erik Erickson’s Ego integrity vs. Despair on his Psychosocial Theory.
As articulated, this theory proposes eight developmental phases spanning infancy
through older adulthood. In each stage the person confronts, and hopefully masters,
new challenges. Each stage builds on the successful completion of earlier stages. The
challenges of stages not successfully completed may be expected to reappear as
problems in the future.

This stage tasks to developmentally review one’s life and derive meaning from
both positive and negative events, while achieving a positive sense of self. As the
person reaches maturity (55 years old – death) or become senior citizens, productivity
slows down, and explores life as a retired person. During this time, the individual
contemplate accomplishments and are able to develop integrity, if he sees himself living
a successful life. On one hand, seeing his life as unproductive, he then feels of guilt
about the past, dissatisfaction of life followed by the development of despair leading to
depression and hopelessness.

Based on the assessment conducted, we have come up with the idea that the
patient has developed integrity through verbalization of self-acceptance worth and
importance as a husband and as a father. He has been able to share wisdom and
guidance to his only daughter to become a responsible adult. Gladly accepts his
daughter and wife’s mates and friends and is very much proud with the fact that his has
able to send his daughter to college who is now about to have a degree in Nursing.
 NURSING ASSESSMENT
Clinical Inspection Clinical Inspection On-going Appraisal
Nursing History
Observation During Observation on First Observation on Others Sources/
Normal Patterns of
Assessment Day Day of Duty Second Day of Duty Laboratory Exam
Functioning
(September 21, (September 22, (September 24, Results
(Before Admission)
2009) 2009) 2009)

ACTIVITY/REST
• Retired 5 years ago as • Has limited range • Performs passive • Performs passive
a jeepney driver of motion on the range of motion on range of motion on
• Spends time reading, right side of the the affected the affected
watching television, and body extremities extremities
working in the yard • Always lies on bed • Lies in semi- • Lies in semi-
• Has no regular exercise • Actual hours slept: Fowlers position, Fowlers position,
routine about 9 hours and reads and listens to
• Visits friends or visited • Has decreased newspaper to music through his
by friends once in a energy level relieve boredom music player to
while • Actual hours slept: relieve boredom
• Had sufficient energy about 8 hours • Actual hours slept:
for all desired and about 10 hours
required activities • No signs of skin
• Sleeps about 10:00 PM breakdown over
each evening and rises bony prominences
about 6:30 AM; feel • Absence of
well-rested contractures and
• No sleeping difficulties foot drop.

CIRCULATION
• Known hypertensive • HR: 80 bpm • HR: 91 bpm • HR: 69 bpm Blood chemistry
 since May 2009 (average), with (average), (average), with Abnormal findings:
• No complaints of chest regular rhythm palpitations regular rhythm 9/21/09
pain, irregular • Normal pulse with reported • Normal pulse with Glucose: 161.1
heartbeats, and capillary refill time • Normal pulse with capillary refill time (increased)
palpitations, except of 1 sec capillary refill time of 1 sec 9/23/09
when blood pressure is • BP: 135/80 mmHg of 1 sec • BP: 140/90 mmHg Glucose: 155.3
very high (left arm, lying) • BP: 160/100 (left arm, lying) (increased)
• Doesn’t smoke • Skin warm and dry; mmHg (left arm, • Skin warm and
• Drinks alcoholic no edema noted; lying) dry; no edema
beverages occasionally with good skin • Skin warm and noted; with good
for the last 35 years turgor; with normal moist; no edema skin turgor; with
• Has family history of skin tone noted; with good normal skin tone
hypertension, stroke, • T: 36.6 skin turgor; with • T: 37.1
and heart disease normal skin tone
• Has brown skin tone • T: 37.4
and some diffused dark
brown patches of
pigmentation on both
upper and lower
extremities

EGO INTEGRITY
• A passive member of • Initially feels • Feeling of • Reports of gradual
the Roman Catholic depressed and depression and acceptance of his
Church helpless because helplessness was condition
• Has positive self- of his diagnosis somewhat relieved
concept; one reason is • He hopes to get because of the
that he was able to well soon, and his moral support
provide his family a family is given by his friends
good life supportive. and healthcare
• They have a stable • Prays to God providers
marriage although they
 have had some
problems over the years
• Has adjusted well to
retirement and had
expresses satisfaction
with this stage of life

ELIMINATION
• Usually no complaints • Wasn’t able to • Defecated once to • Defecated once to
in urinating and defecate for the a formed brown a formed brown
defecating whole day stool stool
• Normal bowel pattern is • Total urine output • Total urine output • Total urine output
1, soft formed stool for 24 hours: 1,150 for 24 hours: 1,450 for 24 hours: 1,360
everyday or every other mL mL mL
day • Yellow, aromatic • Yellow, aromatic • Yellow, aromatic
• Urinates 4-6 times a urine urine urine
day, light yellow in color • no complaints in • no complaints in • no complaints in
• Doesn’t use laxative or urinating urinating and urinating and
suppositories defecating defecating

FOOD/FLUID
• A good eater; eats 3x a • Has IVF of PNSS • Has IVF of • Has IVF of PNSS Special diet
day; enjoys all types of 1L regulated @ PNSS 1L 1L regulated @ (since 9-20-09)
food and a particular big 30gtts/min @ right regulated @ 20gtts/min @ right Low fat, low salt, soft
pork eater arm 30gtts/min @ right arm diet
• Loves to eat noodles • Actual food taken: arm • Actual food taken:
and bread soup and rice • Actual food soup and rice
• Weight is 62 kg and • Total fluid intake in taken: soup and • Total fluid intake in
height is 5’6” 24 hrs: 2050ml rice 24hrs: 2200ml
• Has some mastication • Consumed ¾ of • Total fluid • Consumed whole
problems due to his share with fair intake in 24hrs: of share with good
 upper and lower appetite 2100ml appetite
dentures • Pink palpebral • Consumed • Pink palpebral
conjunctiva, whole of share conjunctiva,
anicteric sclerae, with good appetite anicteric sclerae,
dry lips, moist • Pink palpebral moist lips, moist
tongue; no edema conjunctiva, tongue; no edema
anicteric sclerae, • No recent weight
moist lips, moist gain or loss
tongue; no edema

