I.

INTRODUCTION

A cerebrovascular accident (CVA), an ischemic stroke or “brain attack”, is a

sudden loss of brain function resulting from a disruption of the blood supply to a part
of the brain. It is usually the result of long-standing cerebrovascular disease.

Symptoms
Include numbness or weakness of face, arm or leg; confusion or change in mental
status; trouble speaking or understanding speech; visual disturbance, loss of
balance, dizziness, difficulty walking, or sudden severe headache.
• Motor loss
-hemiplegia, hemiparesis
-flaccid paralysis and loss of our decrease in the deep tendon reflexes
(initial clinical features) followed by (alter 48 hours) abnormally increased
muscle tone (spasticity).
• Communication loss
-dysarthria( difficulty speaking)
-Pysphasia or aphasia (defective speech or loss of speech)
-apraxia (inability to perform as previously learned action)
• Perceptual disturbances and sensory loss
-visual percetual dysfunctions (homonymous hemianopia [loss of half of the
field])
-disturbances in visuospatial relationships (perceiving the relation of two or
more objects in spatial areas), frequently seen in patients with left
hemispheric damage.
-sensory losses: slight impairment of touch or more severe with loss of
proprioception, difficulty in interrupting visual, tactile, and auditory stimuli
• Impaired cognitive and psychological effects
-frontal lobe damage; learning capacity, memory , or other higher cortical
intellectual functions may be impaired. Such dysfunction may be reflected
in a limited attention span, difficulties in comprehension, forgetfulness, and
lack of motivation.
-depression, other psychological problems: emotional ability, hostility,
frustration, resentment, and lack of cooperation.
• Bladder dysfunction
-transient urinary incontinence
-persistent urinary incontinence or urinary retention (may be symptomatic
of bilateral brain damage)
-continuing bladder and bowel incontinence (may reflect extensive
neurologic damage)

Causes
• 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.

Diagnosis
• Complete urinary incontinence
• Persistent urinary incontinence or urinary retention (may be symptomatic
of bilateral brain damage)
• Continuing bladder and bowel incontinence (may reflect extensive
neurologic damage)

Risk factors
• Hemorrhagic strokes are caused by arteriovenous malformations
(AVMs),aneurysm ruptures, certain drugs, uncontrolled hypertension,
hemangioblastomas, and trauma. These strokes can occur in epidural,
subarachnoid, or intracerebral hemorrhage.
• Ischemic strokes can be caused by cardiovascular disease (cerebral
embolism may originate in the heart) and dysrythmia (atrial fibrillation); risk
factors for coronary also be caused by vasospasm, migraines, and
coagulopathies 9eg, high hematocrit)

Treatment
• Help patients alter risk factors for stroke
• Prepare and support patient through carotid endarterectomy
• Administer anticoagulant agents as ordered (eg,low-dose aspirin therapy)

Mortality/ morbidity
• The incidence is 2.5 times greater in black than whites. Black between the
ages of 55 & 64 who live in the southern states are about 50% more likely
to die of stroke than blacks of the same age who live in the north.

Race
• High risk group are African Americans, the incidence of first stroke in
Africans is almost twice that in Caucasian Americans.

Sex
• Man has a higher rate of stoke than women do.

Age
 • High risk groups include people older than 55 years old the incidence of
stroke more than double in each successive decade.

Significant of the study

The objective of our study is to acquire knowledge on how to deal or manage a

patient with Cerebrovascular Accident.

This study will aid us, student nurses, in revealing and educating individuals and
family members about neurologic disorder, treatment and recovery. This would permit
the development of appropriate strategies to target high risk group.

II. NURSING HISTORY/HEALTH ASSESSMENT

A. PATIENT’S PROFILE

Name: Mr. M
Address: Mapalad, San Agustin, Isabela
Sex: Male
Age: 61 years old
Civil Status: Married
Occupation: Farmer
Religion: Roman Catholic

Admission Data:
Chief Complain: Left sided body weakness and numbness.
Date of Admission: Dcember 1, 2009
Time of Admission: 3:25pm
Mode of Arrival: Assisted by his son and wife.
Attending Physician: Dra. NS Ipac

B. History of Present Illness

According to his wife, Mr. M was apparently well until few hour, when
he suddenly felt dizzy and fell down from his chair. Since then he felt
numbness of the whole eye, side of his body with associated slurred speech
and left sided body weakness.
Mr. M didn’t receive a complete immunization. And he had no known
allergies for both foods and medicines.

