What Is Cerebral Vascular Disease?
Cerebrovascular disease: Disease of the blood vessels and, especially, the arteries that supply the brain Cerebrovascular disease is usually caused by atherosclerosis and can lead to a stroke.

What Is It?
-Hemorrhagic stroke is a term used to refer to the sudden onset of bleeding within the brain. The cause of this brain hemorrhage can vary depending on the underlying pathology that caused the stroke. Primary hemorrhage can be caused by pathologies that can lead to sudden bleeding. Some examples of these causes are:


Aneurysmal Subarachnoid Hemorrhage: The rupture of a cerebral aneurysm leads to subarachnoid hemorrhage, bleeding around the brain in the subarachnoid space. This typically leads to the sudden onset of headache and/or other neurological symptoms and is one of the most common forms of spontaneous brain hemorrhage. Hypertensive Hemorrhage: High blood pressure (hypertension) can lead to spontaneous hemorrhage into the brain leading to the sudden onset of neurological symptoms.

-Hemorrhagic stroke can also refer to a condition that occurs secondary to an ischemic stroke (cerebral infarction). If the brain and blood vessels are damaged by decreased blood flow to a region of the brain and then blood flow is restored, either due to some treatment or to natural processes within the body, then bleeding into that area of damaged brain can occur. The previously "bland" infarct can then undergo "hemorrhagic transformation", bleeding into the area of infarction. This is often referred to as a hemorrhagic form of stroke.

I. Objectives of the Study II. Patient¶s Profile x Personal Data x History of Present Illness x Past Medical History x Familial History x Social/Lifestyle History x Physical Examination III. Anatomy and Physiology IV. Pathophysiology V. Diagnostic Test/Special Procedure x Laboratory Test x Special Procedures VI. Treatment x Drug Study VII. Nursing Care Plan VIII. Health Education/Patient¶s Education

-This study aims to convey familiarity and provide effective nursing care to a patient diagnosed with Cerebral Hemorrhage; HPN, Cerebro Vascular Diseases through understanding the patient history, disease process and management.

‡ Formulate a workable nursing care plan on the subjective and objective cues gathered through nurse-patient interaction to be able to help the patient towards wellness. ‡ To plan management/strategies to patient. ‡ To use the nursing process as a framework for care in patients with hernia. ‡ To improve status of the patient ‡ To correct defect and prevent strangulation. ‡ To include adequate nutritional intake. ‡ Enumerate the necessary medications needed and be familiar to its mode of action.



Name Age DOB

: Ms. Z : 82 years old : March 16, 1928 : Mauban, Quezon

Place of Birth Sex Religion

: Female : R. Catholic

Occupation : none Nationality : Filipino Civil Status : Single

History of present illness
Date of Admission Time of Admission Chief Complaint Admitting Diagnosis : September 2, 2010 : 2:50a.m : U.T.I. , Hypertension : Hemorrhagic Cerebro Vascular Disease

Vital Signs: Temp: 37rC BP: 140/70 mmHg Pulse Rate: 72 bpm RR : 23 cycle/min

PAST MEDICAL HISTORY (+)Community acquired Pneumonia (+)Gastritis (-) Allergy (+) Asthma- Last attack during childhood FAMILY HISTORY (+) Hypertension ± Parent¶s Side

SOCIAL/LIFESTYLE -Non smoker -Non-Alcoholic Beverage Drinker -His diet consist of nutritional intake according to his satisfaction

Physical Examination
‡General Survey: Conscious and Coherent ‡Vital Signs: Temp=36.8º c PR: 98 bpm RR: 20 cycles/min BP: 100/70 mmHg ‡Integumentary: -Skin: Warm, Moist skin -Hair: Hair evenly distributed Oily with traces of white hairs evenly distributed Absence of dandruff Absence of infestation Thick hair -Nails: Oval in shape with slight thickness At end part of nail, smooth texture Normal Capillary refill (1-2 secs.)