HYGIENE
• Had no limitations to • Requires • Requires • Requires
self-care assistance from assistance from assistance from
• Takes a bath once a another person and another person and another person
day, and uses shampoo equipment to equipment to and equipment to
& antibacterial soap perform bathing, perform bathing, perform bathing,
• Brushes dentures 1-2 toileting, and toileting, and toileting, and
times a day dressing dressing dressing
• Visits dentist once a • Has dry body, and • Was able to use of • Was able to
year unkempt his left unaffected perform self-care
appearance hand in cleaning activities within his
• Hair is dry, nails some parts of his level of own ability
are dirty body with clean • Hair and nails are
wet cloth and clean
combing his hair
• Hair and nails are
clean
 NEUROSENSORY
• No history of brain • LOC: conscious • LOC: conscious • LOC: conscious Neurologic Assessment
(9-20-09)
injury or trauma and alert and alert and alert
CN I: Not tested
• Slightly stooped • Oriented to person, • Oriented to place, • Oriented to place, CN II & III: 3/3 isocoric,
• No diagnosed hearing place, but person, but person, and time equally reactive to light
problem, although wife disoriented to time disoriented to time • Has appropriate CN III,IV,VI: Full
extraocular movements
believes Mr. Strokeman • Has appropriate • Has appropriate affect and mood
CN V: (+) Corneal reflex
may have slight hearing affect and mood affect and mood • Has intact taste CN VII: (+) facial
loss • Has intact taste • Has intact taste sensation asymmetry
• Worn eyeglasses sensation sensation • Pupil CN VIII: intact hearing
and equilibrium
(bifocals) for 20 years • Pupil size/reaction: • Pupil size/reaction: 3/3
CN IX & X: (+) Gag reflex
(farsighted) 3/3 isocoric, size/reaction: 3/3 isocoric, equally CN XI: (+) Shoulder lag
• No previous perceptual equally reactive isocoric, equally reactive CN XII: (+) tongue
problems noted • Has facial reactive • Has facial deviation
asymmetry, • Has facial asymmetry,
Muscle strength in
drooping right asymmetry, drooping right extremities:
eyelid drooping right eyelid • Right upper:1/5
• Left-sided eyelid • Left-sided • Left upper:5/5
weakness • Left-sided weakness
• Right lower:3/5
• No problem with weakness • No problem with
• Left lower:5/5
swallowing • No problem with swallowing Legend:
• Slurred speech swallowing • Slurred speech 5-full ROM against gravity
• Muscle strength in • Slurred speech • Muscle strength in and resistance
extremities: • Muscle strength in extremities: 3-full ROM against gravity
only
o Right upper:1/5 extremities: o Right upper:1/5 1- a weak muscle
o Left upper:5/5 o Right upper:1/5 o Left upper:5/5 contraction when muscle
o Right lower:3/5 o Left upper:5/5 o Right lower:3/5 is palpated, but no
o Right lower:3/5 movement
o Left lower:5/5 o Left lower:5/5
o Left lower:5/5 Deep Tendon Reflexes
 Legend:
+(Diminished)

CT Scan Result
(9-22-09)
Subacute
hemorrhage centered
in the left lentiform
nucleus with minimal
surrounding edema
(2mm) rightward
subfalcine herniation
and partial
effacement the left
lateral ventricle
PAIN/DISCOMFORT
• Usually doesn’t • No complaints of • No complaints of • No complaints of Chest X-Ray
experience pain in any pain pain pain (9/20/90)
part of his body except • Complaints of body • Complaints of body • Complaints of -mild cardiomegaly,
when he has a weakness weakness and body weakness left ventricular form
significantly high blood palpitations -atheromatous aorta
pressure

RESPIRATION
• Doesn’t smoke • Not in respiratory • Not in respiratory • Not in respiratory
• No history of COPD; distress; thorax distress; thorax distress; thorax
 tuberculosis; and other symmetric with symmetric with symmetric with
lung diseases equal expansion equal expansion equal expansion
• No family history of lung • RR=19 cpm • RR= 20 cpm, • RR= 16cpm,
diseases (average); regular bounding pattern normal pattern
• Did not complain of pattern • No cough; clear • No cough; clear
dyspnea at rest or on • No cough; clear breath sounds breath sounds
exertion breath sounds • Head of bed • Head of bed
• Head of bed elevated at semi- elevated at semi-
elevated at semi- fowler’s position fowler’s position
fowler’s position with 1 pillow with 1 pillow
with 1 pillow
SAFETY
• No known food & drug Has bedside rails • Has bedside • Has bedside
allergies His wife watches over rails rails
• Immunization history: him • His wife • His wife
cannot be recalled if watches over watches over
complete him him
• When he was 37 years • No • No
old, he had a vehicular unusualities unusualities
accident had bruises noted that will noted that will
but no permanent promote injury promote injury
damage developed,
• No surgical procedure
• No past major illness
SEXUALITY
• Has one daughter only • Feels quite
• Finds sex life uncomfortable
satisfactorily, but sexual with the subject
activity lessens due to matter
increasing age
• No history of STD’s or
reproductive tract
 problems
SOCIAL
INTERACTIONS
• Role within the family • Although he • Although he • His speech is
structure: head of the converses, his converses, his quite
family, housekeeper speech is unclear speech is unclear understandable
• Lives with his wife and due to slurring of • Few friends were although slurred
daughter, together with speech and able to visit, and because he
their maid, in a house absence of he feels happy wears his
thy have owned for 30 dentures • Communicates by dentures
years • Has impaired nodding, hand • Few relatives
• Has several friends articulation of gestures, and were able to visit
• Speech is clear and words, using short
understandable if incomprehensible sentences
dentures are worn words from the
patient, inability to
use facial or body
expressions
TEACHING/LEARNING
• Dominant language: • Follows treatment • Follows treatment • Follows
Filipinos (Cebuano) regimen regimen treatment
• High school • Listens carefully to regimen
graduate; literate health teachings • Reported that he
• Seeks doctor’s imparted is willing to have
consultation when
a healthy
having health
problems
lifestyle
• Takes prescribed
amlodipine as a
maintenance
antihypertensive
drug, but doesn’t
have a strict
medication
 compliance
• Nonprescription
drugs: paracetamol,
bigesic, neozep as
needed; doesn’t use
street drugs
ANATOMY AND PHYSIOLOGY OF THE BRAIN
There is nothing in the universe to compare with the human brain. This
mysterious three-pound squishy tissue controls all necessary functions of our physical
body, receives information from the outside world and makes it understandable, and
goes beyond that which is understandable to embody the essence of our mind and soul.
Intelligence, creativity, emotion, love, memories are but a few of the many things the
brain does. The weight of the brain changes from birth through adulthood. At birth, the
average brain weighs about one pound, and grows to about two pounds during
childhood. The average weight of an adult female brain is about 2.7 pounds, while the
brain of an adult male weighs about three pounds.

The brain receives information through our five senses: sight, smell, touch, taste,
and hearing - often many at one time. It puts together the messages in a way that has
meaning for us, and can store that information in our memory. Our brain controls our
thoughts, memory and speech, the movements of our arms and legs and the function of
many organs within our body. It also determines how we respond to stressful situations
(i.e., writing of an exam, loss of a job, illness) by regulating our heart and breathing
rate.

