PATIENT’S DATA

NAME OF THE PATIENT : Surinder Singh

AGE : 55 years

SEX : Male

RELIGION : Sikh

MARITAL STATUS : Married

ADDRESS : Village Bhangewala, distt. Muktsar

ADMISSION/ IN-PATIENT NO : 153878

NAME OF THE WARD : Neuro Ward

DATE OF ADMISSION : 02-6-2018

EDUCATIONAL STATUS : Metric

OCCUPATION : Shopkeeper

CONSULTANT DOCTOR : Dr. Sulena

DIAGNOSIS : CVT with seizures

CHIEF COMPLAINTS:
At the time of admission:
Seizures × 5 hrs
Weakness of left side × 2 hrs
Vomiting × 3 hrs
Unconsciousness × 2 hrs
Present chief complaints:
Paralysis of left side since admission
Weakness of left side since admission

HISTORY OF PRESENT ILLNESS-

Pt was admitted on 4-5-2018 IN NEURO WARD at GGS Hospital, Faridkot with Chief complaints of seizures, weakness of left side
and vomiting. Patient had sudden seizure attack followed by frothing from mouth. After that he developed weakness of left side of
both upper and lower limb.

PAST HISTORY-

 MEDICAL :
H/O similar episode of stroke 15 yrs back is present when patient developed weakness of upper limb first followed by lower
limb. The weakness in lower limb improved but there was residual paralysis in upper limb. Deviation of mouth to right was
present. No H/O Diabetes Mellitus, HTN is present since 10 yrs, no incontinence of urine or feaces. No H/O diarrhea,
constipation, chest pain, dyspnea or rash.

FAMILY HISTORY
Name of the family member Relationship Age/ Sex Marital status Occupation Health status Educational
with patient background
Pritam Kaur Wife 45 Yrs/ Married Housewife Good Secondary
Female

Ravneet Kaur Daughter 24Yrs/Female Unmarried Student Good Graduation

Gurpreet Singh Son 18 Yrs/Male Unmarried Student Good Higher

Secondary
FAMILY TREE:

Patient wife
(55 yrs/M) (45yrs/F)

(18yrs/M) (24yrs/F)

Symbols:

Male Female Patient

SOCIOECONOMIC STATUS
Housing – Pucca house with 3 rooms and 1 kitchen, 1 toilet and 1 bath room
Water supply – Tap water
Sanitation – Good sanitation facility
Income -1, 50,000 per annul
PERSONAL HISTORY
 Dietary habits – vegetarian with three meals per day
 Addictions- non addicted

Personal hygiene:
Oral hygiene : brush with tooth paste
Bath : per day frequency-1 time. , Agent-soap.
Diet : Vegetarian
No of meals per day : three
Food preferences : rice chapatti, pulses and vegetarian
Type of food : Indian
Fluid : 06-7 glasses per day
Tea & coffee : 2-3 Cups / day
Sleep & rest : 7-8 hours / day
Elimination
Urine frequency : During day: 3-4times Night-1time
Mobility & Exercise
Exercise/ Activity: Restricted
Joints: No Pain
Sexual & Marital history
Spouse Health: Good
Spouse occupation: None (Housewife)
 Relationship: Satisfactory
Staying together: Yes
No. of children: Male…1……Female…1…..
General health of children: Good
Substance use: Do not use Tobacco/ Drug/ Alcohol
Addiction use: No
Immediate problem due to hospitalization on admission day:
Anxiety due to hospitalization is present

PHYSICAL ASSESSMENT
General appearance & Behavior: Patient is unconscious, not oriented to time, person, place

