CEREBROVASCULAR

ACCIDENT

CEREBROVASCUL
AR ACCIDENT

INTRODUCTION
Cerebrovascular accident: The sudden
death of some brain cells due to lack of
oxygen when the blood flow to the brain
is impaired by blockage or rupture of an
artery to the brain. A CVA is also
referred to as a stroke.

Symptoms of a stroke depend on the area of

the brain affected. The most common symptom
is weakness or paralysis of one side of the
body with partial or complete loss of voluntary
movement or sensation in a leg or arm. There
can be speech problems and weak face muscles,
causing drooling. Numbness or tingling is very
common. A stroke involving the base of the
brain can affect balance, vision, swallowing,
breathing and even unconsciousness.

The causes of stroke: An artery to the brain

may be blocked by a clot (thrombosis) which
typically occurs in a blood vessel that has
previously been narrowed due to
atherosclerosis ("hardening of the artery").
When a blood clot or a piece of an
atherosclerotic plaque (a cholesterol and
calcium deposit on the wall of the artery)
breaks loose, it can travel through the
circulation and lodge in an artery of the brain,
plugging it up and stopping the flow of blood;
this is referred to as an embolic stroke.

A blood clot can form in a chamber of the

heart when the heart beats irregularly, as in
atrial fibrillation; such clots usually stay
attached to the inner lining of the heart but
they may break off, travel through the blood
stream, form a plug (embolus) in a brain
artery and cause a stroke. A cerebral
hemorrhage (bleeding in the brain), as from
an aneurysm (a widening and weakening) of a
blood vessel in the brain, also causes stroke.

Stroke look-alikes: Just because a person has

slurred speech or weakness on one side of the
body does not necessarily mean that person has
had a stroke. There are many other nervous
system disorders that can mimic a stroke
including a brain tumor, a subdural hematoma (a
collection of blood between the brain and the
skull) or a brain abscess (a pool of pus in the
brain caused by bacteria or a fungus). Virus
infection of the brain (viral encephalitis) can
cause symptoms similar to those of a stroke, as
can an overdose of certain medications.

Treatment of a stroke: Early use of

anticoagulants to minimize blood clotting has
value in some patients. Treatment of blood
pressure that is too high or too low may be
necessary. (Lowering elevated blood pressure
into the normal range is no longer
recommended during the first few days
following a stroke since this may further
reduce blood flow through narrowed arteries
and make the stroke worse.)

NURSING HEALTH HISTORY

BIOGRAPHIC DATA

Name: Mrs. M A
Address: Omawas, Maydolong Eastern Samar
Age: 82 years old
Sex:
Female
Race:
Filipino
Marital Status: Married

Occupation: Housewife
Religious Orientation: Roman Catholic
Health Care Financing:
Phil health
Admitting Diagnosis: Cerebrovascular Accident

Admission Data
Chief Complaint:
Right sided body
weakness and numbness.
Date of Admission: January 20, 2012
Time of Admission: 6:15 pm

 Mode of Arrival:
Assisted by his son son
and daughter in law.
Attending Physician: Dr. Jessica
Sabalbarino, MD
(Chief of Clinics)

HISTORY OF PRESENT ILLNESS

MrsM A lives in Brgy Omawas, without a
husband and eight children. Her seven
children are now residing in manila, except
with her youngest son. Mrs. M is the fourth
sibling of her parent she has three sisters
and two brothers.

Prior to admission, according to her son, It was

a sunny afternoon Mrs. M was apparently well
lying in her bed until few hours, when she
suddenly felt dizzy while trying to get up and
fell down from her bed. Since then she felt
numbness of the whole eye, side of her body
with associated slurred speech and right sided
body weakness. He called his sister-in-law to
check for his mother, and his sister-in-law told
him that she had a sudden stroke and must
need to be brought in the hospital, and so they
did.

FAMILY HISTORY OF ILLNESS

According to Mrs. Ms son, they have no
history of neurologic disorder. He also said,
that his mothers uncle had heart attack,
there are also members of the clan that are
suffering from diabetes and hypertension.
Her father died from hypertension, her
mother from Diabetes Mellitus and her
brother of hypertension also.

All of her pregnancies were delivered at

home, NSVD. She doesnt have any prenatal
visits. She experienced lock jaw during her
7th delivery.

HISTORY OF HOSPITALIZATION
According to Mrs. Ms son there were no
history of hospitalization of his mother.

ENVIRONMENTAL HISTORY
Mrs. M is residing in Barangay Omawas,
Maydolong E. Samar. Their house is located
at the center of their barangay. It is made
up of concrete materials and is surrounded
with ornamental plants. The surroundings is
clean, and not crowded. They have manually
flushed toilet and is near the kitchen. Their
water supply for drinking, cooking, washing,
are taken from NAWASA.

Food preparation is usually prepared by her

son, they used to store their left over food
in their cabinet. The garbage collector is
primarily utilized in the collection of the
household, garbage.

PSYCHOSOCIAL HISTORY
Mrs. M is a Elementary graduate from
Omawas Elementary School. She is not
working anymore due to her age, but during
her 20s she used to work in their farm as
her source of living for 30 years. She work
from morning until afternoon, ranges from 67 hours. She used to socialized through
chatting with her neighbors.

She was married at the age of 19 and they

were blessed with 8 children. During her 20s
she occasionally drink alcoholic beverages,
and can consumed 1-2 bottles. She stopped
drinking during her 50s.
Mrs. M is doing the so-called Bittle- nut
chewing, shes been doing it for 60 years, 810 times per day. She likes to eat processed
foods(can goods, dried fish, and junk foods),
almost every other day.

PATTERNS OF FUNCTIONING
HEALTH PERCEPTION PATTERN
BEFORE HOSPITALIZATION
According to SO, she experienced weakness on
the right side of her body when she does some
household task . She manages it by having a
period of rest in bed. She is still uncomfortable
with her state of health because it greatly
affects her daily activities. She cannot perform
the things she likes and usually do.

Client believed that proper diet, exercises,

and adequate financial support are the things
needed to maintain proper health diet and no
vices are factors of having a healthy body.
She does not perform self-breast
examination. When signs and symptoms arise
they sought medical consultation once the
Physician prescribed her (neo-bloc) but they
were not able to maintain it, due to lack of
financial support. The client also believed in
albularyo and use herbal medicines such as
lagundi, guava leaves, pito-pito (7 different
kinds of leaves).

