…………………………………………………………………………

…………..TABLE OF CONTENTS

TITLE PAGE NO.

I. Introduction 1-2

II. Objectives 2-3

III. Nursing Assessment

1. Personal History

1.1. Patient’s Profile 3-4

1.2. Family and Individual Information 4

1.3. Level of Growth and Development

1.3.1. Normal Development at Particular Stage 5-7

1.3.2. Ill Person at Particular Stage of Patient 8

2. Diagnostic Results 8-11

3. Present Profile of Functional Health Pattern 11-14

4. Pathophysiology and Rationale 14-22

II. Nursing Intervention

1. Care Guide of Patient 22-25

2. Actual Patient Care

2.1. Nursing Assessment 26-27

2.2. Nursing Care Plan 27-32

2.3. Drug Study 33-34

2.4. Health Teaching Plan 35-36

III. Evaluation and Recommendation 36

IV. Evaluation and Implication 36-37

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V. Referral and Follow –up 37-38

VI. Bibliography 38-39

I. Introduction

“Cerebrovascular disorders” is an umbrella term that refers to any functional

abnormality of the central nervous system (CNS) that occurs when the normal blood

supply to the brain is disrupted. It also refers to any functional or structural abnormality

of the brain caused by a pathological condition of the cerebral vessels or of the entire

cerebrovascular system. This pathology either causes hemorrhage from a tear in the

vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the

vessel lumen with transient or permanent effects. Stroke is the primary cerebrovascular

disorder and it is the third leading cause of death after heart disease and cancer and is the

leading cause of disability among nations.

Stroke is a term used to describe neurologic changes caused by an interruption in

the blood supply to a part of the brain. The most common vessels involved are the

carotid arteries and those of the vertebrobasilar system at the base of the brain. The two

major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by a

thrombotic or embolic blockage of blood flow to the brain, with thrombosis being the

main cause of both CVA’s and transient ischemic attacks (TIAs). A thrombotic CVA

causes a slow evolution of symptoms, usually over several hours, and is “completed”

when the condition stabilizes. An embolic CVA occurs when a clot is carried into

cerebral circulation and causes a localized cerebral infarct. Ischemia may be transient

and resolve within 24 hours, reversible with resolution of symptoms over a period of 1

week (reversible ischemic neurologic deficit [RINDI]), or progress to cerebral infaction

with variable effects and degrees of recovery.

Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic

stroke. It is caused by other conditions such as a ruptured aneurysm, hypertension,

arteriovenous (AV) malformations, or other bleeding disorders. Symptoms depend on

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distribution of the cerebral vessels involved. Ischemic strokes account for

approximately 83% of all strokes. The remaining 17% of strokes are hemorrhagic.

Cerebrovascular disorder are the third leading cause of death in the United State.

And in the Philippine setting, it ranked as the second leading causes of mortality with a

62.3 rate per 100,000 population in both sexes and with a percentage of 12.5 by the year

2002. Therefore, giving emphasis in the study of this disease condition is very relevant.

Breakthroughs could happen and may help in the welfare of not just to Filipinos but to all

people at risk in this condition.

The advent of thrombolytic therapy for the treatment of acute ischemic stroke has

revolutionized the care of the client following a stroke. Before, health care professionals

could offer only supportive measures and rehabilitation to stroke survivors. New

therapies can now prevent or limit the extent of brain tissue damage caused by acute

ischemic stroke. Thrombolytic therapy must be administered as soon as possible after the

onset of the stroke; a treatment window of 3 hours from the onset of manifestations has

been established. To convey this sense of urgency regarding the evaluation and treatment

of stroke, health care professionals now refer to stroke as brain attack. Public education

is focused on prevention, recognition of manifestations, and early treatment of brain

attack.

II. Objectives

Student Nurse

General Objectives

After 2 days of giving holistic nursing care to the patient who have viral

meningitis, the nurse will be able to gain adequate knowledge, attitude and skills in

taking care of a patient who is suffering from this disease condition.

Specific Objectives

After 8 hours of giving holistic nursing care, the nurse will be able to:

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1. relate the patients history and level of growth and development

2. explain the significance of the diagnostic results

3. review the anatomy and physiology of the brain

4. explain the disease process and organ involved

5. compare the chart in classical and clinical symptoms of the disease

process

6. formulated appropriate nursing care plan based on identified problem of

patient

7. impart health teachings to the patient and significant others on viral

meningitis

Patient and Family

General Objective

After 2 days of nurse- client interaction the client and family will be able

to acquire adequate knowledge, attitude and skills in the promotion of health and

prevention of injuries and disease as well as rehabilitation from the condition.

Specific Objective

After 8 hours of giving holistic nursing care, the patient and significant

others will be able to:

1. establish a trusting relationship with the nurse

2. verbalize feelings and thoughts to the nurse

3. share information about self and the family and life experiences to the

nurse

4. explain the disease process in their own level of understanding

5. show willingness in the implementation of planned nursing care

III. Nursing Assessment

1. Personal History

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1.1Patient’s Profile

Name: Lee, George Ang

Age: 54 years Old

Sex: Male

Civil Status: Married

Religion: Buddhist

Date of Admission: January 2, 2006

Room number: 221

Complaints: Right sided weakness and slurred speech

Impression/Diagnosis: Cerebrovascular Accident (Bleed- left basal ganglia)

Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez

Hospital Number: 782349

1.2 Family and Individual Information, Social and Health History

A case of Mr. George Ang Lee, 54 year old, male, Filipino and Buddhist.

He is a businessman living at 515 MJ Cuenco Avenue, Cebu City.

Patient is a known hypertensive for many years already with a usual blood

pressure of 140/90. He has a maintenance medication when systolic blood

pressure reaches to 170. He is non-diabetic and non-asthmatic. Inspite, his

condition, he has no previous hospitalization until January 2, 2006 when he

experienced a sudden onset of weakness at the right side of his body. Patient was

later noted to be on the floor with slurred speech and drowsiness, then was rushed

immediately to Chong Hua Hospital- Emergency Room and later transferred to

Cebu Doctor’s University Hospital after basic diagnostic procedures were taken.

CT Scan taken revealed 25 cc bleed at left basal ganglia with medial shift to the

right. BP was noted to be elevated with highest BP at 190/110 and captopril was

given.

The patient doesn’t smoke and drink alcoholic beverages. His usual diet

consist of vegetable and no meat. He also has a regular exercise schedule

everyday but he has a strong heredofamilial disease of hypertension. His wife

shared that lately his husband was under stress due to increase sales in their

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business on the month of December and missed to have his regular exercise and

only sleeps a lesser hour per night compared to his usual sleep.