‡Head and Neck: -Head: Normocephalic Symmetric -Eyes: Visual acuity and convergence was not assessed Both eyes coordinated movement with parallel alignment Symmetric evenly distributed Eyebrow/Eyelashes Eyelids color matches the skin with coordinated movement Pink partial conjunctiva -Ears: Symmetric , Smooth auricle with light brown color, Small in shape No discharge, No wounds, Presence of cerumen -Nose: Located at the midline of the face and there is no swelling or lesions noted -Mouth: Pale lips, smooth and not scaly. Absence of tooth decay Pinkish and reddish gums. Pink pharynx Normal flow of saliva Tongue is pinkish in color, both palate is still and normal position -Neck: Client was able to turn his neck from left to right motion Head position is equal on both sides

-Thorax and lungs: Spine vertically aligned No tenderness or masses Client is tachypneic with 23 cycles per minute with occasional dyspnea. -Abdomen: Unblemished skin and uniform in color Dullness at the lower right quadrant -Musculoskeletal: Irregular movements Weak in appearance -Lower Extremities: Symmetrical on both sides of the body with no contractures Muscles are weak with limited movements No deformities, no tenderness, or swelling with joints moving smoothly -Neurologic: Full consciousness, response to verbal stimuli -Genitourinary System: Client refuse

-Cerebrovascular disease (CVD) includes all disorders in which an area of the brain is transiently or permanently affected by ischemia or bleeding and one or more of the cerebral blood vessels are involved in the pathological process. -A doctor commonly diagnoses a stroke through a physical examination of the person affected as well as a description of the symptoms they are experiencing. A doctor attempts to find the location in the person's brain that has experienced damage through testing involving a CT or MRI scans, which may also help to rule out brain hemorrhage or tumors. A doctor considers the person's age, as well as any vascular, cardiac, or brain conditions the person may have. The doctor will attempt to determine whether the stroke was either hemorrhagic or ischemic. Ischemic strokes are often followed by additional strokes unless the problem is treated. A doctor may order an EEG if the person has experienced seizure activity, or an echocardiogram if they have a preexisting heart condition. A doctor will attempt to rule out things such as encephalitis, meningitis, bleeding inside the person's skull, neurodegenerative disorders, brain abscess, or migraines as causes of the stroke symptoms the person is experiencing. There are a number of tests that a doctor can use to assist in reaching a diagnosis of cerebrovascular disease. The majority of the tests involved are designed to detect carotid artery disease (CAD) before the person experiences a stroke. CAD, unlike hemorrhagic cerebrovascular disease, often progresses for many years while presenting no symptoms at all, accounting for approximately ninety-five percent of all cases of cerebrovascular disease.

Causes, Incidence, And Risk Factors:
-A stroke happens when blood flow to a part of the brain is interrupted because a blood vessel in the brain is blocked or bursts open. If blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen. Brain cells can die, causing permanent damage. 2 major type of stroke: -Ischemic stroke -Hemorrhagic stroke


A stroke is an interruption of the blood supply to any part of the brain. A stroke is sometimes called a "brain attack´. A stroke happens when blood flow to a part of the brain is interrupted because a blood vessel in the brain is blocked or bursts open.

A Cerebrovascular disease can be caused due to any disease that affects the arteries supplying blood and oxygen to the brain. The most common disease being is Atherosclerosis, which is caused due to fatty deposits (plaques) in the arterial wall which in turn causes narrowing of the arteries.

Another factor that could cause a blockage in the artery or arteries is a blood clot, also known as Thrombosis. In this situation, the blood clots usually occur in the heart and parts of that blood clot then break off and travel (embolize) to the arteries in the brain and cause a stroke. This condition is known as Embolism which can cause Transient ischaemic attacks (TIAs) in the brain leading to a loss of brain function in one area. The rupture of an artery causes hemorrhage (bleeding) in the brain and is known as Cerebral hemorrhage. The most common condition that can cause bleeding within the brain is an uncontrolled High Blood Pressure. A second condition that could affect the arteries is a defect or weakness in a blood vessel causing it to expand or balloon out is known as an aneurysm or arteriovenous malformations (AVM) in which there is an abnormal collection of blood vessels that are fragile and can cause bleeding.