C. Past Medical History

The patient has been hospitalized at the same hospital due to the
same illness but lesser complication (absence of hemiplegia). According to
his wife, he also experienced common illness like fever, cough and colds.

D. Family Medical History

 According to Mr. M’s wife, they have no history of neurologic disorder.
She also said, that her husband’s uncle had heart attack, there are also
members of the clan that are suffering from diabetes and hypertension.

E. Socio-Economic History
Mr. M is an elementary undergraduate. He works and earns money for
his family – his wife and 2 children.

F. Gordon’s 11 Functional Health pattern

1. Health Perception-Health Management

BEFORE HOSPITALIZATION

Mr. M was an active worker before because of being a farmer. He was an energetic
grandfather to his grandson and granddaughters. Client believed that proper diet,
exercises, and adequate financial support are the things needed to maintain proper
health diet are factors of having a healthy body. He also drank liquor irregularly and
smokes 3 sticks of cigarette daily. Once he felt wrong, he and his family sought medical
consultation. They also believed in “albularyo” and use herbal medicines such as guava
leaves, pito-pito and oregano.

DURING HOSPITALIZATION

Now that he is currently confined, her wife is also advised by his attending
physician to take only the prescribe medicines. He has no known allergies on both food
and medicine.

2. Nutritional-Metabolic
BEFORE HOSPITALIZATION
According to his wife, when he was not paralyzed yet, he was able to play with his
grandchildren. Drink beer with his friends and mingle with them. He was also eating what
he wants regarding those foods that are prepared and able to eat on his own.

DURING HOSPITALIZATION
His wife is advised to prepare low salt, low fat diet, soft with aspiration precaution
where he is assisted by his wife. He cannot eat on his own now because half of his body
was paralyzed; he is assisted by his wife always.
An IVF of D5NM 1L as ordered by his physician was infused.

3. Elimination
BEFORE CONFINEMENT
Mr. M, according to his wife defecate once a day, and felt normal when urinating.

DURING HOSPITALIZATION
According to his wife, he is still defecate once a day but cannot go in the rest room
on his own, also in urinating - he needs to be assisted always.

4. ACTIVITY-EXERCISE
BEFORE CONFINEMENT
Mr. M is a farmer, visiting his farm and doing farm works is considered as a dorm
of exercise.
 DURING HOSPITALIZATION
Now that he has right hemisphere stroke, he is only allowed to move the right side
of his body where his movements are very limited.
His pulse is normal, well palpable with the total 57bpm.

5. Sleep-Rest
BEFORE CONFINEMENT
Mr. M according to his wife sleeps early and wake up early. He had his
maximum sleep of 8 hours.

DURING HOSPITALIZATION
Mr. M can take his sleep easily.

6. Cognitive-perceptual
BEFORE CONFINEMENT
He can do works easily with his bare hands. He communicates to people
through Ilocano language.

DURING HOSPITALIZATION
Mr. M is an elementary undergraduate, he has ability to read and write. He
communicates through his movements and slurred speech.
In terms of his visual, Mr. M cannot visualize people easily, there are abnormalities
due to an infarct in the brain, vision and normal eye function can be affected. In his ears,
it is clean though there are some white scales because of the cold weather.
Now, his movements are limited that he can grasp through his right hand only and
kick with his right foot only.

7. Role-relationship
BEFORE CONFINEMENT
The client lives in a nuclear family, considering that his two children live with their
own family and he is still living with his two remaining children. 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.

DURING HOSPITALIZATION
The client’s family maintains a harmonious relationship even though he is in this
condition.

8. Self-perception
BEFORE CONFINEMENT
According to Mr. M’s wife, he was strong and confident to do farm
works.

DURING HOSPITALIZATION
Now that he is paralyzed, the confidence that he had will change into lesser
confidence.

9. Sexuality-Reproductive
BEFORE CONFINEMENT
 Our patient is sexually active regarding of his age according to his wife. He also
use contraceptive before, a condom and never tried it again, as said by his wife. He is
already circumcised when he was still a child.
Mr. M is having a loving wife, four children and three grandchildren that can prove
him being a real man.