1.3 Level of Growth and Development

1.3.1 Normal Development at Particular Stage

Physical

Appearance Changes

Hair begins to thin, and gray hair appears. Skin turgor and

moisture decreases, subcutaneous fat decreases and wrinkling occurs.

Fatty tissue is redistributed, resulting in fat deposits in the abdominal

area.

Cardiovascular Changes

Blood vessels lose elasticity and become thicker.

Gastrointestinal Changes

Gradual decrease in tone of large intestine may predispose the

individual to constipation.

Sensory Perception Changes

Visual acuity declines, often by the late forties, especially for near

vision (presbyopia). Auditory acuity for high-frequency sounds

(presbycusis) also decreases, particularly in men. Taste sensation also

diminish.

Metabolism Changes

Metabolism slows, resulting in weight gain.

Urinary changes

Nephron units are lost during this time, and glomerular filtration

rate decreases.

Sexuality Changes

Hormonal changes takes place.

Musculoskeletal Changes

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Skeletal muscle bulk decreases at about age 60. Thinning of the

intervertebral disks causes a decrease in height of about 1 inch. Calcium

loss from bone tissue may occur. Muscle growth continues in

proportion to use.

Psychosocial

Erickson viewed the development tasks of middle-aged adult as

generativity versus stagnation. Generativity is defined as the concern

for establishing and guiding the nest generation. In other words, there is

concern about providing for the welfare of humankind that is equal to

the concern of providing for self. In middle age, the self seems more

altruistic, and concepts of service to others and love and compassion

gain prominence. These concepts motivate charitable and altruistic

actions, such as church work, social work, political work, community

fund-raising drives, and cultural endeavors. Marriage partners have more

time for companionship and recreation; thus, marriage can be more

satisfying in the middle years of life. Generative middle-aged persons

are able to feel a sense of comfort in their life-style and receive

gratification form charitable endeavors.

Erickson believes that persons who are unable to expand their

interests at this time and who do not assume the responsibility of middle

age suffer a sense of boredom and impoverishment, that is, stagnation.

These persons have difficulty accepting their aging bodies and become

withdrawn and isolated. They are preoccupied with self and unable to

give to others. Some may regress to younger patterns of behavior.

Cognitive

The middle-aged adult’s cognitive and intellectual abilities change

very little. Cognitive processes include reaction time that stays much

the same or diminishes during the later part of the middle years,

perception, learning that continues and can be enhanced by increased

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motivation oat the time in life, memory and problem solving that are

maintained through middle adulthood, and creativity.

Middle-aged adults are able to carry out all the strategies described

in Piaget’s phase of formal operations. Some may use post-formal

operations strategies to assist them in understanding the

contraindications that exist in both personal and physical aspects of

reality. The experiences of the professional, social and personal life of

middle-aged persons will be reflected in their cognitive performance.

Thus, approaches to problem solving and task completion will vary

considerably in a middle-aged group. The middle-aged adult can

“reflect on the past and current experiences and can imagine, anticipate,

plan and hope”

Moral

According to Kohlberg, the adult can move beyond the

conventional level to the postconventional level. Kohlberg believes that

extensive experience of personal moral choice and responsibility is

required before people can reach to postconventional level. Kohlberg

found that few of his subjects achieved that highest level of moral

reasoning. To move from stage 4, a law and order orientation, to stage

5, a social contract orientation, requires that the individual move to a

stage in which rights of others take precedence. People in stage 5 take

steps to support another’s right.

Spiritual

Not all adults progress through Fowler’s stages to the fifth, called

the paradoxical-consolidative stage. At this stage, the individual can

view the “truth” from a number of viewpoints. Fowler’s fifth stage

corresponds to Kohlberg’s fifth stage of moral development. Fowler

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believes that only some individuals after the age of 30 years reach this

stage.

In middle age, people tend to be less dogmatic about religious

beliefs, and religion often offers more comfort to the middle-aged person

than it did previously. People in this age group often rely on spiritual

beliefs to help them deal with illness, death and tragedy.

1.3.2 The Ill Person at a Particular Stage of Patient

The three most common causes of death in older adults are heart

disease, cancer and stroke. Other frequently reported causes of death are lung

disease, accidents/falls, diabetes, kidney disease, and liver disease. Heart

disease is the leading cause of death in older adults. Common cardiovascular

disorders are hypertension and coronary artery disease. Cancer or malignant

neoplasms are the second most common cause of death among older adults.

Cerebrovascular accidents, the third leading cause of death, occurring as brain

ischemia or brain hemorrhage. Cigarette smoking has been recognized as a risk

factor in the four most common cause of death for older adults: heart disease,

cancer, stroke and lung disease. Dental carries, gingivitis, broken or missing

teeth and ill-fitting or missing dentures may affect nutritional adequacy, cause

pain, and lead to infection.

2. Diagnostic Results

Diagnostic Test Normal Values Patient’s

Result

Significance

Hematology

Hemoglobin 11.5-16 g/dl 11.5 g/dl Normal

Hematocrit 35-49 vol % 35 vol % Normal

RBC 4.5-5.3x10^6/dl 4.73x10^6/dl Normal

WBC 4.5-15.0x10^3/dl 12.2x10^3/dl

Elevated in acute

disease.Source: Brunner and Suddarth’s

Textbook of Medical –

9

Surgical Nursing, 9th Ed.

Smeltzer, Suzanne C.

Bare, Brenda G., p.1954

MCV 72-98 fl. 91 fl. Normal

MCH 25-35 pg 30.3 pg Normal

MCHC 30-37 g/dl 33.3 g/dl Normal

Platelets 150,000-450000

cu/mm

361,000 cu/mm Normal

Segmenters 54-62% 84% Elevated in acute

disease.Source: Brunner and Suddarth’s

Textbook of Medical –

Surgical Nursing, 9th Ed.

Smeltzer, Suzanne C.

Bare, Brenda G., 1953

Eosinophils 1-3% 01% Normal

Lymphocytes 25-33% 10% Normal

Urinalysis

Macroscopic

Color Yellow Yellow Normal

Appearance Clear Slightly cloudy Not normal

Reaction 5.5-7.5 6.0 Normal

Specific gravity 1.001-1.045 1.020 Normal

Protein Negative Trace Not normal

Glucose Negative Negative Normal

Ketones Negative Negative Normal

Blood Negative Negative Normal

Macroscopic

RBC <3 RBC’s/HFF 0-1 Normal

WBC 0-5 WBC/ HPF 3-5 Normal

Epithelial Cells Rare Few Normal

Mucus Threads Rare Rare Normal

Bacteria None Negative Normal

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Leukocytes Negative Negative Normal

Nitrites Negative Negative Normal

Urobilinogen Trace Normal Normal

Bilirubin Negative Negative Normal

Serum

Glucose 65-110 142 Increased in infectionsSource: Brunner and Suddarth’s

Textbook of Medical –

Surgical Nursing, 9th Ed.

