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R.N.P. Blvd., Carmen, Cagayan de Oro City
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A Care Study



Cardio Vascular Accident,

Submitted to:

Clinical Instructor

Submitted by:
Group B6

I. Introduction

II. Patient’s Profile

III. Nursing System Review Chart

IV. Growth and Development

V. Pathophysiology

VI. Doctor’s Order

VII. Ideal Nursing management

VIII. Actual Nursing Management

IX. Progress Notes

X. Evaluation and Implication

XI. Referral and Follow-up

XII. Health Teachings

XIII. Prognosis

XIV. Bibliography

I. Introduction

Thrombosis, embolism, and hemorrhage are the primary causes for CVA,
with thrombosis being the main cause of both CVAs and transient ischemic
attacks (TIAs). The most common vessels involved are the carotid arteries and
those of the vertebrobasilar system at the base of the brain. 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.
Hemorrhagic CVA is caused by other conditions such as a ruptured aneurysm,
hypertension, arteriovenous (AV) malformations, or other bleeding disorders.
Symptoms depend on distribution of the cerebral vessel(s) involved. Ischemia
may be (1) transient and resolve within 24 hours, (2) reversible with resolution of
symptoms over a period of 1 week (reversible ischemic neurological deficit
[RIND]), or (3) progress to cerebral infarction with variable effects and degrees of

Stroke (or cerebrovascular accident or CVA) is the clinical designation for a
rapidly developing loss of brain function due to an interruption in the blood supply
to all or part of the brain. This phenomenon can be caused by thrombosis,
embolism, or hemorrhage. In medicine the process of being struck down by a
stroke, fit or feint is sometimes called an ictus, from the Latin icere (“to strike”),
especially prior to the definitive diagnosis being made.

Risk factors for stroke include advanced age, hypertension (high blood
pressure), previous stroke or TIA (transient ischaemic attack), diabetes mellitus,
high cholesterol, cigarette smoking, atrial fibrillation, migraine with aura, and
thrombophilia. In clinical practice, blood pressure is the most important
modifiable risk factor of stroke; however many other risk factors, such as
cigarette smoking cessation and treatment of atrial fibrillation with anticoagulant
drugs, are important.

The traditional definition of stroke, devised by the World Health Organization in
the 1970s, is of a 'neurological deficit of cerebrovascular cause that persists
beyond 24 hours or is interrupted by death within 24 hours'. In recognition of this,
and improved methods for the treatment of stroke, the term "brain attack" is
being promoted in the Western World as a substitute for stroke or TIA. The new
term makes an analogy with "heart attack" (myocardial infarction), because in
both conditions, an interruption of blood supply causes death of tissue that is
highly time dependent ('time is brain') and potentially life-threatening. Many
hospitals have "brain attack" teams within their neurology departments
specifically for swift treatment of stroke

b. Objective of the study

This care study aims to know about the disease condition Cerebrovascular
Accident, its pathophysiology, its medical management and the nursing
interventions that a student nurse can apply. It also aims to gather pertinent
information about the clients’ health history and how this disease developed.

c. Scope and Limitation of the study

This study was done during the clinical duty at X specifically at the Station 5
dated September 20, 2007 and visitations on September 19, 22, and 23, X. The
period of the study is limited only to four days thus all events that will happen
after the said period is not included.

The scope of the study includes the factors that predisposes and precipitates
the client to acquire the said disease condition. It also includes obtaining history
of the clients’ present illness. Moreover, as a student nurse, it is our responsibility
to attend to our clients needs and to intervene properly according to my nursing
care plan with the supervision of my clinical instructor.

II. Patient’s Profile

Name: ? Date Admitted: Sept. 16, 2007

Age: X Time Admitted: 12:30 AM

Sex: Female Weight: 55 kg

Religion: X Height: 5 ft

Civil Status: Married Birthday: Feb. 12, 1953

Number of Children: 5 children Nationality: Filipino

Address: ?

Occupation: ?

Husband: ?

Income: P2,600/Month

Informant ? (son) Contact #: ?

Educational Attainment: College level

Chief Compliant: (she suddenly fainted)

Admitting Diagnosis: CVA, thrombotic

Attending Physician: Dr. Agcopra

BP: 150/100 mmHg

T: 37.5º C

PR: 75 bpm

RR: 28 cpm

Health History

Our patient was born via Normal Spontaneous Vaginal Delivery with the help
of “mananabang” last February 12, X. The patient’s watcher didn’t know if D.B.
Chavez has been immunized when she was still young. According to the
watcher, D.B.C. was still 19 when she got married to X and they were blessed
with 5 children. All of them were born via normal spontaneous vaginal delivery.

According to the watcher, D.B.C. had experienced common colds, cough,
fever and diarrhea before. She had no known allergies to food and drugs. She
doesn’t smoke but she’s an occasional drinker. Her usual diet consists mainly of
vegetables, fruit, fish, pork and beef.

Year X, she had also experienced pneumonia. That very same year, she had
undergone a surgery due to the tumor found in her neck at Maria Reyna Hospital
and had been transfused with blood with no adverse reactions. His attending
physician at that time discovered that she was hypertensive. Due to this, she was
given medications but wasn’t able to maintain and follow it due to personal
reasons. This had been believed as the primary cause that predisposes her to
her condition now. Stress was also said to be one of the reason. She and her
husband had been finding ways to supply the needs of their three children which
are all now in college. Last 3 months, she was also diagnosed with UTI during
her check-up.
History of present illness

One day prior to her admission, she was very stressed in doing their
household chores alone. The night prior to her admission, she suddenly fainted
and was found flat and unconscious on floor after going to the comfort room. The
following morning, she was brought and admitted to X at X and was immediately
transferred to X for further observation. At X, she was diagnosed with Thrombotic
III. Nursing System Review Chart

Name: ? Date:_September 19, 2007

Vital Signs:

Pulse: _75 bpm BP: _150/100 mmHg Temp:_38º C Height: 5 ft Weight: 55kg

[ ] impaired vision [ ] blind
[ ] pain redden [ ] drainage
[ ] gums [ ] difficulty of hearing [ ] deaf O2 inhalation @ 2L/m
[ ] burning [ ] edema [ ] lesion [ ] teeth
[ ] assess eyes ears nose Dry lips and Cough
[ ] throat for abnormality [ ] no problem
RESP: Scar (operation)
[ ] asymmetric [x ] tachypnea [ ] barrel chest
[ ] apnea [x ] rales [x ] cough Asymmetric RR
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ] dyspnea
Tachypnea RR: 28cpm/ Rales
[ ] orthopnea [ ] labored [x ] wheezing
[ ] pain [ ] cyanotic
Dry skin/yellowish/ Warm to
[x ] assess resp. rate, rhythm, pulse blood touch/ Poor skin turgor
[x ] breath sounds, comfort [ ] no problem
[ ] arrhythmia [ ] tachycardia [ ]numbness
[ ] diminished pulses [x] edema [x] fatigue Scar(ligation)
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [x] pain Distended GI
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort FBC (yellowish urine)
[ ] no problem
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
[x] assess abdomen, bowel habits, swallowing
[x] bowel sounds, comfort [x] no problem
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding Dirty long nails
[ ] hematuria [ ] discharge [x] nocturia
[x] assess urine frequency, control, color, odor, comfort Immobility
[ ] gyne bleeding [ ] discharge [ ] no problem
NEURO: unconsciousness
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors dehydrated
[ ] confused [ ] vision [ ] grip
[x] assess motor function, sensation, LOC, strength IVF D5NSS 1L @ 40 gtts/m
[x] grip, gait, coordination, speech [ ] no problem
[ ] appliance [ ] stiffness [x] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [x ] poor turgor [ ] cool [ ] flushed
[x] hematoma [x] rash [ ] pain [ ] ecchymosis [ ]
diaphoretic moist
[x] assess mobility, motion gait, alignment, joint function
[ X] skin color, texture, turgor, integrity [ ] no problem
[ ] hearing difficulty Comments: “dili nag [x] glasses [ ] languages
a buka iyang mata, [ ] contact lenses [x] hearing
[x] visual changes
usahay mu lihok siya difficulties due to age
[ ] denied kung storyahan.” As Pupil size:3 mm [x] speech
verbalized by the difficulties
patien’ts daughter. Reaction: PERRLA (Pupil Equally Round
Reactive to Light and Accomodation)
OXYGENATION: Resp. [ ] regular [x] irregular
[x] dyspnea Comments: “gahi iya Describe: Patient has rapid respiration and
[ ] smoking history ubo dayun pas-pas adventitious breath sounds noted upon
[x] cough iynag ginhawaan” as auscultion.
[x] sputum verbalized by the
[ ] denied patient’s husband. R: full and symmetrical to the left lung
L: full and symmetrical to the right lung
[ ] chest pain Comments: “na Heart Rhythm [x ] regular []
comatose na mana irregular
[ ] leg pain
siya dili na niya ma Ankle Edema: Ankle edema is present on
[x] numbness of lihok iyang lawas” as both extremities
verbalized by the Pulse Car Rad. DP Fem*
patient’s daughter. R
[ ] denied 90bpm_+_______+_______+_____+___
Comments: Right and left pulses are equal;
strong and palpable.
Diet:osteorized Comments: “I agi [ ]dentures [x]none
feeding through nalang aning tubo
NGT ang iyang pagkaon Full Partial with
[Character kay dili naman siya patient
[ ] recent change in ka tulon” as
weight verbalized by the Upper [] [x] [ ]
[x] swallowing patient’s daughter.
Difficulty Lower [] [x] [ ]
[ ] denied
ELIMINATION: Comments: “dili Bowel sounds
Usual bowel pattern [ ] urinary frequency namu Slightly not Audible
Once a [ ] urgency mahinumduman bowel sounds
day________ [ ] dysuria kanus-a siya Abdominal Distention
[ ] constipation [ ] hematuria nakalibang basta Present [ ] yes [x] no
remedy [ ] incontinence wala pa siya ka Urine* (color,
Date of last BM [ ] polyuria libang sugod pa sa consistency, odor)
Not recalled [x] foley in place iyang pagka admit” urine color is
[ ] diarrhea [ ] denied as verbalized by yellowish, slightly
character the patient’s hazy and with
daughter. aromatic odor
MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to
[ ] alcohol [x] denied follow treatments (diet, meds, etc.) for
(amount & frequency) chronic health problems (if present).
“wala man gani ko ga inum siya pa kaha” Patient is following accurately on his
treatment according to doctor’s order
as verbalized by the patient’s husband
religiously with the support of the
[ ] SBE Last Pap Smear: not recalled significant others.
LMP: Not recalled