DURING HOSPITALIZATION
Now, he’ll have hard time to get back the active phase of having sexual
intercourse.
He is still a man regarding of his condition.

10.Coping-Stress Tolerance
BEFORE CONFINEMENT
The patients engage himself with his work and to his family according to his wife.
He is family centered and gain strength from them.

DURING HOSPITALIZATION
Now that he is hospitalized, stress is increased that is observable through his
nonverbal cues, especially being paralyzed.

11.Value-Belief
Before Hospitalization
Mr. M is a Roman Catholic member, he do not attend mass, but he is listening the
preaches of the priest through radiocast.

During Hospitalization
He cannot listen a mass through radio because he is hospitalized and any kind of
noise is prohibited.

III. PHYSICAL EXAMINATIONS

L10%
R100%
3/5
5/5
5/5
100
%
 Mr. M is suffering from Right hemisphere stroke that indicates weakness or
paralyzed of the left side of the body. Where he cannot move his left hand and left leg
like he moves before confinement and also the left side of the brain damage that it
cannot think fast like before.

PSYCHOSOCIAL INTERPRETATION
Significant others The patient is visited by A very supportive family who
his daughter’s, son and shows comfort and care that
nieces. can relieve stress that is felt
by the patient

Coping Mechanism Interacting with SO. Being happy during

Mingling with them treatment can contribute to
through non-verbal patients fast recovery and
cues. interaction with in the family
can be a diversion activity
thus reducing pain and
stress.

Religion Roman Catholic It is important to know, for

there might be beliefs of a
certain religion that has a
conflict with a health
intervention.

Primary Language Ilocano/Tagalog Language can be a barrier

for an effective nursing
intervention thus it is
important for a nurse to
know what language to use
to have an effective
communication.

Occupation Farming

General appearance Conscious Brain damage not that

severe.

Weak in appearance
Due to decreased O2 supply
and perfusion in the brain.
 Due to illness.

Orientation The patient still knows An abnormal orientation can

where she is, when she be a symptom of brain
was admitted and who damage caused by CVA
are the SO present.

Memory Patient still has a good Damaged cause by the

memory infarct is not yet that severe
to affect the memory of the
patient.

Speech Slurred speech with Dysarthria resulting from

tongue deviation to the lacunar infarcts, right and
right left basal ganglia

Non-verbal behavior Silence Patient expresses his feeling

through not speaking
especially when she is
feeling bad.

ELIMINATION

Stool Frequency: Once a day

Pattern: Every morning

Consistency: Normal
Stool

Amount: Approximately
9-10 inches in length

Color: Golden Yellow-

Light Brown

Odor: Normally foul

stool odor

Abdomen: contour Rounded, (-) palpable

palpation mass

Urine Quantity: Due to oral and IV fluid

600ml(urinate 4 times) intake.

Color: Yellow

Due to the general liquid diet

of the patient.
 REST AND ACTIVITY

Current activity level Lie and sit on bed Patient moment varies due
to body weakness

Sleep 8 hours a day during

the confinement period

Pain/relief measures Patient tries to position Patient usually positions

himself on a himself on his back and
comfortable position. sometimes lie left laterally or
right laterally, depending on
patients choice of comfort.

SAFETY

Allergic Reaction Sea foods

Medications Gentamicin 160 mg IV Antibiotics were

OD administered so as to stop,
or if not, lessen infection
Cefuroxime 750 mg IV which caused the disease.
q8h
CV agent drugs were ordered
Clonidine 1 tab SL now to lower the blood pressure
Imidapril 1 tab OD/ NGT of the patient.

Antibacterial ointment was

ordered to prevent infection
Bactoban ointment to of the wound.
wound TID

Eye/vision

Pupils: Right pupil is dilated Due to an infarct in the

non-reactive to light. brain, vision and normal eye
Left Pupil constricted function can be affected.
with minimal reaction
to light.

