INTRODUCTION

DEFINITION Cerebrovascular accident, also called stroke, is the infarction (death) of a specific portion of the brain due to insufficient blood supply. Stroke can occur from an occlusion (blockage) of one of the major vessels feeding the brain, a partial or complete obstruction of a major intracranial vessel, or hemorrhage within the brain. The blood vessel affected determines the area and extent of infarction. TYPES OF STROKE I. ISCHEMIC STROKE  In an ischemic stroke (approximately 80% of strokes), a blood vessel becomes occluded and the blood supply to part of the brain is totally or partially blocked. Division: a. Thrombotic stroke  In thrombotic stroke, a thrombus-forming process develops in the affected artery. The thrombus a built-up clot gradually narrows the lumen of the artery and impedes blood flow to distal tissue. These clots usually form around atherosclerotic plaques. Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower. A thrombus itself (even if nonoccluding) can lead to an embolic stroke if the thrombus breaks offat which point it is then called an "embolus."  It can be divided into two types depending on the type of vessel the thrombus is formed on: a. Large vessel disease involves the common and internal carotids, vertebral, and the Circle of Willis. b. Small vessel disease involves the intracerebral arteries, branches of the Circle of Willis, middle cerebral artery, stem, and arteries arising from the distal vertebral and basilar artery. b. Embolic stroke  Embolic stroke refers to the blockage of arterial access to a part of the brain by an embolusa traveling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a blood clot, but it can also be a plaque broken off from an atherosclerotic blood vessel or a number of other substances including fat (e.g., from bone marrow in a broken bone), air, and even cancerous cells.  It can be divided into four categories: a. those with known cardiac source b.those with potential cardiac or aortic source (from transthoracic or transesophageal echocardiogram) c. those with an arterial source d. those with unknown source c. Systemic hypoperfusion (Watershed stroke)  Systemic hypoperfusion is the reduction of blood flow to all parts of the body commonly due to cardiac pump failure from cardiac arrest or arrhythmias, or from reduced cardiac output as a result of myocardial infarction, pulmonary embolism, pericardial effusion, or bleeding. Hypoxemia (low blood oxygen content) may precipitate the hypoperfusion.  Because the reduction in blood flow is global, all parts of the brain may be affected, especially "watershed" areas --- border zone regions supplied by the major cerebral arteries. Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur. This

phenomenon is also referred to as "last meadow" to point to the fact that in irrigation the last meadow receives the least amount of water. II. HEMORRHAGIC STROKE  A hemorrhagic stroke or cerebral hemorrhage occurs when a blood vessel in the brain ruptures or bleeds.  It interrupts the brain's blood supply because the bleeding vessel can no longer carry the blood to its target tissue. In addition, blood irritates brain tissue, disrupting the delicate chemical balance, and, if the bleeding continues, it can cause increased intracranial pressure which physically impinges on brain tissue and restricts blood flow into the brain. In this respect, hemorrhagic strokes are more dangerous than their more common counterpart, ischemic strokes.  It can be due to: a. Intracerebral hemorrhages This is bleeding inside the brain. The symptoms and prognosis of an intracerebral bleed vary depending on the size and location of the bleed. b. Subarachnoid hemorrhages This is bleeding between the brain and the membranes that cover the brain. c. Subdural hemorrhages This is bleeding between the layers of the brains covering (the meninges) d. Epidural hemorrhages This is bleeding between the skull and the covering of the brain. SIGNS and SYMPTOMS Types of Stroke   Ischemic strokes usually only affect regional areas of the brain perfused by the blocked artery. Hemorrhagic strokes can affect local areas, but often can also cause more global symptoms due to bleeding and increased intracranial pressure. Loss of consciousness, headache, and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing on the brain.

Areas of the brain affected  If it contains one of the three prominent Central nervous system pathwaysthe spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include: a. hemiplegia and muscle weakness of the face b. numbness c. reduction in sensory or vibratory sensation In most cases, the symptoms affect only one side of the body. The defect in the brain is usually on the opposite side of the body (depending on which part of the brain is affected). However, the presence of any one of these symptoms does not necessarily suggest a stroke, since these pathways also travel in the spinal cord and any lesion there can also produce these symptoms. A stroke affecting the brainstem therefore can produce symptoms relating to deficits in these cranial nerves: a. altered smell, taste, hearing, or vision (total or partial) b. drooping of eyelid (ptosis) and weakness of ocular muscles c. decreased reflexes: gag, swallow, pupil reactivity to light