Comments: “uga na bitaw [x] dry [ ] cold [x]
iyang panit karun pero pale
[x] dry wala man siyay mga [ ] flushed [x] warm
samad samad.” As [ ] moist [ ] cyanotic
[x] other
verbalized by the patient’s *rashes, ulcers, decubitus (describe
daughter. size, location, drainage: (-) rashes; (-)
[ ] denied
ulcers ; (-) decubitus (There were
presence pf hematomas on patients
anticubital areas and wrist).
SAFETY: Comments: “na comatose [ ] LOC and orientation Patient is not
[ ] convulsion na mana siya, dili na niya oriented as to the place, date and
[ ] dizziness malihok iya lawas” as time.
[x] limited motion verbalized by the patient’s Gait: [ ] walker [ ] cane [ ]
of daughter.” other (ambulant)
[x] steady [ ]
Limitation in unsteady_________
Ability to [ ] sensory and motor losses in face
[ ] ambulate or
[ ] bathe self extremities presence of sensory and
[x] other motor losses on face or extremities
[ ] denied [x] ROM limitations: Patient can
perform passive ROM with the help of
the nurse or care provider.

P/ Comments: “dili nag a [ ] facial grimaces
AWAKE: buka iyang mata, usahay [ ] guarding
[ ] pain mu lihok siya kung [ ] other signs of pain :
storyahan.” As verbalized No signs of pain noted
by the patien’ts daughter. [ ] side rail release form signed (60 +
No side rails, supported by pillows
[] nocturia
[] sleep difficulties
[ ] denied

Occupation: Observed non-verbal behavior: No
Members of household: 7 members in the Eye to eye contact
family (wife and 5 children) Phone number that can be reached
Most supportive person: husband (Mr. Chavez)anytime:
Contact #: 09277165120
______N/A Daily weight _N/A___ PT/OT __ N/A
_every 4 hour_ _ BP q shift ____N/A___ Irradiation
____N/A___ _ Neuro vs __ done _Urine test
____N/A_ _CVP/SG Reading _No Order__24 hour Urine Collection
Date Date I.V. Date
Laboratory Date done
ordered ordered Fluids/Blood Disc.
September .
22, 2007 Chest X-ray September September D5NSS 1L @40 Still
22, 2007 15,2007 cc/min hooked

September ABG September
22, 2007 22, 2007

September Hematology 22, 2007
21, 2007 Test

IV. Growth and Development
Growth as we define it is the physical change and increase in size, and
development is defined as the increase in the complexity of function and skill
progression. Every individual undergo this process as we age and grow older.
We encounter changes that only on physical aspect but mentally and emotionally
as well. As we try to identify our client’s growth and development we have
identified several theories and these are:


According to freud Psychosocial Theory, the patient is assigned to the
last stage, the Genital stage. Begins at puberty involves the development of the
genitals, and libido begins to be used in its sexual role. Characteristics of this
stage are that energy of a person is directed toward full sexual maturity and
function, and development of skills needed to cope with the environment as well
as its demands.

With Freud, our client is in her Genital stage. She has successfully
achieved this stage because she was able to identify herself as a woman and a
wife to her husband. She had a family and was able to cope struggles life on her
own. She can stand on her own and make decision for her self.


Havighurst defines a developmental task as one that arises in a certain
period in our lives, the successful achievement of which leads to happiness and
success with later task: while failure to accomplish leads to unhappiness, social
disapproval and difficulty with later tasks. Havighurst has identified six major age
periods and each of these periods has a distinguishing feature that delineates it
from other stages. Each of this feature must be accomplished successfully move
to the next level.

Mrs. Chavez in her stage of development she was not able to accomplish
the task during earlier age towards the later age. She failed to achieve the next
task which, it leads to unhappiness this was evidenced of being a housewife,
poor functioning in the society because of her educational attainment in life and
take early responsibility at age of 21. This implies that she never achieved her
social and civic responsibility.


Development according to Erikson, functions by the epigenetic principle.
The principle says that we develop through a predetermined unfolding of our
personalities in eight stages. Each stage is characterized by a different conflict
that must be resolved by the individual. When the environment makes new
demands on people, the conflicts arise. The person is faced with a choice
between two ways of coping with each crisis, an adaptive or maladaptive way.
Only when crisis is resolved, which involves personality, does the person have
sufficient strength to deal with the next stages of development. If a person is
unable to resolve a conflict at a particular stage, they will confront him and he
struggles with it later life. Our patient Mrs. Chavez belong to the stage 7 of
Erikson's theory. This stage is characterized by the conflict between generativity
and stagnation. During this stage, the individual is expected to establish
satisfying relations with his or her partner, has successfully guided the younger
generations about the complexities of life, has determined the chosen career,
and has established relation with other people. Our patient has reached the
stage of growth and development wherein she had achieved some of the
expected task during this stage considering that she has satisfying relations with
her husband and has verbalized good guidance and unconditional or non-
reciprocating care towards her children.

VI. Doctor’s Order
September 15, 2007

11:52 pm
To ensure that the patient will be treated
properly with a physician of choice,
• Please admit under the service creating more intensive treatment to deal
of Dr. Agcopra with the current condition.
Legal measures to carry out prior to
providing to patient.
• Secure consent to care
To monitor the current physiologic status
of the patient and prevent deterioration of
• TPR every 4 hours complication.

Alert the care providers to apply
appropriate intervention before
complications will occur.

• LAB: As part of a routine medical exam to
determine general health status and to
screen for a variety of disorders, such as
anemia and infection

This test measures the amount of
potassium in the blood. Potassium (K+)
helps nerves and muscles communicate. It
also helps move nutrients into cells and
waste products out of cells.

To ensure that the patient’s potassium
level is within normal range, otherwise
KCL therapy may be administered to
promote cardiac contractility.


A blood sodium test may ordered when a
patient has symptoms of hyponatremia,
such as weakness, confusion, and
lethargy, or symptoms of hypernatremia
such as decreased urinary output.


Ordered to evaluate the rate and efficiency
of kidney filtration. It is used to help detect
kidney dysfunction and/or the presence of
decreased blood flow to the kidneys to
help monitor the progress of the disease
and evaluate its severity.


This test is used to determine level of
enzyme in the blood indicating tissue
necrosis or disease in the tissues.

ECG 12 lead

Most frequently done to follow
normalization of electrical conduction
patterns/ventricular functions or to identify

CT SCAN BRAIN plain stat

A method use to narrow a beam x-ray to
scan successive layers of the brain tissues
in order to determine the location of its
Maintains circulating volume enhancing
tissue perfusion
• IVF started at Bukidnon
hospital, D5NSS 1L @ 40 cc/hr

• Meds given at Bukidnon
To dissolve clot in the brain that is causing
acute ischemic brain damage
• Citicholine 1 gm IV, OD characteristic of stroke.
Reduces or neutralizes gastric acid,
preventing discomfort of gastric irritation.
• Ranitidine 50 mg, IVT every 8
Any unusual health occurrences should be
reported to a physician in order to provide
• Please inform AP appropriate medical intervention and to
keep an up to date interaction between the
nurse and physician regarding the
patient’s critical condition.
September 16, 2007

The endotracheal tube facilitates the use
of a mechanical ventilator in the critical
• Ideally for ET intubation & situations.
hooking to mechanical
ventilator once with consent. ET Serves as an open passage through
the upper airway to permit air to pass
freely to and from the lungs in order to
ventilate the lungs of the patient. ET is
then connected to ventilator machines to
provide artificial respiration, to help when a
patient is unconscious and by maintaining
a patent airway. Also it is often used when
patients are critically ill and cannot
maintain adequate respiratory function to
meet their needs.
A mechanical ventilator is a machine that
generates a controlled flow of gas into a
• MV setting patient’s airways.