Nervous system

 CENTRAL NERVOUS SYSTEM (CNS) is composed of the brain and spinal cord
 PERIPHERAL NERVOUS SYSTEM (PNS) is composed of spinal nerves that branch from
the spinal cord and cranial nerves that branch from the brain. The PNS includes
the autonomic nervous system, which controls our vital internal functions such as
respiration, digestion, heart rate, and secretion of hormones.
Brain

The brain is composed of the cerebrum, cerebellum, and brainstem

The brain is composed of three parts: the brainstem, cerebellum, and cerebrum.
The cerebrum is divided into four lobes: frontal, parietal, temporal, and occipital.

A. Brainstem - includes the midbrain, pons, and medulla. It acts as a relay center
connecting the cerebrum and cerebellum to the spinal cord. It performs many
automatic functions such as breathing, heart rate, body temperature, wake and
sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing. Ten of the
twelve cranial nerves originate in the brainstem. The brainstem is the lower
extension of the brain, located in front of the cerebellum and connected to the
spinal cord. It consists of three structures: the midbrain, pons and medulla
oblongata. It serves as a relay station, passing messages back and forth
between various parts of the body and the cerebral cortex. Many simple or
primitive functions that are essential for survival are located here.

1. Midbrain - is an important center for ocular motion

2. Pons - is involved with coordinating eye and facial movements, facial sensation,
hearing and balance.
3. Medulla oblongata - controls breathing, blood pressure, heart rhythms and
swallowing. Messages from the cortex to the spinal cord and nerves that branch
from the spinal cord are sent through the pons and the brainstem. Destruction of
these regions of the brain will cause "brain death." Without these key functions,
humans cannot survive.

The reticular activating system is found in the midbrain, pons, medulla and part of
the thalamus. It controls levels of wakefulness, enables people to pay attention to their
environments, and is involved in sleep patterns. Originating in the brainstem are 10 of
the 12 cranial nerves that control hearing, eye movement, facial sensations, taste,
swallowing and movements of the face, neck, shoulder and tongue muscles. The cranial
nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves
originate from the pons: nerves 5 through 8.

B. Cerebrum - the largest part of the brain and is composed of right and left
hemispheres. It is separated from the cerebrum by the tentorium (fold of dura).
The cerebrum, which forms the major portion of the brain, is divided into two
major parts: the right and left cerebral hemispheres. The cerebrum is a term
often used to describe the entire brain. A fissure or groove that separates the two
hemispheres is called the great longitudinal fissure. The two sides of the brain
are joined at the bottom by the corpus callosum. The corpus callosum connects
the two halves of the brain and delivers messages from one half of the brain to
the other. The surface of the cerebrum contains billions of neurons and glia that
together form the cerebral cortex

C. Cerebellum - located under the cerebrum. Its function is to coordinate muscle

movements, maintain posture, and balance. The cerebellum fine tunes motor
activity or movement, e.g. the fine movements of fingers as they perform surgery
or paint a picture. It helps one maintain posture, sense of balance or equilibrium,
by controlling the tone of muscles and the position of limbs. The cerebellum is
important in one's ability to perform rapid and repetitive actions such as playing a
video game. It performs higher functions like interpreting touch, vision and
hearing, as well as speech, reasoning, emotions, learning, and fine control of
movement.

The cerebral cortex appears grayish brown in color and is called the "gray
matter." The surface of the brain appears wrinkled. The cerebral cortex has sulci (small
grooves), fissures (larger grooves) and bulges between the grooves called gyri.
Beneath the cerebral cortex or surface of the brain, connecting fibers between neurons
form a white-colored area called the "white matter."
 The cerebral hemispheres have several distinct fissures. By locating these
landmarks on the surface of the brain, it can effectively be divided into pairs of "lobes."
Lobes are simply broad regions of the brain. The cerebrum or brain can be divided into
pairs of frontal, temporal, parietal and occipital lobes. Each hemisphere has a
frontal, temporal, parietal and occipital lobe. Each lobe may be divided, once again, into
areas that serve very specific functions. The lobes of the brain do not function alone –
they function through very complex relationships with one another.

Lobes of the brain

Frontal lobe

• Personality, behavior, emotions

• Judgment, planning, problem solving
• Speech: speaking and writing (Broca’s area)
• Body movement (motor strip)
• Intelligence, concentration, self awareness

Parietal lobe

• Interprets language, words

• Sense of touch, pain, temperature (sensory strip)
• Interprets signals from vision, hearing, motor, sensory and memory
• Spatial and visual perception

Occipital lobe

• Interprets vision (color, light, movement)

Temporal lobe

• Understanding language (Wernicke’s area)

• Memory
• Hearing
• Sequencing and organization

Messages within the brain are delivered in many ways. The signals are
transported along routes called pathways. Any destruction of brain tissue by a tumor
can disrupt the communication between different parts of the brain. The result will be a
loss of function such as speech, the ability to read, or the ability to follow simple spoken
commands. Messages can travel from one bulge on the brain to another (gyri to gyri),
from one lobe to another, from one side of the brain to the other, from one lobe of the
brain to structures that are found deep in the brain, e.g. thalamus, or from the deep
structures of the brain to another region in the central nervous system.
Deep structures

Hypothalamus - The hypothalamus is located in the floor of the third ventricle and is
the master control of the autonomic system. It plays a role in controlling behaviors such
as hunger, thirst, sleep, and sexual response. It also regulates body temperature, blood
pressure, emotions, and secretion of hormones.

Thalamus - The thalamus serves as a relay station for almost all information that
comes and goes to the cortex. It plays a role in pain sensation, attention, alertness and
memory.

Basal ganglia - The basal ganglia include the caudate, putamen and globus pallidus.
These nuclei work with the cerebellum to coordinate fine motions, such as fingertip
movements.

Limbic system - The limbic system is the center of our emotions, learning, and
memory. Included in this system are the cingulate gyri, hypothalamus, amygdala
(emotional reactions) and hippocampus (memory).
Cranial nerves

The brain communicates with the body through the spinal cord and twelve pairs
of cranial nerves ten of the twelve pairs of cranial nerves that control hearing, eye
movement, facial sensations, taste, swallowing and movement of the face, neck,
shoulder and tongue muscles originate in the brainstem. The cranial nerves for smell
and vision originate in the cerebrum.