DURING HOSPITALIZATION
The client still feels right sided body
weakness

NUTRITIONAL AND METABOLIC PATTERN

PRIOR TO HOSPITALIZATION
The clients typical food intake is
composed of rice, vegetables, and fish.
Occasionally she eats meat. Shes fond of
eating processed food like corned beef,
anything with preservatives, and fried dish.
She used a lot fish sauce, MSG when cooking.
Her appetite was good and drinks 6 glasses
of water daily. She also does bittle-nut
chewing as part of her everyday hobby.

FOOD
INTAKE

FLUID
INTAKE

Breakfast

NGT (low salt, 1 glass of

low fat, low
water
cholesterol)

Lunch

NGT (low salt, 1 glass of

low fat, low
water
cholesterol)

Dinner

NGT (low salt, 1 glass of

ELIMINATION PATTERN
BEFORE HOSPITALIZATION
Client usually defecates at least 2-3 times
of soft and watery stool consisting of small
amounts which is light brown color, with
discomfort or difficulties and experienced
excessive sweating. Client urinates 6x a day
which is yellowish- orange color w/out any
discomfort.

Stool Characteristics
Color

Light brown

Consistency

Formed stool

Smell

Foul odor

Frequency and

Once a day

amount

Urine Characteristics
Color

Yellowish- orange

Smell

aromatic

Frequency and

6 times a day at

Amount

least 1000ml/day

DURING HOSPITALIZATION
Client usually defecate at least once
every 2 days semi formed stool which is
light brown to brown. She has difficulty in
defecation with excessive sweating.
Client was catheterized, her usual output
is 1500 ml per day.

Stool Characteristics
Color

Light

brown

to

Consistency

brown
Semi formed

Smell

Foul odor

Frequency and

Once every 2 days,

Amount

with little amount

Urine Characteristics
Color

yellow

Smell

aromatic

Frequency and

at

Amount

1500ml/day

least

ACTIVITY-EXERCISE PATTERN
BEFORE HOSPITALIZATION
The clients SO said that her activities at
home were limited because she has
experience high blood pressure and also due
to her age. She spends her days sitting on
their azotea, sewing, and doing the so-called
Bittle-chewing. She has difficulty walking
even in short distances due to her age and
body weakness.

DURING HOSPITALIZATION
Client shows tiredness and limited
movement. A client doesnt perform any
routine exercise. In the hospital the clients
significant others are instructed to assist
patient to perform ROM by the health care
provider.

SLEEP-REST PATTERN
BEFORE HOSPITALIZATION
The client sleeps for 8-9 hours usually
from 8pm-5am but not continuous because
of prompt abdominal pain. She doesnt take
any sleep medications. She takes naps
during afternoon. The client sleeps
inadequately at night. Clients usually watch
TV shows and do the so-called ma-ma.

DURING HOSPITALIZATION
The client was always asleep, and been
unconscious for several days.

COGNITIVE-PERCEPTUAL PATTERN
The client have hearing difficulty and
cant remember past events. She has a
visual problem far-sightedness. Through
demonstration she could easily learn things.
Abdominal pain is the one which alters her
comfort and she manages it with taking
prescribed medications (Zantac) and
assumes upright position.

SELF PERCEPTION AND SELF CONCEPT

PATTERN
The clients significant others said that
her condition was not improving; shes still
experiencing right sided body weakness and
high blood pressure. Financial problems and
health condition usually makes her worried.

ROLE-RELATIONSHIP PATTERN
The client lives in extended family. They
live peacefully even there are hardship and
difficulties that arrives to their lives. By
means of good conversation they can easily
fixed family problems. When family
experienced difficulty of caring for the
client they just take it as trials given by
god. They have harmonious relationships
with the family and their neighbors.

COPING STRESS TOLERANCE PATTERN

The client was observed to be withdrawn
but the behavior improved as evidenced by
her socialization with other people. When
things are not so well, her youngest son
takes thing over whos to be the most
helpful person. When big problems
encountered, she always prays and ask
assistance with the Lord. Some of the time
they failed to attain what they want and try
other alternatives in solving it.

VALUE-BELIEF PATTERN
The client is a Born Again Christian
usually goes to the church to attend mass
every Sundays. But she is not active in
participating religious activities

PHYSICAL ASSESSMENT and

REVIEW OF SYSTEM
January 24, 2012 - 1:33pm
Vital signs
Upon Admission
The clients pulse rate is 78 beats per
minute, his respiratory rate is 21 breaths
per minute, temperature is 38.1c, and blood
pressure of 210/130 mmHg.

January 21, 2012

January 23, 2012
T - 39.1
T -38.8
P - 82
P - 88
R - 24
R - 23
BP - 160/100
BP- 140/100
January 22, 2012
January 24, 2012
T - 38.2
T - 39.5
P - 79
P - 78
R - 25
R - 24
BP - 140/110
BP- 140/100

General appearance

The client is in medium frame, the

client is bedridden since she was admitted
to the hospital last January 20, 2012. Not
properly groomed and has no body odor. She
doesnt have any deformity. Weight: 210 lbs,
Height: 143 cm, BMI: 39.7
BMI Categories: Normal weight = 18.5
24.9, Overweight = 2529.9, Obesity = BMI
of 30 or greater

Mental status
The client has low level of consciousness
and uncooperative. The client cant talk
because she was stroke.

Skin
The clients skin is of normal racial tone
which is brown. It is dry and smooth. There
is presence of erythema on her lower back.
The skin turgor is wrinkled and loss of
elasticity. The body hair is evenly
distributed. She has a pitting type of edema
in her lower extremities, with a grade of 1+,
2mm. She has a skin lesion (warts) on his
right elbow, rough, shaped like a dome, and
gray-brown in color.

Nail
The clients nail shape is convex clubbing,
the nail is rough and the nail bed is pink.
The capillary refill is within 5 seconds and
there is an absence of beaus line.

Head and Face

The clients skull is proportionate to the
body size; there were no tenderness in the
scalp. There were no presence of nodules,
and infestation. Her hair is evenly
distributed and the strands are thin and
brittle. The color of her hair is a mixture of
white and black. Her head is round and
symmetrical its consistency is hard. Her
head and the shape of his face are round
and asymmetrical and its consistency is
soft.