Hearing/hearing aid Patient has normal

hearing

Skin integrity Intact Skin

Lesion scars With scars on left hand Due to an accident caused

by bakery machineries.
Mucus membrane Moist and intact

Temperature Temperature, via

axillary, of the patient
varies from 37.3°C to
37.4°C

OXYGEN

Activity Tolerance Can move minimally Patient has general

weakness (Left side of the
body is paralyzed)

Airway clearance

Nose With no secretions

Mouth Clear

Respiration rate 17 cycle per minute

Depth Normal

Rhythm Harsh breath sound Patient is having a hard time

adjusting to his condition
that even his breaths was
change in a heavier sound

Color

Skin Pale Patient has a low

hemoglobin count.
Nails Pinkish

Lips Somewhat dry

Capillary refill 1-2 seconds Normal Oxygenation of

tissue cells

Pulses Within normal range

Blood pressure 140-210/70-110 mmHg Patient is having an elevated

BP due to illness.

Edema None

NUTRITION

Hospital Low salt, low fat diet Physicians order.

Diet/Restrictions
 IVFs (according to D5NM 1L x 20-21 For minimal carbohydrates
chart) gtt/min calories from dextrose.

Tissue turgor Good skin turgor

Ability to:

Chew Able

Swallow Able

Feed self With SO’s assistance Due to decreased hand

movement accuracy.

IV. LABORATORY EXAMINATIONS

HEMATOLOGY

PARAMETERS NORMAL VALUES RESULT

HEMOGLOBIN 140-170 107

HEMATOCRTI (HCT) .40-.50 .32

WBC x109/L 5.0-10.0 12.4

RBC x1012/L

Platelet x109/L 140-440

Neutrophils % 55-65 77

Lymphocytes % 25-40 16

Monocyte 2-8 1

Eosinophils 1-3 6

Band or stab 2-6

Intrepretation:
The decreased in Hemoglobin and hematocrit indicates that there is an internal
hemorrhage, particularly in the brain. It isn’t 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.

V. REVIEW OF SYSTEM

A. ANATOMY AND PHYSIOLOGY

The Brain

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

1. Brain Stem
➢ Stalk of the mushroom
➢ Consist of medulla oblongata, pons and midbrain

2. Diencephalon
➢ Consisting primarily of the thalamus and hypothalamus

1. Cerebrum
➢ Spreads over the diencephalons
➢ Constitute about seven-eights of the total weight of the brain and occupies
most of the cranium.
1. Cerebellum
➢ Inferior to the cerebrum and posterior to the brain stem

Protection and Coverings

The brain is protected by the cranial bones. Like the spinal cord. The brain is also
protected by meninges. The cranial meninges surround the brain are continues with the
spinal meaninges and have the same basic structure and bear the same names as the
spinal meninges.
 1. Dura meter – pachymenix, tough fibrous tissue
- outermost covering

2. Arachnoid - together with the pia meter is called Leptomeninges

- middle, delicate thin cob-web like membrane

3. Pia meter - innermost

- soft thin membrane which closely lines brain and spinal cord
extending into all fissures and sulci.

- extends around blood vessels throughout the brain.

Main Sulci and Fissures of Cerebral Cortex

1. Lateral or Sylvian Fissure

➢ Divided the temporal lobe from the frontal and parietal lobe
➢ Buried under the posterior part of the SYLVIAN FISSURE is the TRANSVERSE
TEMPORAL gyri which contains the AUDITORY RECEPTIVE AREA.

2. Rolandic or Central Sulcus

➢ Separates the frontal lobe from the parietal lobe
➢ It separates the precentral gyrus from the Postcentral gyrus, thus
separating the motor from the somasthetic area.

1. Longitudinal Cerebral Fssure

➢ Divides the cerebral hemispheres into right and left halves.
1. Parietooccipital Fissure
➢ Separates the parietal lobe from the occipital lobe.

1. Calcarine Sulcus
➢ This sulcus is surrounded by the visual receptive area.

Lobes of Cerebral Cortex and Brodmann’s Classification

The function of the cerebral cortex has been mapped out into areas by
Broadmann. These two major types of cortical areas are:

1. Primary Cortical Area – regions directly related to a specific function

2. Secondary Cortical Area/ Association Area– these lie adjacent to the primary area
and are concerned with a higher level of organization and integration.

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 - Wernicke’s 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

AREA 4: PRIMARY MOTOR AREA

Location : precental gyrus and paracentral lobule

Function : contralateral voluntary motor activity

Clinical findings when damaged:

➢ Irritative lesions will present with convulsive seizures

➢ Gross lesions will result in flaccid paralysis and areflexia
AREA 6: PREMOTOR AREA

Location : Superior Frontal Gyrus (lateral aspect)

Function : Sensorially guided movements – this refers to voluntary motor

activity dependent on sensory, inputs; these movements are activated in
response to visual, auditory and somatosensory stimuli.