Number Name Function

I Olfactory Smell
II Optic sight
III Oculomotor moves eye, pupil
IV Trochlear moves eye
V Trigeminal face sensation
VI Abducens moves eye
VII Facial moves face, salivate
VIII Vestibulocochlear hearing, balance
IX Glossopharyngeal taste, swallow
X Vagus heart rate, digestion
XI Accessory moves head
XII Hypoglossal moves tongue
Blood supply

Blood is carried to the brain by two paired arteries, the internal carotid arteries
and the vertebral arteries. The internal carotid arteries supply most of the cerebrum.
The vertebral arteries supply the cerebellum, brainstem, and the underside of the
cerebrum. After passing through the skull, the two vertebral arteries join together to form
a single basilar artery. The basilar artery and the internal carotid arteries “communicate”
with each other at the base of the brain called the Circle of Willis. The communication
between the internal carotid and vertebral-basilar systems is an important safety feature
of the brain. If one of the major vessels becomes blocked, it is possible for collateral
blood flow to come across the Circle of Willis and prevent brain damage.

The Circle of Willis

 The Circle of Willis or the Circulus Arteriosus is an arterial polygon where the
blood carried by the two internal carotid arteries and the basilar system comes together
and then is redistributed by the anterior, middle, and posterior cerebral arteries. The
posterior cerebral artery is connected to the internal carotid artery by the posterior
communicating artery.

Internal Carotid System

The internal carotid artery divides into two main branches called the middle
cerebral artery and the anterior cerebral artery. The middle cerebral artery supplies
blood to the frontoparietal somatosensory cortex. The anterior cerebral artery supplies
blood to the frontal lobes and medial aspects of the parietal and occipital lobes. Before
this divide, the internal carotid artery gives rise to the anterior communicating artery and
the posterior communicating artery.

Vertebral Artery
The two vertebral arteries run along the medulla and fuse at the pontomedullary
junction to form the midline basilar artery, also called the vertebro-basilar artery. Before
forming the basilar artery, each vertebral artery gives rise to the posterior spinal artery,
the anterior spinal artery, the posterior inferior cerebellar artery (PICA) and branches to
the medulla.

Basilar Artery
At the ponto-midbrain junction, the basilar artery divides into the two posterior
cerebral arteries. Before this divide, it gives rise to numerous paramedian, short and
long circumferential penetrators and two other branches known as the anterior inferior
cerebellar artery and the superior cerebellar artery.
 PATHOPHYSIOLOGY
RISK FACTORS: PRECIPITATING
Age: 60 yrs. old FACTORS:
Gender: male Alcohol Drinking
Genetics: has family Diet: High Fat/Cholesterol
history of stroke and diet
hypertension Hypertension
Sedentary Lifestyle

Lipid deposits and

turbulent blood flow in
intima of arterial
cerebral wall

Inflammatory response Fever

Ingestion of Lipids

Atheroma Formation
Hypertension
Narrowing of arterial
lumen

Plaque ruptures

Thrombosis

Occlusion of cerebral artery

Lysed or moved thrombus from the vessel

Vascular wall becomes weakened or fragile

Leaking of blood from the fragile vessel wall

Cerebral hemorrhage Legend:

Bold – applicable
Mass of blood forms and proliferates to patient

Vasospasm of tissue and arteries - - - - signs and

symptoms
Cerebral hypoperfusion - flow of
disease
Impaired distribution of process
oxygen and glucose
 Tissue hypoxia and
cellular starvation

Cerebral ischemia

Initiation of ischemic
cascade

Anaerobic metabolism by Production of oxygen-

mitochondria free radicals and other
reactive oxygen species

Generates large Failure of production

amounts of lactic acid of ATP

Metabolic Acidosis Failure of energy

dependent process
(ion pumping) Damage to the blood
vessel endothelium
Release of excitatory
neurotransmitter
glutamate

Anaerobic metabolism
by mitochondria

Activates enzymes that Failure of

digest cell proteins, lipids mitochondria
and nuclear material
Further energy
depletion

Brain sustains an irreversible

damage

Release of metalloprotease (zinc and

calcium-dependent enzymes)

Break down of collagen, hyaluronic acid

and other elements of connective tissue

Structural integrity loss of brain

tissue and blood vessels

Breakdown of the protective

Blood Brain Barrier
 Cerebral edema

Vascular Congestion

Compression of tissue

Increased intracranial
Pressure Sx:
• Numbness or
Impaired perfusion and weakness of the
function face, arm, leg,
esp. on one side
of the body
• Confusion or
Middle Cerebral Artery change in
mental status
• Memory deficits
Lateral hemisphere, frontal, • Trouble
parietal and temporal lobes, speaking or
basal ganglia understanding
speech
(dysphasia,
dysarthia,
If managed (long-term With ineffective or without apraxia)
medical and nursing medical and nursing • Sensory loss
intervention): interventions • Visual
disturbances
Partial or total recovery in Continued insufficiency of • Drooping of
any of the following: blood flow eyelids
• Understanding and • Difficulty walking,
forming speech dizziness
• Cognitive loss Further compression of • Sudden severe
• Mobility of extremities tissues headache
and facial muscles
• Mental status Coma

Cerebral Death

Loss of neural feedback

mechanisms

Cessation of physiologic
functions
 Cardiovascular Pulmonary GIT GUT Other systems
System System

Relaxation
Loss of cardiac Relaxation of Sx: restlessness,
of intestines
muscle venous abnormal
and
function valves thermoregulation,
sphincters
mental confusion,
increased
Sx: Sx: Loss of secretions,
bradycardia hypotension bowel decreased urinary
control output.

Decreased Failure of Loss of lung

cardiac output accessory movement
muscles for Neurogenic Loss of
breathing bladder sphincter
function control

Sx:
Apnea

Cardiopulmonary arrest

Systemic Failure

Death
 DOCTOR’S ORDER
DATE TIME ORDER
Septembe 6:30pm • Please admit at P1F2 (Male Pay
r 20, 2009 Ward)
• PWI: Cardiovascular disease,
infarct, Left Mid Cerebral Artery
• Diet: Low fat, low salt, soft
• Change IVF to PNSS 1L @30
gtts/min IVFTF
PNSS 1L @ 30 gtts/min
• Nursing:
Monitor v/s q2º and chart. Refer if
BP > 160/90 mmHg or <90/60
mmHg
HR > 100 bpm or < 60 bpm
RR > 24 cpm or or < 12 cpm
Monitor SPERM q4º and chart
Monitor I & O qshiftº and chart
Monitor for change in sensorium,
determination of any neurologic
deficits, chest pain, SOB, and
other unusualities
• Diagnostics:
CBC
RATIONALE
• For immediate medical
attention
• Basis for medical and
nursing
• Ideal for clients have
cardiovascular disease
and mastication
problems
• For continued
surveillance of the
condition of the patient
• To provide an
assessment level of
consciousness of the
patient
• To provide physician
view of the abnormal and
normal function of the
urinary organ as well as
the ambulation of the
patient
• To monitor a decrease in
the function of the brain
and/or nerves and
provide baseline data for
additional treatment