Vital signs:
VITAL SIGNS 4-6-2018 5-6-2018 6-6-2018 7-6-2018

TEMPERATURE 98 .8 ̊ F 98.6 ̊ F 98.2 ̊ F 98.6 ̊ F

PULSE 54/min 55/min 58/min 60/min

RESPIRATION 18/min 22/min 14/min 58/min

BLOOD PRESSURE 128/64 mmHg 152/93mmHg 140/70mmHg 128/64mmHg

GENERAL PHYSICAL EXAMINATION:
 General appearance:
Well built, well groomed.
Sensorium : present
Posture : Erect
Gait : Disturbed
Skin color : Pale
 Head:
Scalp : Dry
Hair : Rough texture
Dandruff : No dandruff present, no alopecia.
Pediculosis : Not present
 Eyes:
Conjunctiva : Pale in colour
Cornea : Normal
Sclera : whitish
Vision : Proper
Discharge : No abnormal discharge present
 Ears:
External ear : Normal
Hearing: Normal
No discharge present, no bleeding
 Nose:
Deviated Nasal septum- Not present
Discharge : No bleeding or abnormal discharge present
Olfaction: Normal Intensity
 Oral cavity:
Salivation : In normal amount
Stomatitis, Gingivitis : Not present
Teeth : Normal, plaque
Tongue : Not coated. No lesions present.
Range of motion : normal
  Chest:
Abnormal sounds : No wheezing or Grunting present
Breathing Rate : 14/ min
Shape and size : Anatomically normal
 Abdomen:
Size and shape : Normal
Distension : Not distended
 Extremities:
Upper extremities : Anatomically symmetrical, left limb is non functional
Lower extremities : Restricted movements, no activity in left limbs.

SYSTEMIC EXAMINATION:
SUBJECTIVE DATA OBJECTIVE DATA
HEAD: Normal in symmetry and shape.
VISION: No impairment
HEARING: Normal no any abnormality
SPEECH & ORIENTATION Unable to speak and convey verbally, disoriented to time, place and person
RESPIRATORY SYSTEM: On inspection: Normal in anatomy and physiology
On palpation: No abnormal mass present
On percussion: No fluid accumulation
On auscultation: No added sounds
CIRCULATORY SYSTEM: Pulse: 54 beats/min
Blood pressure: 152/93 mm of Hg.
On inspection: Normal shape and size
On palpation: No hematoma formation
On auscultation: No murmur

LYMPHATIC SYSTEM:
On palpation: Normal in anatomy and physiology
GASTROINTESTINAL SYSTEM AND On inspection: Normal shape and size of all organs
NUTRITION/HYDRATION: On auscultation: No added sounds
On palpation: abdomen is soft,non tender
On percussion: No abnormal fluid accumulation
URINARY SYSTEM: Normal in anatomy and physiology , Intake of patient is higher than output.

REPRODUCTIVE SYSTEM: Normal in anatomy and physiology

REST AND SLEEP: Patient is able to sleep for normal hours.

PSYCHO-SOCIAL ASPECT: He is psychologically ill and depressed because of disease condition.

MUSCULO SKELETON SYSTEM: Lower and upper limbs are paralysed. They do not show activity.Right power tone is normal.
NEUROLOGICAL SYSTEM: Level of consciousness: E2V4M3=9/15
Memory:
Recent: Present
Remote: Absent
Orientation: Not oriented to time and place.
Insight and Judgment: Not present
General Intelligence: Present
Speech: Slurred
Behavior: Good

REFLEX:
 Deep tendon reflexs (muscle-Stretch Reflex):
Biceps Triceps Brachio- Patellar Achilles
radialis (Quadriceps)

Right
Present Present Present Present Present
Left Diminished Diminished Absent Absent Absent
 Superficial Reflexes: Diminished in case of left limbs
INVESTIGATIONS
Date Investigation carried out Patient’s value Normal values Remarks
4-6-18 HB 9.4gm/dl 12-14gm/dl Decreased
WBC 7.61×1000/µl 4-11×1000/µl Normal
Neutrophilis 84.2% 40-80% Increased
Lymphocytes 19.1% 20-40% Decreased
Monocytic 3.4% 2-10% Normal
Eosinophils 0% 1-6% Decreased
Basophils 0.3% 0-1% Normal