Smeltzer, Suzanne C.

Bare, Brenda G., 1960

Creatinine .7-1.5 .9 Normal

Sodium 137-145 137 Normal

Potassium 3.6-5.0 4.6 Normal

Chloride 98-107 103 Normal

Calcium 8.4-10.2 8.8 Normal

ELECTROCARDIOGRAPHIC REPORT

Atrial Rate: 120/min.

Ventricular: 120/min.

PR Interval: 0.14 sec.

QRS Complex: Transition zone in V3-V4

ST Segment: Isoelectric

T-wave: Upright

QRS: 0.08 sec.

AXIS: 0 degree

P-wave: upright

Interpretation: Sinus tachycardia with non specific ST-T wave changes

ECHOCARDIOGRAPHY REPORT

1. Quality of study- Optimal

2. Sinus Tachycardia- 107 beats/ min

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3. Cardiac Measurements- IVSd= 1.05 cm

LVIDd= 5.75 cm

LVPWd= 1.67 cm

LVIDs= 3.89 cm

Ejection Fraction= 61%

Ao rest= 2.97 cm

LA diameter= 3.40 cm

4. Cardiac Values: normal

5. Color and Doppler exam- Normal Pulmonic Valve/ Aortic/ left ventricular outflow

tract velocities. Normal mitral inflow pattern.

6. Left Ventricular Systolic Function- preserved global and regional with visual ejection

fraction estimate 70%.

7. Right Ventricular Systolic Function- preserved

8. No pericardial Effusion

CONCLUSION:

1. Well preserved biventricular systolic function.

2. Left ventricular hypertrophy.

3. Mild diastolic dysfunction.

CT SCAN

IMPRESSION: (as compared to the previous study done January 6, 2006.)

1. Further interval decrease in volume and density of the intraparenchymal

(hemorrhage in the left putamen/ left external capsule now measuring

approximately 34cc in volume (previous was 39cc), as described above.

2. Slight further decrease in the small amount of intraventricular hemorrhage

(extension) within the lateral ventricular.

3. No change in the subfalcine deviation (midline shift) to the right, still by 0.6 cm.

4. Chronic lacunar infarct in the right thalamus.

3. Present Profile of Functional Health Patterns

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3.1 Health perceptions/ Health management

According to Mr. Lee’s wife, his husband take a great deal with regards to

his health. He disciplined his self well to achieve an optimum health cause he

believes in the saying “health is wealth”. He values it well enough since it’s

something that gives him greater favor in his business. Whenever he

experiences sickness he manages it using Chinese herbal medications. Mrs. Lee

believes that her husband will recover gradually because he is a determined and

disciplined person who strongly value his health. As of the moment, the family

religiously follows the doctor’s instruction in restoring Mr. Lee’s health.

3.2 Nutritional/Metabolic pattern

According to Mrs. Lee, prior to admission, patient usually eats 3 meals a

day which usually consist of vegetables and fruits, rice, and less meat but more

on fish. He usually drinks tea every after meal or whenever he feels drinking.

He has no allergies to foods. His water consumption is replaced with tea. He has

Chinese drug supplements and has a maintenance medication for his

hypertension. Currently, he is on nasogastric tube feeding (blenderized) with

1800 calories in 1800 u volume. He is also allowed to take sip of water with

strict aspiration precaution.

3.3 Elimination Patterns

According to Mrs. Lee, before her husband’s admission, Mr. Lee voids

and defecates normally and has no problems/complaints in defecating and

urinating. He defecated about once a day usually at the morning. In the hospital

he is on diaper and lactulose is given to soften his stool. His skin is dry and

rough because he can’t take a bath but lotion is given to prevent further dryness.

3.4 Activity/ Exercise Pattern

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According to Mrs. Lee, before her husband’s admission, his usual activity

is managing and supervising his own wholesale business of different stuffs. He

helps in transferring boxes from the truck to the stock rooms, without any

complaint of dyspnea or fatigue after. Every morning he takes time to go to his

gym and exercise. And during breakfast he reads newspaper or watch news

from television. Currently, in the hospital passive exercise is done by Mrs. Lee

or the Private Nurse. Turning on the television whenever he is awake is

recommended by the doctor to rehabilitate his senses.

3.5 Cognitive/Perceptual Pattern

According to Mrs. Lee, her husband manages to read newspaper without

the aid of eye glasses, he still has a 20/20 vision and can also hear clearly prior

to admission. He was also able to comprehend well. But at the moment, he

doesn’t respond to any questions asked of him, he can’t speak yet. But he can

show some facial expressions like grimacing his face whenever he feels pain at

some parts of his body.

3.6 Rest/ Sleep Pattern

According to Mrs. Lee, he sleeps about 7 hours a day, usually goes to bed

early around 9 PM and arises early as well around 4 AM. He has no problems

or difficulty in sleeping. Before sleeping he usually pray with his Buddha beads.

In the hospital he sleeps most of the time, waking up occasionally. He is

drowsy.

3.7 Self- Perception Pattern

According to Mrs. Lee, he is a very responsible father to his children as

well as a good husband to her. She believes that Mr. Lee is also cooperating for

his quick recovery since he is looking forward to visit his relatives in China as

soon as he gets well.

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3.8 Roles- Relationship Pattern

According to Mrs. Lee, he speaks Bisaya and Mandarin. He can’t speak at

the moment yet. He has 3 children. The two has a family of their own already

and is presently residing in China. One son ,the eldest who is still single, is left

in Cebu with them who’ll take care of him at the hospital. In time of needs he

usually turns to his wife

3.10 Coping- Stress Management Pattern

According to Mrs. Lee, whenever problems occur especially with business

matters, both of them are solving it but most of the time his decision influenced

a lot. He also have his friends and relatives who’ll listen and advices him. He

also has a strong faith that he always pray whenever he has problems. Mrs. Lee

decided to have a private nurse to monitor his husband closely.

3.11 Values- Belief System

According to Mrs. Lee, they are Buddhist. They are religious in the

practices and faith of the Buddhist. Most spare time of Mr. Lee is spend in

prayers. They have their prayer room at the house. They are also active in their

temple activities and tries not to miss it. In the hospital they requested to play a

Buddhist chant which they believe could help him recover early. They also

have incenses that can soothe or make him sleep well.

4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ System Affected

The Nervous system is the body’s most organized and complex

structural and functional system. It profoundly affects both psychological and

physiologic function.