UA • To determine presence
of inflammatory process
Chest X-Ray PA View • Determines functionality
of kidneys
• To evaluate the lungs for
the presence of
Serum Na, K, BUN, Crea
abnormalities and also
the condition and size of
12 lead ECG
the heart
• To determine the
presence of damage in
 CT Scan of the Brain, Plain cardiac cells
• To identify
cardiovascular
• Therapeutics: involvement
Citicoline 1gm IVTT now then • To provide view and
q12º detect possible
Imidapril 10mg 1tab now then OD hematomas and reduce
PO the need for more
Simvastatin 80mg 1tab now then invasive procedures
OD at 8pm PO
Captopril 25mg 1tab SL q6º and
PRN for BP > 140
• Refer accordingly
• Thank you!
Septembe 6:00am • Start Aspirin 80mg tab PC lunch
r 21, 2009 OD PO
Senna concentrate 2tabs @
HS
Omeprazole 20mg 1cap OD
PO
• Turn patient side to side • Prevents muscle atrophy
and bedsores
• Refer to Rehab Medicine • Indicated for restoration
of neurologic function
• For follow-up CT Scan of the • To provide view and
brain, plain detect possible
hematomas and reduce
the need for more
invasive procedures
• IVFTF with PNSS 1L @
20gtts/min
Septembe 11:00 • D/C aspirin • Confirmation of
r 22, 2009 am • Continue other medications hemorrhagic stroke
• IVFTF with PNSS 1L @ through CT scan
20gtts/min
• Follow-up referral to Rehab
Medicine
• Start mannitol 20% 75cc q6º
Tranexamic acid 1gm IVTT
q8º
• Decrease simvastatin to 20mg
1tab OD @ HS
 LABORATORY RESULTS AND DIAGNOSTIC
TESTS
BLOOD CHEMISTRY

Sept. 21, Interpretation Reference values

2009
Potassium 4 Normal 3.5-5.3 mmol/L
Sodium 145 Normal 134-149 mmol/L
Creatinine 1.13 Normal 0.59-1.21 mg/dL
Blood Urea 22.2 Normal 4.6-23.4 mgs %
Nitrogen
Glucose 161.1 Increased 59.9-110.1 mg/dL

Sept. 23, Interpretation Reference values

2009
Potassium 3.6 Normal 3.5-5.3 mmol/L
Sodium 141.9 Normal 134-149 mmol/L
Creatinine 0.82 Normal 0.59-1.21 mg/dL
Blood Urea 20.63 Normal 4.6-23.4 mgs %
Nitrogen
Glucose 155.3 Increased 59.9-110.1 mg/dL

CT SCAN RESULT (BRAIN, PLAIN)

September 22, 2009

Impression:
Subacute hemorrhage centered in the left lentiform nucleus with minimal
surrounding edema (2mm) rightward subfalcine herniation and partial effacement
the left lateral ventricle

CHEST X-RAY (POSTERIOR-ANTERIOR VIEW)

September 20, 2009

Impression:
-Suspicious right apical infiltrates; suggest apicolordotic view
-Mild cardiomegaly, left ventricular form
-Atheromatous aorta
 DRUG STUDY
Dose/
Classifi Therapeutic Route/ Contraindication Nursing
Drug Name Indication(s) Adverse effects
cation action and caution considerations
Timing

Omeprazole proton like other 20 mg prevention of upper Malignant • Headache • Take the drug
pump proton-pump gastrointestinal neoplasm of • Dizziness befor meals.
inhibitor inhibitors, 1 cap bleeding in critically ill stomach • Dry cough Swallow whole
(PPI) blocks the patients capsule. Do not
Adverse • Dry mouth
enzyme in the OD chew, open, or
wall of the
reaction to • Fatigue
proton pump • Disturbances of the crush them.
stomach that PO
produces acid. inhibitors gut such as dia
-rrhoea,constipation, • Instruct to take
By blocking the Omeprazole 30
enzyme, the nausea, vomiting,
indigestion or minutes apart
production of from Atacids
acid is abdominal pain
• Pain in the muscles because of
decreased possible
or joints
antagonistic
• Chest pain (angina).
interactions
• Pins and needles
sensations
• Tell the patient
(paraesthesia)
that he may
• Feeling of experience the
weakness (asthenia) said side effects
• Low blood pressure
(hypotension)
 DRUG STUDY
Dose/
Classifica Therapeutic Contraindication Adverse
Drug Name Route/ Indication(s) Nursing considerations
tion action and caution effects
Timing

Senna Stimulant Precise 40 mg Constipa- • Intestinal • CNS: • Ensure adequate

concentrate laxative mechanism of 2 tabs tion to obstruction Faintness hydration.
action not at HS prevent • Abdominal pain, • GI: • Offer support and
Brand Name known. More (8PM) straining nausea, Abdominal encouragement to deal
recent PO at defecating vomiting, or discomfort, with GI discomforts.
Senokot evidence To prevent ↑ other nausea • Administer 2 hours
shows that ICP symptomsof before or 2 hours after
• Other: Mild
stimulant appendicitis or taking other
cramps,
laxatives alter undiagnosed medications.
griping,
fluid and abdominal pain. • Advise the patient not to
laxative
electrolyte • Diabetes use laxative products for
dependence
absorption, mellitus a period longer than 1
, electrolyte
producing net week unless directed by
disturbances
intestinal fluid a clinician.
accumulation • Advise patients of a
and laxation. potential discoloration in
urine.
 DRUG STUDY
Dose/
Drug Classifica Therapeutic Contraindication Nursing
Route/Ti Indication(s) Adverse effects
Name tion action and caution considerations
ming

Ace prevents the 10 mg Hypertension Aortic stenosis or • Dizziness, • Take the drug with
inhibitor conversion of outflow tract • headache, food or after meals
Imidapril angiotensin I 1 tab Essential obstruction; • fatigue, if GI upset occurs.
to hypertension • GI and taste • Assess renal
renovascular
angiotension OD Poor disturbances, function before and
disease; ascites.
II by hypertension • persistent dry during therapy
inhibiting control cough • Tell the patient that
ACE. Peripheral vascular
diseases, • skin rash, he may experience
generalised • angioedema, the said side effects
Limits
atherosclerosis, • hyperkalaemia,
Brand chronic
idiopathic or • hyponatraemia,
Name: ischemic
hereditary • blood disorders,
injury
angioedema, heart • proteinuria,
failure, patients • chest pain
likely to be salt or • palpitations,
Tinatril water depleted.
• tachycardia,
• alopecia,
• musclecramps,
• paraesthesias,
• mood and sleep
disturbances,

• impotence.
 DRUG STUDY
Dose/ Contraindic
Drug Classifi
Therapeutic action Route/ Indication(s) ation and Adverse effects Nursing considerations
Name cation
Timing caution