A/G mode

BUR: 16

FiO2: 100%

TV: 450 ml
To determine proper placement of ET
• CXR post - intubation
Determines adequacy of respiratory
function and to determine the specific rate
• ABG 1 hr – post MV settings for O2 therapy.
September 16, 2007 2:00 am

Increases amount of oxygen available for
myocardial uptake to improve contractility
• Os @ 2 l/min via nasal cannula and to reduce ischemia.

Serve as route for drug administration.

• IVFTF with D5NSS 1L @ 40 At KVO rate patient may not tolerate
cc/hr increased fluid volume. (patient with
cardiovascular disease also excretes less
sodium, which causes fluid retention and
increases myocardial workload)

Maintains circulating volume enhancing
tissue perfusion.

• September 17, 2007
Usually provides adequate control of fever.

• Give paracetamol 300 mg IVT
To meet increased metabolic needs,
maintain weight and encourage tissue
• Start feeding of TCR 1200 kcal regeneration.

• CHO 180 kcal

• CHON 35 g

• FATS, rest
Equal feeding 1:1 dilution

Maintains circulating volume enhancing
tissue perfusion.
• IVFTF D5NSS 1L @40 cc/hr
September 18, 2007

Usually provides adequate control of fever.

• PCM 300 mg IVT now
Usually provides adequate control of fever.

• PCM 500 mg every 4 hours,
PRN for fever
Indicated to enhance urinary output and to
prevent fluid overload, especially to patient
• Mannitol 100 cc 1 tab IVT whose kidney function is impaired.
every 6 hours
(antianginals, antihypertensives)

• Metoprolol 100 mg 1 tab PO, For management of hypertension and
BID angina pectoris and post-myocardial
September 19, 2007 -Continue supportive care

Drug Study

GENERIC NAME(BRAND NAME) Metoprolol (Neobloc)

DATE ORDERED September 17, 2007

MECHANISM OF ACTION Exerts mainly beta-1 adrenergic
blocking activity but also blocks beta-2
receptors at high doses.
SPECIFIC INDICATION -treatment for Congestive Heart Failure
and Hypertension
CONTRAINDICATION Patients on monoamine oxidase

Patients with inadequate Myocardial
ADVERSE EFFECTS Fatigue, dizziness, headache,
GI disturbance, skin rashes
NURSING PRECAUTION Give before, after meal: tablet may be
crushed or swallowed whole

Give with food to prevent GI upset

Instruct patient to take oral form with
meals to enhance absorption
GENERIC NAME(BRAND NAME) Salbutamol (Ventolin)

DATE ORDERED September 22, 2007
MECHANISM OF ACTION Stimulates beta-2 receptors of
bronchioles by increasing levels of
cAMP which relaxes smooth muscles to
produce bronchodilatation.
SPECIFIC INDICATION -treatment for bronchospasm
CONTRAINDICATION Contraindicated to patients
hypersensitivity to drugs
ADVERSE EFFECTS Headache, nausea, vomiting, dizziness,
NURSING PRECAUTION -monitor for evidence of allergic
reactions and paradoxical
GENERIC NAME(BRAND NAME) Azithromycin (Zithromax)

DATE ORDERED September 22, 2007
MECHANISM OF ACTION Binds to the P site of 50S bacterial
ribosomal subunits thereby inhibiting
protein synthesis
SPECIFIC INDICATION Treatment of infections of respiratory
CONTRAINDICATION Contraindicated to patients
hypersensitive to drugs
ADVERSE EFFECTS Dizziness, diarrhea, headache, nausea,
NURSING PRECAUTION Taken without regards to food. Do not
give with fruit juice

DATE ORDERED September 22, 2007
MECHANISM OF ACTION Interferes with protein synthesis in
bacterial cell by binding to ribosomal
subunit, causing misreading of genetic
SPECIFIC INDICATION Treatment for infection
CONTRAINDICATION Contraindicated to patients
hypersensitive to drugs
ADVERSE EFFECTS Headache, dizziness, fever, muscle
weakness, rash,
NURSING PRECAUTION Advise patient to drink adequate amount
of water unless instructed to restrict fluid

Advise patient to eat small frequent
meals to prevent GI irritation
GENERIC NAME(BRAND NAME) Ranitidine (Zantac)

DATE ORDERED September 16, 2007
MECHANISM OF ACTION Inhibits histamine at H2 receptor site in
the gastric parietal cells, which inhibits
gastric acid secretion
SPECIFIC INDICATION Used in the management of various
gastrointestinal disorder
CONTRAINDICATION Contraindicated in patients
hypersensitivity to drugs
ADVERSE EFFECTS Headache, fatigue, dizziness, nausea,
vomiting, diarrhea, constipation
NURSING PRECAUTION May be given with or without meals


DATE ORDERED September 22, 2007
DOSE/FREQUENCY/ROUTE 500 mg 1 tab every 12 hrs/ NGT
MECHANISM OF ACTION Inhibits bacterial DNA gyrase thus
preventing replication in susceptible
SPECIFIC INDICATION Treatment for infection of the respiratory
CONTRAINDICATION Contraindicated in patients
hypersensitivity to drugs
ADVERSE EFFECTS Nausea, vomiting, rash, dizziness,
headache, fever
NURSING PRECAUTION Administer 2 hrs before or 2 hrs after
GENERIC NAME(BRAND NAME) citicoline (somazone)

CLASSIFICATION neuroprotection
DOSE/FREQUENCY/ROUTE 1 gm IVT every 12 hours
MECHANISM OF ACTION The therapeutic action of citicoline is
thought to be caused by stimulation of
PtdCho synthesis in the injured brain,
although the experimental evidence for
this is limited. This review attempts to
shed some light on the properties of
citicoline that are responsible for its
SPECIFIC INDICATION In the treatment of patients with acute
ischemic cerebral vascular disease,
citicoline accelerates recovery of
consciousness and motor deficit,
achieves a better final outcome, and
facilitates rehabilitation of these
ADVERSE EFFECTS Citicoline has a low side effect profile.
Some citicoline side effects include
elevated body temperature,
restlessness, and difficulty sleeping if
the supplement is taken in the evening.
GENERIC NAME(BRAND NAME) Paracetamol (naprex)

CLASSIFICATION nonopioid analgesics and antipyretics
MECHANISM OF ACTION blocks pain impulses by inhibiting
synthesis of prostaglandin in the CNS.
The drug may relieve fever through
central action in the hypothalamic heat-
regulating center
SPECIFIC INDICATION For relief of fever

CONTRAINDICATION hypersensitivity, use cautiously in
patients with long term alcohol use
because therapeutic doses cause
hepatotoxicity in these patients.
ADVERSE EFFECTS Hematologic – hemolytic anemia,
leucopenia, neutropenia

Hepatic – jaundice

Metabolic – hypoglycemia

Skin - rash, urticaria
NURSING PRECAUTION many OTC and prescription products
contain acetaminophen; be aware of this
when calculating total daily dose
CLASSIFICATION antiurolithics
MECHANISM OF ACTION It works by neutralizing some of the acid
in the urine, which helps

reduce the formation of crystals
SPECIFIC INDICATION to prevent certain types of kidney stones

CONTRAINDICATION hypersensitivity, high level of potassium
in the blood,

stomach ulcers, kidney disease, heart
ADVERSE EFFECTS Diarrhea or loose bowel movements;
nausea; stomach pain; upset stomach;
vomiting. Severe allergic reactions
(rash; hives; difficulty breathing;
tightness in the chest; swelling of the
mouth, face, lips, or tongue); black, tarry
stools; confusion; severe stomach pain;
tingling of hands or feet; vomit that looks
like coffee grounds; weakness.
NURSING PRECAUTION take drug with food, the empty tablet
shell may appear in the stool. This is
normal and it is no cause for concern.

DOSE/FREQUENCY/ROUTE 100 cc IVT every 8 hours
MECHANISM OF ACTION increases osmotic pressure of
glomerular filtrate, inhibiting tubular
SPECIFIC INDICATION to prevent oliguria or renal failure

CONTRAINDICATION hypersensitivity, anuria, severe
pulmonary congestion, severe heart
ADVERSE EFFECTS CNS – dizziness, headache, fever
CV – edema, hypotension,
hypertension, tachycardia

EENT – blurred vision, rhinitis

GI – thirst, dry mouth
NURSING PRECAUTION monitor vital signs, report increasing
oliguria, use urinary catheter in
comatose patient for strict evaluation of
GENERIC NAME(BRAND NAME) acetylcysteine (fluimicil):

CLASSIFICATION miscellaneous respiratory tract drugs
DOSE/FREQUENCY/ROUTE 200 mg sachet every 12 hours
MECHANISM OF ACTION mucolytic that reduces the viscosity of
pulmonary secretions
SPECIFIC INDICATION adjunct therapy for abnormal viscid or
thickened mucous secretions.
CONTRAINDICATION hypersensitivity, use cautiously in
ADVERSE EFFECTS CNS – fever, drowsiness, gait

CV – tachycardia, hypotension, flushing,
chest tightness

EENT – ear pain, eye pain, throat

GI – nausea, vomiting

Respiratory – cough, dyspnea

Skin – rash, diaphoresis, pruritus
NURSING PRECAUTION drug smells strongly of sulfur, monitor
patient for bronchospasm especially if
asthma is present
Laboratory results

CT Scan

Date: September 16, 2007

Examination: Cranial Plain

Multiple sequential axial tomographic secretions of the head from skull base to
the vertex without IV contrast were obtained revealing the following findings:

There is a round hyperdensity involving the pons around 2.0 X 2.8 X 3.2 cm. The
fourth ventricle is compressed with mild dilatation of the lateral and third ventricle.
No middle shifting is seen.