d. decreased sensation and muscle weakness of the face e. balance problems and nystagmus f. altered breathing and heart rate g. weakness in sternocleidomastoid muscle with inability to turn head to one side h. weakness in tongue (inability to protrude and/or move from side to side)  If the cerebral cortex is involved, it can produce the following symptoms: a. aphasia (inability to speak or understand language from involvement of Broca's or Wernicke's area) b. apraxia (altered voluntary movements) c. visual field defect d. memory deficits (involvement of temporal lobe) e. hemineglect (involvement of parietal lobe) f. disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe) If the cerebellum is involved, the patient may have the following: a. trouble walking b. altered movement coordination c. vertigo and or disequilibrium If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.

RISK FACTORS         High blood pressure. Heredity (family history). Obesity. Prior stroke. Male sex. Diabetes mellitus. Carotid artery disease. Excessive alcohol intake Certain kind of drug abuse.

DIAGNOSIS y y y y Neurological examination A CT scan can make an immediate diagnosis especially of hemorrhagic strokes A MRI may be performed, but usually is done for 2-3 days. Laboratory: A. Complete blood count, Blood glucose, sedimentation rate, PT, PTT, Lipid (cholesterol) profile. B. If a hypercoaguable (blood clots too easily) is suspected, then the lupus anticoagulant, and anticardiolipin antibodies are examined. Blood cultures are checked if endocarditis (heart infection) is suspected. y y y y An EKG can rule out a cardiac problem Pulse oximetry to check blood oxygenation Cardiac monitoring to rule out an arrythmia Echocardiogram (or Transesophageal echo)to check for blood clots on the heart valve.

TREATMENT y Ischemic Stroke: 1. If treatment can be started within 3 hours of the first symptom, then thrombolytic therapy ("clot breaking drug") with Altepase may be considered as an option 2. Low doses of intravenous heparin is sometimes an option 3. Supportive measures may be considered as an option 4. Blood pressure is cautiously controlled (Lowering blood pressure too much may cause another Stroke to occur) y Hemorrhagic Stroke: 1. Supportive measures only. All blood thinning medications will make a Stroke worse, and therefore need to be avoided. 2. Correct any bleeding problems. Again, blood pressure is controlled very cautiously.

PATIENTS PROFILE
            Name: Home Address: Age: Date of Birth: Place of Birth: Nationality: Religion: Gender: Civil Status: Chief Complaint: Attending Physician: Diagnosis: S2K Maraburab, Alcala 53 years old October 6, 1954 Maraburab, Alcala Filipino Roman Catholic Female Married Dizziness Dr. Amparo Quintos Cerebrovascular Accident

NURSING HEALTH HISTORY

Family History  Client S2Ks mother and siblings have history of hypertension.

Past Medical History  Client S2K experienced cough and colds and fever during her childhood. She did not have any serious medical problems in the past. She also had chicken pox during her childhood.

History of Present Illness  Last May, the client experienced dizziness. The SO stated that the dizziness started when the client ate fried birds and fried carabaos meat. Her husband brought her to a clinic located at Centro, Alcala. The doctor gave her some medications. The names of which can no longer be recalled by her daughter. After some time, she did strenuous activities at their house. Because of this, four days after her check- up at the hospital of Alcala, she suddenly fell at the ground while sitting and conversing with her husband and grandchildren. The husband then brought her immediately at Cagayan Valley Medical Center (CVMC) where she was confined for three weeks under Dr. Amparo Quintos. She undergone CT scan and was diagnosed to have cerebrovascular accident (CVA).