RBS 129mg/dl <140mg/dl Normal

B.Urea 32mg/dl 15-45mg/dl Decreased
S.Creatinine 0.9mg/dl 0.8-1.3mg/dl Normal
Na+ 132meq/l 135-155meq/l Decreased
K+ 3.9meq/l 3.5-5.5meq/l Normal
Cl 99meq/l 98-107meq/l Normal

SPECIAL INVESTIGATION:
 Ultrasound: not significant
 X ray: not done
 Ct scan/MRI: ct scan shows acute /sub acute infarct in left medial occipital lob
 PLAN OF TREATMENT-
MEDICAL MANAGEMENT:
A. MEDICATION-
Route/
Name of drug Dose/Fre Salt/
quency Action Indications Contraindications Nsg.Responsibility
 It is an osmotic  Congestive heart failure as it  Check seven rights before giving
diuretic, prescribed for increases extracellular fluid the medicine.
increased intracranial thereby increasing the load  Monitor for any side effects of the
pressure, medication.
on already decompensated
 eye pressure,  PRECAUTIONS
 to maintain urine flow heart
 Pulmonary congestion  The cardiovascular status of the
in kidney failure
patients,  Electrolyte Depletion patient should be carefully evaluated
 promotion of urinary  Severe Dehydration before rapidly administering
excretion of toxic  Well established Anuria NEUROTOL since with mannitol
materials.  Acute intracranial bleeding sudden expansion of extracellular
except during craniotomy. fluid may lead to culminating
0.1gm
IV/0.2gm mannitol/  Progressive renal damage congestive heart failure.
Inj.Neurotol  NEUROTOL should not be
BD 0.1gm
administered simultaneously with
Glycerine
blood as it may cause pseudo
agglutination due to presence of
mannitol in the preparation. If at all it
is essential that blood is to be given
simuyltaneusly , atleast 20mEq of
sodium chloride should be added per
litre to the preparation
 Rapid infusion of NEUROTOL
should be carefully monitored as
glycerol is not to be infused rapidly.
 There are no clinical evidences of use
 of NEUROTOL in pregnant or
lactating women
 The dosing in elderly requires careful
monitoring but no dose adjustment
may be required.


 Inflammatory and Contraindications include:

 Monitor blood pressure before and
autoimmune conditions, such after giving the medicine.
 Administer with caution in
as rheumatoid  Uncontrolled infections
patients with cardiac problems.
arthritis and bronchospasm.  Known hypersensitivity to
 dexamethasone
Idiopathic
 Check seven rights before giving
thrombocytopenic  Cerebral malaria the medication
purpura.  Systemic fungal infection

Oncologic uses brain  Concurrent treatment with
tumors (primary or live virus vaccines
metastatic), (including smallpox)
dexamethasone is used
IV/8mg/ to counteract the
Inj.Dexona
BD development of edema,
which could eventually
compress other brain
structures.

It is also given in cord
compression, where a
tumor is compressing
the spinal cord.
 Used as a direct
chemotherapeutic agent
in
certain haematological
 malignancies,
especially in the
treatment of multiple
myeloma.

.  Unconsciousness  Check seven rights before giving

 Memory disorders  Brain surgery the medicine.
 Pregnancy  Monitor for any side effects of the
In the hippocampi of rats with  Breast feeding medication.
induced Alzheimer’s Disease,
citicoline counteracts neuronal
degeneration and reduces the
number of apoptotic cells
present. Citicoline
supplementation also improves
memory retention.
 Ischemic stroke
IV
 Citicoline is approved
Inj,Citicolin /500mg/
for treatment in cases
BD
of head trauma, stroke,
and neurodegenerative
disease Vision
 Citicoline improves
visual function in
patients
with glaucoma, amblyo
pia, and non-arteritic
ischaemic optic
neuropathy.
 Satiety
  Rheumatism 1. Allergy to NSAID  Monitor blood pressure before and
 Rgeumatoid arthritis 2. Asthma after giving the medicine.
 Infectious allergic 3. Rhinitis  Administer with caution in
myocarditis 4. Nasal polyps patients with cardiac problems.
 Fever during infection 5. Urticaria
 inflammatory disease 6. Angioedema
7. Bronchospasm  Check seven rights before giving
 pain syndrome the medication
 Weak and medium 8. Peptic ulcer
Acetylsal 9. DM
Orally/15 intensity of neuralgia,
Tab.Ecosporin i-cylic 10. Gastritis
0mg/BD  myalgia,
acd 11. Hemophilia
 Prevention of
12. Rey's syndrome
thrombosis and
embolism
 Primary and secondary
prevention of mi
 Prevention of violation
of cerebral circulation
of ischemic type