Small-ill defined hypdensity seen at the let frontal periventricular white matter.
Another small hypodensity at the left caudate nucleus.

No evidence of mass. The gray-white matter differentiation is maintained.

Included petromastoids, parenasal sinuse and orbits are intact.


Acute Hemorrhage involving the pons beginning mild dilatation of the lateral and
third ventricles secondary to extrinsic compression of the fourth ventricle.

Lacunar infarcts, left frontal periventricular white matter and the caudate nucleus.

Hematology Test

Date: September 16, 2007

Total WBC: 6.20 5 – 10 x10^9/L
♦ Normal
RBC: 4.02 3.69 – 5.9 x10^12/L
♦ Normal
Hemoglobin: 12.8 11.70 – 14.00 g/dL
♦ Normal
Hematocrit: 37.1 34.10 – 44.0 % ♦ Normal

Mean Corpuscular Volume 70.00 – 97.00 fL ♦ Normal
(MCV) : 92.0
26.10 – 33.30 pg ♦ Normal
Mean corpuscular
hemoglobin (MCH): 32.0 32.0 – 35.0 g/dL ♦ Normal

Mean corpuscular 150 – 390.0 x10^g/L ♦ Normal
hemoglobin concentration
(MCHC): 34.6 55 – 62 % ♦ Increased: Infection

Platelet count: 169 20 – 40 % ♦ Decreased: anemia

Differential count 4 – 10 % ♦ Normal

Neutrophils: * 82.0 1–6% ♦ Increased: Infection

Lymphocytes: * 11.1 0–1% ♦ Normal

Monocytes: 5.7 11.5 – 14.5 % ♦ Slight Increased:
Deficiencies of Iron, Vitamin
Eusonophils: * 0.9 B1 or Folic acid

Basophils: 0.3

Red Cell Distribution Width
(RDW-CV): * 14.6
Blood Chemistry Normal values September 16, 2007
Uric acid: *8.19 2.40 – 5.70 mgs/dL ♦ Increased: Impaired
kidney function to excrete
SGPT (APT): * 83.71 urine
9.00 – 34.00 U/L
Creatinine: * 1.93 ♦ Increased:
0.70 – 1.30 mgs/dL
LDL ♦ Increased: Impaired
135 – 155 meq/L Kidney function (diminished
Sodium: 138.40 ability of the kidneys to filter
3.5 – 5.5 mmol/L these waste products from
Potassium: 3.07 the blood and excrete them
in the urine)
♦ Normal

♦ Decreased: Effect of

Radiologic Report

Date: September 17, 2007

Examination: Chest PA

There is a wedged homogenous opacification in the right lower lobe. The rest
of the lungs field are clear. The heart is enlarged (CTR:0.57) exhibiting
inferolateral displacement of the cardiac apex midline structures are not
displaced. The CP sulci and hemidiaphragms are intact. The rest of the included
structures are unremarkable.

• Pneumonia, Right
• LV Cardiomegally is considered, ECG correlations suggested

Hematology Test

Date: September 21, 2007

Total WBC: 7.60 5 – 10 x10^9/L
♦ Normal
RBC: 4.03 3.69 – 5.9 x10^12/L
♦ Normal
Hemoglobin: 12.8 11.70 – 14.00 g/dL
♦ Normal
Hematocrit: 37.1 34.10 – 44.0 %
♦ Normal
Mean Corpuscular Volume 70.00 – 97.00 fL
(MCV) : 92.0 ♦ Normal
26.10 – 33.30 pg
Mean corpuscular ♦ Normal
hemoglobin (MCH): 31.7 32.0 – 35.0 g/dL
Mean corpuscular 150 – 390.0 x10^g/L ♦ Normal
hemoglobin concentration
(MCHC): 34.4 55 – 62 % ♦ Normal

Platelet count: 160 20 – 40 % ♦ Increased: Infection

Differential count 4 – 10 % ♦Decreased: Chronic
Neutrophils: * 78.8 1–6%
♦ Increased: Chronic
Lymphocytes: * 5.9 0–1% inflammation; infection

Monocytes: 13.3 11.5 – 14.5 % ♦ Normal

Eusonophils: 1.2 ♦ Normal

Basophils: 0.8 ♦ Normal

Red Cell Distribution Width
(RDW-CV): 13.7

Chest XRAY

Date: September 21, 2007

Follow-up study (done with obliquity) for the previous examination dated 9/16/07
shows increased haziness of the right lower lung field and new haziness of the
left lower lung field. Although, the mediastinal structures appear shifted to the left
due to positioning, the left cardiac border and hemidiaphragm have been
silhouted by new infiltrates.

The rest of the chest findings are unchanged.

Calcific plaques line the aortic knob.

Trachea is midline.

The right hemidiaphragm and costophrenic angle are intact.

The osseous structures and the rest of the soft tissue structures are

• Pneumonia, bilateral, progressing
• Atherosclerotic thoracic aorta
• Intercurrent minimal pleural effusion, left not ruled out
• Pls. correlate clinically, follow-up suggested.


Date: September 22, 2007

Time: 4:30 pm

F1O2: 100%

RR: 16

Tidal Volume: 450

Normal Values

pH: 7.43 7.35 – 7.45 ♦ Normal

PaCO2: 32.5 mmHg 35 – 45 mmHg ♦ Decreased: Alkalosis

PO2: 131 80 – 100 ♦ Increased:

HCO3: 21.6 22 – 26 mEq/L ♦ Decreased: Acidosis

Base Excess(BE): - 3 + -2 mEq/L

O2 Sat: 99% - 97%

• Fully Compensated Metabolic Acidosis

Chest PA (XRAY)

Date: September 22, 2007

Comparative Study

Recent Xray (9/22/07) show no significant interval changes of the previously
noted confluent hazy infiltrates in the lower lobes from that of previous study (9-
21-07). The upper lobes are clear. The heart is enlarged (CTR:0.54) exhibiting
inferolateral displacement of the cardiac apex. Midline structures are not
displaced. Endotracheal is in place in the midline 2cm alone the carinae angle.
The CP sulci and hemidiaphragm are intact. The rest of the included structures
are unremarkable.


• Bibasal Pneumonia with consolidation. No significant interval changes
from 09-20-07
• LV Cardiomegally is considered. ECG Correlation suggested

VII. Ideal Nursing Mangaement
NURSING DIAGNOSIS: Tissue Perfusion, ineffective cerebral

May be related to

Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vasospasm,
cerebral edema

Possibly evidenced by

Altered level of consciousness; memory loss

Changes in motor/sensory responses; restlessness

Sensory, language, intellectual, and emotional deficits

Changes in vital signs


Neurological Status (NOC)

Maintain usual/improved level of consciousness, cognition, and motor/sensory

Demonstrate stable vital signs and absence of signs of increased ICP.

Display no further deterioration/recurrence of deficits

Cerebral Perfusion Promotion (NIC) Influences choice of interventions.
Deterioration in neurological
Independent signs/symptoms or failure to improve
after initial insult may reflect decreased
Determine factors related to individual intracranial adaptive capacity requiring
situation/cause for coma/decreased patient be transferred to critical care area
cerebral perfusion and potential for for monitoring of ICP, other therapies. If
increased ICP. the stroke is evolving, patient can
deteriorate quickly and require repeated
Monitor/document neurological status assessment and progressive treatment. If
frequently and compare with baseline. the stroke is “completed,” the
(Refer to CP: Craniocerebral Trauma neurological deficit is nonprogressive,
[Acute Rehabilitative Phase], ND: Tissue and treatment is geared toward
Perfusion, ineffective cerebral for rehabilitation and preventing recurrence.
complete neurological evaluation.) Assesses trends in level of
consciousness (LOC) and potential for
Monitor vital signs, i.e., note: increased ICP and is useful in
determining location, extent, and
Hypertension/hypotension, compare BP progression/resolution of CNS damage.
readings in both arms; May also reveal presence of TIA, which
may warn of impending thrombotic CVA.

Fluctuations in pressure may occur
because of cerebral pressure/injury in
vasomotor area of the brain.
Hypertension or postural hypotension
may have been a precipitating factor.
Hypotension may occur because of shock
(circulatory collapse). Increased ICP may
occur because of tissue edema or clot
formation. Subclavian artery blockage
may be revealed by difference in
pressure readings between arms.


