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TABLE OF CONTENTS
I.

Introduction
a. Overview of the case
b. Objective of the study
c. Scope and Limitation of the study
II.
Health History
III. Developmental Data
IV. Medical Management
a. Medical orders with rationale
b. Drug Study
c. Laboratory results
V.
Anatomy and Physiology with Pathophysiology
VI. Nursing Assessment
VII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
VIII. Referrals and Follow-up
IX. Evaluation and Implications
X.
Bibliography

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INTRODUCTION
A.OVERVIEW:

Cerebrovascular disease is a group of brain dysfunctions related to disease of the

blood vessels supplying the brain. Hypertension is the most important cause; it 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, uneven and more vulnerable to fluctuations in blood pressure.
A fall in blood pressure during sleep can then lead to a marked reduction in blood flow
in the narrowed blood vessels causing ischemic stroke in the morning. Conversely, a sudden
rise in blood pressure due to excitation during the daytime can cause tearing of the blood
vessels resulting in intracranial hemorrhage. Cerebrovascular disease primarily affects people
who are elderly or have a history of diabetes, smoking, or ischemic heart disease. The results
of cerebrovascular disease can include a stroke, or occasionally a hemorrhagic
1

stroke. Ischemia or other blood vessel dysfunctions can affect the person during a
cerebrovascular incident.
A transient ischemic attack (TIA) leaves little to no permanent damage within the brain.
The symptoms of this include facial weakness, visual impairment, loss of coordination, or
balance, a sudden headache, and mental confusion with unintelligible speech. Severe
blockage of the arteries to the brain is known as carotid stenosis.
Carotid artery affects retina, cerebral hemisphere, or both. Retinal Transient blackouts;
the sense of a shade pulled over the eyes. Cerebral Contralateral (opposite sided) paralysis of
a single body part; paralysis of one side of the body; localized tingling, numbness; hemianopic
visual loss; aphasia (loss of speech); rare loss of consciousness. Vertebrobasilar Bilateral
visual disturbance including dim, gray, or blurred vision or temporary total blindness; diplopia
(double vision). Labyrinth/medulla Vertigo; unsteadiness; nausea; vomiting. Brainstem
Slurring dysarthria (tongue weakness causing impaired speech); dysphagia (difficulty
swallowing); numbness, weakness; all four limb paresthesia; drop attacks from sudden loss of
postural tone are basilar in origin; a vertebrobasilar artery occlusion episode causes
symptoms to be induced by abrupt position changes.
Cerebrovascular disease can be divided into embolism, aneurysms, and low flow
states depending on its cause. Major modifiable risk factors
includehypertension, smoking, obesity, and diabetes.
The most common forms of cerebrovascular disease are cerebral thrombosis (40% of
cases) and cerebral embolism (30%), followed by cerebral hemorrhage (20%).[2]
Cerebrovascular disease is primarily one of old age; the risk for developing it goes up
significantly after 65. CVD tends to occur earlier than Alzheimer's Disease (which is rare
before the age of 80). In some countries such as Japan, CVD is more common than AD. CVD
occurs more rarely in younger people due to conditions such as syphilis that lead to artery
damage and strokes.

B.OBJECTIVES OF THE STUDY

After 1 hour of case presentation, I should be able to achieve the following objectives:
1. Present a thorough general health assessment of the client which includes physical
assessment and family history taking.
2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited by
the client.
3. Thoroughly discuss, explain, and elaborate the nature of the disease process.
4. Efficiently provide appropriate and proper nursing diagnosis in line with the clients
medical condition.
5. Skillfully formulate nursing care plans for the different problems identified.
6. Appropriately provide nursing interventions according to the standards of nursing
practice.
2

7. Effectively apply the learned concepts and theories of disease.

8. Efficiently appraise the effectiveness and efficacy of nursing interventions rendered to
the client.
9. Impart the outcome of the rendered nursing interventions.
10. Convey the significance of clients response to the rendered nursing interventions.
11. Correctly provide concise and concrete information with regards to the patients
disease condition.
12. Appropriately provide appropriate environment for learning.

C.Scope and Limitation

The limitation of this Case Presentation focused on the patient whom the researcher
had rendered care with, in Northern Mindanao Medical Center Hospital during their 4 days
duty in the Medical ward. Also the study follow the required concept in their midterms which is
the neural disturbances since they cant find it in the Medical ward, hence, this patient is
chosen by the researcher for a case presentation. This case study encompasses the concepts
of the circulatory system. The data presented in this case was primarily obtained from student
nurse-patient interaction as well as with the significant other who partly served as informant
and is based on the patients chart. The student nurse was able to render care to the patient
during the 16 hours of duty on May 26, 2013. During the course of this 2 day nursing care, the
student nurse assess patient thoroughly, plan nursing care, implement plan of care and give
health teachings. The scope of this statistics is only limited to the occurrence of the
cerebrovascular disease in Northern Mindanao which comprises about 75.5% of the total
population.
II. HEALTH HISTORY
PATIENTS PROFILE

Name:

C.B

Address:

Brgy. 4 Poblacion Talakag Bukidnon

Birthday:

December 9, 1980

Birthplace:

Bukidnon

Age:

32 years old

Nationality:

Filipino

Religion:

Catholic

Civil Status:

Married

Occupation:

None

Educational
Attainment:

High School Graduate

Family Income:

Php 6000/month

Height:

52

Weight:

70 kgs

Admitting
Diagnosis:

Attending
Physician:

Cerebrovascular Disease

Shielamar B. Flores MD

Past Health History:

A. Heredo-familial Disease
The patients mother has a history of Goiter. On the other hand, his father has a history
of heart disease
B. Diet and Lifestyle
The patient exercise regularly but he is a chain smoker in which he can consume 10
sticks per day for almost 40 years duration. He is also into drinking alcohol, 2 bottles of
beer occasionally. His diet contains high fat and sodium diet, which are chicharon,
bulalo, and canned foods. He respond to stressful events by just verbalizing it to her
wife.
C. History of admission.
The patient was admitted at Camp Evangelista Station Hospital last 2005 diagnosed to
have peptic ulcer, and last 2010 having been diagnosed with Hepatitis B and UTI.

Chief Complaint and History of Present Illness

A case of M.E ,56 yrs. old, female, Married, Pentecostal, Filipino and currently residing
in Brgy.Besigan Cagayan de Oro City, Admitted for the 1st time in Northern Mindanao Medical
Center with a chief complaint of Loss of Consciousness. 6 hrs prior to admission patient was
noted with sudden onset of slurring of speech associated with several episodes of nonprojectile vomiting. Patient then had Loss of Consciousness and was noted to have body
weakness. Bp was noted to be elevated @ 200/140 mmHg. And Captopril 25mg SL was then
given. Patient was then referred in Northern Mindanao Medical Center for further
management.
III. Developmental Data:

Theorist

Sigmund
Freud

Theory

Stage

Psychosexual

Genital Stage

Result and
Justification
My patient was able to

Development Theory (Puberty-onwards):

find a lifetime partner

- It is a theory of how

Libido reawakened

where they are

our sexuality starts

as genital organs

happily living together

from a very young

mature and focuses

with his 9 children.

age.

on relationships with
members of the
opposite sex.

Theorist

Theory
Psychosocial

Result and
Justification

Stage
Generativity Vs.

Development Theory Stagnation.(Ages

- It describes 8
Erik Erikson

developmental stages
through which a
healthily developing
human should pass
from infancy to
adulthood. In each
stage the person
confronts, and
hopefully masters
new challenges. Each
stage builds on the

40-65)
Achieve the life goals
established for
oneself while
considering the
welfare of future
generations.

My patient has
her own salary to
support for his
children who are in
school and he had
already 5 children
who are married
and can support
their own family.
He has able to
maintain healthy
lifestyle and able to
accept childs
mates.

successful completion
of earlier stages. The
challenges of stages
not successfully
completed may be
expected to reappear
as problems in the
future.
5

Theorist

Theory
Theory of

(Ages 40-60)

Developmental TaskLearning is fundamental

The following Tasks

Five of the patients

must be developed:

children are already

Robert

to life and in order to

Havighurst

have a deeper insight

Assisting teenage

on growth and

children to become

development, one must

understand it and

to guide them in their

marriage life and

responsible and

helped them
whenever there are

Achieving adult

that human being

problems. He

social and civic

continues to learn

depends on his

throughout life.

responsibility,

Happiness is being

Reaching and

achieved when a

maintaining

particular task of a

satisfactory

certain age is achieved

performance in ones

by the person

occupational career,

successfully but if not,

Developing adult

failure occurs which is a

feeling of unhappiness
and disapproval from
people surrounding the
client.

Theory
Theory of Cognitive

Jean Piaget

married. He was there

happy adults,

recognize the premise

Theorist

Result and
Justification

Stage

Development A comprehensive theory

Relating oneself to
ones spouse as a
person, To accept

solves all types of

intelligence. It deals with

problems; thinks

acquire it, construct it,

and use it. Cognitive

mainly watching TV
and listening to radio.
He also understands
his current situation
and is aware of the
changes in his
lifestyle. His wife and

children were the one

Result and
who
takes care on
Justification
him and has the
Formal
Operational
changes
of middle My patient usually
responsibility on his
Stage
11- to understands his
age,(Age
Adjusting
current condition.
onwards).
situation but cannot
aging parents.

development of human

come gradually to

leisure activities are

and adjust to the

Stage
physiological

A person logically

itself and how humans

earn money. His

leisure time activities,

about the nature and

the nature of knowledge

income and works to

scientifically; solves
complex problems;
cognitive structures

directly identify
solutions for his
problems because he
is paralyzed and
unable to talk well
due to CVA.

mature.

development is at the
centre of human
organism and language
is contingent on
cognitive development.

IV. MEDICAL MANAGEMENT A. DOCTORS ORDER

November 20, 2012

1:10 am

Please admit at the

Medical Ward
TPR every shift

NPO temporarily

I and O every shift

and record

For furher
evaluation of his
condition.
To monitor any signs
of deterioration of
health status

Aspiration risk is
greater, so as to
avoid aspiration.

To monitor fluid loss

To monitor
abnormalities in the
blood, and fifferent
enzymes and waste
products of the
body.

Venoclysis to supply
blood vessels and
prevent dehydration.