GORDONS TYPOLOGY OF 11 FUNCTIONAL HEALTH

1. HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN Before:  Ang kalusugan ay napakaimportante sa buhay ng tao, as verbalized by the SO. She also stated that if you are unhealthy, you couldnt perform very well the activities of daily living. After:  According to the SO, she regularly takes medicines as prescribed by her doctor. She had a routinely exercise to promote good circulation. 2. NUTRITION/METOBOLIC PATTERN Before:  Mahilig siyang kumain ng pritong ibon at karne ng kalabaw, as verbalized by the SO. The patient eats 1-2 cups of rice every meal three times a day. She drinks 6-8 glasses of water a day. The SO further stated that the patient has no food allergies. The patient drinks 1 bottle of liquor (Ginebra: San Miguel) every day before meals to increase appetite. After:  The clients appetite didnt change according to the SO. However, she swallows and chews slower compared before due to her condition. According to the SO, the patients body reduced in size. 3. ELIMINATION PATTERN Before:  According to the SO, the patient voids 4-6 times a day (700-1000mL). Her urine color is yellow with no foul odor. She defecates twice a day with a brown colored stool. Patient had no difficulty in voiding and defecating. She drinks 6-8 glasses of water with two glasses every after meal. After:  Tumatae at umiihi siya kung saan ang kinalalagyan niya, as verbalized by the SO. Her stool is still brown in color. She sweats minimally. She still voids 4-6 times a day (700-1000mL) with a yellow color of urine. She still drinks 68 glasses of water a day with two glasses every after meals. 4. ACTIVITY/EXERCISE PATTERN Before:  According to the SO, the patient was a plain housewife. She goes to the mountain to gather fire woods and fruits. She usually do cooking, laundry, and cleaning their house. After:  Kami na lang ang nagpapaligo sa kanya dahil hindi na siya masyadong nakakagalaw, as verbalized by the SO. The pt. is being assisted when she is being transferred from a chair to a duyan. Her body movements became limited, restricted and can only move her body a little when she gets up with the aid of simple assistance. Her grandchildren lift the affected part of the patient but sometimes she resists such. The unaffected part is still able to function normally as when he eats with a spoon. 5. SLEEP/REST PATTERN Before:

 According to the SO, the patient sleeps from 7 in the evening and wakes up 3 in the morning. She has no sleeping disorders and takes no sleeping pills. SO further stated that pt. takes a nap in the afternoon for 20-30 minutes. After:  According to the SO, the pt. still sleeps at 7 in the evening and wakes up 3 in the morning. She also sleeps in the afternoon for 30 mins to 2hrs. 6. COGNITIVE/PERCEPTUAL PATTERN Before:  According to the SO, the patient finished grade three. She is able to understand Tagalog and Ilocano. She speaks Ilokano fluently. She is literate. The SO also stated that she has no speaking and talking difficulties and the patient is also oriented to time, space and person. After:  The pt. has already difficulty in talking. 7. ROLE/RELATIONSHIP PATTERN Before:  According to the SO, the pt. lives with her husband and a grand son in their house. She has a good relationship with her husband and kids. She takes good care of her family. She meets with her friends in the afternoon to do bonding with a simple drinking session. After:  Binibisita siya ng kanyang mga anak at sila na mismo ang bumibili ng kanyang gamot at kapag siya ay nauubusan ang kanyang anak na din mismo ang pumupunta sa klinika para kumaha ng libreng gamot, as verbalized by the SO. The pt. can no longer perform her major roles as a mother and a wife. 8. SELF- PERCEPTION/SELF CONCEPT PATTERN Before:  According to the patient, she sees herself as a good mother and a loving wife. She is very sensitive to the needs of her family. She is even very proud of her self because two of her children is working abroad.

After:  According to the patient, she has already accepted her present status but she sometimes became irritable. She also became dependent on her husband and children.

9. SEXUAL/REPRODUCTIVE PATTERN Before:  According to the SO, the patient had her menopause at the age of 48. The pt. had five normal spontaneous deliveries at home. She has no reproductive dysfunctions and disorders however she was ligated after the birth of her fifth child. After:  According to the SO, she has no sexual contact with her partner. She and her husband stay in one room but in separate beds. 10. COPING/STRESS MANAGEMENT PATTERN Before:

 According to the SO, the pt. just does household chores whenever she has problems. Her husband is counseling her. Her grandchildren are entertaining her. After:  According to the SO, the pt. just cries whenever she has problems. 11. VALUE/BELIEF PATTERN Before:  According to the SO, the patient believes in supernatural powers kulam. She also believed in albularyo and herbal plants to treat some of her illnesses. She is a Roman Catholic and goes to church 2-3 times a month. After:  According to the SO, the patient dont attend church gathering anymore due to her condition. SO further stated that the pt. still continue to pray and believe in Christ despite of her condition.