Cerebral Perfusion Promotion (NIC) Changes in rate, especially bradycardia,
can occur because of the brain damage.
Independent Dysrhythmias and murmurs may reflect
cardiac disease, which may have
Heart rate and rhythm; auscultate for precipitated CVA (e.g., stroke after MI or
murmurs; from valve dysfunction).

Respirations, noting patterns and rhythm, Irregularities can suggest location of
e.g., periods of apnea after cerebral insult/increasing ICP and need
hyperventilation, Cheyne-Stokes for further intervention, including possible
respiration. respiratory support. (Refer to CP:
Craniocerebral Trauma [Acute
Evaluate pupils, noting size, shape, Rehabilitative Phase], ND: Breathing
equality, light reactivity. Pattern, risk for ineffective)

Document changes in vision, e.g., Pupil reactions are regulated by the
reports of blurred vision, alterations in oculomotor (III) cranial nerve and are
visual field/depth perception. useful in determining whether the
brainstem is intact. Pupil size/equality is
Assess higher functions, including determined by balance between
speech, if patient is alert. (Refer to ND: parasympathetic and sympathetic
Communication, impaired verbal[and/or enervation. Response to light reflects
written].) combined function of the optic (II) and
oculomotor (III) cranial nerves.
Position with head slightly elevated and
in neutral position. Specific visual alterations reflect area of
brain involved, indicate safety concerns,
Maintain bedrest; provide quiet and influence choice of interventions.
environment; restrict visitors/activities as
indicated. Provide rest periods between Changes in cognition and speech content
care activities, limit duration of are an indicator of location/degree of
procedures. cerebral involvement and may indicate
deterioration/increased ICP.
Prevent straining at stool, holding breath.
Reduces arterial pressure by promoting
Assess for nuchal rigidity, twitching, venous drainage and may improve
increased restlessness, irritability, onset cerebral circulation/perfusion.
of seizure activity.
Continual stimulation/activity can
Collaborative increase ICP. Absolute rest and quiet
may be needed to prevent rebleeding in
Administer supplemental oxygen as the case of hemorrhage.
Valsalva maneuver increases ICP and
potentiates risk of rebleeding.

Indicative of meningeal irritation,
especially in hemorrhage disorders.
Seizures may reflect increased
ICP/cerebral injury, requiring further
evaluation and intervention.

Reduces hypoxemia, which can cause
cerebral vasodilation and increase
pressure/edema formation.

Cerebral Perfusion Promotion (NIC) Thrombolytic agents are useful in
dissolving clot when started within 3 hr of
Collaborative initial symptoms. Thirty percent are likely
to recover with little or no disability.
Administer medications as indicated: Treatment is based on trying to limit the
size of the infarct, and use requires close
Alteplase (Activase), t-PA; monitoring for signs of intracranial
hemorrhage. Note: These agents are
Anticoagulants, e.g., warfarin sodium contraindicated in cranial hemorrhage as
(Coumadin), low-molecular-weight diagnosed by CT scan.
heparin (Lovenox); antiplatelet agents,
e.g., aspirin (ASA), dipyridamole May be used to improve cerebral blood
(Persantine), ticlopidine (Ticlid); flow and prevent further clotting when
embolus/thrombosis is the problem.
Antifibrolytics, e.g., aminocaproic acid Contraindicated in hypertensive patients
(Amicar); because of increased risk of hemorrhage.

Antihypertensives; Used with caution in hemorrhagic
disorder to prevent lysis of formed clots
Peripheral vasodilators, e.g., and subsequent rebleeding.
cyclandelate (Cyclospasmol), papaverine
(Pavabid), isoxsuprine (Vasodilan); Preexisting/chronic hypertension requires
cautious treatment because aggressive
Steroids, e.g., dexamethasone management increases the risk of
(Decadron); extension of tissue damage. Transient
hypertension often occurs during acute
Neuroprotective agents, e.g., calcium stroke and resolves often without
channel blockers, excitatory amino acid therapeutic intervention.
inhibitors, gangliosides;
Used to improve collateral circulation or
Phenytoin (Dilantin), phenobarbital; decrease vasospasm.

Stool softeners. Use is controversial in control of cerebral
Prepare for surgery, as appropriate, e.g.,
endarterectomy, microvascular bypass, These agents are being researched as a
cerebral angioplasty. means to protect the brain by interrupting
the destructive cascade of biochemical
Monitor laboratory studies as indicated, events (e.g., influx of calcium into cells,
e.g., prothrombin time (PT)/activated release of excitatory neurotransmitters,
partial thromboplastin time (aPTT) time, buildup of lactic acid) to limit ischemic
Dilantin level. injury.
May be used to control seizures and/or
for sedative action. Note: Phenobarbital
enhances action of antiepileptics.

Prevents straining during bowel
movement and corresponding increase of

May be necessary to resolve situation,
reduce neurological symptoms/risk of
recurrent stroke.

Provides information about drug
effectiveness/therapeutic level.

NURSING DIAGNOSIS: Communication, impaired verbal [and/or written]

May be related to

Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle
tone/control; generalized weakness/fatigue

Possibly evidenced by

Impaired articulation; does not/cannot speak (dysarthria)

Inability to modulate speech, find and name words, identify objects; inability to
comprehend written/spoken language

Inability to produce written communication


Communication Ability (NOC)

Indicate an understanding of the communication problems.

Establish method of communication in which needs can be expressed.
Use resources appropriately.

Communication Enhancement: Helps determine area and degree of brain
Speech Deficit (NIC) involvement and difficulty patient has with
any or all steps of the communication
Independent process. Patient may have trouble
understanding spoken words (receptive
Assess type/degree of dysfunction: e.g., aphasia/damage to Wernicke’s speech
patient does not seem to understand area), speaking words correctly
words or has trouble speaking or making (expressive aphasia/damage to Broca’s
self understood. speech areas), or may experience
damage to both areas.
Differentiate aphasia from dysarthria;
Choice of interventions depends on type
Listen for errors in conversation and of impairment. Aphasia is a defect in
provide feedback; using and interpreting symbols of
language and may involve sensory and/or
Ask patient to follow simple commands motor components, e.g., inability to
(e.g., “Shut your eyes,” “Point to the comprehend written/spoken words or to
door”); repeat simple words/ sentences; write, make signs, speak. A dysarthric
person can understand, read, and write
Point to objects and ask patient to name language but has difficulty
them; forming/pronouncing words because of
weakness and paralysis of oral
Have patient produce simple sounds, musculature.
e.g., “Sh,” “Cat”.
Patient may lose ability to monitor verbal
Ask patient to write name and/or a short output and be unaware that
sentence. If unable to write, have patient communication is not sensible. Feedback
read a short sentence. helps patient realize why caregivers are
not understanding/responding
Post notice at nurses’ station and appropriately and provides opportunity to
patient’s room about speech impairment. clarify content/meaning.
Provide special call bell if necessary.
Tests for receptive aphasia.
Provide alternative methods of
communication, e.g., writing or felt board, Tests for expressive aphasia; e.g., patient
pictures. Provide visual clues gestures, may recognize item but not be able to
pictures, “needs” list, demonstration). name it.

Anticipate and provide for patient’s Identifies dysarthria, because motor
needs. components of speech (tongue, lip
movement, breath control) can affect
articulation and may/may not be
accompanied by expressive aphasia.

Tests for writing disability (agraphia) and
deficits in reading comprehension
(alexia), which are also part of receptive
and expressive aphasia.

Allays anxiety related to inability to
communicate and fear that needs will not
be met promptly. Call bell that is activated
by minimal pressure is useful when
patient is unable to use regular call

Provides for communication of
needs/desires based on individual
situation/underlying deficit.

Helpful in decreasing frustration when
dependent on others and unable to
communication desires.

Communication Enhancement: Reduces confusion/anxiety at having to
Speech Deficit (NIC) process and respond to large amount of
information at one time. As retraining
Independent progresses, advancing complexity of
communication stimulates memory and
Talk directly to patient, speaking slowly further enhances word/idea association.
and distinctly. Use yes/no questions to
begin with, progressing in complexity as Patient is not necessarily hearing
patient responds. impaired, and raising voice may irritate or
anger patient. Forcing responses can
Speak in normal tones and avoid talking result in frustration and may cause
too fast. Give patient ample time to patient to resort to “automatic” speech,
respond. Talk without pressing for a e.g., garbled speech, obscenities.
It is important for family members to
continue talking to patient to reduce
patient’s isolation, promote establishment
Encourage SO/visitors to persist in of effective communication, and maintain
efforts to communicate with patient, e.g., sense of connectedness with family.
reading mail, discussing family
happenings even if patient is unable to Promotes meaningful conversation and
respond appropriately. provides opportunity to practice skills.

Discuss familiar topics, e.g., job, family, Enables patient to feel esteemed,
hobbies. because intellectual abilities often remain
Respect patient’s preinjury capabilities;
avoid “speaking down” to patient or Assesses individual verbal capabilities
making patronizing remarks. and sensory, motor, and cognitive
functioning to identify deficits/therapy
Collaborative needs.

Consult with/refer to speech therapist.