Eyes
She cant move her eyes on her right
side; the eye brows are evenly distributed.
Eyelids have effectively closure. The blink
response is bilateral, eye balls are
symmetrical, bulbar conjunctiva is clear, the
palpebral conjunctiva is pink and the sclera
is white. The palpebral slant is aligning with
the tip of the pinna.

The corneal sensitivity reflex is present

cornea is transparent, the color of her eyes
are brown, the shape are equal, it is uniform
in color. Pupils are equal in size. Pupils are
equally round but are not equally reactive to
light and accommodation. She cannot
execute the occular movements. She cannot
recognize objects within 12-14 inches away.
The lacrimal apparatus are moist.

Ear
The color of the ear is of normal racial
tone which is brown, it is symmetrical. The
alignment of the pinna is symmetrical. The
pinnas are elastic and recoil when folded.
The mastoid process is tender. The
auditory canal contains some cerumen, the
color is brown and there is an absent of
discharges.

Nose
The color of the clients nose is of racial
tone which is brown. Her septum is in the
midline. The mucosa is pink, nostrils are
both patent, nasal flaring is absent.
Landmarks are visible. Sinuses are nontender. There is an NGT in his right
nostrils.

Mouth and Oropharynx

The lips is symmetrical and brown, the
consistency is smooth, buccal mucosa is pink,
the gum is pink, the tongue is in the midline,
the color is pink and it is smooth. The
tongue movements are not that smooth. Its
texture is rough. The color of the hard and
soft palate is pink. And it is intact. The
tonsils are inflamed grade of + 2. There is
presence of mucous and some residue of her
so-called ma-ma.

Uvula is in the midline, gag reflex is absent.

The teeth are incomplete . There are 30
tooth present, 2 molars are absent on both
side.

Neck
The neck is straight, no visible mass or lumps,
symmetrical. The neck has no movement,
the muscle strength 1/5. Head tilted to one
side (muscle weakness).

Chest and Lungs

The color of the chest is of normal racial
tone which is brown, the shape is AP to
lateral ratio 1:2. There is absence of
intercoastal retraction, costal angle is 45
chest wall are symmetrical, and the chest
expansion is symmetrical. Rib slope is less
than 90. Respiratory rhythm is irregular.
The respiratory depth is shallow.
Respiratory pattern is not normal. When
palpated he doesnt feel any tenderness.

The vocal fremitus is normal, tactile

fremitus is symmetrical. The lung expansion
is normal. When percussed the sound is
resonance. When auscultated adventitious
sound is present (crackles). No adrentition
sound. Respiratory rate is 21 breaths per
minute.

Heart
The rhythm is regular. PMI is located in
the apical pulse. Heart rate is 78 beats per
minute.

Abdomen
Skin is of normal racial tone which is
brown, the contour is flat. Peristalsis is nonvisible. The color of her stool is brown, it is
solid and formed. The bowel sound is normal
active and no bruits. When percussed the
sound is tympany. When palpated she has
tenderness and when deep palpation is done
muscle guarding is present. The liver is not
palpable.

Upper extremities
Muscle strength is 1/5 her right arm is
paralyze. She has a skin lesion in her right
elbow (warts), the peripheral pulses are
equal. Lympnodes are not palpable. The IV
site is in her left arm.
Lower extremities
Muscle strength is 1/5. She doesnt have
any deformity. The peripheral pulses are
equal. Lympnodes are non-palpable. Her
right leg is paralyze.

PHYSICAL EXAMINATIONS
Motor
Sensory
R
L
R
L
1/5
2/5 10%
70%

1/5

2/5 10%

70%

Mrs. M is suffering from left hemisphere

stroke that indicates weakness or paralyzed
of the right side of the body, where she
cannot move her left hand and left leg like
she moves before confinement and also the
left side of the brain damage that it cannot
think fast like before.

GLASGOW COMA SCALE

1

Eyes

Does
not
open
eyes

Makes
Verbal no
sounds

Opens
Opens
eyes
Opens
eyes
in
eyes
in
respon
sponta
N/A
respon
se to
neousl
se to
painful
y
voice
stimuli
Incom Utters
Oriented
Confus
prehe inappr
,
ed,
nsible opriat
convers
disorie
sound
e
es
nted
s
words
normally

Tota
l

Exten
sion
to
painf
Makes
ul
Mot
no
stimu
or movem
li
ents (dece
rebra
te
respo
nse)

Abnor
mal
flexio
n to
Flexion Locali
painf
/
zes
ul
Withdr painfu
stimu
awal to
l
li
painful stimul
(deco
stimuli
i
rticat
e
respo
nse)

7/15

Interpretation:
Severe, with GCS 8
Moderate, GCS 9 - 12
Minor, GCS 13.

ANATOMY AND PHYSIOLOGY

BRAIN

-Made up of 1000 billion neurons and is one

of the largest organs of the body,
-weighing about 1300 kg (3 lbs).
- It is a mushroom shaped

4 Principal Parts
Brain Stem
Stalk of the mushroom
Consist of medulla oblongata, pons and
midbrain
Diencephalon
-Consisting primarily of the thalamus and
hypothalamus
Cerebral Hemisphere
-Spreads over the diencephalons

Cerebellum
Inferior to the cerebrum and posterior to
the brain stem

The Major Primary and Association Areas

1. Frontal Lobe
Area 4
- primary motor area
Area 6
- premotor area
Area 8
- frontal eye movement
and papillary change area
Area 44
- motor speech (Brocas
Area)

2. Parietal Lobe
Area 3, 1, 2
- primary sensory areas
Area 5, 7
- sensory
association areas
Area 39 40
- Wernickes area
Area 5, 7, 39 40 - Gnostic area
Area 43
- primary gustatory
area

3. Occipital Lobe
Area 17
- primary visual cortex
Area 18 29
- visual association areas
4. Temporal Lobe
Area 41
- primary auditory
cortex
Area 42 & 22
- auditory
association areas

CEREBRAL ARTERIES
1. MIDDLE CEREBRAL ARTERY (MCA)
From internal carotid artery
Blood supply to deep structures
Enters lateral fissure sends cortical
branches to lateral aspect of FRONTAL,
TEMPORAL, PARIETAL, & OCCIPITAL
LOBES.
Basal MCA sends small penetrating
lenticulo striate arteries to supply internal
capsule and adjacent structures.