 Pain fever  Hypersensitivity to  Check seven rights before giving

 Acute gout domperidone the medicine.
 Migraine  Prolactin releasing pituatry  Monitor for any side effects of the
tumor medication.
 Prolectinoma
 GI obstruction
Orally/ PCM,  Nausea and vomiting
Tab.Nectar DT 500mg/ Domperi  GI disorders
SOS d-one  Migraine
 Delayed gastric emptying of
functional region
 Antiemetic in pt. receiving
cytotoxic drugs
 Preanesthetic drug
 Hypersensitivity to PCM
ANATOMY AND PHYSIOLOGY
CENTRAL NERVOUS SYSTEM:
The brain and the spinal cord are collectively as the central nervous system. The CNS is divided into 3 major functional divisions:
1. High level brain or cerebral cortex
2. Lower level brain (basal ganglia, thalamus, hypothalamus, midbrain, pons, medulla oblongata, cerebellum)
3. Spinal cord
These structures are protected by a rigid bony encasement, three layers of membranes, a fluid cushion, and a blood brain or blood-
spinal cord barrier.

THE MENINGES: The brain and the spinal cord are completely surrounded by three layers of tissue, the meninges, lying between the
skull and the brain, and between the vertebral foramina and the spinal cord. Named from outside inwards they are the:
 Dura matter
 Arachnoid matter
 Pia matter
The dura and arachnoid matters are separated by a potential space , the subdural space. The arachnoid and pia matters are separated by
the subarachnoid space, containing cerebrospinal fluid.
Dura mater:- the cerebral dura mater consists of two layers of dense fibrous tissue. The outer layer takes the place of the periosteum on
the inner surface of the skull bones and the inner layer provides a protective covering for the brain.
Arachnoid mater:- this is a layer of fibrous tissue that lies between the dura and pia maters. It is separated from the dura mater by the
subdural space, and from the pia mater by the subarachnoid space, containing cerebrospinal fluid.
Pia materthis is a delicate layer of connective tissue containing many minute blood vessles. It continues downwards surroundings the
spinal cord.

VENTRICLES OF THE BRAIN: within the brain there are four irregular shaped cavities, or ventricles, containing cerebrospinal fluid.
They are:
 Right and left lateral ventricles
 Third ventricle
 Fourth ventricle
The lateral ventricles :- these cavities lie within the cerebral hemispheres, one on each side of the median plane just below the corpus
collasum. They are separated from each other by a thin membrane, the septum lucidum, and are lined with ciliated epithelium. They
communicate with the third ventricle by interventricular foramina.
The third ventricle :- it is a cavity situated below the lateral ventricles between the two parts of the thalamus. It communicates with the
fourth ventricle by a canal, the cerebral aqueduct..
The fourth ventricle: the fourth ventricle is a diamond shaped cavity situated below and behind the third ventricle, between the
cerebellum and Pons. It is continuous below with the central canal of the spinal cord and communicates with the subarachnoid space
by foramina in its roof.

BRAIN:
 CEREBRUM: this is the largest part of the brain and is occupies the anterior and middle cranial fossae. It is divided by a deep
cleft, the longitudinal cerebral fissure, into right and left cerebral hemispheres, each containing one of the lateral ventricles.
Deep within the brain the hemisphere are connected by a mass of white mater called the corpus collasum. The superficial part
of the cerebrum is composed of nerve cell bodies or grey mater, forming the cerebral cortex, and the deeper layers consists of
nerve fibres or white mater. Each hemisphere is divided into lobes which takes the names of the bones of the cranium under
which they lie: frontal, parietal, temporal and occipital.