For hydration
purposes

An ACE inhibitors
help reduce blood
pressure and also
increased
prostaglandin
synthesis
A calcium-channel
blocker whichdilates
blood vessel making
the heart easier to
pump blood.

Labs:

CBC, U/A, S/E, ECG

12 leads, Chest-xray
PAL view, FBS,
triglycerides, lipid
profile, BUN, BUA,
creatinine
Continue venoclysis
plain NSS 1L to 20
drops/min
To follow plain NSS
@ SR

Meds:

Captopril 25 mg SL
now then prn if the
BP is 160/100 and
above
Amlodipine 10 mg
OD

November 22, 2012

11ooH

O2 inhalation 23L/min with dyspnea

(pm)

Refer to Dr.Jolo

Refer accordingly
IM NOTES
For CT Scan
brain plain
Citicholine 500
mg I tab

To increase oxygen
supply in the blood.

For further
evaluation and
treatment of disease
condition.

For further
evaluation and
referral of the
disease condition.
To note any clot in
the brain.

November 23, 2012

12ooH

Simvastatin 20
mg 1 tab OD H.S

A CNS stimulant
which increases
blood supply and
oxygen to the brain.

An anti-

B. Drug Study

Name
of
Drug
Amlod
ipine

Classification

Name
of
Drug
Citich
oline

Classification

Calcium
channel
blocker

CNS stimulant

Dose/
frequen
cy
10mg
OD PO

Mechanis
m of
Actions
Inhibits
influx of
calcium
through the
cell
membrane,
resulting in
a
depression
of
automaticity
and
conduction
velocity in
cardiac
muscle.

Specific
Indication

Dose/
frequen
cy
500 mg
OD PO

Mechanism
of Actions

Specific
Indicatio
n
Citicholine
in CVA,
stimulates
brain
function

Increases
oxygen
supply and
blood to the
brain.

Contraindi
cation

Side
effects

Nsg
Precautions

Treatment
allergy to
for essential amlodipine
hypertensio
n.

CNS:
Dizzine
ss,
light
heade
dness,
fatigue,
letharg
y

1. Monitor
vital signs,
CBC, and
ECG.
2. Instructed
to avoid
grape fruit
juice
3. Can be
taken with or
without meals
4. Note and
report chest
pain, SOB
and dizziness

Contraindic
ation

Side
effects

Nsg
Precautions

Any allergy
or
hypersensitivi
ty to the drug

headac
he,
dizzine
ss,
nausea
and
vomitin
g,
abdomi
nal
cramps

1. May
reduce
dosage with
impaired
renal
function,
2. May take
with meals
3. Monitor
vital signs,
CBC
4. Monitor
mental
status.
9

Name
of
Drug
Captop
ril

Classification

ACE inhibitor

Dose/
frequ
ency
25 mg
SL
when
BP is
160/1
00 or
above
PO

Mechanism
of Actions

Specific
Contraindica Side
Indication tion
effects

Nsg
Precautions

Inhibits
angiotensio
n-converting
enzyme
resulting in
decreased
plasma
angiotensin
II, which
leads to
decreased
vasopressor
activity and
decreased
aldosterone
secretion.

Managem
ent of
hypertensi
on

1. Take 1
hour before
meals,

Name
of
Drug

Classification Dose/ Mechanism

frequ of Actions
ency

Specific
Indication

Senna
conce
ntrate

Laxative

to soften
the stool

2tabs
OD

promotes
incorporation
of water into
stool,
resulting in
softer fecal
mass.

Hypersensitiv
ity to
captopril,
other ACE
inhibitor or
any
component

Contraindicat
ion

Abdomi
nal
pain
Nause
a and
vomitin
g

Rash,
gastric
irritation,
headach
e,
dizzines
s,
fatigue,
malaise,
dry
mouth,
N&V

Side
effects
commo
n side
effects
mild
cramps

2.Report
fever, chest
pain, skin
rash and
irregular
heartbeat
3. Withhold
potassiumsparing
diuretics

Nsg Precautions

Advise
patient that
laxative
should only
be used for
short
therapy
Encouraged
patient to
use other
forms of
bowel
regulation,
such as
increasing
bulk in the
diet and
10

increasing
fluid intake
and
increasing
mobility

Name
of Drug
Simvast
atin

Name
of
Drug
perind
opril

Classification Dose/
freque
ncy
Antilipidemics 200mg
1tab
OD HS

Classification Dose/
freque
ncy
anti:
hypertensive
500mg
1tab
OD

Mechanism
of Actions

Specific
Indication

Contraindi
cation

Side
effect
s
active liver
Consti
disease or
pation,
unexplained Dyspe
persistent
psia,
elevations
Flatule
of serum
nce,
transaminas Heada
es
che
porphyria

inhibits
HMG-COA
reductase,
an early
step in
cholesterol
biosynthesis

in
hyperlipide
mia: an
adjunct to
diet to
reduce
elevated
total LDL

Mechanism
of Actions

Specific
Contraindic
Indication ation

Side
effects

Nsg
Precautions

inhibits ACE
activity,
thereby
preventing
conversion

prevention
of stroke
recurrenc
e in
combinati

Palpitati
on,
Edema,
Chest
pain,

1.Use
cautiously in
patient with a
history of
angioedema

in patients
hypersensiti
vity to drug
or other ACE
inhibitor

Nsg
Precautions
1.Instruct
patient to take
drug with the
evening meal
2.Use drug
only after diet

11

of
angiotensin
1 to 2, a
potent
vasoconstrict
or.