Date run: 9/01/10 ± 7:31:06 A.M.

hite Blood Cells Red Blood cells Hemoglobin Hematocrit Platelet Count

17.5 3.83 116 0.34 Adequate

Normal Value
M:5-10x10 9/L F:5-10x10 9/L M:4.5-6x10 12/L F:4.5-5.5x10 12/L M:130-160 g/L F:120-140g/L M:0.40-0.50 F:0.37-0.47 150-350 g/L

DIFFERENTIAL COUNT Segmenters Lymphocytes Eosionophil Monocytes 0.30 0.10 0.00 0.00 .40-.60% .20-.40% .01-.04% .02-.04%

2nd Hematology
Date run: 9/02/10 ± 3:41:13 P.M.

hite Blood Cells Red Blood cells Hemoglobin Hematocrit Platelet Count

11.0 4.28 130 0.38 Adequate

Normal Value
M:5-10x10 9/L F:5-10x10 9/L M:4.5-6x10 12/L F:4.5-5.5x10 12/L M:130-160 g/L F:120-140g/L M:0.40-0.50 F:0.37-0.47 150-350 g/L

DIFFERENTIAL COUNT Segmenters Lymphocytes Eosionophil Monocytes 0.87 0.13 0.00 0.00 TOTAL: 100% .40-.60% .20-.40% .01-.04% .02-.04%

Blood Chemistry
Date run:9/03/10 ± 2:31:19 P.M.

FBS(Fasting Blood Sugar) Creatinine

8.45 93.9 mol/l

Normal Value
3.89 - 5.84mmol/l 44.16-150.16 mol/l

Date run: 9/1/2010 ± 9:53:30 P.M.

Color Dark-Yellow

RBC:2-4 /HP



WBC: Too numerous to count Squamous: Moderate Mucus: Moderate

Reaction Specific Gravity

Acidic 1.020

Bacteria: Moderate

A.Urates: Moderate

Chemical Examination: ‡ Sugar: Negative

‡ Albumin: Negative

2nd Urinalysis
Date run: 9/2/2010 ± 9:55:40 P.M.

Color Yellow

RBC:0-1 /HP



WBC: >100 /HP

Reaction Specific Gravity

Acidic 1.015

Squamous: Moderate Mucus: Few Bacteria: Rare

A.Urates: Few

Chemical Examination: ‡ Sugar: Negative

‡ Albumin: Trace

3rd Urinalysis
Date run: 9/4/2010 ± 7:53:16 A.M.

Color Yellow

RBC:0-3 /HP



WBC: >100 /HP

Squamous: Few Specific Gravity 1.010 Mucus: Few

A.Urates: Few

Chemical Examination: ‡ Sugar: Negative

‡ Albumin: Negative


Buscopan® [amp]- 10mg I.V q 8
Classification : Antispasmodics Mechanism of action: To relieve pain in gastrointestinal and urogenital tract. Its targets are muscles in the walls of stomach and intestines. Buscopan helps those muscles to relax. Indications: GIT spasm & hypermotility. Spastic pain in the biliary & urinary tract. Dyskinesia, peptic ulcer, spastic constipation & dysmenorrhea. Post-op vomiting.

Contraindications: Tachycardia, megacolon (parenteral only); glaucoma, urinary or GI obstruction, intestinal atony, paralytic ileus, asthma, myasthenia gravis, ulcerative colitis, hiatal hernia, serious hepatic or renal disease. Adverse Drug Reactions: Increased intraocular pressure, cycloplegia, mydriasis, dry mouth, blurred vision, flushing, urinary hesitancy & retention, tachycardia, palpitations, constipation, elevated body temp, CNS excitation, rash, vomiting, photophobia. Drug Interactions: Anticholinergic activity may be increased by other parasympatholytics. Guanethidine, histamine & reserpine can antagonise the inhibitory effect of anticholinergics on gastric acid secretion. Antacids may impair absorption. Nursing Responsibility: -Drug compatibility should be monitored closely in patients requiring adjunctive therapy -Avoid strict heat

Lanoxin® [amp]- .25 mg. I.V
Contents: Digoxin

Mechanism of Action: Inhibits sodium potassium-activated adenosine triphosphatase, promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contraction. Also acts on CNS to enhance vagal tone, slowing conduction through the SA and AV nodes and providing an anti-arrhythmic effect.
Indications Cardiac failure accompanied by atrial fibrillation; management of chronic cardiac failure where systolic dysfunction or ventricular dilatation is dominant; management of certain supraventricular arrhythmias, particularly chronic atrial flutter & fibrillation. Contraindications Intermittent complete heart block or 2nd degree AV block esp if there is a history of StokesAdams attacks; arrhythmia caused by cardiac glycoside intoxication, supraventricular arrhythmia caused by Wolff-Parkinson-White syndrome; ventricular tachycardia or fibrillation; hypertrophic obstructive cardiomyopathy. Hypersensitivity to other digitalis glycosides. Adverse Drug Reactions CNS disturbances, dizziness; visual disturbances (blurred or yellowish vision); arrhythmia, conduction disturbances, bigeminy, trigeminy, PR prolongation, sinus bradycardia; nausea, vomiting, diarrhea; urticarial or scarlatiniform w/ eosinophilia. Drug Interactions Sensitivity is increased w/ agents causing hypokalemia Classification:
Cardiac Drugs