SUPPLEMENTARY MOTOR AREA

Location : Medial aspect of Area 6

Function : Programming and planning of motor activities and perhaps their

imitation.

Has presentation for both right and left sides as well as proximally
and distally.

AREA 8: FRONTAL EYE FIELD AREA

Location : Frontal lobe

Function : Center of voluntary movements of the eye INDEPENDENT of visual

stimuli such as the conjugate eye movements.

All three areas with motor function (4, 6 & 8) receive inputs from the
thalamus, cerebellum, other cortical regions and other peripheral receptors.

AREA 17: PRIMARY VISUAL AREA

Location : OCCIPITAL LOBE specifically along the lips of the calcarine sulcus;
this is called the visual or striate area.

Function : vision

Clinical findings when damanged:

➢ an irritative lesion will present with visual hallucinations

➢ a destructive lesion will cause contralateral homonymous defects of visual
fields and visual disorganization.
Area 18 & 19 – secondary visual areas

AREA 41: PRIMARY AUDITORY AREA

 Location : TEMPORAL LOBE specifically at the transverse gyri

Function : hearing

Clinical findings when damaged:

➢ irritative lesion will cause buzzing and roaring sensation

➢ unilateral destructive lesion will lead to a mild hearing loss
➢ bilateral destructive lesion will lead to a complete hearing loss

SECONDARY AUDITORY AREA: AREA 42 & 22, HESCHIL AREA

The auditory association area is involved in the comprehension of language and

lesions in this area results in auditory agnosia or the inability to recognize what he hears
but patient has intact hearing).

FRONTAL LOBE: additional notes

➢ lie interior to the central sulcus and lateral fissure

➢ main function: motor, cognition, speech, affective behavior
➢ PREFRONTAL CORTEX (Area 9, 10, 11, 12) is essential for abstract thinking,
foresight and judgement
➢ A lesion in the prefrontal cortex results in behavior at changes and changes in
cognitive function.

Functions of Principal Parts of the Brain

PARTS FUNCTION

BRAIN STEM

Medulla 1. Relays motor & sensory impulses between other parts

of the brain and the spinal cord.
2. Reticular formation (also in pons, midbrain and
diencephalons) functions in consciousness and arousal)
3. Vital reflex centers regulate heartbeat, breathing
(together with pons) and blood vessel diameter.
4. Nonvital reflex centers coordinate swallowing,
coughing, sneezing and hiccupping.
5. Contains nuclei of origin for CN 8, 9, 10, 11 and 12.
6. Vestibular nuclear complex helps maintain equilibrium.
 Pons 1. Relay impulses with in the brain and between parts of
the brain and spinal cord.
2. Contains nuclei of origin of CN 5, 6, 7 & 8
3. Pneumotoxic area and apneustic area, together with
the medulla, help control breathing.

MIDBRAIN 1. Relay motor impulses from the cerebral cortex to the

pons and spinal cord and relays sensory impulses from
the spinal cord to the thalamus.
2. Superior colliculi coordinates movements of the
eyeballs in response to visual and other stimuli and the
inferior colliculi coordinate movements of the head and
trunk in response to auditory stimuli.
3. Contains nuclei of origin for cranial nerves III & IV.
DIENCEPHALON

Thalamus 1. Several nuclei serve as relay stations for all sensory

impulses, except small, to the cerebral cortex.
2. Relays motor impulses from the cerebral cortex to the
spinal cord.
3. Interprets pain, temperature, light touch, and pressure
sensations.
4. Anterior nucleus functions in emotions and sensory.

Hypothalamus 1. Controls and integrates the autonomic nervous

system.
2. Receives impulses from viscera
3. Regulates and controls the pituitary gland
4. Center for mind-over-body phenomena
5. Secrets regulating hormones
6. Functions in rage and aggression
7. Controls normal body temperature, food intake and
thirst
8. Helps maintain the walking state and sleep
9. Functions as a self-sustained oscillator that drives
many biological rhythms.

Cerebrum 1. Sensory areas interprets sensory impulses, motor

areas function in emotional and intellectual processes.
2. Basal ganglia control gross muscle movements and
regulate muscle tone.
3. Limbic system functions in emotional aspects of
behavior related to survival.