Captopril ACE Blocks ACE from 25 mg hyperten- • Contraindic • CV: Tachycardia, angina • Administer 1 hr before
inhibitor converting 1 tab sion ated with pectoris, MI, Raynaud's or 2 hr after meals.
Antihype angiotensin I to every 6 allergy to syndrome, CHF, • Monitor patient’s blood
Brand rtensive angiotensin II, a hours captopril, hypotension in salt- or pressure and pulse
Name powerful and history of volume-depleted patients rate frequently.
vasoconstrictor, PRN for angiodema • Dermatologic: Rash, • Monitor patient closely
Capoten leading to BP pruritus, scalded mouth for fall in BP secondary
decreased BP, >140/90 • Use sensation, exfoliative to reduction in fluid
decreased cautiously dermatitis, alopecia, volume (due to
aldosterone with photosensitivity excessive perspiration
secretion, a small impaired and dehydration,
• GI: Gastric irritation,
increase in serum renal vomiting, diarrhea);
aphthous ulcers, peptic
potassium levels, function; excessive hypotension
ulcers, dysgeusia,
and sodium and CHF; salt may occur.
cholestatic jaundice,
fluid loss; increased or volume • Report mouth sores;
hepatocellular injury,
prostaglandin depletion sore throat, fever,
anorexia, constipation
synthesis also may chills; swelling of the
be involved in the • GU: Proteinuria, renal
insufficiency, renal failure, hands, feet; irregular
antihypertensive heartbeat, chest pains;
action. polyuria, oliguria, urinary
frequency swelling of the face,
eyes, lips, tongue,
• Hematologic:
difficulty breathing.
Neutropenia,
agranulocytosis,
thrombocytopenia,
hemolytic anemia,
pancytopenia
• Other: Cough, malaise,
dry mouth,
lymphadenopathy
 DRUG STUDY
Dose/
Drug Therapeutic Indication( Contraindication Nursing
Classification Route/ Adverse effects
Name action s) and caution considerations
Timing

Citicoline Nootropics Activates the 500 mg Cerebrovas- • Hypersensitiv • Transient • May be

biosynthesis of 1 cap cular e to drug headaches administered with
Neurotonics structural BID disorders • Hypertonia of • Stomach pain or without food.
phospholipids in PO the • Diarrhea (Take w/ or
Brand the neuronal parasympathe • Hypotension between meals.)
Name membrane, tic • Tachycardia • Inform the patient
increases that she may
• Bradycardia
Somazine cerebral experience the
metabolism and said side effects
increases the • It must not be
level of various administered in
neurotransmitter conjunction with
s, including medicaments
acetylcholine containing
and dopamine. meclofenoxate
(also known as
clophenoxate).
 DRUG STUDY
Dose/
Drug Classifica Therapeutic Contraindication Adverse
Route/ Indication(s) Nursing considerations
Name tion action and caution effects
Timing
simvast
a-tin HMG-CoA Inhibits 20 mg To reduce risk • Contraindicate • Headache • Ensure that patient has
reductase HMG-CoA 1 tab of CV events, d in patients • Flatulence tried a cholesterol-
Brand inhibitor reductase, OD including hypersensitive • Diarrhea lowering diet regimen for
Name an early (and At HS stroke, TIA to drug and in • Abdominal 3-6 months. Before
Antihyper- rate-limiting) (8PM) those with pain beginning therapy.
Zocor lipidemic step in PO active liver • Cramps • Obtain liver function test
cholesterol disease or result at start of therapy
• Constipa-tion
biosynthesis. condition that and then periodically.
• Nausea
causes • Give in the evening
unexplained • Inform the patient that
persistent she may experience the
eleva-tions of said side effects.
transami-nase • Report severe GI upset,
levels. changes in vision,
unusual bleeding or
bruising, dark urine or
light-colored stools, fever,
muscle pain, or soreness
 DRUG STUDY
Dose/
Drug Classifica Therapeutic Contraindicati
Route/ Indication(s) Adverse effects Nursing considerations
Name tion action on and caution
Timing

Mannitol Osmotic Increase the 20% • Cerebral Hypersensitivity Confusion,

diuretic osmotic 75 cc edema ; anuria, headache, • Observe infusion site
agent pressure of Every 6 • To prevent dehydration; & blurred vision, frequency for
the hours ↑Intracranial active rhinitis, transient infiltration;
glomerular Pressure intracranial volume. extravasation may
filtrate bleeding. Expansion, chest cause tissue irritation
thereby pain, CNF, and necrosis
inhibiting pulmonary edema • Do not administer
reabsorption tachycardia, electrolyte-free
of H2Oand nausea, thirst, mannitol solution with
electrolytes vomiting, renal blood; if food must be
and causes failure, urinary administered
excretion of retention, spontaneously with
water, dehydration, mannitol; and at least
sodium, hyperkolena, 20 mEq NaCl to each
potassium, hypernatremia, liter of mannitol
chloride hypokalemia, • IV: Administer by IV
calium, hyponatremia. infusion undiluted; if
phosphorus, solution contains
magnesium, crystals warm bottle 1
urea, and hot H2o & share
uric acid. vigorously; do not
administer solution in
w/c crystals remain
undissolved; cool to
body temperature; use
an in-line filter for 15%,
20% and
25% infusions.
 DRUG STUDY
Dose/
Drug Classifica Therapeutic Contraindicati
Route/ Indication(s) Adverse effects Nursing considerations
Name tion action on and caution
Timing

Tranexa Fibrinolytic Forms a 1 gm • Acquired • Diarrhea, • Tell the patient that he

mic acid Inhibitor reversible IVTT • Treatment of Chromatopsia • Nausea, may experience the
complex Every 8 excessive • Vomiting said side effects
Brand that hours bleeding • Blurred Vision, • Report any signs of
name displaces resulting • Subarachnoid bleeding or myopathy,
• Hypotension,
plasminoge from Hemorrhage vision changes; GI
• Local
Cyklokap n from fibrin systemic or upset usually
local infiltration
ron resulting in disappears when dose
inhibition of hyperfibrinoly is reduced
fibrinolysis; sis
it also
inhibits the
proteolytic
activity of
plasmin
 NURSING CARE PLAN #1
Nursing Outcome
Cues Nursing Interventions Rationale Evaluation
Diagnosis Identification

Objective Cues: Ineffective Short Term Independent: Goal met.