Nursing Responsibility: -Monitor apical pulse for 1 full min. before administering. -Assess for peripheral edema,& auscultate lungs for rales/crackles through out therapy.

Nubain® [amp]- 10mg. I.V.
Contents: Nalbuphine HCl Indications: -For the relief of moderate to severe pain. Nalbuphine HCl can also be used for preoperative analgesia, as a supplement to balanced anesthesia, surgical anesthesia, for obstetrical analgesia during labor and for the relief of pain following acute myocardial infarction. Postoperative somatic and visceral pain. Contraindications Patients who are hypersensitive to nalbuphine HCl.
Mechanism of Action:

-Clinical experience suggests that in some patients, analgesia may be longer lasting than from comparable doses of morphine, effects having been observed in acute and chronic pain for 3-8 hrs. Nalbuphine HCl has the effect of lowering the cardiac work load and can be used immediately in myocardial infarction (use with caution where emesis is involved). Adverse Drug Reactions -The most commonly occurring reactions are sedation, drowsiness, sweating, nausea, dry mouth and dizziness. Pain at injection site, headache, vomiting and lightheadedness occur less frequently. Restlessness, blurred vision, chills, euphoria and impaired respiration have been infrequent. -Nubain produces few if any psychotomimetic side effects eg, visual hallucinations and dysphoria. Drug Interactions: -With Other Central Nervous System Depressants: Although nalbuphine HCl possesses narcotic antagonistic activity, there is evidence that in non-dependent patients, it will not antagonize a narcotic analgesic administered just before, concurrently, or just after an injection of nalbuphine HCl. Therefore, patients receiving narcotic analgesics, general anesthetics, phenothiazines or other tranquilizers, sedatives, hypnotics or other CNS depressants (including alcohol) concomitantly with nalbuphine HCl may exhibit an additive effect. When such combined therapy is contemplated, the dose of one or both agents should be reduced.

Classification: Anaesthetics - Local & General / Analgesics (Opioid) Nursing Resposibility: -Caution patient to change positions slowly to minimize orthostatic hypotension -Encourage patient to turn, cough, & breathe every 2 hrs. to prevent atelectasis

Micardis Plus® [40/12.5 mg tab] 1tab daily
Indications: -Treatment of essential hypertension for patients in whom combination therapy is appropriate. Mechanism of action: - A combination of an angiotensin II receptor antagonist, telmisartan and a thiazide diuretic, hydrochlorthiazide. The combination of these ingredients has an additive antihypertensive effect, reducing blood pressure to a greater degree than either component alone. Micardis Plus once daily produces effective and smooth reductions in blood pressure across therapeutic dose range. Administration: -May be taken with or without food Contraindications: -Cholestasis & biliary obstructive disorders. Severe hepatic & renal impairment. Adverse Drug Reactions: -Telmisartan: Headache, upper resp tract infection, dizziness. Hydrochlorothiazide: Anorexia, gastric irritation, muscle spasm, sleep disturbances. Classification:
-Angiotensin II Antagonists / Diuretics

Nursing Responsibility: -Special precaution in patients with impaired hepatic and renal impairment -Special precaution with volume and/or Na-depleted patients