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The brain is the largest and most complex part of the nervous

system. It is composed of more than 100 billion neurons and associated

fibers. The brain tissues have a gelatin-like consistency. This semi-solid

organ weighs about 1400 g in the adult. It is divided into three major areas:

the cerebrum, the brain stem and the cerebellum. The cerebrum is composed

of two hemispheres, the thalamus, the hypothalamus and the basal ganglia and

connections of the olfactory and optic nerves. The brain stem includes the

midbrain, pons, medulla, and connections of cranial nerve II, IV and VII. The

cerebellum is located under the cerebrum and behind the brain stem.

The BASAL GANGLIA consist of several structures of subcortical

gray matter buried deep in the cerebral hemisphere. These structures include

the caudate nucleus, putamen, globus pallidus, substantia nigra, and

subthalamic nucleus. The basal ganglia serve a processing stations linking the

cerebral cortex to thalamic nuclei. Almost all the motor and sensory fibers

connecting the cerebral cortex and the spinal cord travel through the white

matter pathways near the caudate nucleus and putamen ganglia. These

pathways are known as the internal capsule. The basal ganglia, along with the

corticospinal tract, is important in controlling complex motor activity.

CEREBRAL CIRCULATION. The cerebral circulation receives

approximately 15% of the cardiac output, or 750 ml per minute. The brain

does not store nutrients and has a high metabolic demand that requires the

high blood flow. The brain’s blood pathway is unique because it flows

against gravity; it’s arteries fill from below and the veins drain from

above. In contrast to other organs that may tolerate decreases in blood

flow because of their adequate collateral circulation, the brain lacks

additional collateral blood flow, which may result in irreversible tissue

damage when blood flow is occluded for even short periods of time.

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Brain: Basal ganglia

Coronal slices of human brain showing the basal ganglia, globus pallidus: external segment (GPe),

subthalamic nucleus (STN), globus pallidus: internal segment (GPi), and substantia nigra (SN).

17

Coronal section of brain immediately in front of pons. (Not all basal ganglia are visible, but caudate nucleus

and substantia nigra are labeled. Subthalamic nucleus would be between thalamus and internal capsule.)

4.2 Schematic Drawing on Pathophysiology of Disease

Predisposing Factors Precipitating Factors

HeredityAge – 54 years old High sodium diet

History of stroke High blood pressureStress

Etiology

Plaque formation

Thrombi formation

Bloodstream is loaded

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High blood pressure

Dislodgment of thrombi

Emboli

Occlusion of cerebral vessels and Rupture of arteriosclerotic hypertensive vessels

Hemorrhage

Cerebral anoxia

CVA

Clinical symptoms Classical symptomsFacial asymmetry Facial asymmetry Slurring of speech Slurring of speechAphasia AphasiaHemiparesis Hemiparesis

ApraxiaHemiplegiaConfusion

4.3 Disease process and Effects on Different Organ System

Stroke, ischemic damage of the brain owing to a blockage in blood flow,

or to a hemorrhage of blood vessels in the brain. Without blood, sections of brain

tissue quickly deteriorate or die, resulting in paralysis of limbs or organs controlled

by the affected brain area. Most strokes are associated with high blood pressure

(hypertension), atherosclerosis (development of fatty plaques in artery walls), or both.

Some of the signs of major stroke are facial weakness, inability to talk, loss of

bladder control, difficulty in breathing and swallowing, and paralysis or weakness,

particularly on one side of the body. Stroke is also called cerebral apoplexy and

cerebrovascular accident.

The majority of stroke cases are due to arterial blockage caused by either

thrombosis or embolism. Thrombosis involves the clotting of the surface of an 19

atherosclerotic plaque, in a branch of one or more of the four main arteries leading to

the brain. As these arteries become narrowed, a potential stroke victim often

experiences recurrent warnings, which take the form of transient paralysis (such as in

one arm or leg or on one side of the face), or discovers impairments in speech, vision,

or other motor functions. At this stage, deposits in the linings of the cerebral arteries

can often be treated by surgical removal or bypass of blockages.

Embolism occurs when a cerebral artery suddenly becomes blocked by

material—such as clotted blood, air, or fat—coming from another part of the

bloodstream. Such masses, known as emboli, often form as clots in a diseased or

malfunctioning heart, but can also come from dislodged fragments of atherosclerotic

plaque or even an air bubble. Treatment is largely preventive, consisting of

monitoring of the diet, and, if possible, use of anticoagulants.

Hemorrhaging of cerebral blood vessels, a less frequent but usually more

serious cause of stroke, can occur where aneurysms, or blister-like bulges, develop on

the forks of large cerebral arteries on the brain surface. The rupture of aneurysms

causes brain damage, owing to the seepage of blood into brain tissue or to the reduced

flow of blood to the brain beyond the point of rupture.

4.4 Comparative Chart

Classical Symptom Clinical Symptom Rationale

a. Motor changes:

contralateral hemiparesis or

hemiplegia;

Sensory changes: contralateral

hemisensory alterations;

neglect of involved

extremities;

Visual changes:

homonymous hemianopia;

hemiplegia

contralateral hemisensory

alterations

- affectation in the middle

cerebral artery

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inability to turn eyes toward

the affected side;

Speech changes: dyslexia,

dysgraphia, aphasia;

Others: vomiting may occur

b. Motor changes:

contralateral hemiparesis, foot

and leg deficits greater than

arm, footdrop gait

disturbances;

Sensory changes: contralateral

hemisensory alterations;

Visual changes: deviation of

eyes toward affected side;

Speech changes: expressive

aphasia;

Mental changes: confusion,

amnesia; flat affect, apathy;

shortened attention span; loss

of mental acuity;

Others: apraxia (inability to

carry out purposeful

movements in nonaffected

areas)

c. Motor changes: mild

contralateral hemiparesis (with

thalamic or subthalamic

involvement); intention

tremor;

Sensory changes: diffuse

Dysphagia, aphasia

Footdrop, contralateral

hemiparesis

Contralateral

hemisensory alteration

Expressive aphasia

Amnesia, shortened

attention span

Memory deficit

- affectation in the anterior

cerebral artery

- affectation of the

posterior cerebral artery

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sensoryloss (thalamic);

Visual changes: papillary

dysfunction (brain stem); loss

of conjugate gaze, nystagmus;

loss of depth perception;

cortical blindness;

homonymous hemianopia;

Speech changes:

perseveration; dyslexia;

Mental changes: memory

deficits;

Others: visual hallucinations

d. Motor changes:

contralateral hemiparesis with

facial asymmetry;

Sensory changes: contralateral

sensory alterations;

Visual changes: hemianopia;

ipsilateral periods of blindness

(amaurosis fugax);