NURSING DIAGNOSIS: Sensory Perception, disturbed (specify)

May be related to

Altered sensory reception, transmission, integration (neurological trauma or deficit)

Psychological stress (narrowed perceptual fields caused by anxiety)

Possibly evidenced by

Disorientation to time, place, person

Change in behavior pattern/usual response to stimuli; exaggerated emotional

Poor concentration, altered thought processes/bizarre thinking

Reported/measured change in sensory acuity: hypoparesthesia; altered sense of

Inability to tell position of body parts (proprioception)

Inability to recognize/attach meaning to objects (visual agnosia)
Altered communication patterns

Motor incoordination


Cognitive Ability (NOC)

Regain/maintain usual level of consciousness and perceptual functioning.

Acknowledge changes in ability and presence of residual involvement.

Demonstrate behaviors to compensate for/overcome deficits.

Environmental Management (NIC) Awareness of type/area of involvement
aids in assessing for/anticipating specific
Independent deficits and planning care.

Review pathology of individual condition. Individual responses are variable, but
commonalities such as emotional lability,
Observe behavioral responses, e.g., lowered frustration threshold, apathy, and
hostility, crying, inappropriate affect, impulsiveness may complicate care.
agitation, hallucination. (Refer to CP:
Craniocerebral Trauma [Acute Reduces anxiety and exaggerated
Rehabilitative Phase], ND: Thought emotional responses/confusion
Processes, disturbed). associated with sensory overload.

Eliminate extraneous noise/stimuli as Patient may have limited attention span
necessary. or problems with comprehension. These
measures can help patient attend to
Speak in calm, quiet voice, using short communication.
sentences. Maintain eye contact.
Assists patient to identify inconsistencies
Ascertain/validate patient’s perceptions. in reception and integration of stimuli and
Reorient patient frequently to may reduce perceptual distortion of
environment, staff, procedures. reality.

Evaluate for visual deficits. Note loss of Presence of visual disorders can
visual field, changes in depth perception negatively affect patient’s ability to
(horizontal/vertical planes), presence of perceive environment and relearn motor
diplopia (double vision). skills and increases risk of
Approach patient from visually intact accident/injury.
side. Leave light on; position objects to
take advantage of intact visual fields. Provides for recognition of the presence
Patch affected eye if indicated. of persons/objects; may help with depth
perception problems; prevents patient
from being startled. Patching may
decrease the sensory confusion of double

Peripheral Sensation Management Diminished sensory awareness and
(NIC) impairment of kinesthetic sense
negatively affects balance/positioning
Independent and appropriateness of movement,
which interferes with ambulation,
Assess sensory awareness, e.g., increasing risk of trauma.
differentiation of hot/cold, dull/sharp;
position of body parts/muscle, joint Aids in retraining sensory pathways to
sense. integrate reception and interpretation of
stimuli. Helps patient orient self spatially
Stimulate sense of touch; e.g., give and strengthens use of affected side.
patient objects to touch, grasp. Have
patient practice touching walls/other Promotes patient safety, reducing risk of
boundaries. injury.

Protect from temperature extremes; Presence of agnosia (loss of
assess environment for hazards. comprehension of auditory, visual, or
Recommend testing warm water with other sensations, although sensory
unaffected hand. sphere is intact) may lead to/result in
unilateral neglect, inability to recognize
Note inattention to body parts, segments environmental cues/meaning of
of environment; lack of recognition of commonplace objects, considerable
familiar objects/persons. self-care deficits, and disorientation or
bizarre behavior.
Encourage patient to watch feet when
appropriate and consciously position Use of visual and tactile stimuli assists
body parts. Make patient aware of all in reintegration of affected side and
neglected body parts, e.g., sensory allows patient to experience forgotten
stimulation to affected side, exercises sensations of normal movement
that bring affected side across midline, patterns.
reminding person to dress/care for
affected (“blind”) side.
NURSING DIAGNOSIS: Self-Care deficit (specify)

May be related to

Neuromuscular impairment, decreased strength and endurance, loss of muscle

Perceptual/cognitive impairment



Possibly evidenced by

Impaired ability to perform ADLs, e.g., inability to bring food from receptacle to
mouth; inability to wash body part(s), regulate temperature of water; impaired
ability to put on/take off clothing; difficulty completing toileting tasks


Self-Care: Activities of Daily Living (ADLs) (NOC)

Demonstrate techniques/lifestyle changes to meet self-care needs.

Perform self-care activities within level of own ability.

Identify personal/community resources that can provide assistance as needed.

Self-Care Assistance (NIC) Aids in anticipating/planning for meeting
individual needs.
These patients may become fearful and
Assess abilities and level of deficit (0–4 dependent, and although assistance is
scale) for performing ADLs. helpful in preventing frustration, it is
important for patient to do as much as
Avoid doing things for patient that patient possible for self to maintain self-esteem
can do for self, but provide assistance as and promote recovery.
May indicate need for additional
Be aware of impulsive behavior/actions interventions and supervision to promote
suggestive of impaired judgment. patient safety.

Maintain a supportive, firm attitude. Allow Patients need empathy and to know
patient sufficient time to accomplish caregivers will be consistent in their
tasks. assistance.

Provide positive feedback for efforts and Enhances sense of self-worth, promotes
accomplishments. independence, and encourages patient to
continue endeavors.
Create plan for visual deficits that are
present, e.g.: Patient will be able to see to eat the food.

Place food and utensils on the tray Will be able to see when getting in/out of
related to patient’s unaffected side; bed and observe anyone who comes into
the room.
Situate the bed so that patient’s
unaffected side is facing the room with Provides for safety when patient is able to
the affected side to the wall; move around the room, reducing risk of
tripping/falling over furniture.
Position furniture against wall/out of
travel path. Enables patient to manage for self,
enhancing independence and self-
Provide self-help devices, e.g., esteem; reduces reliance on others for
button/zipper hook, knife-fork meeting own needs; and enables patient
combinations, long-handled brushes, to be more socially active.
extensions for picking things up from
floor; toilet riser, leg bag for catheter; Reestablishes sense of independence
shower chair. Assist and encourage and fosters self-worth and enhances
good grooming and makeup habits. rehabilitation process. Note: This may be
very difficult and frustrating for the
Encourage SO to allow patient to do as SO/caregiver, depending on degree of
much as possible for self. disability and time required for patient to
complete activity.
Assess patient’s ability to communicate
the need to void and/or ability to use Patient may have neurogenic bladder, be
urinal, bedpan. Take patient to the inattentive, or be unable to communicate
bathroom at frequent/periodic intervals needs in acute recovery phase, but
for voiding if appropriate. usually is able to regain independent
control of this function as recovery
Identify previous bowel habits and progresses.
reestablish normal regimen. Increase
bulk in diet; encourage fluid intake, Assists in development of retraining
increased activity. program (independence) and aids in
preventing constipation and impaction
(long-term effects).


Self-Care Assistance (NIC) May be necessary at first to aid in
establishing regular bowel function.
Provides expert assistance for developing
Administer suppositories and stool a therapy plan and identifying special
softeners. equipment needs.

Consult with physical/occupational

NURSING DIAGNOSIS: Swallowing, risk for impaired

Risk factors may include

Neuromuscular/perceptual impairment

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]


Swallowing Status (NOC)

Demonstrate feeding methods appropriate to individual situation with aspiration

Maintain desired body weight.


Nutritional interventions/choice of feeding
Swallowing Therapy (NIC) route is determined by these factors.

Independent Timely intervention may limit
amount/untoward effect of aspiration.
Review individual pathology/ability to
swallow, noting extent of paralysis; clarity Promotes optimal muscle function, helps
of speech; facial, tongue involvement; to limit fatigue.
ability to protect airway/episodes of
coughing or choking; presence of Promotes relaxation and allows patient to
adventitious breath sounds; focus on task of eating/swallowing.
amount/character of oral secretions.
Weigh periodically as indicated. Counteracts hyperextension, aiding in
prevention of aspiration and enhancing
Have suction equipment available at ability to swallow. Optimal positioning can
bedside, especially during early feeding facilitate intake/reduce risk of aspiration,
efforts. e.g., head back for decreased posterior
propulsion of tongue,head turned to weak
Promote effective swallowing, e.g.: side for unilateral pharyngeal paralysis,
lying down on either side for reduced
Schedule activities/medications to pharyngeal contraction.
provide a minimum of 30 min rest before
eating; Uses gravity to facilitate swallowing and
reduces risk of aspiration.
Provide pleasant environment free of
distractions (e.g., TV); Patients with dry mouth require a
moisturizing agent (e.g., alcohol-free
Assist patient with head control/support, mouthwash) before and after eating;
and position based on specific patients with excess saliva will benefit
dysfunction; from use of a drying agent (e.g., lemon or
glycerin swabs) before meal and a
Place patient in upright position moisturizing agent afterward.
during/after feeding as appropriate;

Provide oral care based on individual
need prior to meal;

Swallowing Therapy (NIC) Increases salivation, improving bolus
formation and swallowing effort.
Lukewarm temperatures are less likely to
Season food with herbs, spices, lemon stimulate salivation so foods/fluids should
juice, etc. according to patient’s be served cold or warm as appropriate.
preference, within dietary restrictions; Note: Water is the most difficult to
Serve foods at customary temperature
and water always chilled; Aids in sensory retraining and promotes
muscular control.
Stimulate lips to close or manually open
mouth by light pressure on lips/under Provides sensory stimulation (including
chin, if needed; taste), which may increase salivation and
trigger swallowing efforts, enhancing
Place food of appropriate consistency in intake. Food consistency is determined
unaffected side of mouth; by individual deficit. For example:
Patients with decreased range of tongue
Touch parts of the cheek with tongue motion require thick liquids initially,
blade/apply ice to weak tongue; progressing to thin liquids, whereas
patients with delayed pharyngeal swallow
Feed slowly, allowing 30–45 min for will handle thick liquids and thicker foods
meals; better. Note: Pureed food is not
recommended because patient may not
Offer solid foods and liquids at different be able to recognize what is being eaten;
times; and most milk products, peanut butter,
syrup, and bananas are avoided because
Limit/avoid use of drinking straw for they produce mucus/are sticky.
Can improve tongue movement and
Encourage SO to bring favorite foods. control (necessary for swallowing), and
inhibits tongue protrusion.
Maintain upright position for 45–60 min
after eating. Feeling rushed can increase stress/level
of frustration, may increase risk of
Maintain accurate I&O; record calorie aspiration, and may result in patient’s
count. terminating meal early.