Dilzem®- 30mg./tab
Contents: Diltiazem HCl Mechanism of Action: -Block calcium entrance into cardiac and vascular smooth muscle cells by blocking the L-type voltage sensitive calcium channel which is abundant in cardiac and smooth muscle. In smooth muscle, calcium binds to calmodulin resulting in activating myosin light chain kinase, an enzyme that phosphorylates the myosin light chain. This phosphorylation is essential for muscle contraction, thus by decreasing calcium levels in the vascular smooth muscle these agents lessen contraction. In the heart, calcium binding to troponin removes the inhibitory effect of troponin on the actin-myosin interaction thus allowing contraction. Thus, blockade of the slow calcium channel by these agents can result in negative inotropic effect. Indications: -Treatment of angina pectoris due to coronary artery spasm. Treatment of spontaneous coronary artery spasm presenting as Prinzmetal's variant angina (resting angina with ST-segment elevation occurring during attacks). -Treatment of hypertension: It may be used alone or in combination with other antihypertensive medication eg, diuretics. Administration: Should be taken on an empty stomach (Preferably taken before meals. SA & SR tab: Swallow whole, do not chew/crush.). Contraindications: Patients who are hypersensitive to diltiazem; with sick sinus syndrome except in the presence of a functioning ventricular pacemaker; with 2nd- or 3rd-degree AV block except in the presence of a functioning ventricular pacemaker; with hypotension (<90 mm Hg systolic); with acute myocardial infarction; with pulmonary congestion documented by x-ray on admission. Classification: Calcium Antagonists Nursing Responsibility: -Monitor BP & Pulse before therapy, during titration, & periodically during therapy. -Monitor intake & output ratios and daily weight.

Vastarel MR® [tab]- 35mg/tab
Contents: Trimetazidine Mechanism of Action: -Metabolic anti-ischemic agent. -By preserving the energy metabolism in cells exposed to hypoxia or ischaemia, trimetazidine prevents a decrease in intracellular ATP levels, thereby ensuring the proper functioning of ionic pumps and transmembranous sodium-potassium flow while maintaining cellular homeostasis. Indications -Long-term treatment of episodes of coronary insufficiency; angina pectoris. Administration -Should be taken with food (Swallow whole, do not chew/crush.) 1 tab at mealtimes in the morning and evening. Contraindications -Hypersensitivity to any of the constituents of Vastarel MR Side Effects: Rare cases of gastrointestinal disorders (nausea and vomiting) Classification:
-Anti-Anginal Drugs

Nursing Responsibility: -use cautiously in patients with heart failure or hypertension and in elderly patients

Kremil-S (Reformulated)® [tab]- 1 tab
Indications: Symptomatic relief of hyperacidity associated w/ peptic ulcer, gastritis, esophagitis & dyspepsia. Supplement to H2-blockers or proton pump inhibitors for rapid relief of ulcer symptoms. Antiflatulent to alleviate the symptoms of gassiness, including post-op gas pain, associated w/ hyperacidity. Mechanism of action: -May increase the intestinal absorption of aluminium by forming aluminium citrate, which is more soluble and absorbable, resulting in increased aluminium serum concentrations. This may lead to aluminium accumulation, encephalopathy and toxicity, especially in patients with renal failure. Fatalities have been reported in patients with renal failure, hence this combination should be strictly avoided in renal patients. Dosage: Adult 1-2 tab 1 hr after each meal and at bedtime. Administration: Should be taken on an empty stomach (Take 1 hr after each meal & at bedtime. Break/ chew before swallowing.) Contraindications: Patients with renal failure. Partial intestinal obstruction, appendicitis, fecal impaction, gastric outlet obstruction & constipation. Phosphate depletion, low serum phosphate & osteomalacia. Classification: Antacids, Antireflux Agents & Antiulcerants Nursing Responsibility: -Advise patient that changing positions often and walking will help pass flatus. -Tell patient to chew tablet before swallowing.

Rowagel® [gel]- CAP, P.O/ T.I.D.
Contents: Carbenoxolone Na Mechanism of action:
-Exerts a mineralocorticoid effect causing fluid retention and hypokalaemia. When co-administered with digoxin, carbenoxolone may theoretically increase the risk of digoxin toxicity (including arrhythmias) due to its hypokalaemic effect. If coadministration cannot be avoided, use with extreme caution and take steps to avoid hypokalaemia. Serum potassium should be monitored at regular

Indications: Mouth ulcers, lip sores, cold sores, orofacial lesions, sores or blisters caused by herpes simplex, herpes labialis, herpes febrilis or herpes stomatitis. Contraindications: Severe cardiac, renal or hepatic failure. Patients on digitalis glycosides. Classification:
ENT Drugs/ Mouth/Throat Preparations/Genito-Urinary System

Nursing Responsibility: -Advise patient to avoid the use of herbal meds or to consult his prescriber. -Encourage patient to eat potassium-rich foods.