ANATOMY AND PHYSIOLOGY

Nervous System the human nervous system differs from that of other mammals chiefly in the great enlargement and elaboration of the cerebral hemispheres. Much of what is known of the function of the brain is derived from observations of the effects of disease or by analogy with the results of experimentation on animals, particularly the monkey. Such sources of information are clearly inadequate for the elucidation of the nervous activity underlying many properties of the human brain particularly speech and mental processes. It is not surprising therefore, that knowledge of the functions of this uniquely complex system, although rapidly expanding is far fro complete. Divisions of Nervous System: *Central Nervous System (CNS): The central nervous system is that part of the nervous system that consists of the brain and the spinal cord. Spinal Cord It connects a large part of the peripheral nervous system to the brain. Information (nerve impulses) reaching the spinal cord through sensory neurons are transmitted up into the brain. Signals arising in the motor areas of the brain travel back down the cord and leave the motor neurons. The Brain The largest divisions of the brain, the cerebrum, consist of two sides, the right and left cerebral hemispheres, which are interconnected by the corpus callosum. The two hemispheres are twins, each with centers of receiving sensory (afferent) information and for initiating motor (efferent) responses. The left side sends and receives information to/from the right side of the body, and vice versa. Various intellectual functions are concentrated in either the left or right hemispheres. Cerebrum The largest divisions of the brain, the cerebrum, consist of two sides, the right and left cerebral hemispheres, which are interconnected by the corpus callosum. The two hemispheres are twins, each with centers of receiving sensory (afferent) information and for initiating motor (efferent) responses. The left side sends and receives information to/from the right side of the body, and vice versa. Various intellectual functions are concentrated in either the left or right hemispheres. The four lobes perform specific functions: 1. Frontal lobe controls fine movements (Betz cells/upper motor neuron) and smell. Also, center for abstract thinking, judgment and language (left hemisphere). 2. Parietal lobe coordinates afferent information dealing with pain, temperature, form, shape, texture, pressure, and position. Some memory functions are also found here. 3. Temporal lobe handles dreams, memory, and emotions. Center for auditory function. 4. Occipital lobe governs vision Cerebellum

The cerebellum is the second largest brain structure, sits below the cerebrum. Like the cerebrum, the cerebellum has an outer cortex of gray matter and two hemispheres. It receives/relays information via the brain stem. The cerebellum performs three major functions, all of which have to do with skeletal muscle control: Function summary: y Balance/equilibrium of the trunk y Muscle tension, spinal nerve reflex, posture and balance of the limbs y Fine motor control, eye movement. (incoming information is transferred fro the cerebral via the pons. Outgoing information goes back to the cortex via the thalamus.) Diencephalon The diencephalon, located between the cerebrum and the midbrain, consists of several important structures, two of which are: y Thalamus: large, bilateral (right thalamus/left thalamus) egg-shaped mass of gray matter serving as the main synaptic relay center. Receives/relays sensory information to/from the cerebral cortex, including pain/pleasure centers. Hypothalamus: a collection of ganglia located below the thalamus and intimately assocoated with the pituitary gland . It has a variety of fuctions: senses changes in the body temperature; controls autonomic activities and hence regulates the sympathetic and parasympathetic nervous systems; links to the endocrine system/ controls the pituitary gland; regulates appetite; functions as part of the arousal or alerting mechanisms; and links the mind(emotions) to bodysometimes, unfortunately, to the degree of producing phychosomatic disease.

Function summary:  Voluntary movement/ motor integration  Perception/ sensory/ mind-body integration  Temperature  Appetite Brain Stem The medulla oblongata, pons and midbrain (mesecephalon or cerebral pedoncles)often referred to collectively as the brainstem Controls the most basic life fucntions. Of this three, the medulla is the most important. In fact, so vital is the medulla to survival that decreases or injuresnaffecting it often prove fatal. All fuctions of the brain stem are bassociated with cranial nerves IIIIVM

Fuction summary:  Breathing/respiration (pons, medulla)  Heart rate action (medulla)  Blood pressure (vasoconstriction)  Blood vessel dfiameter (medulla)  Reflex centers for pupillary reflexes and eye movement(midbrain, pons)  For vomiting, coughing, sneezing, swallowing and hiccuping(medulla) Blood Supply An intricate arterial structures supplies the brain with oxygen-rich blood. At the brain stem, the two vertebral arteries, entering through the cervical vertebrae, join to form

basilar artery. The basilar artery along with two inter carotid arteries, entering through holes at the base of the skull, interconnect at the Cente of Willis. From here, the anterior and middle cerebral arteries arise; the posterior cerebral artery arises from the basilar system

PERIPHERAL NERVOUS SYSTEM The peripheral nervous system (PNS) is one of the major divisions of nervous system. The pther is the central nervous system(CNS) which is made up of brain and spinal cord. Somatic Nervous System -controls skeletal muscle as well as external sensory organs such as the skin. This system is said to be voluntary because the responces can be controlled consciously. Reflex reaction of the skeletal muscle however are exception. These are involuntary reaction to external stimuli. Autonomic Nrevous System -controls involuntary muscle, such as smooth and cardiac muscle. This system is also called involuntary nervous system.. It can be divided into the parasympathetic and sympathetic nervous system division. Parasympathetic Division -controls various functions which include inhibiting heart rate, constricting pupils, and contracting the bladder. The nerves of the sympathetic division often have opposite effect when they are located within the same organ such as parasympathetic nerves. Nerves of the sympathetic division speed up heart rate, dilate pupils and relax the bladder. The sympathetic system is also involved in the flight or fight rewsponce. This is a response to a potencial danger that results in accelerated heart rate and increase in metabolic rate.