CEREBELLUM 1. Controls subconscious skeletal muscle contraction’s

required for coordination, posture and balance.
2. Assume a role in emotional development, modulating
sensations of anger and pleasure.
 Vascular Anatomy

Blood

➢ Transport oxygen, nutrients and other substances for brain functioning

➢ Carries away metabolites
➢ Approximately 18% of total blood volume in brain.

➢ Brain uses 20% of oxygen absorbed in the lungs

➢ Two major arteries supplying blood to the brain are the INTERNAL CAROTID
ARTERY & VERTEBRAL ARTERY.
➢ Branches of ICA: ophthalmic, middle cerebral and anterior cerebral artery.
➢ Vertebral artery unites to form the basilar artery in the pons.
➢ Branches of vertebrobasilar artery: posterior cerebral, posterior and anterior
inferior cerebellar, pontine and internal auditory arteries.
➢ The circle of Willis is formed by the PCA, ACA, anterior communicating and
posterior communicating arteries.
➢ The MIDDLE CEREBRAL ARTERY does not form part of the circle of Willis
➢ The venous drainage of the cerebrum includes the veins of the brain itself, dural
venous sinuses, meningeal veins (dura) and diploic veins.

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
With calcarine artery and perforating branches to posterior thalamus and subthalamus.

A. PATHOPHYSIOLOGY

Etiology (Unknown)
↓
Tissue injury in the brain
↓
Causing compression of tissue
↓
Expanding hematoma or hematomas
↓
Distort and injure tissue
↓
The pressure may lead to a loss of blood supply to affected tissue with resulting
infarction
↓
The blood released by brain hemorrhage appears to have direct toxic effects on brain
tissue and vasculature
↓
Left sided body weakness and numbness.

↓
Right Hemisphere stroke

VI. COURSE IN THE WARD

 Physicians order Nursing interpretation

12-01-09

3:25pm

➢ Please admit to ROC ➢ patient is for admission, patient’s

preference room
➢ Consent form is secured from the
➢ Consent for admission patient.
Informed consent is an agreement
by a client to accept a course of
treatment or a procedure after being
provided complete information,
including the benefits and risk of
treatment, alternatives treatment ,
and prognosis if not treated by the
health care provider.
➢ Monitoring client’s vital signs should
be thoughtful and scientific
assessment. Vital signs should be
evaluated with reference to the
➢ TPR every shift & record client’s present and prior health
status. To obtain baseline data.
➢ To lessen the high risk eat food like
oatmeal or lugaw
➢ D5NM is indicated for parenteral
maintenance of routine daily fluid
and electrolyte requirements with
minimal carbohydrate calories from
dextrose. Magnesium in the formula
➢ Low salt, low fat diet, soft with
may help to prevent iatrogenic
aspiration precaution
magnesium deficiency in patients
➢ IVF: D5NM 1Liter x 12 hours
receiving prolonged parenteral
therapy.

➢ CBC: to determine hemoglobin,

hematocrit and erythrocytes or RBC
count, and assess the blood ability to
carry oxygen; which signal elevated.

➢ Mannitol: reduction of elevated

intracranial pressure
➢ Ranitidine: indicated for treatment of
gastric & duodenal ulcer
➢ To monitor rapid changes on his
blood pressure
➢ Lab:
VII. NURSING CARE PLAN
ASSESSM DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
ENT

Subjective: Impaired After 3 ➢ Established ➢ To build After 3 hours

“hindi mo verbal hours of rapport. trusting of Nursing
talaga communicat Nursing ➢ Monitored relationship Intervention
maintindih ion related Interventio and . shall be able
an to brain n the client recorded ➢ To have to improved
pananalita damage will V/S. baseline communicatio
niya neng” establish ➢ Established data. n abilities.
as methods of good ➢ To maintain
verbalized communica relationship, good
by the wife tion in listening communica
which carefully tion skills
needs can and with the
Objective: be express. attending to patient.
client’s
➢ pati verbal and
ent non-verbal
app expressions.
ears ➢ Kept
wea communicat
k ion simple, ➢ Assist the
➢ slurr using all pt.’s need
ed modes of to establish
spe accessing means of
ech information, communica
➢ diffi visual ting.
cult auditory and
y kinesthetic.
expr ➢ Provided
essi sufficient
ng time for
thou client to
➢ To give
ghts respond.
right
verb ➢ Used
manner
ally confrontatio
when
n skills,
communica
when
ting.
appropriate,
➢ To clarify
within an
discrepanci
establish
es between
nurse-client
verbal and
relationship.
non-verbal
➢ Involved SO/
cues.
family in
➢ To help the
plan of care
pt. recover
ASSESSME DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIO
NT N