Speech changes: dysphagis;

Others: mild Horner’s

syndrome; carotid bruits

e. Motor changes: alternating

motor weaknesses; ataxic gait,

dysmetria (uncoordinated

actions);

Sensory changes: numbness

of the tongue;

Visual changes: double

Contralateral hemiparesis

dysarthia; dysphagia

Dysarthia, dysphagia,

temporary memory loss,

disorientation

- affectation of the internal

carotid artery

- affectation of the

vertebral – basilar system

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vision; homonymous

hemianopis; nystagmus,

conjugate gaze paralysis;

Speech changes: dysarthia;

dysphagia;

Mental changes: memory

loss; disorientation;

Others: drop attacks; tinnitus,

hearing loss

f. Motor changes: Ipsilateral

ataxia; facial paralysis;

Sensory changes: ipsilateral

loss of sensation in face,

sensation changes on trunks

and limbs;

Visual changes: nystagmus;

Others: Horner’s syndrome;

tinnitus, hearing loss

g. Motor changes: ataxia;

paralysis of larynx and soft

palate;

Sensory changes: ipsilateral

loss of sensation on face,

contralateral on body;

Visual changes: nystagmus;

Speech changes: dysarthia;

dysphagia; dysphonia; Others:

Horner’s syndrome; hiccoughs

and coughing

None

Dysarthia, dysphagia,

coughing, hiccoughs.

- affectation of the

anteroinferior cerebellar

(lateral pontine)

- affectation of the

posteroinferior cerebellar

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IV. Nursing Interventions

1. Care Guide of Patient with Disease Condition

IDENTIFY STROKE EARLY. A critical factor in the early intervention

and treatment of stroke is the proper identification of stroke manifestations.

The initial assessment of the client who is thought to have had a stroke includes

level of consciousness, papillary response to light, visual fields, movement of

extremities, speech, sensation, reflexes, ataxia, and vital signs. This data are

recorded and scored on the Glasgow Coma Scale. Intracranial pressure is also

monitored, the baseline pressure values and waveforms should be noted.

MAINTAIN CEREBRAL OXYGENATION. Always maintain a patent

airway. The client should be turned on the affected side if he or she is

unconscious, to promote drainage of saliva in the airway. The collar of the shift

should be loosened to facilitate venous return. The head should be elevated, but

the neck should not be flexed. Oxygen should be supplied an if the client

demonstrates poor ventilatory effort, intubation and mechanical ventilation may

be required to prevent hypoxia and increased cerebral ischemia. ECG is

performed and blood pressure is evaluated, and hypertension may be reduced

with vasodilators. Caution is exercised when treating blood pressure, as

lowering the blood pressure too far may lower cerebral perfusion pressure and

increase cerebral ischemia. Laboratory test for hematology, chemistry and

coagulation are obtained to rule out stroke-mimicking conditions and to detect

bleeding disorders that would increase the risk of bleeding during thrombolytic

therapy.

PREVENT COMPLICATION. Such as bleeding, cerebral edema, stroke

recurrence, aspiration and other potential complication.

REHABILITATION AFTER STROKE. Early premobilization efforts are

aimed at preventing the complications of neurologic deficit and immobility.

Relearning can take place even though damage in the CNS is irreversible. It is

extremely important that relearning take place as soon as possible after the

injury. An interdisciplinary rehabilitation team is necessary to assist and

24

support clients and their families during this time. The recommended plan of

care includes using interdisciplinary services to :

document the client’s condition and course fully, including deficits, status

of other disease, complications, changes in status, and functional status

before stroke.

Begin physical activity as soon as the client’s medical condition is stable;

use caution with early mobilization in clients with progressing neurologic

deficit, subarachnoid or intracerebral hemorrhage, severe orthostatic

hypotension, acute myocardial infarction, or acute deep vein thrombosis

Assist n managing general health functions throughout all stages of

treatment such as managing dysphagia, nutrition, hydration, bladder and

bowel function, sleep and rest, co-morbid conditions, and acute illnesses.

Prevent complications, including deep vein thrombosis and pulmonary

embolism, aspiration, skin breakdown, urinary tract infections, falls,

spasticity and contractures, shoulder injury and seizures.

Prevent recurrent strokes through control of modifiable risk factors, oral

anticoagulation, antiplatelet therapy, or surgical intervention.

Assess throughout acute and rehabilitation stages

Use reliable standardized instruments for evaluation

Evaluate for formal rehabilitation during acute stage

Choose individual or interdisciplinary program based on the client’s and

family’s needs; success of the program requires full support and active

participation of the client and family; families must be involved at the

outset

Choose the local rehabilitation program that best meets the client’s and

family’s needs

INTERDISCIPLINARY MANAGEMENT. Physical therapy,

occupational therapy, speech therapy.

PHARMACOLOGIC MANAGEMENT. Steroids and osmotic diuretics

may be used to reduce ICP. Hypertension is commonly controlled with

antihypertensives and diuretics.

25

Anticoagulants are commonly used initially through intravenous routes

and then orally. Monitoring of clotting times is important for preventing

overanticoagulation, which increases the risk of bleeding.

Headache and neck stiffness can usually be treated with mild analgesics,

such as codeine and acetaminophen. Stronger narcotics are usually avoided; these

agents sedate the client and can make neurologic assessment inaccurate.

If the client develops seizures, phenytoin (Dilantin) or Phenobarbital may

be used. Barbiturates and other sedative agents are avoided. If the client

develops fever, antipyretics may be prescribed.

DIETARY MANAGEMENT. Because of the high risk for aspiration;

choking, excessive coughing, and vomiting, oral food and fluids are generally

withheld for 24 to 48 hours. If the client cannot eat or drink after 48 hours,

alternative feeding routes are used, such as tube feedings or hyperalimentation.

When the swallowing mechanism has returned, the client can be fed orally.

SURGICAL MANAGEMENT. Several criteria are used to determine

candidates for rapid evacuation of hematoma in clients with hemorrhagic stroke

or bleeding on the dominant side. Another guide commonly used in the

determination of the need for surgery is ICP. Pressures below 20 mm HG are

usually managed without surgery; pressures above 30 mm Hg often require

surgery. Clients who have large areas of blood removed have been shown to

recover a substantial portion of speech. Clients with relatively large areas of

superficial cerebral bleeding or shifts may also require surgery. Likewise, clients

who suddenly deteriorate to from lethargy to unconsciousness may benefit from

surgery. Surgery is usually not performed on clients with bleeding in the basal

ganglia or thalamus.

Surgery is also performed on some intracranial aneurysms and on the

carotid arteries (carotid endarterectomy) to reduce the risk of CVA.