Cerebral Goal After 8 hours of
• Slurred Tissue • Monitor vital signs • Fluctuations in nursing
speech Perfusion At the end of 8 noting hypertension pressure may intervention, the
• Right-sided related to hours of nursing and hypotension. occur because of patient was able
weakness alteration interventions, cerebral pressure to maintain
noted of the patient will in the vasomotor usual level of
• Disorientation Cerebral be able to area of the brain consciousness,
to time noted arterial maintain usual cognition and
• Loss of ability blood flow level of • Monitor • Assesses motor and
to perform consciousness, neurological status trends in level of sensory function
purposeful cognition, and frequently and consciousness as evidenced by
movements motor and compare with and potential for the absence of
sensory baseline; Glasgow increased ICP further
function. Coma Scale. and is useful in deterioration of
determining neurologic
location, extent, status.
and progression
of CNS damage.

• Assess for • This might be a

restlessness and sign of hypoxia
irritability
• Promotes
• Elevate HOB and circulation/venou
maintain head/neck s drainage
in midline or neutral
 position

• Maintain bed rest; • Continual

provide quiet stimulation can
environment, limit increase
visitors and intracranial
activities as pressure.
indicated. Absolute rest and
quite may be
• Provide rest periods needed to
between care prevent
activities, limit rebleeding in the
duration of case of
procedures. hemorrhage.

• Review specific • To prevent

dietary exacerbation of
changes/restrictions symptoms and
constipation
with client
emphasizing
decreased sodium
and fat and
increased fluids and
fiber.

Collaborative: • Blocks
Angiotensin
Administer medications converting
as indicated: enzyme thereby
• Neuroprotective reducing blood
agents pressure and
• Imidapril – 10 mg limiting ischemic
1tab OD injury.
 NURSING CARE PLAN #2
Nursing Outcome Nursing
Cues Rationale Evaluation
Diagnosis Identification Interventions

Subjective Cue: Impaired Short Term Goal Independent: Goal met.

physical After 8 hours of
“ Maglisud sya ug Mobility At the end of 8 • Assess • Identifies nursing
lihuk ug sya ra usa“ related to hours of nursing functional ability strengths or interventions,
as verbalized by the neuromus interventions, the or extent of deficiencies and the patient was
Patient’s wife. cular patient will be impairment may provide able to maintain
involveme able to maintain initially information optimal position
Objective Cues: nt optimal position regarding recovery of function as
• Limited range secondary of functions as • Observe affected evidenced by
of motion on to evidenced by side for color, • Edematous absence of
the right underlyin absence of edema or other tissue is more contractures and
affected g contractures and signs of easily traumatized foot drop.
extremities pathologic foot drop. compromised and heals more
• Loss of ability process circulation slowly
to execute
purposeful • Begin passive
motor act on range of motion
both upper exercise to right
and lower • Minimizes
affected
right muscle atrophy,
extremities
extremities promotes
circulation and
• Right -sided • Prop extremities
helps prevent
weakness in functional
contractures
noted position: use of
• Unequal hand foot board during
• Prevent
grasp noted the period of
contractures or foot
flaccid paralysis
drop and facilitates
 and maintain use when or if
neutral position function returns
of head.

• Reposition or
turn the client to
sides every two
hours • Prevents
development of
pressure ulcer,
muscle strain, and
superficial nerve
• Provide client and blood vessel
with ample time damage
to perform
mobility-related • Enhances self-
tasks. concept and sense
of independence
• Encourage
adequate intake
of
fluids/nutritious • Promotes well-
foods. being and
maximizes energy
• Involve client production
and wife in care,
assisting them to
learn ways of • Enhances
managing commitment to
problems of plan, optimizing
immobility. outcome
 NURSING CARE PLAN #3
Outcome Nursing
Cues Nursing Diagnosis Rationale Evaluation
Identification Interventions

Subjective Cue: Impaired verbal Short Term Independent: Goal met.

communication Goal After 4 hours of
“Dili kayo me makasabot related to • Assess type/ • Helps nursing
sa iya ginasulti”, as hemorrhagic changes At the end degree of determine area interventions,
verbalized by the wife of in the brain affecting of 4 hours of dysfunction like and degree of the patient was
the patient. communication nursing when the patient brain able to establish
centers interventions, has trouble involvement method of
Objective Cues: the patient will speaking or and difficulty communication
• Impaired articulation of be able to making self client has with in which needs
words establish understood any steps or all can be
• Incomprehensible method of steps of expressed
words from the patient communication communication appropriately.
• Inability to use facial or in which needs process
body expressions can be
expressed • Assist with • Enhances
appropriately necessary sense of
adaptations to independence
accomplish
ADLs. Begin
with familiar,
easily
accomplished
tasks

• Ask client to • Provides for

follow simple communicatio
commands such n needs/
 as nodding for a desires based
yes and repeat on individual
simple words/ situation/
sentences and underlying
pointing to deficit.
objects that he
may need

• Provide privacy • Helpful in

and equipment decreasing
within easy frustration
reach during when
personal care dependent on
activities. Allow others and
sufficient time unable to
for client to communicate
accomplish desires
tasks to fullest
extent of ability.

• Provide • Reduces
alternative confusion/
methods of anxiety at
communication having to
such as writing process and
boards. Provide respond to
visual clues large amount
(gestures and of information
pictures) at one time,
advancing
complexity of
communicatio
n stimulates
 memory and
enhances
word
association

• Anticipate and • Client is not

provide for necessarily
client’s needs. hearing

• Talk directly to
• impaired
the client,
and raising
speaking slowly
voice may
and distinctly.
irritate the
Use only yes or
client
no questions in
asking the client
then
progressing in
complex
questions

• Encourage wife
or visitors to • This
persist in efforts reduces
to communicate client’s
with client isolation,
promote
Collaborative: establishment
of effective
communicatio
• Consult with or n
refer to speech
therapist • Assesses
individual
verbal
capabilities
and sensory,
motor and
cognitive
functioning to
identify
therapy needs
 NURSING CARE PLAN #4
Cues Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation
Subjective
Cue: Self-Care Deficit Short Term Goal Independent: Goal met.
regarding After 8 hours of
“ Kinahanglan bathing/hygiene, At the end of 8 hours of • Assess abilities and • Aims in nursing
pa sya dressing/grooming nursing interventions, the level of deficit (0-4 participating interventions, the
tabangan and toileting patient will be able to scale) 3-performing or planning patient was able
kung maligo“ related to perform self-care activities ADL’s related to for meeting to perform self-
as verbalized neuromuscular within level of patient’s own bathing, dressing individual care activities
by the impairment and ability and toileting. needs within his level of
Patient’s wife. weakness own ability as
• Assist with • Encourage evidenced by the
Objective necessary s client and use of his left
Cues: adaptations to builds on unaffected hand
• Inability to accomplish ADLs. successes in cleaning some
wash Begin with familiar, parts of his body
body; dry easily with clean wet
body accomplished cloth and
• Inability to tasks. combing his hair.
put • Maintain a • The
on/take off supportive, firm consistency
necessary attitude. of caregiver
items of provides
clothing assurance to
• Inability to the client
get to
toilet and • Avoid doing things • This client
carry out for client that client may become
proper can do for self, fearful, it is
toilet providing important for
hygiene assistance as the client to
necessary do as much
 as possible to
maintain self
esteem