CRANIAL NERVES: The 12 pairs of cranial nerves are traditionally abbreviated by the corresponding Roman Numerals. Tey are numbered according to where their nuclei lie in the brain stem, e.g. Cranial Nerve III (the oculomotor nerve) leaves the brain stem at the higher position the Cranial Nerve xii, whose origin is located more caudally (lower) than the cranial nerve. # 0 Name Cranial nerve 0 (CN0) is not traditionally recognized Olfactory nerve Optic nerve Oculomotor nerve Nuclei Function Olfactory trigone, Still controversial medial olfactory gurus, and lamina New research indicates CN0 may play a termonali role in the detection of pheromones. Anterior olfactory nucleus Lateral geniculate nucleus Oculomotor nucleus, EdingerWestphal nucleus Transmits the sense of small; located in olfactory foramina of ethmoid Transmits visual information to the brain; located in the optic canal Innervates levator palpebrae superioris, superior rectus, medical rectus, inferior oblique, which collectively perform most eye movements; located in superior orbital fissure Trochlear nucleus Innervates the superior oblique muscle, which depresses,pulls laterally, and intorts the eyeball; Located in superior orbital fissure

I II III

IV

Trochlear nerve

Trigeminal nerve

VI

Abducens nerve

Principal sensory trigeminal nucleus, Spinal trigeminal nucleus, mesencephalic trigeminal motor nucleus, trigeminal motor nucleus Abducens nucleus Facial nucleus, solitary nucleus, superior salivary nucleus

Receives sensation from the face and innervates the muscles of mastication; Located in superior orbital fissure (ophthalmic branch),foramen rotundum(maxillary branch).and foramen ovale (mandibular branch)

VII

Facial nerve

VIII Vestibulocochlear Vestibular nuclei, nerve cocchlear nuclei

IX

Glossopharingeal nerve

Nucleus ambiguus, inferior salivary nucleus, solitary nucleus

Vagus nerve

XI

Accessory nerve

XII

Hypoglosssal nerve

Nucleus ambiguus, dorsal motor vagal nucleus, solitary nucleus Nucleus Motor to 2 neck and upper back muscles; ambiguus, spinal swallowing and speech accessory nucleus Hypoglossal Motor to tongue muscles nucleus

Innervates the lateral rectus, which abducts the eye;Located in superior orbital fissure Provides motor innervation to the muscles of facial expression and stapedius,receives the special sense of tasts from the anterior 2/3 of the tongue, and provides secretomtor innervation to the salivary glands(except parotid)and the lacrimal mastoid gland; Located and runs through internal acoustic canal to facial canal and exits at stylomastoid foramen Senses sound ,rotation and gravity(essential for balance and movement;Located in internal acoustic canal Receives taste from the posterior 1/3 of the tongue,provides secretomtor innervation to the parotid gland,and provides motor innervation to the stylopharyngeus(essential for tactile ,pain, Sensory to pharynx, larynx, and viscera; motor to palate, pharynx, and larynx; parasympathetic to viscera of thorax and abdomen.

DRUG STUDY
Generic Name: Metoprolol Tartrate Brand Name: Lopressor Classification: Beta-blocker Dosage and Route:
y Adults: Initially, 50 mg P.O. b.i.d. or 100 mg P.O. once daily

Action: Unknown. A selective beta blocker that blocks bate1 receptors; decreases
cardiac output, peripheral resistance, and cardiac oxygen consumption; and depresses rennin secretion.

Indication: Metoprolol is used to treat angina (chest pain) and hypertension (high
blood pressure). It is also used to treat or prevent heart attack.