2. ANTERIOR CEREBRAL ARTERY (ACA)

. Also branch of the internal carotid artery
. Internal carotid artery to longitudinal
fissure to genes of corpus callosum sends branches to medial frontal and
parietal lobes and adjacent cortex,
extending posteriorly.
.

3. POSTERIOR CEREBRAL ARTERY (PCA)

. Basilar artery sends branch to medial
and inferior surface of the temporal lobe
and medial occipital lobe.
. Blood supply to choroids plexuses of III &
IV ventricles

PATHOPHYSIOLOGY
PREDISPOSING FACTORS

Age
Heredity
Sex
Lifestyle

PRECIPITATING FACTORS

Hypertension
Prone to CVA
Poor diet
Physical Inactivity
Obesity

Formation of
plaques deposits

Atherosclerosis

Thrombosis

Occlusion of
major vessels
Vascular walls
become
weakened and
fragile

Leaking of blood from

the fragile vessel wall

Hypertension

Cerebral
Hemorrhage

Sx.
Headache
Nausea and
Vomiting

Cerebral
Hypoperfusion
Tissue hypoxia
and cellular
starvation

Sx. Altered
consciousness
Vision changes
Aphasia
Memory
deficits

COMA
Cerebral death
Cessation of
Physiologic
functions

Systemic
failure

Bradycardia
Hypotention
Urinary
output
Weight loss

DEATH

Diagnostic Procedure
Hematology
Description:
The branch of biology (physiology),
pathology, clinical laboratory, internal
medicine, and pediatrics that is
concerned with the study of blood, the
blood forming organs, and blood
diseases.

Indication:
- this is used to evaluate anemia,
leukemia, reaction to inflammation and
infections, peripheral blood cellular
characters, state of hydration and
dehydration, polycythemia, hemolytic
disease of the newborn, to manage
chemotheraphy decisions.

Nursing Responsibilities:
Pre-test
Explain procedure
Gather all equipments
Fasting is not necessary
During Test
Record the result
Post Test
Monitor patient response
Document

PARAMETERS NORMAL RESULT INTERPRETATI

VALUES
HEMOGLOBIN 140-170

107

ON
Blood loss,
hemolytic
anemia, bone
marrow
suppression,
sickle cell

HEMATOCRIT
(HCT)

.40-.50

.32

anemia.
Blood loss, over
hydration,

WBC
x109/L
RBCx1012/
L
Platelet
x109/L

5.0-10.0

140-440

12.4

Leukocyt
osis and
infection

Neutrophil 55-65
s%
Lymphocyt
25-40
es %

Eosinophils
Monocyte

1-3
2-8

77
16

6
1

Stress and
acute infection
Adrenal
corticosteroids
and other
immune
suppressive
drugs
Allergic reactions
Drug therapy:
prednisone

Intrepretation:

The decreased in Hemoglobin and

hematocrit indicates that there is an
internal hemorrhage, particularly in the
brain. It isnt a simple bleeding but it
leads the client to suffer
cerebrovascular accident.

Raised white blood cell count above the

normal range indicates Leukocytosis. This
increase in WBC (primarily neutrophils) is
usually accompanied by a "left shift" in the
ratio of immature to mature neutrophils.
The increase in immature leukocytes
increases due to proliferation and release
of granulocyte and monocyte precursors in
the bone marrow which is stimulated by
several products of inflammation including
C3a and G-CSF. Although it may be a sign
of illness, leukocytosis in-and-of itself is
not a disorder, nor is it a disease.

ELECTRO CARDIOGRAPHY
Definition:
The electrocardiogram (ECG or EKG)
is a diagnostic tool that is routinely
used to assess the electrical and
muscular functions of the heart. While
it is a relatively simple test to perform,
the interpretation of the ECG tracing
requires significant amounts of training.
Numerous textbooks are devoted to the
subject.

Indication:
Indications for ECG monitoring include:
 Chest pain;
 Myocardial infarction;
 Shock;
 Heart failure;
 Palpitations;
 History of syncope;
During cardiopulmonary resuscitation
(CPR)

Result:
Regular sinus rhythm left axis
deviation probable old inferior wall
infarct.

DRUG STUDY

Ceftazidime (Fortaz, Tazicef)

Action:
Interferes with bacterial cell-wall
synthesis and division by binding to
cell wall, causing cell to die. Active
against gram-negative and grampositive bacteria, with expanded
activity against gram-negative
bacteria. Exhibits minimal
immunosuppressant activity.

Indication :

It is prescribed for treatment

of documentedPseudomonas
aeruginosainfection and other
bacterial infections of the lower
respiratory tract, urinary tract,
skin, abdomen, blood, bones and
joints, and central nervous
system.

Contraindication :
Hypersensitivity to cephalosporins or
penicillins
Adverse Effects
Pruritus
Fever
skin rash
diarrhea
eosinophilia,
thrombocytosis, phlebitis
discomfort at the site of injection, and
positive Coombs'

Nursing responsibilities :
Monitor for extreme confusion, tonicclonic seizures, and mild hemiparesis
when giving high doses.
Assess CBC and kidney and liver
function test results.

Monitor for signs and symptoms of

super infection and other serious
adverse reactions.
Be aware that cross-sensitivity to
penicillin may occur.
Instruct patient to report reduced
urine output, persistent diarrhea,
bruising, and bleeding.

Citicholine
(Nicholin, Somazine, 5-Cytidine
diphosphate choline, CDPC, CDP Choline,
CDP-Choline, Citicholine, Citicolina,
Cytidine 5-Diphosphocholine, Cytidine
5-diphosphocholine, Cytidine (5)
diphosphocholine)

Action :
Citicoline seems to increase a brain
chemical called phosphatidylcholine.
This brain chemical is important for
brain function. Citicoline might also
decrease brain tissue damage when the
brain is injured. It is usually known that
phospholipid, especially lecithin,
decreases following decline in brain
activity with cerebral trauma. Citicoline,
which is a co-enzyme, accelerates the
biosynthesis of lecithin in the body.

 This medication enhances the action of

the brain stem ciliary body especially
the ascending ciliary body activating
system, which is closely related to
consciousness, but does not exert
effort on the extrapyramidal system.
Citicoline increases cerebral blood flow
and oxygen consumption of the brain
and improves cerebral circulation and
metabolism.

 Scientific research demonstrates that

Citicoline consumption promotes brain
metabolism by enhancing the synthesis
of acetyl-choline, restoring phospholipid
content in the brain and affecting
neuron membrane excitability and
osmosis (by its effect on the ATPdependent sodium and potassium pump).
When taken orally, its two main
components, Cytidine and Choline are
absorbed into the bloodstream.