NURSING MANAGEMENT. The initial assessment of the client with

CVA is very important. The assessment must be complete and accurate to

provide a baseline for ongoing assessments. The client who is awake and alert

should be taught about the pathologic process and instructed to inform the nurse

about any changes in sensation, movement, or function regardless of how minor

26

they may seem. Increasing neurologic deficits may indicate either progression of

the infarct or ischemia of the area from cerebral edema or bleeding. Changes in

neurologic assessments must be reported promptly to the physician.

A complete history of the presenting problem as well as past medical and

social history will provide data about the problem source of the CVA.

Ongoing assessments of the neurologic status and vital signs are

imperative. These assessments may be required as often as hourly for unstable

clients. Assessment of hemiplegia includes the repeated assessment of motor

function, sensation, and reflex activity.

2. Actual Patient Care

2.1 Nursing Assessment

Name of Patient: Mr. George Ang Lee

Impression/Diagnosis: Cerebrovascular accident

Attending Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez

ACTIVITY/REST

Difficulty with activity due to generalized weakness, loss of sensation, or

paralysis (hemiplegia) tires easily; difficulty resting. Altered muscle tone and level

of consciousness. Incoherent.

27

CIRCULATORY

Electrocardiogram (ECG) changes. Elevated BP 160/100. strong

peripheral pulses.

EGO INTEGRITY

Feelings of helplessness and hopelessness, emotional liability an

inappropriate response to anger, sadness and happiness, difficulty expressing self.

ELIMINATION

Constipated.

FOOD/ FLUID

Mastication problems. Loss of sensation in tongue, cheek.

NEUROSENSORY

Weakness on the right side of the body, drowsy, sensory loss on

contralateral side (right side of body) in extremities and some part of the left face.

Disturbances in senses of taste and smell. Aphasia: defect or loss of language

function may be global.

PAIN/ DISCOMFORT

Guarding behavior on the GUT (scrutom).

RESPIRATION

On tracheostomy.

SAFETY

Swallowing difficulty, inability to meet own nutritional needs. Diminish

response to heat and cold.

SOCIAL INTERACTION

Speech problems, inability to communicate.

TEACHING/LEARNING

Family history of hypertension, strokes. Requires medication regimen/

therapeutic treatments.

2.2 Nursing Care Plan

28

Name of Patient: Mr. George Ang Lee Age: 5 4

Room/Ward: 221 Sex: Male

Chief Complaints: Right sided weakness and slurred speech

Needs/

Problems/

Cues

Nursing

Diagnosis

Scientific

Basis

Objectives

of Care

Nursing

InterventionRationale

NCP 1Subjective:no subjective cues

Objective:-on semi-Fowler’s position

-with NGT in place

-with D5NSS 1L @ 20 gtts/min

-with O2 @ 2LPM

-with FBC-UB

-lethargy noted

-slurring of speech noted

-with the ff. V/S:

BP – 170/100 mm HgPR – 90 bpm

RR – 24

Altered

cerebral

tissue

perfusion

related to

interruption

of blood

flow

(occlusive

disorder /

hemorrhag

e)

Cerebral infarction is deprivation of blood supply to a localized area of the brain. The extent of infarction depends on factors such as the location and the size of an occluded vessel and the adequacy of collateral circulation to the area supplied by the occluded vessel. If cerebral circulation is interrupted extensively, cerebral anoxia develops, that is, lack of oxygen to the

After eight hours of nursing interventions, the patient will be able to maintain usual/ improved level of consciousness, cognition, and motor sensory function.Specifically, he shall be able to:1.demonstrate stable vital signs and absence of any signs of increased ICP.

2.displays no further deterioration/ recurrence of deficits.

Independent1. Determine factors related to individual situation/ cause for decreased cerebral perfusion, and potential for increased ICP.

2. Monitor/ document neurologic status frequently and compare with baseline.

3. Monitor vital signs, note: - Hypertension / hypotension, compare BP readings in both arm.

1. Influences choice of interventions. Deterioration in neurologic signs and symptoms or failure to improve after initial insult may require surgical intervention and/or that the patient be transferred to critical care area for monitoring of ICP.(Doenges,p293)

2. Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression/ resolution of CNS damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA. (Doenges p293)

3. Variations may occur because of cerebral pressure / injury in vasomotor area of the brain. Hypoertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse).

29

cpmT – 37.5*C

brain. (Black:199

3,p707)

- Heart rate and rhythm, auscultate for murmurs.

- Respirations, noting patterns and rhythm, e.g., periods of apnea after hyperventilation.

4. Document changes in vision.

5. Assess higher functions, including speech, if patient is alert.

6. Position with head slightly elevated and in neural position.

7. Maintain bed rest;

Increased ICP may occur (tissue edema, clot formation). Subclavian artery blockage may be revealed by difference in pressure readings between arms. - Changes in rate especially bradycardia can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA. - Irregularities can suggest location of cerebral insult/ increasing ICP and need for further intervention, including possible respiratory support. (Doenges,p293)

4. Specific visual alterations reflect are of brain involved, indicate safety concerns, and influence choice of interventions. (Doenges,p293)

5. Changes in cognition and speech content are indicator of location/ degree of cerebral involvement and may indicate deterioration / increased ICP. (Doenges,p293)

6. Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation/ perfusion. (Doenges,p293)

7. Continual

30

NCP2

Subjective:-no subjective

Impaired

physical

Hemiplegia results from

After eight hours of nursing

provide quiet environment. Provide rest periods in between care activities, limit duration of procedures.

8. Prevent straining at stool, holding breath.

9. Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.

Collaborative1. Administer supplemental oxygen as indicated.

2. Administer medications (Antihypertensive) as indicated.

3. Monitor lab studies as indicated, e.g., PT/PTT time.

Independent1. Assess functional ability/ extent of

stimulation/ activity can increase ICP. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.

8. Valsalva maneuver increases ICP and potentiates risk of rebleeding. (Doenges,p293)

9. Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP/ cerebral injury, requiring further evaluation and intervention. (Doenges,p293)

1. Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/ edema formation. (Doenges,p293)

2. Preexisting / chronic hypertension requires cautious treatment, because aggressive management increases the risk of extension of tissue damage. (Doenges,p293)

3. Provides information about drug effectiveness/ therapeutic level. (Doenges,p293)

1. Identifies strengths/ deficiencies and may

31

cues

Objective:-on semi- Fowler’s position

-with NGT in place

-with D5NSS 1L @ 20 gtts/min

-with O2 @ 2LPM

-with FBC-UB

-lethargy noted

-slurring of speech noted

-inability to purposely move noted

-impaired coordination noted

-limited ROM noted

-decreased muscle strength and control observed

-with the ff. V/S:

BP –

mobility

related to

paralysis

damage to the motor area of the cortex or pyramidal tract fibers. Hemorrhage or clot in the brain’s left side causes right-sided hemiplegia, and vice-versa. This is because the nerve fibers cross over in the pyramidal tract as they pass from the brain to the spinal cord.(Black:199

3,p709)

interventions, the patient will be able to maintain optimal position of function.Specifically, he shall be able to:1.demonstrate absence of contractures, footdrop.