Prevents patient from swallowing food
before it is thoroughly chewed. In
general, liquids should be offered only
after patient has finished eating foods.

Although use may strengthen facial and
swallowing muscles, if patient lacks tight
lip closure to accommodate straw or if
liquid is deposited too far back in mouth,
risk of aspiration may be increased.
Provides familiar tastes and preferences.
Stimulates feeding efforts and may
enhance swallowing/intake.

Helps patient manage oral secretions and
reduces risk of regurgitation.

If swallowing efforts are not sufficient to
meet fluid/nutrition needs, alternative
methods of feeding must be pursued.

Swallowing Therapy (NIC) May increase release of endorphins in
the brain, promoting a sense of general
Independent well-being and increasing appetite.

Encourage participation in Aids in determining phase of swallowing
exercise/activity program. difficulties (i.e., oral preparatory, oral,
pharyngeal, or esophageal phase).
May be necessary for fluid replacement
Review results of radiographic studies, and nutrition if patient is unable to take
e.g., video fluoroscopy. anything orally.

Administer IV fluids and/or tube feedings. Inclusion of dietitian, speech and
occupational therapists can increase
Coordinate multidisciplinary approach to effectiveness of long-term plan and
develop treatment plan that meets significantly reduce risk of silent
individual needs. aspiration.
VIII. Actual Nursing Management

S “gahi iya ubo dayun pas-pas iyang ginhawaan” as verbalized by the patient’s
O Productive cough

RR= 28 cpm

A Ineffective airway clearance related to productive cough and immobility
P At the end of 8 hours, patient will be able to maintain airway patency
I 1. Monitored respiratory status at least every 4 hours.

To detect early signs of compromise

2. Placed patient in moderate high back rest and support upper
extremities. To aid breathing and chest expansion and to ventilate
basilar lung fields
3. Suctioned patient as necessary.

To stimulate cough and clear airway

4. Turned patient to sides every 2 hours.

To help prevent pooling of secretions and to maintain airway patency

5. Performed percussion and chest tapping.

To facilitate secretion movement

6. Monitored sputum, noting amount, odor and consistency.

Sputum amount and consistency may indicate hydration status and
effectiveness of therapy. Foul smelling sputum may indicate respiratory

7. Administered oxygen at 2 L/min as ordered by the physician.

To help prevent respiratory distress
E At the end of 8 hours, patient will be able to maintain airway patency with the
help of frequent suctioning, turning to sides & also with the help of oxygen.

S “Sige siya ug hilantan” as verbalized by the significant others.

O Temp.: 38C
A Hyperthermia related to increase ICP secondary to disease processes
P At the end of 15-30 minutes, the patient’s temperature will be near normal
I 1.tepid sponge bath done to promote heat loss by evaporation.

2.loosened the patient’s clothing to promote heat loss. bed linens to promote surface cooling.

4.Elevated head part 45 degrees to decrease pressure.

5.administered Paracetamol 500 mg 1 tab q4h PRN and Mannitol 100 cc IVT
every 8 hours as prescribed by Dr. Agcopra. to relieve fever through central
action in the hypothalamic heat-regulating center and increases osmotic
pressure of glomerular filtrate, inhibiting tubular
E At the end of 15-30 minutes, the patient’s temperature will be near normal
range of 37.5 C

“high blarun na jud na siya daan” as verbalized by the significant others.

O BP: 150/100 mmHg
A Risk for decrease cardiac output related to increase peripheral resistance.
P At the end of the shift, the patient’s blood pressure will be within near normal
I >provide rest to promote relaxation
>limit visitors to reduce stimulus that may trigger the increase of BP.

>monitor cardiac rhythm continuously to note effectiveness of the

>administer supplemental O2 as prescribed by Dr. Agcopra to increase O2
available for tissues.

>administer metoprolol (neobloc) 100 mg tab 1 tab BID per NGT as
prescribed by Dr. Agcopra for adrenergic blocking activity but also blocks
beta-2 receptors at high doses for hypertension.
E At the end of the shift, the patient’s blood pressure will be within near normal
range 130/90 mmHg.

S “Uga na bitaw iyang panit karun pero wala man siyay mga samad samad.” As
verbalized by the patient’s daughter.

O Patient is comatose

Dry and pale skin
A High risk for skin integrity impairment related to immobility
P At the end of 8 hours, patient will experience no skin breakdown and family
will demonstrate preventive skin care measures.
I 1. Inspected skin every shift & instructed SO to assist in the inspection.

Early detection of changes prevents or minimizes skin breakdown

2. Turned patient to sides every 2 hours & instructed family to do the
same. These measures reduce pressure on tissues, promote
circulation and avoid skin breakdown.
3. Kept patients skin clean and dry; lubricate as needed. Avoided rubbing
the skin. Patted skin to dry. These measures alleviate skin dryness,
promote circulation and reduces risk of irritation and skin breakdown
4. Kept linens dry, clean and free of wrinkles or crumbs. Change wet bed
linens and incontinence pads immediately.

Dry smooth linens avoid excoriation and skin breakdown.

5. Used preventive skin care devices as needed such as pillows, padding
and foam mattress.
To avoid discomfort and skin breakdown

6. Educated family in preventive skin care: maintaining good personal
hygiene, patting rather than rubbing to dry skin and inspecting skin on
a daily basis.

These measures encourage compliance with skin care regimen
E At the end of 8 hours, patient’s skin remained intact and family demonstrated
preventive skin care measures such as inspecting the skin especially the
back portion, patting rather than rubbing to dry & turning patient to sides
every 2 hours.

S Comatose patient/ No verbalization

O - restlessness

- altered level of consciousness
A Ineffective cerebral tissue perfusion related to interruption of blood flow by
space-occupying lesions as evidenced by changes in motor/sensory
P At the end of 4 hours the patient will be able to maintain stable vital signs.
I 1. Monitored neurological status by using Glasgow Coma Scale

Rationale: Assesses trends in level of consciousness (LOC) and potential
for increased ICP and is useful in determining location, extent, and
progression/resolution of central nervous system (CNS) damage.

2. Evaluated pupils, noting size, shape, equality, light reactivity.

Rationale: Response to light reflects combined function of optic (II) and
oculomotor (III) cranial nerves. Pupil reactions are regulated by the
oculomotor (III) cranial nerve and are useful in determining whether the
brainstem is intact.

3. Elevated head of bed gradually to 15–30 degrees as tolerated.

Rationale: Promotes venous drainage from head, thereby reducing
cerebral congestion and edema/risk of increased ICP.
4. Administered supplemental oxygen as prescribed.

Rationale: Reduces hypoxemia, which may increase cerebral vasodilation
and blood volume, elevating ICP.
E At the end of 4 hours the patient was able to maintain stable vital signs.

IX. Progress Notes


Last September 18, 2007, we had our assessment for our last rotation at
Polymedic General Hospital (PGH) station 5. Our clinical instructor was Ma’am
Oro and she assigned each of us an individual patient. One of those was Mrs.
Chavez with the case of CVA and she was assigned to Kena Edao.

A thorough assessment was done by Kena her patient Mrs. Chavez
from head to foot. She takes her vital signs and interviewed her watchers or
significant others about the history of the patient’s condition. And she was also
able to check the patient’s chart for some of its information such as; doctor’s
orders and laboratory results.


On September 19, 2007, we had our first duty and we were on 3-11 pm
shift. At 4:00 pm, Kena takes the patient’s vital signs and after that she then
monitor her condition. She was able also to give the patient’s medications
through NGT feeding because the patient was in comatose.

Kena had done a morning and bedside care to the patient by changing the
patient’s linens and washes the patient’s body with the use of a clean towel with
water. Also, suctioning was done to the patient to prevent aspiration. And lastly,
imparted health teachings to the patient’s significant others.

On September 20, 2007 10:00 am we had our first visit after our rotation
to our case study client and a follow-up visit at 4:30 in the afternoon. We first ask
the permission to her significant others if it’s ok for them that we will take Mrs.
Chavez as our patient for our case study. And when they approved it, we ask if
it’s ok to take pictures, then they permit us to it.