 Citicoline is also believed to protect

nerve cells when in low oxygen
conditions. Citicoline may be used for
nutritional support in cerebral vascular
disease, head trauma, stroke,
andcognitive disorders. It also is used
by those who have age related mental
decline, such as Alzheimers and
Parkinsons.

Indication :
Parkinsons disease
Head injury
Cerebral vascular disease
Alzheimers disease
Cerebral surgery or acute cerebral
disturbance
Disturbance of consciousness following
brain surgery

Contraindication :
Parasympathetic hypertonic
Adverse effects :
Stomach pain
Hypotension
Diarrhea
Tachycardia
Nursing Responsibilities :
Somatic must not be administered along
with the medicaments containing
mechlonexophate.

Furosemide (Apo-Furosemide (CAN),

Furosemide (CAN), Lasix, Myrosemide
(CAN)
Action :
Inhibits the re absorption of sodium and
chloride from the proximal and distal
renal tubules and the loop of Henle,
leading to a sodium-rich diuresis.

Indication :
Edema associated with CHF, cirrhosis,
renal disease (oral, IV)
Acute pulmonary edema (IV)
Hypertension (oral)
Contraindication :
Contraindicated with allergy to
furosemide, sulfonamides; allergy to
tartrazine (in oral solution); electrolyte
depletion; anuria, severe renal failure;
hepatic coma; pregnancy; lactation

Adverse Effects :
Dizziness, vertigo, paresthesias,
xanthopsia, weakness, headache,
drowsiness, fatigue, blurred vision,
tinnitus, irreversible hearing loss,
Orthostatic hypotension, volume
depletion, cardiac arrhythmias,
thrombophlebitis, Photosensitivity,
rash, pruritus, urticaria, purpura,
exfoliative dermatitis, erythema
multiforme,

Nausea, anorexia, vomiting, oral

and gastric irritation,
constipation, diarrhea, acute
pancreatitis, jaundice, Polyuria,
nocturia, glycosuria, urinary
bladder spasm, Leukopenia,
anemia, thrombocytopenia, fluid
and electrolyte
imbalances,Muscle cramps and
muscle spasms

Nursing Responsibilities :
Administer with food or milk to prevent
GI upset.
Reduce dosage if givenwith other anti
hypertensive; readjust dosage gradually
as BP responds.
Give early in the day so thatincreased
urination will not disturb sleep.
Avoid IV use if oral use is atall possible.
Do not mix parenteral solution with
highly acidicsolutions with pH below3.5.

 Do not expose tolight, may discolor

tablets or solution; do not use
discolored drug or solutions.
Discard diluted solution after 24 hr.
Refrigerate oral solution.
Measure and record weight to monitor
fluid changes.
Arrange to monitor serum electrolytes,
hydration, liver function.
Arrange for potassium-rich diet or
supplemental potassium as needed.

Losartan ( cozaar )
Action :
Selectively blocks the binding of
angiotensin II to specific tissue
receptors found in the vascular smooth
muscle and adrenal gland; this action
blocks the vasoconstriction effect of
the renin-angiotensin system as well as
the release of aldosterone leading to
decreased blood pressure.

Indication :
Treatment of hypertension, alone or in
combination with other antihypertensive
agents
Treatment of diabetic neuropathy with
an elevated serum creatinine and
proteinuria in patients with type 2
diabetes and a history of hypertension

Contraindicated :
Contraindicated with hypersensitivity to
losartan, pregnancy (use during the second
or third trimester can cause injury or even
death to the fetus), lactation.
Adverse Effects :
Headache, dizziness, syncope, insomnia,
Hypotension, Rash, urticaria, pruritus,
alopecia, dry skin, Diarrhea, abdominal pain,
nausea, constipation, dry mouth, URI
symptoms, cough, sinus disorders, Cancer in
preclinical studies, back pain, fever, gout,
muscle weakness

Nursing Responsibilities :
Administer without regard to meals.
Ensure that patient is not pregnant
before beginning therapy, suggest the
use of barrier birth control while using
losartan; fetal injury and deaths have
been reported.
Find an alternative method of feeding
the baby if given to a nursing mother.
Depression of the renin-angiotensin
system in infants is potentially very
dangerous.

 Alert surgeon and mark patient's chart

with notice that losartan is being taken.
The blockage of the renin-angiotensin
system following surgery can produce
problems. Hypotension may be reversed
with volume expansion.
Monitor patient closely in any situation
that may lead to a decrease in blood
pressure secondary to reduction in fluid
volume--excessive perspiration,
dehydration, vomiting, diarrhea
excessive hypotension can occur.

Mannitol (osmitrol )
Action :
In the oliguric phase ofacute renal failure,
Mannitolincreases osmotic
pressure(pressure needed to stop the
absorption of something or osmosis) of the
glumerular filtrate, thereby,promoting
diuresis(treating the oliguric phase of renal
failure) andexcretes toxic
materials(management for toxic overdose).

It also elevates blood plasma osmolality

thus,inhibiting the reabsorption of
water and electrolytes(for relief of
edema) andmobilizing fluids in the
cerebral and ocular spaces(lowers
intracranial or intraocular pressure).

Indication :
Acute oliguric renal failure
Toxic overdose
Edema
Increased intracranial pressure(ICP)
Intraocular pressure (IOP)
Contraindication :
Susceptibility
Dehydration

Adverse Effects :
Dehydration
Anuria
Intracranial bleeding
Headache
Blurred vision
Nausea and vomiting
Volume expansion
Chest pain

 Pulmonary edema
Thirst
Tachycardia
Hypokalemia (increases the risk
ofdigoxintoxicity)
Chronic renal failure

Nursing Responsibilities :
monitor weight
monitor I and o
monitor VS
give medication in morning
monitor client for fluid electrolytes
imbalance
observe injection site for signs of
inflammation or edema

Metoprolol (Apo-Metoprolol (CAN),

Betaloc (CAN), Lopresor (CAN),
Lopressor, Novometoprol (CAN), NuMetop (CAN), Toprol-XL)

Action :
Competitively blocks beta-adrenergic
receptors in the heart and juxtaglomerular
apparatus, decreasing the influence of the
sympathetic nervous system on these
tissues and the excitability of the heart,
decreasing cardiac output and the release
of renin, and lowering BP; acts in the CNS
to reduce sympathetic outflow and
vasoconstrictor tone.