Name
of
Drug
Bisaco
dyl

Name
of
Drug

Classification

Mucokenitics/
expectorants

Dose/
frequen
cy
1tab
supp
per
rectum

Classification Dose/
frequency

Mechanism
of Actions
Increases
peristalsis
and motor
activity of
the small
intestines by
acting
directly on
the smooth
muscle.

on with
indapamid
e in
patients
with a
history of
CVA.

Specific
Indicatio
n
Constipati
on relief of
avacuatio
n in
hemorrhoi
ds prep
for barium
enema,
pre and
post op.

Mechanism Specific
of Actions
Indicatio
n

Abnorm
al ECG

unrelated to
ACE inhibitor
therapy
2.Also use
cautiously in
pt. with
impaired
renal
function

Contraindica
tion

Side
effects

Nsg
Precautions

Hypersensitivi
ty to drugs

Nause
a,
Vomitin
g,
Abdom
inal
pain
,
Ulcerat
ive
lesions
of
colon

1.Monitor
frequency
and
character of
stool
2.Swallow
the tablet
whole
3.Do not
crush or
chew the
drug

Contraindi
cation

Side
effects

Nsg
Precautions
12

Cepha cephalosporin
lexin
s

500 mg,
every 8
hours, PO

Interferes
with the
final step in
cell wall
formation,
resulting in
unstable
cell
membranes
that
undergo
lysis. Also,
cell division
and growth
are
inhibited.

GU
infections
and
respirator
y infection

Hypersensit
ivity to
drugs

Diarrhe
a,
nausea
and
vomitin
g,
abdomi
nal
pain,
dizzine
ss, skin
rash,
fever

1. Refrigerate
suspension
after
reconstitution
2. May
reduce
dosage with
impaired
renal function,
3. May take
with meals
4. Consume
2-3 L/day of
fluids to
prevent
dehydration.

c. LABORATORY RESULTS
Name: Gulle, Euberto

November 25, 2012

Age: 55 years old

URINALYSIS
Color: Yellow

WBC: 0-2/hpf

Transparency: clear

RBC: (-)/hpf

Sugar: Negative
Albumin: Negative

Amorphous urates: Few

Specific Gravity: 1.015

pH: 6.0

CT SCAN REPORT
GULLE, EUBERTO

November 27, 2012

Interpretation:
Plain CT Scan of the brain with serial axial views disclose the following findings.

13

There is a hypodense focus at the left frontal lobe measuring around 7.6 cms in widest
diameter. There is another one at the right occipital lobe measuring around 2.2 cms. There
are tiny hypodensities in the superior left fronto parietal lobes.
There is no abnormal attenuation of the cerebellum and brain stem.
The ventricles are not dilated.
The midline structures are intact.
Petro mastoids, sinuses, orbits and sellar areas are unremarkable.

Impression:
CONSIDER ACUTE TO SUB-ACUTE INFARCTS, LEFT FRONTO PARIETAL LOBES AND
RIGHT OCCIPITAL LOBE.

Gulle, Euberto

November 22, 2012

CHEST X-RAY
Cardiothroracic ratio 60.58. Both lungs are clear. Trachea, diaphragm, and bronchus are
unremarkable.
Impression:
Moderate Cardiomegaly

HEMATOLOGY
WBC: 13, 700/cumm above normal which suggests infection.
Hemoglobin: 13.8 gm % - normal findings
Hematocrit: 45.3 vol % - normal findings
Platelet count: 277, 000/cumm normal findings
Differential count
Neutrophil: 77 above normal findings which suggest bacterial infection
Lymphocytes: 18 below normal which suggests viral infection
Eosinophil: 05 normal findings

14

15

V. ANATOMY AND PHYSIOLOGY with ACTUAL PATHOPHYSIOLOGY

Overview
Nothing in the world can compare with
the human brain. This mysterious threepound organ controls all necessary
functions of the body, receives and
interprets information from the outside
world, and embodies the essence of the
mind and soul. Intelligence, creativity,
emotion, and memories are a few of the
many things governed by the brain.
The brain receives information through
our five senses: sight, smell, touch, taste, and hearing - often many at one time. It assembles
the messages in a way that has meaning for us, and can store that information in our memory.
The brain controls our thoughts, memory and speech, movement of the arms and legs, and
the function of many organs within our body. It also determines how we respond to stressful
situations (such as taking a test, losing a job, or suffering an illness) by regulating our heart
and breathing rate.
Nervous system
The nervous system is divided into central and peripheral systems. The central nervous
system (CNS) is composed of the brain and spinal cord. The 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 vital
functions such as breathing, digestion, heart rate, and secretion of hormones.
Skull
The purpose of the bony skull is to protect the brain from injury. The skull is formed from 8
bones that fuse together along suture lines. These bones include the frontal, parietal (2),
temporal (2), sphenoid, occipital and ethmoid (Fig. 1). The face is formed from 14 paired
bones including the maxilla , zygoma, nasal, palatine, lacrimal, inferior nasal conchae,
mandible, and vomer.
Inside the skull are three distinct areas: anterior fossa, middle fossa, and posterior fossa (Fig.
2). Doctors sometimes refer to a tumors location by these terms, e.g., middle fossa
meningioma.
Similar to cables coming out the back of a computer, all the arteries, veins and nerves exit the
base of the skull through holes, called foramina. The big hole in the middle (foramen
magnum) is where the spinal cord exits.
Brain
The brain is composed of the cerebrum, cerebellum, and brainstem (Fig. 3).