Subjective: Risk for After 4 hours ➢ Establish ➢ To gain After 4 hours

”hindi niya impaired of nursing rapport the S.O’s of nursing
maigalaw skin integrity intervention ➢ Monitored trust intervention
ang related to the patient vital signs ➢ To obtain the client
kalahati ng hemiplegia will & recorded baseline demonstrate
kanyang demonstrate ➢ Assessed data d techniques
katawan”as techniques skin for ➢ Reduces to prevent
verbalize to prevent signs of likelihood skin
by his wife skin breakdown of breakdown.
breakdown with progressio
by the help if emphasis n to skin
Objective: his wife. on bony breakdow
areas & n
➢ Limit dependent
ed body parts
rang ➢ Provide ➢ To provide
e of adequate comfort
moti clothing
on ➢ Keep bed ➢ To prevent
➢ Slow clothes irritation
ed dry, use on skin
mov non- and
eme irritating decreases
nt materials risk for
➢ Limit & keep infection
ed bed free of
abilit wrinkles & ➢ To prevent
y to crumbs the risk for
perfo ➢ Encourage impaired
rm d S.O to integrity
gross continue
and regular
fine positioning
moto every 2 ➢ Maintainin
r hours g clean &
minimally dry skin
➢ Keep skin provides a
clean & barrier to
dry infection
➢ To provide
➢ Gently relaxation
massage
healthy ➢ To
dry skin improved
ASSESSME DIAGNISIS PLANNIN INTERVENTION RATIONALE EVALUATIO
NT G N

subjective: Self Care After 4 ➢ Monitored vital ➢ For After 4

deficit r/t hours of signs and baseline hours of
neuromuscu nursing recorded data nursing
Objective: lar, interventi ➢ Encouraged intervention
musculoskel on the relaxation ➢ To gain the patient
➢ Patie etal patient techniques energy identified
nt impairment will be ➢ Noted client personal
appe able to report of resources
ars identify weakness & ➢ To which can
weak personal difficulty conserve help in
➢ Inabil resources accomplishing energy providing
ity to which can tasks promotin assistance.
feed help in ➢ Provide g rest
hims providing positive and
elf assistanc atmosphere recovery.
➢ Diffic e while ➢ To
ulty acknowledging prevent
in difficulty of the further
turni situation for stress
ng the client and
➢ Established fatigue
nurse & client
relationship

➢ Turned pt.
slowly from ➢ To build
trusting
side to side
relations
hip

➢ To
provide
➢ Determined pt. proper
strengths and circulatio
skills n of
➢ Assisted pt. in blood
his activities flow on
both
 sides of
he body
➢ Encouraged
➢ To
adequate
assess
intake of fluids
degree
& Nutritious
of
foods
disability
➢ To
promote
➢ Provided time
optimal
for listening to
level of
patient and
function
SO, and
➢ Promotes
provided
well-
privacy during
being
personal care
and
activities.
maximiz
➢ Involved
es
client’s
energy
SO in care
producti
on.
➢ To assist
with the
patient’s
current
disability
or
condition
.

➢ To assist
in
learning
ways of
 managin
g
problems
of
immobilit
y and for
providing
appropri
ate
nursing
care.