Indication :
Hypertension, alone or with other drugs,
especially diuretics
Prevention of reinfarction in MI patients
who are hemodynamically stable or within 3
10 days of the acute MI (immediate-release
tablets and injection)
Treatment of angina pectoris
Treatment of stable, symptomatic CHF of
ischemic, hypertensive, or cardiomyopathic
origin (Toprol-XL only)

Contraindication :
sinus bradycardia (HR <> 0.24 sec),
cardiogenic shock, CHF, systolic BP <>

Adverse Effects :
Pharyngitis, erythematous rash, fever, sore
throat, laryngospasm
Dizziness, vertigo, tinnitus, fatigue, emotional
depression, paresthesias, sleep disturbances,
hallucinations, disorientation, memory loss,
slurred speech
CHF, cardiac arrhythmias, peripheral vascular
insufficiency, claudication, CVA, pulmonary
edema, hypotension
Rash, pruritus, sweating, dry skin

 Eye irritation, dry eyes, conjunctivitis,

blurred vision
Gastric pain, flatulence, constipation,
diarrhea, nausea, vomiting, anorexia,
ischemic colitis, renal and mesenteric
arterial thrombosis, retroperitoneal
fibrosis, hepatomegaly, acute pancreatitis
Impotence, decreased libido, Peyronie's
disease, dysuria, nocturia, frequent
urination

Nursing Responsibilities :
Do not discontinue drug abruptly after longterm therapy (hypersensitivity to
catecholamines may have developed, causing
exacerbation of angina, MI, and ventricular
arrhythmias). Taper drug gradually over 2 wk
with monitoring.
Ensure that patient swallows the ER tablets
whole; do not cut, crush, or chew.
Consult physician about withdrawing drug if
patient is to undergo surgery (controversial).

 Give oral drug with food to

facilitate absorption.
Provide continual cardiac
monitoring for patients
receiving IV metoprolol.

Ranitidine ( Zantac )
Action :
Inhibits the action of histamine at the
H2 receptor site located primarily in
gastric parietal cells, resulting in
inhibition of gastric acid secretion.
In addition, ranitidine bismuth citrate
has some antibacterial action against H.
pylori.

Indication :
Short-term treatment of active duodenal
ulcer; maintenance therapy for duodenal
ulcer patient after healing of acute ulcer;
treatment of gastroesophageal reflux
disease; short-term treatment of active,
benign gastric ulcer; treatment of pathologic
GI hypersecretory conditions (e.g., ZollingerEllison syndrome, systemic mastocytosis, and
postoperative hypersecretion); heartburn.

Contraindication :
Potent anti-ulcer drug that competitively and
reversibly inhibits histamine action at H2receptor sites on parietal cells, thus blocking
gastric acid secretion. Indirectly reduces
pepsin secretion but appears to have minimal
effect on fasting and postprandial serum
gastrin concentrations or secretion of gastric
intrinsic factor or mucus

Adverse Effects :
abdominal pain
agitation
agranulocytosis
alopecia
anaphylactoid reactions
angioedema
aplastic anemia
arthralgia
AV block
blurred vision
bradycardia
bronchospasm

confusion
constipation
delirium
depression
diarrhea
dizziness

elevated hepatic enzymes

eosinophilia
erythema multiforme
gynecomastia
hallucinations
headache

hemolytic anemia
hepatitis
impotence (erectile dysfunction)
insomnia

jaundice
leukopenia
libido decrease
maculopapular rash
myalgia
nausea/vomiting
neutropenia
pancreatitis

pancytopenia
paranoia
premature ventricular contractions (PVCs)
sinus tachycardia
Stevens-Johnson syndrome
thrombocytopenia
toxic epidermal necrolysis
vasculitis

Nursing Responsibilities :
Assess patient for epigastric or abdominal pain
and frank or occult blood in the stool, emesis,
or gastric aspirate.
Nurse should know that it may cause falsepositive results for urine protein; test with
sulfosalicylic acid.

Inform patient that it may cause

drowsiness or dizziness.
Inform patient that increased fluid and
fiber intake may minimize constipation
Advise patient to report onset of black,
tarry stools; fever, sore throat; diarrhea;
dizziness; rash; confusion; or hallucinations
to health car professional promptly.

 Inform patient that medication may

temporarily cause stools and tongue to
appear gray black.

Nursing Care Plan

Assessment
subjective :
nahingit it ak nanay hin gin liliso hiya hit
iya ginhihigdaan, as verbalaized by the SO.

Objective :
Eye lack luster
Grimace
Irritable
Protective gestures
Moaning

V/S taken as follows:

T:
P:
R:
BP:

38.1
78
21
210/130

Pain scale of 6 out of 10.

Diagnosis
Acute pain r/t hemiplegia and disuse as
evidenced by eye lack luster, grimace,
irritable, protective gesture, moaning.

Rationale
Pain may result in physical and mental suffering.
A state of localized or generalized discomfort
that ranges from mild distress to acute agony;
usually caused by injury to a part or disturbance
of the normal condition or functioning of a part
of the body and a result of dilatation of blood
vessels, particularly those around the brain
which may affect individual level of functioning
and sudden behavioral changes.

Planning
After 8 hours of nursing intervention the
patient will able to report if pain is
relieved or controlled.

Intervention
Independent :
Determine clients acceptable level of
pain/ pain control goals.
Note when pain occurs (e.g. only with
ambulation every evening)
Provide comfort measures

Encourage use of relaxation techniques,

such as focused breathing, breathing,
imaging, CDs, or tapes
Work with client to prevent pain. Use flow
sheet to document pain , therapeutic
interventions, response and length of time
before pain occues. Instruct client to
report pain as soon as it begins.

Review procedures/ expections and tell

client when treatment may cause pain.

Dependent :
Administer analgesics, as indicated to
maximum dosage as needed.

Rationale
Varies which individual and situation.
To medicate prophylactically as
appropriate.
To promote nonpharacological pain
management
To distract attention and distract tension.
As timely intervention is more likely to be
successful in allevation pain.

 To reduce concern of the unknown

and associate muscle tension
To maintain acceptable level of pain.
Notify physician of regimen is
inadequate to meet pain control goal.

Evaluation
After 8 hours of nursing intervention the
patient was able to report that pain was
relieved or controlled.