Levofloxacin-200mg T.I.V. q 12
Mechanism of action: Microbiology: Antimicrobial Spectrum of Activity: Levofloxacin has antimicrobial activity against the following gram-positive and gram-negative aerobic and anaerobic bacteria, as well as Chlamydia pneumoniae and Mycoplasma pneumoniae: Indications: Treatment of adults •18 yr w/ mild, moderate & severe infections caused by susceptible strains of microorganisms in the following conditions: Community-acquired pneumonia, acute bacterial exacerbation of chronic bronchitis, acute maxillary sinusitis, complicated & uncomplicated skin & skin structure infections, acute pyelonephritis, complicated & uncomplicated UTI, nosocomial pneumonia, chronic bacterial prostatitis. Contraindications: Hypersensitivity to quinolones. IV Epilepsy, history of tendon disorders related to fluoroquinolone therapy. Childn, pregnancy & lactation. Adverse Drug Reactions: Diarrhea, abdominal discomfort, nausea, anorexia, abdominal pain, vomiting, stomatitis & heartburn; insomnia, headache & dizziness; rash, pruritus & eczema; muscle & joint pain; bone marrow depression. Increased liver enzymes. Pain, reddening at the inj site, phlebitis. General Disorders: Ascites, allergic reaction, asthenia, edema, fever, headache, hot flashes, influenza-like symptoms, leg pain, malaise, rigors, substernal chest pain, syncope, multiple organ failure, changed temperature sensation, withdrawal symptoms. Gastrointestinal Disorders: Dry mouth, dysphagia, esophagitis, gastritis, gastroesophageal reflux, GI hemorrhage, glossitis, intestinal obstruction, pancreatitis, tongue edema, melena, stomatitis. Liver and Biliary System Disorders: Abnormal hepatic function, cholecystitis, cholelithiasis, increased hepatic enzymes, hepatic failure, jaundice. Classification: Quinolones, Anti- infectives Nursing Responsibiilty: -Ensure that patient is well hydrated during course of therapy.
GI problems, weakness, tremors. -Report rash, visual changes, severe

Nursing Care Plan

Long Term goal: The patient will identify healthy ways to deal to enhance his/her condition. Short Term goal: The patient will participate willingly in desired activities. Assessment Nursing Diagnosis
- Ineffective

Scientific Rationale
-Decrease in



Expected Outcome The patient will be able to demonstrate changes to improve circulation.

S>>Patient was

being observed only.
O>> V/S:

Temp: 37ºc BP:140/70mmHg PR : 72 bpm RR : 23cycle/min. -Body Malaise -Facial Grimacing -(+) Tachypnea -Occasionally Dyspnea

Tissue Perfusion related to inadequate oxygen delivery to brain as manifested by hemorrhagic cerebrovascular disease.

oxygen resulting in the failure to nourish the tissues at the capillary level, problems can exist without decreased cardiac output

1. Monitor vital signs 2. Note Baseline data.

3. Encourage patient to change position every 2hrs. 4. Encourage rest periods 5. Review medication regimen.

1. To know present status of patient. 2. Provides comparison with current findings. 3. To optimize circulation of tissues & to relieve pressure. 4. To prevent fatigue. 5. To know adverse side effect/reaction or drug overdose 6. Restriction of protein helps limit BUN.

6. Provide for diet restrictions

Health Education/Patient s Education

‡ After the continuous treatment which consists of the medical and the nursing management of the patient, a development of her present health status is projected.

‡ Continuous administration of therapy had partially alleviated the clients suffering from the disease. Although disease process is incurable and has the tendency to attack again one¶s life, if the client will undergo treatment, by some means this will help reduce the sufferings of the client brought by the disease. But if the client will not subject herself to any medical management, this could lead to further complications; signs and symptoms of the disease will progress and will evidently manifested by the client. Furthermore, this would worsen the condition and eventually leads to death. ‡ Regular exercises are good for the heart and lungs and could stimulate proper circulation and oxygenation in the body. ‡ Regular exercise should be minimal and basic in order not to increase the workload of the heart ‡ Follow your doctor¶s recommendations for physical activity. ‡ Enhance self-care. ‡ Encourage personal hygiene.