Uses: Contraindication:
y y Contraindicated in patients hypersensitive to drug or other beta blockers. Contraindicated in patients with sinus bradycardia, greater than first-degree heart block, cardiogenic shock, or overt cardiac failure when used to treat hypertension or angina. When used to treat MI, drug is contraindicated to patients with heart rate less than 45 beats/minute, greater than first degree heart block, PR interval of 0.24 second or longer with first degree heart block, systolic blood pressure less than 100 mm Hg, or moderate to severe cardiac failure. Use cautiously in patients with heart failure, diabetes, or respiratory or hepatic disease. Contraindicated to pregnant or planning to become pregnant women.

y y

Side Effects: y CNS: fatigue, dizziness, depression y CV: hypotension, bradycardia, heart failure, edema y GI: nausea, diarrhea y Respiratory: dyspnea y Skin: rash Nursing Implications: y Always check patients apical pulse rate before giving drug. If its slower than 60
beats/minute, withhold drug and call prescriber immediately. y In diabetic patients, monitor glucose level closely. y Monitor blood pressure frequently. y Look alike-sound alike: dont confuse metoprolol with metaproterenol or metolazone. Dont confuse Toprol-XL with Topamax, Tegretol, or Tegretol-XR.

NURSING CARE PLAN ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE

Subjective data: hindi niya kayang igalaw ang kanang bahagi ng katawan, as verbalized by the S.O.

Impaired physical mobility related to musculoskeletal impairment as evidence by inability to move purposefully within physical environment.

At the end of the shift, the patient will be able to increase strength of affected and/or compensatory body parts.

 Encourage and facilitate early ambulation and other ADL when possible. Assist with each initial change: dangling, sitting in chair, and ambulation.  Keep side rails up and bed in low position.

 To promote optimal range of motion.

Objective data:  limited range of motion  decreased reaction time  reluctance to attempt movement  functional level classification= 4

 To promote safe environment.

 Maintain limbs in functional alignment. Support feet in  To prevent footdrop and/or dorsiflexed position and use excessive plantar flexion or bed cradle. tightness.  Perform passive/active assistive ROM exercises to all extremities.

 To promote increased venous return, prevent stiffness, and maintain muscle strength and endurance.  To drain bronchial tree.

 Turn patient to prone or semiprone position once daily unless contraindicated.

 Encourage coughing and deep breathing exercises. Use suction as needed.  Encourage liquid intake of 2000-3000 ml/day unless contraindicated.

 To prevent build up of secretions.

 To optimize hydration status and prevent hardening of stool.

ASSESSMENT Objective:-Slurred speech -Difficulty in expressing self

DIAGNOSIS Impaired verbal communication related to alteration of central nervous system and weakening of the musculoskeletal system.

PLANNING At the end of 3 days, the client will be able to establish method of communication in which needs can be expressed.

INTERVENTION Determined ability to read and write.

RATIONALE This will assist client to establish means of communication to express needs, wants, ideas and questions. This will establish good communication.

Established relationship with the client by listening carefully and attending to clients verbal and nonverbal expressions. Maintained calm and provided sufficient time for client to respond.

 Client can talk easily when they are rested and relaxed and when they are talking to one person at a time. To ease anxiet y and establish a means o f communicat ion. To lessen anxiet y.

Maintained eye contact preferably at clients level. Provided calm environment when talking with the client.

ASSESSMENT Subjective data: Ako na ang nagpapalit ng damit niya, at naglilinis ng katawan niya as verbalized by the SO. Objective: Right sided hemiphlegia poor grooming

DIAGNOSIS Self care deficit: Dressing/grooming ,feeding ,toileting related to compression of major cerebral arteries secondary to cerebral ischemia.

PLANNING At the end of a month, the pt. will be able to achieve self-care or performs hygiene care using his unaffected area of the body.

INTERVENTION yAssessed functional activities in performing ADL.

RATIONALE ydetermines the assistance needed

y placed pt. things nearest to yencourages independence the unaffected area. and promotes self esteem yassisted pt. only when in need of help not all the time ytaught to put on clothing by first dressing the affected extremities and then dressing the unaffected extremities yinstructed SO to place in semi-fowlers position for feeding purposes and remain upright after. yencourages independence and promotes self esteem y strengthen muscles to aid in performing basic ADL ythis technique facilitates self dressing with minimal assistance y to prevent accidental aspiration

ASSESSMENT Objective:  Paralysis of the right part of the body

DIAGNOSIS Impaired Walking r/t insufficient muscle strength

PLANNING At the end of 3 weeks, the client will be able to move about within the environment as needed/desired within limits of activity.

INTERVERNTION  Assist with/ review results of mobility testing.