Assessment
subjective :
namumula ngan nangangaplod it kan nanay
left side hit iya balakang as verbalized by
the patient son

Objective :
Erythema
Redness in affected area
Physical immobility noted
Weak looking
V/s taken as follows :
T:
38.1
P:
78
R:
21
BP: 210/130

Diagnosis
Risk for impaired skin integrity r/t
hemiporesis or hemiplegia, decreased
mobility as evidenced by, erethyma,
redness in affected area and physical
immobility weak looking.

Planning
After 2 days of nursing intervention the
patient will able to demonstrate behaviors
or techniques to prevent skin breakdown.

Intervention
independent
Observed for reddened/ and blanched
areas of skin rashes and institute
treatment immediately
Massage bony prominence and use proper
positioning, turning, lifting, and
transferring techniques when moving
client
Provide protection by use of pads, pillows,
foam mattress, water bed, etc.

 Provide preventive skin care to incontinent

clients: change continence pads/ diapers
frequently; cleanse perineal skin daily and
after each incontinence episode apply skin
protectant ointment.
Suggest use of ice, colloidal bath, lotions.
Collaborations :
Consult with wounds/ stoma specialist, as
indicated.

Rationale
Reduces likelihood of progression to skin
breakdown.
To prevent friction or shear injury
To increase circulation and limit/ eliminate
excessive tissue pressure.
To minimize contact with irritant (urine,
stool, excessive moistures )

 To decrease irritable itching.

To assist the developing plan of care for

problematic or potentially serious wounds.

Evaluation

After 2 days of nursing intervention the

patient was able to demonstrate
behaviors or techniques to prevent skin
breakdown.

Assessment
subjective :
No verbal cues
Objective :
Muscle strength of: Right arm: 1/5
Right leg: 1/5
Left arm: 2/5
Left leg: 2/5

 Right hemiplegia
Limited ROM
Slowed movement
Gait changes
Inability to perform ADL
Poor self-care
V/s taken as follows :
T:
38.1
P:
78
R:
21
BP: 210/130

Diagnosis
Impaired physical mobility r/t hemiporesis
and loss of balance and coordination as
evidenced by right hemiplegia, limited
ROM, difficulty turning, slowed movement,
muscle strength of Right arm: 1/5, Right
leg: 1/5, Left arm: 2/5, Left leg: 2/5 , gait
changes, inability to perform ADL, and
poor self-care.

Planning
After 3 days of nursing intervention the
patient will able to achieve maximal
physical mobility within the limitations
imposed by the stroke as evidenced by
more normal movement of the affected
extremity, improved muscle strength, and
the effective use of adaptive devices.

Rationale
Stroke in which nerve cells in the brain die
for lack of oxygen can result in permanent
disability for the pt. because the
pathways that transmit information in the
brain are interrupted. The symptoms
often primarily affect only one side of the
body because blood flow is cut off to only
part of the brain.

Intervention
independent :
Establish rapport
Assess the clients degree of muscle
strength
Note emotional/ behavioral responses to
problems of immobility
Determine readiness to engage in
activities or exercises
Assist pt. reposition self on a regular
schedule

 Provide for safety measures including fall

prevention
Identify energy techniques for ADLs.
Involve pt. and SO in care assisting them
to learn ways of managing problems of
immobility
Demonstrate use of standing deck and
mobility devices ( e.g. walker, strollers,
scooters, braces) and have client/ care
provider demonstrate knowledge about/
safe use of device. Identify appropriate
resources for obtaining and maintaining
appliances/ equipment.

Dependent:
Administer medications prior to activity as
needed for pain reliefs
Consult the physical occupational therapist
as indicated

Rationale
To promote cooperation
To use as baseline value and for
determining and evaluating outcomes
To access functional ability
To assess expected level of participation
To promote optimal level of function and
prevent complications
To prevent occurrence of injury
Limits fatigue, maximizing participation
To promote wellness

 To promote independence and enhance

safety

To permit maximal effort involvement in

activity
To develop individual exercise/ mobility
program and identify appropriate mobility
device.

Evaluation
After 3 days of nursing intervention the
patient achieved maximal physical mobility
within the limitations imposed by the
stroke as evidenced by more normal
movement of the affected extremity,
improved muscle strength, and the
effective use of adaptive devices.

Assessment
subjective :
dire hiya nakakaintindi hit ak ginyayakan ha iya as
verbalized by SO
Objective :
Irritable
Increased lethargy
Drowsiness
V/s taken as follows :
T:
38.1
P:
78
R:
21
BP: 210/130

Diagnosis
Disturbed thought process r/t brain
damage, confusion, inability to follow
instruction as evidenced by irritability,
increased lethargy and drowsiness.

Rationale
If damage has occurred to the frontal
lobe, learning capacity, memory, or other
higher cortical Intellectual functions may
be impaired.

Planning
After 2 days of nursing intervention the
patient will able to demonstrate
behaviors/ lifestyle changes to prevent or
minimize changes in mentation.

Intervention
independent :
Assess attention and span/ distractibility
and ability to make decisions or problem
solve.
Perform periodic neurological/ behavioral
assessments, as indicated and compare
with baseline. Note changes in level of
consciousness and cognition. (e.g.
increased lethargy, confusion, drowsiness,
irritability)

 Reorient to time, place, person as needed.

Maintain a pleasant, quit environment and
approach client in a slow, calm manner.
Give simple directions using short words
and simple sentence.
Collaborative:
Assist in identifying ongoing treatment
needs for the individual.

Rationale
Determines ability to participate in
planning/ executing care.
Early recognition of changes promotes
modifications to plan of care.
Inability to maintain orientation is a sign
of deterioration.

 Client may respond with anxious or

aggressive behaviors if startled or over
stimulated.
To convey interest and worth individual.

To maintain gains and continue progress if

able.

Evaluation
After 2 days of nursing intervention the
patient was able to demonstrate behavior
or lifestyle changes to prevent or minimize
changes in mentation.

Assessment
subjective :
Kinukurian hiya pagyakan as verbalized by the
patients son.
Objective :
Incomprehensive speech noted
Difficulty forming words/sentences
Altered muscle tone noted
Poor eye contact
Sensory aphasia noted
GCS: 7
v/s taken as follows:
T: 38.1
P: 74
R: 30
BP: 210/130

Diagnosis
Impaired verbal communication r/t
neuromuscular dysfunction secondary to
CVA as evidenced by incomprehensive
speech, difficulty forming words/
sentences, altered muscle tone, poor eye
contact and sensory aphasia.