16

The cerebrum is the largest part of the brain and is composed of right and left
hemispheres. It performs higher functions like interpreting touch, vision and hearing, as
well as speech, reasoning, emotions, learning, and fine control of movement.

The cerebellum is located under the cerebrum. Its function is to coordinate muscle
movements, maintain posture, and balance.

The 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 surface of the cerebrum has a folded appearance called the cortex. The cortex contains
about 70% of the 100 billion nerve cells. The nerve cell bodies color the cortex grey-brown
giving it its name gray matter (Fig. 4). Beneath the cortex are long connecting fibers
between neurons, called axons, which make up the white matter.
Right brain left brain
The right and left hemispheres of the brain are joined by a bundle of fibers called the corpus
callosum that delivers messages from one side to the other. Each hemisphere controls the
opposite side of the body. If a brain tumor is located on the right side of the brain, your left arm
or leg may be weak or paralyzed.
Not all functions of the hemispheres are shared. In general, the left hemisphere controls
speech, comprehension, arithmetic, and writing. The right hemisphere controls creativity,
spatial ability, artistic, and musical skills. The left hemisphere is dominant in hand use and
language in about 92% of people.
Lobes of the brain
The cerebral hemispheres have distinct fissures, which divide the brain into lobes. Each
hemisphere has 4 lobes: frontal, temporal, parietal, and occipital (Fig 3). Each lobe may be
divided, once again, into areas that serve very specific functions. Its important to understand
that each lobe of the brain does not function alone. There are very complex relationships
between the lobes of the brain and between the right and left hemispheres.
Frontal lobe
Personality, behavior, emotions
Judgment, planning, problem solving
Speech: speaking and writing (Brocas 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

17

Spatial and visual perception

Occipital lobe

Interprets vision (color, light, movement)

Temporal lobe

Understanding language (Wernickes area)

Memory

Hearing

Sequencing and organization

Deep structures
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.
Pituitary gland - lies in a small pocket of bone at the skull base called the sella turcica. The
pituitary gland is connected to the hypothalamus of the brain by the pituitary stalk. Known as
the master gland, it controls other endocrine glands in the body. It secretes hormones that
control sexual development, promote bone and muscle growth, respond to stress, and fight
disease.
Pineal gland - is located behind the third ventricle. It helps regulate the bodys internal clock
and circadian rhythms by secreting melatonin. It has some role in sexual development.
Thalamus - serves as a relay station for almost all information that comes and goes to the
cortex (Fig. 5). It plays a role in pain sensation, attention, alertness and memory.
Basal ganglia - includes the caudate, putamen and globus pallidus. These nuclei work with
the cerebellum to coordinate fine motions, such as fingertip movements.
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)
HUMAN BRAIN WITH STROKE

18

A stroke occurs
blood to a
blocked.
cells start to die
Sudden bleeding
cause a stroke if

if the flow of oxygen-rich

portion of the brain is
Without oxygen, brain
after a few minutes.
in the brain also can
it damages brain cells.

If brain cells die

stroke, symptoms
these brain cells
sudden
arms, or legs
understanding speech; and

or are damaged because of a

occur in the parts of the body that
control. Examples of stroke symptoms include
weakness; paralysis or numbness of the face,
(paralysis is an inability to move); trouble speaking or
trouble seeing.

ACTUAL PATHOPHYSIOLOGY OF CEREBROVASCULAR DISEASE

Cerebrovascular accident or stroke (also called brain attack) results from sudden
interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting
longer than 24 hours.
REDISPOSING FACTOR

Heredity
Hypertension
Hyperlipidimia

PRECIPITATING FACTOR

VASOCONSTRICTION

Cerebral Ischemia

Blockage of the blood vessels

Cell Death
Decreased Oxygen
Supply

Lack of oxygen supply and

nutrients supply

Intracerebral Hemorrhage

Right
Lower
and upper
extremitie
s

Vices (alcohol and

smoking)
Diet
Stress

Hypoxia
Altered Cerebral
Metabolism

P
A
R
A
L
Y
S
I
S

Decreased Cerebral
Perfusion

Brain
LocalTissue
Acidosis
Good
Prognosis
NecrosisEdema
Aneurysm
Rupture
Cytotoxic