2.maintain/ increase strength and function of affected or compensatory body part

3. maintain in integrity.

impairment initially and on a regular basis.

2. Change position at least every two hours and possibly more often when place on affected side.

3. Begin active/passive ROM to all extremities on admission. Encourage exercises such as squeezing rubber ball, extension of fingers and legs/ feet.

4. Elevate arm and hand.

5. Place knee and hip in extended position.

Collaborative1. Provide egg crate mattress, as indicated.

provide information regarding recovery. Assist in choice of interventions, because different techniques are used for flaccid or spastic paralysis.(Doenges,p296)

2. Reduces risk of tissue ischemia/ injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown / decubitus. (Doenges,p296)

3. Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. (Doenges,p296)

4. Promotes venous return and helps prevent edema formation. (Doenges,p296)

5 Maintains functional position. (Doenges,p296)

1. Promotes even weight distribution decreasing pressure on bony points and helping prevent skin breakdown/ decubitus formation.

32

170/100 mm HgPR – 90 bpmRR – 24 cpmT – 37.5*C

NCP3

Subjective:-no subjective cues

Objective:-on semi-Fowler’s position

-with NGT in place

-with D5NSS 1L @ 20 gtts/min

-with O2 @ 2LPM

-with FBC-UB

-lethargy noted

-slurring of speech noted

-inability to purposely move noted

-impaired coordinati

Self-care

deficit

(inability to

perform

ADLs)

related to

paralysis.

Hemiplegia results from damage to the motor area of the cortex or pyramidal tract fibers. Hemorrhage or clot in the brain’s left side causes right-sided hemiplegia, and vice-versa. This is because the nerve fibers cross over in the pyramidal tract as they pass from the brain to the spinal cord.When voluntary muscle control is destroyed, strong flexor muscles overbalance the extensors.

After eight hours of nursing interventions, the patient will be able to perform self-care activities within level of own ability.Specifically, he shall be able to:1.demonstrate techniques/ lifestyle changes to meet self- care needs.

2. identify personal/ community resources that can provide assistance as needed

2. Consult with physical therapist regarding active, resistive exercises, and patient ambulation

Independent1. Assess abilities and level of deficit for performing ADLs.

2. Avoid doing things for the patient that the patient can do.

3. Be aware of impulsive behaviors/ actions suggestive of impaired judgment.

4. Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks.

5. Provide positive feedback for efforts/ accomplishments.

(Doenges,p296)

2. Individualized program can be developed to meet particular needs/ deal with deficits in balance, coordination and strength. (Doenges,p296)

1. Aids in anticipating for meeting individual needs.(Doenges,p302)

2. These patients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for the patient to do as much as possible for self to maintain self esteem and promote recovery. (Doenges,p302)

3. May indicate need for additional interventions and supervision to promote patient safety. (Doenges,p302)

4. Patients will need empathy but need to know caregivers will be consistent in their assistance. (Doenges,p302)

5 Enhances sense of self-worth, promotes independence, and encourages patient to continue endeavors.

33

on noted

-limited ROM noted

-decreased muscle strength and control observed

-inability to perform ADLs observed

-inability to perform oral care noted

-with the ff. V/S:

BP – 170/100 mm HgPR – 90 bpmRR – 24 cpmT – 37.5*C

This can cause serious deformities.(Black:199

3,p709)

Collaborative1. Administer suppositories and stool softeners.

2. Consult with physical / occupational therapist.

(Doenges,p302)

1. May be necessary at first to aid in establishing regular bowel function. (Doenges,p302)

2. Provides expert assistance for developing a therapy plan and identifying special equipment needs. (Doenges,p302)

2.3 Drug Therapy Record

Hospital No.:782349 Service: Medical

Physician: Dr. M. Lim, Dr. W. Briones, Impression:Cerebrovascular

Dr. G. Lim, Dr. E. Hernandez Accident

Drug/

Route/

Frequency/

Route

Classification/

Mechanism of

Action

Indications/

Contraindications/

Side Effects

Principles

of CareTreatment Evaluation

34

Ranitidine (Zantac)150 mg 1 tab BID

Ciprofloxacin (ciprobay) 500 mg 1 tab q 12H

Histamine2 Antagonist

Competitively inhibits the action of histamine at the histamine2 (H2) receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin. (Karch,p1039)

Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bactericidal

Indicated for duodenal ulcer (short-term treatment), pathologic hepersecretory conditions, maintenance therapy for duodenal or gastric ulcer, erosive esophagitis, heartburn and gastroesophageal reflux dse.

Contraindicated for patients hypersensitive to drugs.

CNS: vertigo, malaise, headacheEENT: blurred visionHepatic: jaundice.

Indicated for mild to moderate urinary tract infections, severe or complicated UTI’s, mild to moderate bone infections, chronic bacterial prostatitis,

Contraindicated in patients sensitive to fluoroquinolones.

CV: edema, chest painCNS: headache, restlessness and tremorGI: abdominal pain

Have regular medical follow-up to evaluate your response.

Use cautiously in patient with hepatic dysfunction.

Drug may cause false-positive results in urine protein test using Multistix.

May be added to total parenteral nutrition solutions.

Use cautiously with patients with CNS disorders

Food doesn’t delay absorption but may delay peak serum levels

Tendon rupture has been reported in patients receiving quinolones.

Take drug with meals and at bedtime. Therapy may continue for 4–6 wk or longer.

If you also are on an antacid, take it exactly as prescribed, being careful of the times of administration.

Adjust dosage in patients with impaired renal function

Assess patient for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate

Obtain specimen for culture and sensitivity test before giving the first dose.

Monitor patient’s intake and output and observe for signs of crystalluria.

Give oral forms 2 hours after a meal or 2 hours before or after taking

Continually given to prevent further complication

Continually given to prevent further complication

35

Phenytoin (dilantin) 100 mg I tab TID

Unknown. A hydantoin dereivative that probably stabilizes neuronal membranes and limits seizure activity by either increasing efflux or decreasing influx of sodium ions across cell membranes in the motor cortex during generation of nerve impulse.

or discomfort, constipation, flatulenceMusculoskeletal: arthralgia, joint inflammation, joint or back pain

Indicated to control for tonic-clonic and complex partial seizures, for patient requiring a loading dose, status epilecticus.