Rationale
Impaired circulation and resultant brain
damage can affect the individuals ability
to communicate which may result to the
individuals inability to communicate or
express despite of intact muscular
control, the inability to understand verbal
messages, is due to the problems with the
muscle used in speech or inappropriate
verbal expression as a result of changes in
mentation.

Planning
At the end of 2 hours span of care, our
patient will be able to perform methods of
communication in which needs can be
expressed such as sign language, written
language.

Intervention
independent :
Review history of neurological condition
that could affect speech; such as CVA,
loss of hearing and damage in brocas area.
Determine clients developmental level of
speech and language comprehension.
Make self available for the client.
Provide alternative methods of
communication; such as use of sign
language and written language.
Anticipate and provide pt. needs.

 Maintain a calm, unhurried manner. Provide

sufficient time for client
Validate meanings of non-verbal
communications and avoid making
assumptions.
Encourage visitors to persist in efforts in
communicating with client.
Dependent:
Refer to appropriate resources (e.g.
speech/ language therapist, support groups
such as stroke club, individual family
counseling.)

Rationale
To determine the different contributing
factors that affected the impairment of
communication.
Provides baseline information for
developing plan for improvement.
To maintain good relationship with the
client and to attend to her needs.
For the client to express her needs.
Helps attend with clients physiologic needs
and helps decreased clients frustration
upon its dependency to others and
communication deficiency.

 Individual with expressive aphasia may

talk more easily when they are talking to
one person.
To determine what the client really
expresses and to attend to her real needs.
To reduce clients social isolation promote
establishment of effective communication.

To provide early/ ongoing sources of

support.

Evaluation
After 2 hours of span of care, our client
was able to established or perform
communication in which needs can be
expressed.

Assessment
subjective :
No verbal cues
Objective :
With coiled clothes
With unsatisfying appearance
With minimal sweating
v/s taken as follows:
T:
38.1
P:
78
R:
21
BP: 210/130

Diagnosis
self-care deficit r/t musculoskeletal
impairment secondary to CVA as
evidenced by coiled clothes, unsatisfying
appearance and minimal sweating.

Rationale
Motor deficit are the obvious effects of
stroke. Symptoms are caused by
destruction of motor neurons in the
pyramidal pathways (nerve fibers in the
brain and passing through the spinal cord
to the motor tract) One of those
symptoms could be inability to perform
ADLs.

Planning
after 2 days of nursing intervention the
patient will able to identify personal
resources that can provide assistance and
be able to verbalize knowledge of health
care practices.

Intervention
independent :
Establish rapport
Monitor vital signs
Asses for the type and severity of
immobility impairment, muscle flaccidity,
spasticity and coordination, ability to walk,
sit. Move in bed perform articles for
brushing teeth, combing hair, clothing that
is easily managed to dress and undress.

 Passive ROM to all limbs and progress to

assistive and then active ROM in all joints
four times a day.

Rationale
To promote cooperation
To have baseline data
Provides data regarding mobility and
ability to perform activities within the
limitations without injury or frustration.
Promote circulation, muscle tone, joint
flexibility, prevent contractures and
weakness.

Evaluation
after 2 days of nursing intervention the
patient was able to identify personal
resources that can provide assistance and
be able to verbalize knowledge of health
care practices.

Assessment
subjective :
makadanay it ak nanay maghiniringit dara hit iya
sitwasyon nga inaatubang As verbalized by the son.
Objective :
Irritable
Sudden behavioral changes
Restlessness
Frustrated
impatient

V/s taken as follows :

T:
38.1
P:
78
R:
21
BP: 210/130

Diagnosis
ineffective coping r/t neuro muscular
impairment, physiologic changes and
frustration as evidenced by Irritable,
Sudden behavioral changes Restless,
Frustrated, impatient.

Rationale
Any major illnesses change in the body
challenges a clients or family coping skills.
This process is particularly true after a
stroke because of the physiologic changes
and frustrations associated with the
resulting deficits. People which stroke in
the left cerebral, or dominant, hemisphere
are frequently slow, cautions and
disorganized.

Planning
after 8 hours of nursing intervention the
patient will able to meet psychological
needs as evidenced by appropriate
expression of feelings, identification of
option and use of resources.

Intervention
Independent :

Observe and describe behavior in

objective terms. Validate observations.
Call client by name. Ascertain how client
prefers to be addressed.
Identify developmental level of
functioning

 Determine previous methods of dealing

the life problems.
Explain disease process/ procedures/
events in a simple, concise manner. Devote
time for listening.
Provide for a quiet environmental, as much
as possible
Identify social support available for client.

Dependent :
Refer to outside resources and/ or
professional therapy as indicated/
ordered

HEALTH TEACHING
M > Instruct the relative to follow
medication regimen (cefuroxime citicoline,
Cerebrolysin, furosemide, metropolol)
E > Encourage the relative to do some
exercises like a passive range of motion in
affected and unaffected parts of the
body of the client.
T > Educate & instruct the family to monitor
the blood pressure and pulse rate before
administering medication.

H >Inform the relative the importance of

proper hygiene of the patient from head
to toe.
>regular inspection of the diaper of the
patient and change if there a presence
of fecal material, urine or even redness
that would lead to skin rashes.
>Educate and instruct the relatives on
how to feed the client through
nasogastric tube.
>Instruct them to turn the client every
2 hrs to avoid pressure sores.

>Inform the family of the patient to

have a regular check-up for the
continuity of treatment.
>Instruct the family of the patient
to monitor if there is any sudden
change to the patient and report
immediately.

D >Instruct the relative to feed the

client on time with nutrition food that is
low in sodium, low in cholesterol, low in
fat and give citrus fruits, moderate in
fluid intake and increase fiber diet to
improve health, (fruits, vegetables,
whole grains and legumes).

PROGNOSIS
Mrs. M. is a 82 year old female, admitted
last January 20, 2012 at Eastern Samar
Provincial Hospital- Borongan with a chief
complaint of right-sided body weakness,
with an admitting diagnosis of
Cerebrovascular Accident. The patient did
not respond to interventions given to her
(Administering medications as ordered).
The patient has a bad prognosis, due to
lack of financial support, the patients
family decided to go home last February
17, 2012.