19

Embolic Stroke

VI. NURSING ASSESSMENT (SYSTEM REVIEW AND NSG. ASSESSMENT II)

NURSING SYSTEM REVIEW CHART
NAME of PATIENT: Mr. E.G

Pulse: 85bpm RR: 22cpm

Date: December 12 , 2012- 10:00 am Area:Medical Ward - CESH

BP: 150/90mmHg
Temp: 370C
Height: 150cm Weight:68 kgs

EENT:
[x] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened
[ ] Drainage [ ] Gums [ ] Hard of Hearing
[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion
[x] Teeth [ ] No Problem
[x] Assess Eyes, Ears Nose, and Throat for Abnormalities.
RESPIRATORY SYSTEM:
[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales
[] Cough [ ] Barrel Chest [ ] Bradypnea
[] Shallow [ ] Rhonchi [ ] Sputum [ ] Diminished
[ ] Dyspnea [ ] Orthopnea [ ] Labored [ ] Wheezing
[ ] Pain
[ ] Cyanotic
[ ] No Problem
[x] Assess Resp. Rate, Rhythm, Depth, Pattern,
Breath Sounds and Comfort.
CARDIO VASCULAR:
[ ] Arrhythmia [ ] Tachycardia [ ] Numbness
[ ] Diminished Pulses [ ] Edema
[ ] Fatigue [ x ] Irregular
[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses
[ ] Pain [] No Problem
[x] Assess Heart Sounds, Rate, Rhythm, Pulse,
Blood Pressure, Circulation, Fluid Retention, and Comfort.

dry lips, partial

lower dentures

Hemiparesis

Normoactive
bowel sounds

GASTRO - INTESTINAL TRACT:

[ ] Obese
[ ] Distention [ ] Mass [ ] Dysphagia
[ ] Rigidly
[ ] Pain [] No Problem
[x] Assess Abdomen, Bowel Habits, Swallowing,
Bowel Sounds and Comfort.
GENITO - URINARY AND GYNE:
[ ] Pain [ ] Urine Color[ ] Vaginal Bleeding
[ ] Hematuria [ ] Discharge [ ] Nocturia
[x] No Problem

Decreased
muscle tone,
limited ROM
20

[x]Assess Urine Frequency, Control, Color,

Odor, Comfort, Gyne-Bleeding and Discharge.

Dry skin

NEURO:
[x ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures
[ ] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors
[ ] Confused [ x] Vision [ ] Grip
[] No Problem
[x] Assess Motor Function, Sensation, LOC, Strength,
Grip, Gait, Coordination, Orientation and Speech.
MUSCULOSKELETAL and SKIN:
[ ] Appliance [x ] Stiffness [ ] Itching [ ] Petechiae
[ ] Hot [ ] Drainage [ ] Prosthesis [ ] Swelling
[ ] Lesion [ ] Poor Turgor [ ] Cool [ ] Deformity
[] Wound [ ] Rash [ ] Skin Color [ ] Flushed
[ ] Atrophy [ ] Pain [ ] Ecchymosis [ ] Diaphoretic
[ ] Moist
[ ] No Problem
[x] Assess Mobility, Motion, Gait, Alignment,
Joint Function, Skin Color, Texture, Turgor, and Integrity.

Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate, using (X).

NURSING ASSESSMENT II
SUBJECTIVE
COMMUNICATION
[ ] hearing loss
[ ] visual changes
[x ]denied

Comments:Okay
naman akong
panan-aw as vb.
By the patient.

OXYGENATION:
[]dyspnea
[x]smoking history
yes
[] cough
[ ]sputum
[x]denied

Comments:Okay
raman akong
pagginhawa
dilinaman sad ko
mag lisud og
ginhawa as vb. By
the patient..

OBJECTIVE

[ ] glasses
[ ]languages
[ ] contact lens
[ ] hearing aide
R
L
Pupil size: 4mm
[ ] speech
difficulties
Reaction: Pupil Equally Round Reactive
to Light and Accommodation
Resp. [x]regular [ ]irregular
Describe: bronchovesicular breath
sounds heard over lungs; RR;20cpm
R:bronchovesicular sounds auscultated
L:bronchovesicular sounds auscultated

CIRCULATION:
[ ]chest pain
[ ] leg pain
[ ] numbness of
extremities
[x] denied

Comments:Dili na
nako mafeel ang sakit
sa pikas nako nga tiil,
as verbalized by the
patient.

NUTRITION:
Diet: Soft diet
[]N[]V
Character:
[ ] recent change in weight
and appetite
[ ] swallowing difficulty
[x]denied

Comments:
okay raman
akong
pagkaon,as vb
by the patient .

Heart rhythm [x] regular

Ankle Edema: none

[ ] irregular

Carotid
Radial Dorsal PedisFemoral
R 85bpm
84bpm
84bpm
refused
L 85bpm
84bpm
84bpm
refused
Comments: all pulses are palpable
*if applicable: not applicable

[x]dentures
Full

Upper
Lower

partial

[ ]
[ ]

[ ]none
with patient

[x]
[x]

[ ]
[ ]

21

ELIMINATION:
Usual bowel pattern
[ ] urinary frequency
Once a day 1-2 times a day
[]constipation
[ ]urgency
Remedies:
[ ]dysuria
Papaya, pineapple
[ ] hematuria
Date of last BM
[ ] incontinence
Dec. 18, 2012
[ ]polyuria
[ ] diarrhea character
[ x ] foley in place
None
[ ] denied

MGT. OF HEALTH & ILLNESS:

[x] alcohol
[]denied
(Amount, frequency): oo mag-inom ko ug
manigarilyo, as verbalized by the
patient..
[] SBE:
Last Pap smear: N/A
LMP: N/A
SKIN INTEGRITY:
[x] Dry
[ ] Itching
[ ] other
[ ] denied

Comments: Wala man

koy gibati na katol-katol
sa akong pamanit, as
verbalized by the patient.