RATIONALE  For differential diagnosis and to guide treatment intervention  To identify behavioral and emotional deficits.

EVALUATION

 Determine clients ability to follow directions and note emotional/ behavioral responses that maybe affecting the situation.  Demonstrate use of help so that client become comfortable with adjunctive devices.  Provide assistance when needed.

 To facilitate mobility.

 To or at least improve impaired posture  To increase stamina/endurance .

 Encourage active and passive exercise. Instruct SO in safety measures as individually indicated.

ASSESSMENT Objective data:  Pt. has difficulties in talking.

DIAGNOSIS Impaired social interaction r/t communication barrier

PLANNING At the end of the 3 days duty, the patient will be able to develop effective social support system; use available resources appropriately.

INTERVENTION  Observed and described social/ interpersonal behaviors in objective terms, noting speech patterns, body language.  Determined clients use of coping skills and defense mechanisms.  Assisted the client to develop positive social skills through practice of skills accompanied by a support from the family.  Worked with the client to alleviate underlying negative self concepts.

RATIONALE  Helps identify the kinds and extent of problems client is exhibiting.

EVALUATION Goal met. The patient was able to express her needs and thoughts through body language.

 These affects ability of the client to be involved in social situations.  Provide positive feedback during interactions with the client

 Attempts at trying to connect with another can become devastating to self esteem and emotional wellbeing.

ASSESSMENT Subjective data: Kaunti na lang ang kinakain niya, hindi katulad ng dati, as verbalized by the SO. Objective data:  Her weight reduced from 51 kgs. to 46 kgs.

DIAGNOSIS Imbalanced Nutrition less than body requirements related to inability to ingest or digest food or absorb nutrients because of biological factors.

PLANNING At the end of 3 weeks, the patient will be able to demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.

INTERVENTION  Determine ability to chew, swallow and taste.

RATIONALE  These are the factors that can affect ingestion and digestion of nutrients.  To appeal to clients likes or desires.

EVALUATION

 Discuss eating habits including food preferences intolerances and aversions.  Assess weight, age, body build, strength, activity or rest level.  Note total daily intake.

 Provides comparative baseline  To reveal changes that should be made in clients dietary intake.  To enhance intake in food.

 Promote pleasant, relaxing environment including socialization.  Emphasize the importance of well balance nutritious intake.

 Ton provide information and to promote wellness.

PATHOPHYSIOLOGY OF CVA (CEREBROVASCULAR ACCIDENT)

Predisposing Factors: *Age *Gender *Genetic Factor Etiology Precipitating Factors: Sedentary Lifestyle Diet; Fatty Foods Excessive Alcohol Consumption Hypertension

Idiopatic

Formation of fatty streaks in arterial wall

Increase lipid accumulation in arterial wall

Formation of plaque

Restriction of expansion and contraction of arteries

Blood Stasis

Blood coagulability

Thrombus

Restriction/obstruction of blood flow

Sympatho-adrenal medullary response SNS Adrenal Medulla Norepinephrine Epinephrine Peripheral vasoconstriction Cool pale skin Cardiac workload Peripheral Resistance Blood volume perfusion RAA system is activated BP Vasoconstriction of systemic arterioles

Heart Rate Tachycardia

Stroke Volume Cardiac Output

Release of Aldosteron Na absorption Water Retention Hypertension

Oliguria

1
Continuous vascular resistance Minute vessel dilate

2
Stimulation of nociceptive neural receptor Nape pain

3
Prolonged hypoxia Cerebral ischemia Nervous tissue injury Triggers inflammatory response Vasodilatation redness and heat Vascular permeability Release of chemostatic agent Cerebral edema/ cytotoxic Compression of brain tissues ICP

Pressure on weakened vessel Rupture of hypertensive vessel

Tension and displacement of pain sensitive structures such as intracerebral vessel headache

Pressure on the vagal motor center Irritation of the vagal nerve in the floor of 4th ventricle Projectile vomiting Papillaedema and capillary changes Pressure on the optic nerve Interference in the normal nerve transmission Z1 Z2 Z3 Z4 Z5

Z1

Z2 Anoxia

Z3 Compression of the hypothalamus BT

Z4 Ischemia of vasomotor center in the medulla PR

Z5 Compensatory mechanism PR, systolic, widened pulse pressure

Compression of the vesicular formation of brainstem LOC

Tissue perfusion in the brain

B
Dislodging of blood clot Join cerebral circulation Embolism goes to cerebral circulation Occludes arterial blood flow on the brain Cerebral perfusion Ischemia Infarction of the left basal ganglion Loss of function of the affected part of the brain Fainting Restlessness