• Enhances
• Provide for sense of
communication independence
among those who
are involved in
caring for/assisting
the client.
• Enhances
• Provide privacy and coordination
equipment within and continuity
easy reach during of care
personal care
activities. Allow
sufficient time for
client to
accomplish tasks
to fullest extent of
ability.
• Reduces
• Review safety risk of injury
concerns. Modify and promotes
activities/environ- successful
ment. functioning.
 NURSING CARE PLAN #5
Outcome Nursing
Cues Nursing Diagnosis Rationale Evaluation
Identification Interventions

No subjective and Risk for impaired skin Short Term Independent: Goal met.
objective cues. integrity related to Goal After 8 hours of
altered • Inspect all skin • Skin is nursing
Risk factors: neuromuscular At the end of 8 areas, noting especially prone interventions,
function hours of nursing capillary to breakdown the patient was
• Physical interventions, blanching/ refill, because of able to
immobility : the patient will redness, swelling. changes in demonstrate
right-sided be able to peripheral behaviours and
weakness demonstrate circulation, techniques to
behaviours and inability to sense prevent skin
techniques to pressure breakdown as
• Altered
prevent skin evidenced by
metabolic state
breakdown. • Change position in • Enhances absence of
bed on a regular coordination and signs of skin
schedule (every 2 continuity of breakdown
hours). care over bony
prominences.
• Encourage • Stimulates
continuation of circulation,
regular exercise enhancing
program, passive cellular nutrition/
range of motion oxygenation to
exercises on the improve tissue
right extremities health
and active range
of motion
exercises on the
 left extremities

• Elevate lower • Enhances

extremities venous return,
periodically if reduces edema
tolerated formation

• Reposition • Improves skin

frequently, circulation and
whether in bed or reduces
in sitting position. pressure time
Place in prone on bony
position prominences
periodically.

• Emphasize • To maintain
importance of general good
adequate health and skin
nutritional fluid turgor
intake
• Wash and dry • Clean, dry
skin, especially in skin is less
high-moisture prone to
areas such as excoriation/
perineum. Take breakdown
care to avoid
wetting lining of
brace
• Massage bony
prominences • To keep the
gently and avoid integrity of the
friction when skin at optimal
moving client level
 DISCHARGE PLAN
Upon discharge, the patient will;

Medication  Strictly adhere to medication regimen specially the prescribed

home medications, to wit;
Amlodipine 5mg tab @ lunch then HS
Imidapril 10mg + 12.5mg tab OD @ breakfast
Senna Concentrate 2 tabs @ HS x 1 week
Omeprazole 20mg tab daily x 1 week
Simvastatin 20mg tab @ HS
Exercise  Have frequent short periods of exercise.

 > Safely engage in active and passive range of motion exercises

on the affected extremity assisted by rehabilitative personnel as
prescribed.

Treatment  Consult with speech therapist to improve ability to communicate.

 Make sure that follow-up care is adhered to religiously.

Health  Given positive reinforcement and emotional support from his
Teaching family.
 Be informed about the expected outcome of stroke, and his
family should be counselled to avoid doing things for him that he
can do.

 > Have at least one family member who will be taught how to
take blood pressure to enable the family to monitor the patient’s
blood pressure at home.

Observable  Be able to report, with the help of his family, exacerbation of

signs and present signs and symptoms and seek prompt medical attention
symptoms when deterioration of neurological status is apparent such as
loss of consciousness, worsening of posture, severe headache,
irritability and restlessness.
Diet  Be advised to take osteorized food as prescribed with aspiration
precaution if nasogastric tube is still in place upon discharge
 Be reminded to thicken osteorized feeding if gag reflex gradually
regains or if there is still residual dysphagia.

 > Adhere to a low-sodium, low-fat diet such as avoidance of

canned and processed foods, milk and dairy products, and
saturated fats from pork and poultry.

Spiritual  -Advise patient not to be discouraged and to have strong faith in

God.

PROGNOSIS
 Based on the criteria given below, the patient has a GOOD prognosis. Mr.
Strokeman’s condition was properly managed and her body responded well with the
interventions and medications given to him.

GOOD FAIR POOR


• Response of the patient regarding the presence of
pain after its managements.


• Physiologic response of the body to the
medications.

• Healing process of the affected organs.


• Performance of the daily living of the patient during
hospitalization (eating, toileting, daily dressing).

• Compliance of patient to medication regimen.


• Consumption of the patient with nutritious and
therapeutic diet.


• Patient’s behavior regarding the health teachings
given by the health caregivers and physician.


• Ability of the patient to understand and demonstrate
the health teachings being given.
 EVALUATION
Through this case presentation, the group was able to have a thorough
understanding of the case of a 60 year old patient with cerebrovascular disease. We
could say that our general and specific objectives for the case study were met.

We were able to gather a detailed profile of the patient, including the

assessment of the patient’s condition throughout our hospital duty, identify the anatomy
and physiology of the brain which is the organ involved in CVD; discuss the
pathophysiology of CVD in relation to the patient’s clinical manifestations, provide
rationale to the physician’s orders, interpret the results of laboratory test and diagnostic
procedures, make a study of the drugs prescribed to the patient, design five actual
priority nursing care plans, formulate effective discharge plan for the patient, and
hypothesize a realistic prognosis based on patients’ response to medical and nursing
interventions.

Through this case presentation, we were able to develop our nursing skills,
knowledge and attitude utilizing the nursing process appropriately which will surely help
us to become better equipped as future nurses ready to take on the challenges of our
profession in the real world in whatever setting.
 REFERENCES

Books

Medical Surgical Nursing, vol. 1 and 2 by Smeltzer

Nursing Care Plans 7th Ed. By Deonges

Internet resources

CliffsNotes.com. The Brain. 25 Apr 2009

<http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/topicArticleId-22032,articleId-
21940.html>.

CliffsNotes.com. Ventricles and Cerebrospinal Fluid. 25 Apr 2009

<http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/topicArticleId-22032,articleId-
21941.html>.

CliffsNotes.com. The Meninges. 25 Apr 2009

<http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/topicArticleId-22032,articleId-
21942.html>.

CliffsNotes.com. The Blood-Brain Barrier. 25 Apr 2009

<http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/topicArticleId-22032,articleId-
21943.html>.

CliffsNotes.com. Cranial Nerves. 25 Apr 2009

<http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/topicArticleId-22032,articleId-
21944.html>.JKL

NeuroScienceForKids.com. The Blood Supply For the Brain.25 Apr 2009

<http://faculty.washington.edu/chudler/vessel.html>.