VIII. DRUG STUDY

NURSING
INDICATIO CONTRAINDICA ADVERSE
DRUG CONSIDERATION
N TION REACTION
S
Generic name: Reduction -Contraindicated -CNS: -Assess patient’s
-Mannitol of elevated in patients dizziness, blood pressure
intracranial hypersensitive headache, history before
Brand name: pressure, to drug fever therapy. Monitor
-Osmofundan cerebral pulse and blood
20% edema or -Contraindicated -CV: pressure regularly
increased in patients with edema,
Classification: intraocular anuria, severe hypotensio -Check weight,
-Osmotic pressure. pulmonary n, renal function,
Diuretic congestion, tachycardia fluid balance and
ACTION frank pulmonary , vascular serum urine
Doctor’s order: Elevates edema, severe overload sodium and
-Manitol 100cc blood heart failure, potassium daily
IV q8 plasma severe -EENT:
osmolality, dehydration, blurred -Monitor CNS
resulting in metabolic vision, symptoms and
enhanced edema or active rhinitis changes in mental
flow of intracranial status.
water from bleeding. -GI: thirst,
tissues, dry mouth, -To relieve thirst,
including nausea, give frequent
the brain vomiting, mouth care or
and diarrhea fluids
cerebrospin -monitor allergic
al fluid, into -GU: urine reaction:
interstitial retention rash,fever,
fluid and pruritus,and
plasma. -Metabolic: urticaria.
 dehydration

-Other:
chills

DRUG INDICATIO Contraindic ADVERSE NURSING

N ation EFFECTS CONSIDERATION

Generic Name: -Active Ranitidine is - -Assess patient for

duodenal contraindicat Bradycardia abdominal pain.
-Ranitidine and gastric ed in patients ,
Hydrochloride ulcer who are constipation
hypersensitiv , diarrhea, -Remind patient to
-Gastro- e to it. It blurred
esophageal take once daily
Brand Name: should be vision, prescription drug at
reflux used cardiac
-Zantac disease bedtime for best
cautiously arrhythmias results.
(GERD) and possibly , burning
-Heartburn at reduced and itching
Classification: dosage in at injection
patients with site, -Take the drug with
-H2 receptor diminished headache foods.
blocker ACTION renal and fatigue.
function.
Competitivel
y inhibits -Advice patient to
Doctor’s order: action of report abdominal
histamine on pain and blood in
-Ranitidine stool or emesis.
the h2 at
50mg IV
receptor
sites of
parietal -Assess potential
cells, for interactions with
decreasing other
gastric acid pharmacological
secretion. agents the patient
 may be taking.

DRUG INDICATIO Contraindic ADVERSE NURSING

N ation EFFECTS CONSIDERATION

Generic Name: Treatment Contraindicat Adverse Culture infected

of a variety ed with effects area before
-Ampicillin of skin and allergies to reported with treatment;
Sodium skin penicillins, ampicillin are reculture area if
structure cephalospori similar to response is not as
infections, ns, or other those expected.
Brand name: soft tissue allergens reported with
infections other
-Ampicin aminopenicill
ACTION Check IV site
Use ins; however, carefully for signs
Bactericidal cautiously diarrhea and of thrombosis or
Classification: action with renal rash have drug reaction.
against disorder. been
-Antibiotic reported
sensitive
penicillin more
organisms; Do not give IM
inhibits frequently
with injections in the
synthesis of same site; atrophy
Doctor’s bacterial ampicillin
than with can occur. Monitor
order: cell wall,
other injection site.
causing cell
-ampicillin 500 currently
death.
mg available
aminopenicill Administer oral
ins. drumg on an
empty stomach, 1
hr before o 2 hrs
after meals with a
full glass of water;
do not give with
fruit juice or soft
drinks.
H

>I
>
nf
En
or
mco
ur
th
eag
e
rel
th
ati
e
ve
rel
th
eati
ve
im
to
po
do
rta
so IX. HEALTH TEACHING
nc
em
e
of
ex
pr
er M
op > Instruct the relative to follow medication regimen.
cis
er
es T
hy > Educate & instruct the family to monitor the blood pressure and pulse
lik
gi rate before administering medication.
e
en
ea
pa O
of >Inform the family of the patient to have a regular check-up for the
ssi continuity of treatment.
th
eve >Instruct the family of the patient to monitor if there is any sudden change
ra
pa to the patient and report immediately.
ng
tie
e
nt D >Instruct the relative to feed the client on time with nutrition food that
of
fro is low in sodium, low in cholesterol, low in fat and give citrus fruits,
mm moderate in fluid intake and increase fiber diet to improve health.
oti
he >Follow the diet prescribed by the doctor.
on
ad
in
to
aff
to
ec
e.
te >regular
d inspection
anof the
d diaper of
unthe patient
affand
ecchange if
te there a
d presence
paof fecal
rtsmaterial,
of urine or
th even
e redness
bothat would
dylead to
of skin
th rashes.
e >
cliduc
enate
t.