LOC

Contractile tone visible in the trunk and right extremities

Inability to maintain gait, balance, and posture

Nerve fiber cannot cross over the pyramidal tract Right sided hemiplegia

Sensory reaction

Decorticate posturing Upper extremities inhibits flexion

Decerebrate posturing Upper and lower extremities inhibits extension

D C
Lesions located in the posterior part of the frontal gyrus Water level in brain tissues Alteration of cortex and subcortal association Altered speech pattern Fluent speech but no meaning Poor comprehension of speech Lack awareness of deficit Difficulty with choice of words Lesion in the posterior half of the dominant hemisphere angular gyrus and supra marginal gyrus

Unable to utter a Difficulty with word articulation of words

Not fluent

Awareness

PHYSICAL ASSESSMENT
Date Assessed: July 2, 2008 Initial Vital Sign: Height: 53 BP: 130/80mmHg Weight: 46 PR: 72 bpm BMI: 21 RR: 18 cpm T: 37 oC General Appearance: Weak, Conscious and Coherent METHOD USED Inspection Inspection/ Palpation Palpation Palpation NORMAL FINDINGS Deep brown Smooth Normally warm Moist to dry ACTUAL FINDINGS Brown Smooth Normal skin temperature Moist to dry EVALUATION

AREA ASSESSED SKIN - Color - Texture - Temperature - Moisture

Normal Normal Normal Normal

HAIR - Distribution - Texture - Color

Inspection Palpation Inspection

Evenly distributed Silky; resilient Black

Evenly distributed Silky Black with white hair

Normal Normal d/t aging

NAILS - Color of the Inspection nail-bed Palpation - Capillary refill Palpation time - Shape HEAD EARS Inspection Shape - Symmetry and Inspection position EYES - Hair distribution Inspection PUPILS Inspection - Color Inspection - Shape - Ocular movement Inspection

Pink transparent Delayed (2-3 sec) Convex

Pink transparent Delayed 2 sec Convex

Normal Normal Normal

Auricles are at Auricles are at Regular Regular level of each other level of each other

Normal Normal

Evenly distributed Black Round and regular in shape Both eyes Both eyes move parallel with move parallel each other in with each other directions of gaze in directions of gaze

Evenly distributed Black Round and regular in shape

Normal Normal Normal

Normal

EXTERNAL AUDITORY CANAL - Hearing

Inspection

Hears equally in both ears

Slight deafness on the right ear

d/t stroke

NOSE - Symmetry - Color

Inspection Inspection

Symmetrical Same color as the face and skin

Symmetrical Normal Same color as Normal the face and skin

LIPS AND MOUTH Inspection - Symmetry Inspection - Color (lips) Inspection - Moisture NECK Palpation - Symmetry Inspection - Alignment of the trachea

Symmetrical Pink Moist

Symmetrical Pale Dry

Normal Due to decrease oxygen Due to hot environment Normal Normal

Symmetrical Symmetrical

Symmetrical Symmetrical

THORAX - Chest contour - Clavicle - Chest wall

Inspection Inspection Inspection/ Auscultation Auscultation

ABDOMEN - General contour

Symmetrical Prominent Absence of crackles upon auscultation Flat

Symmetrical Prominent Absence of crackles upon auscultation Flat

Normal Normal Normal

Normal

UPPER EXTREMITIES - Skin color - Size (arms)

Inspection Inspection

Light to deep brown Equal Size Symmetrical (+)ROM upon movement with no pain

Brown Equal Size

Normal Normal

- Symmetry - ROM

Inspection Inspection

Symmetrical (-) ROM at the right side of the body

Normal d/t numbness and weakness at the right side of the body

LOWER EXTREMITIES - Skin color - Size (legs) - Symmetry - ROM NEUROLOGIC Level of consciousness

Inspection Inspection Inspection Inspection

Interview

Light to deep brown Equal Size Symmetrical (+)ROM upon movement with no pain Can follow simple instructions and commands

Light to deep brown Equal Size Symmetrical (-) ROM at the right side of the body Can follow simple instructions and commands

Normal Normal Normal d/t numbness and weakness at the right side of the body Normal

CEREBELLAR FUNCTION -Muscle tone - Speech

Inspection Inspection

Maintain stability Cannot maintain d/t post stroke in posture posture d/t post stroke Clear and well Slurred speech pronounced words