ACTIVITY/SAFETY:
[ ] convulsion
Comments: dili nako
[ ] dizziness
malihok akong tuo nga
[x] limited motion
lawas as verbalized
of joints
by the patient.
[ ] ambulate
[ ] bathe self
[ ] other
[ ] denied
COMFORT/SLEEP/AWAKE:
[ ] pain
Comments:
(location) frequency Katarong man ko
remedies)
og tulog as
[ ] nocturia
verbalized by the
[] sleep difficulties
patient.
[x] denied
COPING:
Occupation: None
Members of household: *9 members
Most supportive person: Edith Gulle

Comments:
Patient bowel
Normoactive
bowel
sounds(8/mins.)
is
Sounds
normoactive.

Bowel sounds:

Abdominal Distention
Present [ ] yes [x] No
Urine (color,consistency,
odor) yellow,moderate in
amount, aromatic
*if foley balloon catheter
foley in place draining well

Briefly, describe the patients ability to

follow treatments (diet, meds, etc.) for
chronic health problems (if present).
N/A

[x] dry
[ ]cold
[ ] pale
[ ] flushed [x]warm
[ ] moist
[ ]cyanotic
*rashes, ulcers, decubitus (describe size,
location, drainage) none
[ ] LOC and Orientation: Patient is alert
but is disoriented to time, place and
space.
[ ] Gait [ ] walker [ ] care [] others
[ ] steady [x] unsteady
Sensory and motor losses in face or
extremities
none
[ ] ROM limitations: Patient is having
difficulty to move right upper and lower
extremities due to paralysis.
[ ] facial grimace
[ ] guarding
[ ] other signs of pain
[x] side rail release form signed (60 +
years)

Observed non-verbal behavior: none.

Person (Phone Number): none

22

VII. NURSING MANAGEMENT

A.IDEAL NURSING INTERVENTIONS

Nursing Diagnosis

Nursing Interventions:

Activity Intolerance related to

right side body weakness

1. Assess patients level of

functioning using the
functional mobility scale

To determine patients
capabilities

2. Encourage bed exercises

Prepares patient for

late activities but also
offers hope ascends of
optimism about
recovery.

3. Provide emotional support

and encouragement.

To help improve
patients self-concept
and motivation to
perform

4. Turn and position patient at

least every hours

Turning helps prevent

skin breakdown by
relieving pressure

5. Involve patient in cure

related to planning and
decision making

To improve compliance

Rationale

23

Nursing Diagnosis

Nursing Interventions:

Self care deficit related to

decrease strength

1.Observe, document and

report patients functional and
perceptional or cognitive
ability daily

Careful observation
helps you adjust
nursing actions to
meet patients needs

2. Perform the prescribed

treatment for the underlying
condition. Monitor patients
progress and report favorable
and adverse responses

Applying therapy
consistently aids
patients
independence

3. Provide assistive devices

at each meal as needed

This allow patient to do

as much as possible
for self

4. Encourage patient to do as
much for self as possible,
giving simple instructions one
at a time

To aid comprehension

5. Consult with physician with

physical/occupational
therapist

Provides expert
assistive for
developing therapy
plan and identifying
special equipment.

Nursing Diagnosis

Nursing Interventions:

Rationale

Rationale
24

Ineffective Tissue Perfusion

related to interruption to
blood flow

1.Elevate head of bed and

maintain head/neck in midline
or neutral position
2. Keep environment and
patient quiet, space nursing
interventions
3. Maintain adequate nutrition

4. Administer diuretics such

as mannitol as ordered

5. Administer supplemental
oxygen as indicated

To promote
circulation/venous
drainage
This measures reduce
intracranial pressure
To promote tissue
healing, oxygenation
and metabolism
Mobilizes excess fluid
oliguric renal failure or
edema and prevents
ICP
Reduces hypoxia
which can cause
cerebral vasodilation
and increase
pressure/edema
formation

B. ACTUAL NURSING CARE PLAN

S

Dili nako malihok ako tuo nga tiil og kamot as verbalized by the patient.

>weakness in the lower and upper right extremities

>cant perform ADLs
>limited range of motion
>slowed movements

Impaired physical mobility related to hemiparesis Right

Long term: At the end of 2weeks of nursing interventions, patient will be

able to move freely without assistance
Short term: At the end of 1 day nursing interventions, patient can move
slowly with assistance

>Assess affected area

>Instructed patient to perform deep breathing and coughing exercises.
>Placed patient in semi-fowlers position
>Encouraged passive ROM on the affected area and active ROM
exercises on the affected area
>Encouraged adequate rest periods.
>Encouraged frequent turning on to the sides
Collaborative:
>Consult Physical therapist for rehabilitation

Goals partially met.