Contraindicated for hypersensitivity and in those with sinus bradychardia, SA block, second or third degree AV block, and Adam-Strokes syndrome.

CNS: ataxia, slurred speech and dizzinessCV: periarteritis nodosaEENT: nystagmus, diplopia, blurred visionGI: nausea, vomiting and constipationHapatic: toxic hepatitis

Lon g-term therapy may result in overgrowth of organism resistant to ciprofloxacin.

Use cautiously in patients with hepatic dysfunction, hypotension

Elderly patient tends to metabolize phenytoin slowly and may need reduced dosages.

Use only clear solution for injection.

antacids.

Discontinue in pain, inflammation, or tendon rupture occurs.

Divided doses given with or after meals may decrease adverse GI reactions.

Stop drug if rash appears.

Don’t withdraw drug suddenly because seizures may worsen

Continually given to prevent further complication

2.4 Health Teaching Plan

Patient’s Name: Mr. George Ang Lee

Impression: Cerebrovascular Accident

Complaints: Right sided weakness and slurred speech

Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez

Objectives Content Methodology Evaluation

After the period of nursing

care, the patient and family

shall be able to acquire basic

The family

were able

to 36

knowledge, positive attitude,

and beginning skills in

rendering wholistic care to the

patient post hospitalization.

Specifically, the patient and

family shall be able to:

1. be reminded of medication

schedule.

2. establish exercise

routine.

3. adhere to dietary

management.

4. provide psychological

support to patient.

5. visit the attending

physician post

hospitalization to

provide continuity of

care.

Medication should be

administered as ordered.

Provide basic ROM exercises

to prevent contractures.

Low salt, low fat diet should

be facilitated

It is always important to

maintain an open

communication with the

patient to relieve patient’s

anxiety.

Usually when CVA patient is

discharged, constant medical

consultation should be

maintained.

Interaction

(discussion)

15-20 mins

Demonstration

assimilate

the

information

given.

V. Evaluation and Recommendation

After rendering holistic care, the patient and the nurse were able to

achieve the specific objectives.

37

The degree of outcome attainment should be evaluated on an ongoing

basis. After CVA, some outcomes are achieved early (e.g., cerebral perfusion);

others may require rehabilitation (e.g., self-care deficit). It is important to

monitor progress toward outcomes, working with both the client and the family.

Continuing medications even after symptoms abate is recommended.

Continue encouraging the client to verbalizes and express his feelings, this

would always be effective and therapeutic to the client. Emotional support must

be provided to both the client and family members. If the client is to be

discharged home, the family needs clear understanding of the residual deficits.

The family and client need to have realistic expectations about the client’s

abilities; yet encourage independence when the client is able.

VI. Evaluation and Implication of This Case Study To:

Nursing Practice

This case study would make a contribution to the practice of medical

nursing as it would serve as a documentation that would then contribute to the

appropriate plan of care in patients with cerebrovascular accident (CVA). This

would also provide information about cerebrovascular accident (CVA) and

nursing interventions and therapeutic techniques used with patients who have this

disorder. It also provides information about the plan of care for patients who have

this condition for efficient nursing care.

Nursing Education

To nursing education, this case study would help by providing information

about the disease condition, cerebrovascular accident (CVA). The student nurses,

as well as the clinical instructors could gain additional information about this

disorder that ranks 2nd in the ten leading causes of death in the Philippines, so that

it could better equip them for efficient nursing care in the future. This study

38

would explain the future nurses’ adequate background knowledge regarding

medical nursing before one is to be exposed to the clinical setting. This would

help expand knowledge regarding the disease and would correct misconceptions

toward this case. It would then promote awareness.

Nursing Research

Research is now an integral part of nursing. Through research, betterment

or improvement of nursing education to be practiced competitively in the clinical

setting will be achieved. In Nursing Research, this case study may broaden the

scope or extent of research done previously for cerebrovascular accident (CVA).

This may lead to another breakthrough study in the details of the condition. This

can also contribute in upgrading and updating the interventions made for this

condition.

VII. The Referral and Follow-up

Rehabilitation from stroke requires specialized help from neurologists,

physiotherapists, physical therapist, occupational therapist and speech therapists

—especially during the first six months, when most progress is made. Passive

stretching exercises and thermal applications are used to regain motor control of

limbs, which become rigidly flexed after a stroke has occurred. A patient may

recover enough to do pulley and bicycle exercises for the arms and legs and,

through speech therapy, may regain the language abilities often lost following a

stroke; the degree of recovery varies greatly from patient to patient.

39

VIII. Bibliography

Black, Joyce M., Hawks, Jane Hokanson, and Keene, Annabelle. Medical-Surgical

Nursing Clinical Management for Positive Outcomes. 6th Edition. Philadelphia,

PA: W.B. Saunders Company. 2001

Doenges, Marilynn, Moorhouse, Mary Frances and Geissler-Murr, Alice. Nursing Care

Plans Guidelines for Individualizing Patient Care. 6th Edition. Philadelphia: F.A

Davis Company. 2002

Deglin, Judith and Vallerand, April. Davis’s Drug Guide for Nurses. 5th Edition.

Philadelphia, Pennsylvania: 1997

Kozier, Barbara, ET. Al. Fundamentals of Nursing: Concept, Process and Practice. 5th

Edition. USA: Addison-Wesley Longman, Inc., 1998.

Potter, Patricia and Perry, Anne Griffin. Fundamentals of Nursing.5th Edition. St. Louis,

Missouri: Mosby, Inc., 2001

Smeltzer, Suzanne and Bare, Brenda. Textbook of Medical Surgical Nursing. 10th

Edition. Philadelphia, PA: Lippincott Williams and Williams, 2004.

Nettina, Sandra M. Manual of Nursing Practice. 7th Edition. Philadelphia: Lippincott,

1996

Bates, Barbara, MD. A Guide to Physical Examination. 2nd Edition. Philadelphia:

Lippincott, 1996

Positive Outcomes. Vol. 2, 6th Edition. Philadelphia: W. B. Saunders Company, 2001.

Doenges, Marilyn E. et al. Nurses Pocket Guide. 8th Edition F. A. Davis Company, 2002

Porth, Carol Matson. Pathophysiology, Concepts of Altered Health States. 6th Edition.

Lippincott Williams and Wilkins, 2002

MIMS, Philippines Index of Medical Specialties Established Since 1968, 100th Ed., 2004.

40

Oxford Reference. Dictionary of Nursing, Published by Oxford Melbourne, Oxford

University Press, Market House Books Ltd. 1990.

41