We then get her vital signs and asks her significant others of how was the
patient’s condition now. She was still in coma and had a tachypnea or labored
breathing that time. We also noticed that every time the patient breathes, there is
a presence of sputum.She also coughed during the assessment. Her daughter
then suctioned her in order to prevent aspiration to the patient. The family were
cooperative in giving informations.


The next day, September 21, 2007 after the examination around 5:30 in
the afternoon, we had our second visit after the rotation. The patient was still in
her room and the significant others haven’t decided yet her transfer to the ICU.
Necessary information was gathered to complete our data for the care study. We
noticed that the patient condition is not doing good and the need for her transfer
to ICU was badly needed.


The case study greatly helped our group to learn more about patient care
especially in the ward setting where patients confined present with different
conditions now that we are assigned in the ward. Our client for our case study
had Cerebrovascular Accident (THROMBOTIC).
During the days of our duty, we were able to learn about her condition
supported with the laboratory and diagnostic examinations done. We were able
to determine why the medications are prescribed through the drug study. The
doctor’s order also helped us to learn how conditions like these are managed in
actual versus what are presented as management in the medical books and
The care study also inspired us to be efficient student nurses in our quest
for knowledge and skills necessary of a nurse. It is our honor to be able to care
for other people the way we cared ourselves and family members unrelated we
may be to them.
The quest for knowledge should not be limited to the confines of the four
corners of the classroom but also with the clinical exposures that we have and
that is why we nursing students are fortunate enough to learn and discover
“learning” in various ways. It is our initiative to study more and be prepared for
the future where skills and knowledge are greatly significant in patient care.

XI. Referrals and Follow-up

The group advised the patient’s significant others for strict compliance of
prescribed medications. After 4 days of nursing assessment and hospital care,
the proponents of this study were able to performed proper assessment of the
complication of the patient. During assessment, problems experienced by the
patient were identified and appropriate nursing interventions were designed to
address the needs of the patient. Nursing Care Plans were made; all of which are
implemented. Thus, the nursing interventions done were effective and were able
to alleviate the patient’s condition.

XII. Health Teachings


• The family/significant others were instructed to religiously facilitate patient
in taking the prescribed home medication on time as ordered.
• Thoroughly explained to the family/significant others the medication and
treatment regimen including the adverse effects and advised him to watch
for and report any signs such as headache, dizziness, nausea and
• It was explained to the family/significant others the importance of
continuing to take medications to reduce the risk of another CVA and
further complications.


• The family/significant others were taught on how to do the proper passive
range of motion exercises for promotion of proper blood circulation and to
prevent muscle atrophy.
• The family/significant others were instructed to consult health care
provider before starting the exercise.
• They were encouraged to schedule regular exercise to promote utilization
of carbohydrates, assist with weight control, and improve cardiovascular

The family and/or SO were:

• Encouraged to turn patient to sides every 2 hours to prevent pooling of
secretions, to maintain patent airway and to reduce pressure on tissues,
promotes circulation and to prevent skin breakdown.
• Encouraged to place patient in moderate high back rest to prevent
aspiration and to aid breathing and chest expansion.
• Instructed to maintain hygiene by keeping patient’s skin clean and dry,
changing clothes/gown daily and also beddings, to promote comfort and
prevents skin breakdown and/or irritation.
• Encouraged to have lifestyle modifications such as weight reduction, and
increase in physical exercise to decrease blood pressure and improve
cardiovascular tone and reserve.
• Explained the major risk factors that can increase chances for another
attack such as smoking, high blood cholesterol levels, and hypertension.
Related risk factors include obesity, family history, diabetes, stress, and
lack of exercise.
• Advised getting at least 7 hours of sleep each night and take 20 to 30
minutes rest period twice a day to reduce stimulation and promotes
• Encouraged to provide calm, restful surroundings, minimize environmental
activity/noise. Limit the number of visitors and length of stay to help
reduce sympathetic stimulation; promotes relaxation.
• Instructed that the purpose of limited activity and visitors—to help the
heart heal by lowering heart rate and blood pressure to maintain cardiac
workload at lowest level and decrease oxygen consumption.


• The family/significant others were instructed to have a follow up check a
week after discharge and see Dr. Agcopra at CDO-Polymedic General
Hospital Inc., Velez St., Cagayan de Oro city, for further evaluation and to
check if there are complications on the patient’s health status.
• They were also instructed to bring the patient to the nearest
hospital/health center if there is an occurrence of the disease of illness.


The patient and/or significant others were:

• Instructed to eat meal consisting of carbohydrates such as fruits, starches
and vegetables, protein selection that are lean to help reduce fat and
cholesterol intake and fats should be used sparingly to control blood
glucose and lipid levels and maintain ideal weight.
• Encouraged increase intake of soluble and insoluble fiber such as whole
grain, white bread and instructed to eat fresh fruit and vegetables in place
of fruit juices.
• Instructed to avoid salt &/or salt-containing spices whenever possible.
• Advised eating three to four small meals per day rather than large, heavy
meals. Rest one hour after meals.
• Advised limiting caffeine and alcohol intake.
• Encouraged to include MACKS-P (malunggay, alugbati, camote tops,
kangkong, saluyot and pechay) in his diet because it is inexpensive and
nutritious as promoted by the DOH.
• Encouraged to follow dietary instructions provided at the hospital before

XII. Prognosis



As for the severity of the patient’s condition, we rated it poor since our patient
demonstrated no improvement regarding health status or health condition for the
past two days of assessment and nursing care. During our last visit, she was
already transferred to the Intensive Care Unit (ICU).


The patient is already 53 years old, she is relatively old and possesses a
poor immunity that may aid him to recover faster from his present condition.
Relative to this factor, we gave her a poor prognosis.

The significant others poorly complied with the prescribed medications. The
patient took some of her medications via nasogastric tube (NGT) on time as
ordered by the physician. However, they were not able to buy all the medications
prescribed by the physician due to instability. This may be a poor indication of a
quicker recovery, we rated this prognosis as poor.


The patient’s family provides a strong support to him by caring the patient
and watching him by his bedside, making sure that he can be assisted as often
as necessary. Based on these observations, we gave the patient a good


Based on the criteria being rated. Our patient’s overall prognosis is poor with
a score of 1/4.

XIII. Bibliography

Arnold et. al., Lippincott Manual of Nursing Practice Series:
Pathophysiology, 2007, Lippincott William & Williams, Philadephia USA Pages:

Black, Joyce M., MSN, RNC et al. Luckmann and Sorensen’s Medical
Surgical Nursing A Psychophysiologic Approach. Fourth Edition. W.B.
Saunder’s Company, 1993.

Comer, S, Delmar’s Critical Care: Nursing Care Plans. 2nd ed., 2005, Thomson
Delmar Learning, USA Pages : 115-119

Deglin, Judith H., Davi’s Drug Guide for Nurses, 9th Edition, 2005, F.A. Davis

Doenges, M & Moorhouse, FM, Nursing Care Plans: Guidelines for
Individualizing Patient Care, 6th ed., 2002, F.A. Davis Company, Philadephia
USA :Pages 127-140

Gulanick, et. al., Nursing Care Plans: Nursing Diagnosis and Intervention, 3rd
ed., 1994, Mosby, USA Pages: 211-213
Huether & McCance, Understanding Pathophysiology, 2nd edition, 2004,
Mosby, USA

Mosby’s Medical, Nursing, & Allied Health Dictionary, 6th edition, 2002, Mosby,

Nettina, SM, The Lippincott Manual of Nursing Practice, 7th edition, 2001,
Lippincott Williams & Wilkins, Philadephia, USA Pages: 283-286

Nettina, SM, Lippincott’s Pocket Manual of Nursing Practice, 2nd edition,
2003, Lippincott Williams & Wilkins, Philadelphia USA, Pages 841-860

Smeltzer & Bare, Medical-Surgical Nursing, 10th edition; Volume 2, Lippincott
Williams & Wilkins, Philadephia, USA Pages: 1150-1203

Sparks & Taylor, Nursing Diagnosis Reference Manual, 3rd edition, 1995,
Springhouse Corporation, Philadephia USA
V. Pathophysiology

Definition: Stroke (or cerebrovascular accident or CVA) is the clinical designation for a rapidly developing loss of brain function
due to an interruption in the blood supply to all or part of the brain.

Cerebral Thrombosis
Predisposing Factor: Precipitating Factor:
Age(53) • Hypertension
Heridetary ( + Mother side) BP(150/100)
Atherosclerotic Process

Cerbral Atherosclerotic

Slowing of the cerebral circulation

Decrease oxygen to the cerebral tissue

Anaerobic Glycosis

Cerebral Vascular Spasm

Neurostransmital Communication:
Destruction: Aphaxia Perceptual Disturbances:
Weakness of Mouth Paralysis of symphathetic
of the upper motor in the and Throat:
Pyramidal Pathway nerves of the eyes.
(s&sx: Dysphagia)
(s&sx: Akinesia)
Loss of skills and
voluntary movement