25

Kapoy pa ako gibati di man pud ko makalihok ug tarong as verbalized by the

S patient.
O >PR: 56 bpm
>BP: 150/100 mmHg
>fatigue
A Activity Intolerance related to immobility and weakness
P Long Term: At the end of 8 hours of nursing interventions, patient will report
measurable increase in activity intolerance.
Short term: At the end of 30 minutes of nursing interventions, patient will
demonstrate a decrease in physiological signs of intolerance
I

>Assess patients ability to perform normal tasks noting reports of weakness,

fatigue and difficulty accomplishing tasks
>Elevate head of the bed as tolerated
>Recommend quiet atmosphere; bed rest if indicated.
>Suggest patient change position slowly; monitor for dizziness
>Plan activity progression with patient, provide assistance with activities

E Long Term: At the end of 8 hours of nursing interventions, patient was able to
report increase in activity intolerance. Thus, goal met.

Short Term: At the end of 30 minutes of nursing interventions, patient was able to
demonstrate a decrease in physiological signs of intolerance. Thus, goal met.

S Taas gihapon usahay ako BP as verbalized by the patient.

O BP: 130/100 mmHg
Stress
Inactivity
A Decreased cardiac output related to malignant hypertension as manifested by
decreased volume
P Long term: At the end of 5 days nursing interventions patient will be able to
maintain adequate cardiac output and cardiac index
Short term: At the end of 6 hours nursing interventions patient will be able to have
no elevation in blood pressure above normal limits and will maintain blood
pressure.
I

>BP monitored every 1-2 hours

> Encouraged position changes every 2 hours
> Encouraged patient to decreased intake of caffeine, cola and chocolates

26

HEALTH TEACHINGS

Encouraged to comply all medications

MEDICATIONS

Encouraged to take medication on right timing

with right dosage.

Encouraged SO to do passive and active range of

EXERCISE

motion for 30 minutes to promote circulation

Gradually encouraged to do normal daily activities
Taught the importance of proper hygiene
Encouraged SO to do warm compresses n he affected
part

TREATMENT

Instructed the importance of adequate rest periods

and sleep periods.
Instructed to avoid smoking
Instructed lifestyle modifications.
Advised to have followed up check-up on at the

OUTPATIENT
(check-up)

outpatient department, @ CESH to check for any

complications 1 week upon discharge.
Encouraged to avoid high fat, high salt diet such as
pork, beef, fried foods, balut, and instructed to take
green leafy vegetables such as kang kong, cabbage,

DIET

and etc.
Encouraged to eat foods high in fiber like pineapple,

papaya, cereals, pechay, and etc.

Encouraged adequate fluid intake.

VIII. REFERRALS AND FOLLOW-UP

27

The Clients recovery greatly depends on the interventions provided by the health
care team and the willingness of the patient to understand and participate in the
management of the illness. As a student nurse it doesnt end in the hospital premises.
Discharge instructions must be given to the client and family to ensure compliance of
drug regimen and comprehension of instructions.
For more or better promotion and restoration of the patients health status, the
patient should be referred to a nearby and accessible health care facility or hospital and
for further assessment, consultation and management; the patient is referred to CESH.
Instructions were also made regarding the clients follow- up medical check- up
scheduled 1 week after discharge @ Camp Evangelista Station Hospital outpatient
department .This is to monitor and ensure the clients recovery and improvement of
health status.

IX. EVALUATION AND IMPLICATIONS

At the end of the study the researcher was able to attain the goals that have set
from the start of this study. Thorough gathering of data by means of physical
assessment was met and through the gathered data I was able to identify some health
problems and I was able to skillfully formulate nursing care plan that I had applied to our
patient in actual. By means of reviewing, discussing and elaborating the affected
anatomy and physiology of the body enables me to create interventions that could
alleviate pain and any discomforts experienced by the patient. With the help of the
patient's family, I was able to explore part of the patient's personality that also helps me
in creating interventions appropriate for him.
Cerebrovascular accident or stroke (also called brain attack) results from sudden
interruption of blood supply to the brain, which precipitates neurologic dysfunction
lasting longer than 24 hours. This condition is preventable by means of healthy lifestyle,
diet modifications, exercise and regular check ups. We all know that this disease is life
threatening thats why in order to prevent this we should be careful and responsible of
what we do.
Lastly, the researcher was also grateful for having the opportunity to have the
case study for she, not only gain knowledge but also enhanced her skills in the field of
nursing by means of planning interventions and rendering care to the patient. The
researcher was hoping that the readers would be more conscious and be more careful
in taking care of their health to prevent conditions to persist.
X. BIBLIOGRAPHY
28

BOOKS

The Lippincott Manual of Nursing 8th edition, Lippincott Williams & Wilkins

Medical-Surgical, Brunner and Suddart 11th Ed., Respiratory Function and Gas
Exchange/pneumonia, pp 1347-1355, 1347-1348
NURSES POCKET GUIDE. Diagnoses, Prioritized Interventions, and Rationales
by Marilynn E. Doenges , Mary Frances Moorhouse, and Alice C. Murr,
Kozier, B. et al. Fundamentals of Nursing Concepts. Process and Practices. 11th
edition. Upper Saddle, New Jersey, 2007.
Mosbys Drug Guide for Nurses, 8th edition
Nursing Care Plans, Nursing Diagnosis and Intervention 6 th Edition, by
Gulanick /Myers
Psychiatric Nursing, made Incredibly Easy, Lippincott Williams & Wilkins pp. 58

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