Functions of the cerebrum:-

 Mental activities involved in memory, intelligence, sense of responsibility, thinking, reasoning, moral sense and learning are
attributed to the higher centers.
 Sensory perception, including the perception of pain, temperature, touch, sight, hearing, taste and smell.
 Initiation and control of skeletal (voluntary) muscle contraction.
 BASAL GANGLIA: these are the areas of grey mater, lying deep within the cerebral hemispheres, with connection to the
cerebral cortex and thalamus. The basal ganglia from part of the extrapyramidal tracts and are involved in initiation and fine
control of complex movement, and learned coordinated activities. If control is inadequate or absent, movements are jerky,
clumsy and uncoordinated.
 THALAMUS: the thalamus consists of two masses of nerve cells and fibres situated within the cerebral hemispheres just
below the corpus callosum, one on each side of the third ventricle. Sensory input from the skin, viscera and special sense
organs is relayed to the thalamus before redistribution to the cerebrum.
 HYPOTHALAMUS: the hypothalamus is composed of a number of groups of nerve cells. It is situated below and in front of
the thalamus, immediately above the pituitary gland. The hypothalamus is linked to the posterior lobe of the pituitary gland by
nerve fibres and to the anterior lobe by a complex system of blood vessles. Through these connections, the hypothalamus
controls the output of hormones from both lobes of the gland.
 MIDBRAIN: the midbrain is the brain situated around the cerebral aqueduct between the cerebrum above and the pons
below.it consists of nuclei and nerve fibres, which connect the cerebrum with the lower parts of the brain and with the spinal
cord. The nuclei act as relay stations for the ascending and descending nerve fibres.
  PONS: the pons is situated in front of the cerebellum, below the midbrain and above the medulla oblongata. It consists mainly
of nerve fibres that form a brirge between the two hemispheres of the cerebellum, and of fibres passing between the higher
levels of the brain and the spinal cord.
 MEDULLA OBLONGATA: the medulla oblongata, or simply the medulla, extends from the pons above and is continuous
with the spinal cord below. It is about 2.5cm long and it lies just within the cranium above the foramen magnum. Its anterior
and posterior surfaces are marked by central fissures.
 CEREBELLUM: the cerebellum is situated behind the pons and immediately below the posterior portion of the cerebrum
occupying the posterior cranial fossa. It is ovoid in shape and has two hemispheres, separated by a narrow median strip called
the vermis. Grey mater forms the surface of the cerebellum, and the white mater lies deeply.

DISEASE CONDITION

DEFINITION: CVT: Cerebral venous sinus thrombosis (CVST) is the presence of acute thrombosis (a blood clot) in the dual
venous sinuses, which drain blood from the brain. Symptoms may include headache, abnormal vision, any of the symptoms of stroke
such as weakness of the face and limbs on one side of the body, and seizures
 COMPARATIVE STUDY PATIENT STUDY

Risk Factors:

Modifiable, Risk Factors:
 Hypertension
 Cigarette Smoking
 Diabetes
 Carotid artery Disease
 Atrial fibrillation
 Dyslipidemia
 Diet
 Obesity 
 Physical Inactivity 

Non modifiable Risk Factors

 Age
 Race
 Sex
 Family history of stroke/TIA
Etiology
 Local condition
 Brain and skull damage
 Intracranial and local regional infections (mastoiditis)
 Systemic conditions
 Hormonal change specially during pregnancy, and steroidal use
 Hematological and hypercogulated disorder 
  Malignancy
 Dehydration
 Systemic infection
 Idiopathic cause

Pathophysiology:

Ischemic stroke:

Due to etiological factors

Plaques build up/ breaks off and travels

CBF,PaO2 and PaCO2 ,lactic acid and ATP

Ischemia to neuron and bleeding

Dilated veins with arteries

Arterial blood shunted into veins

Rupture of veins

Bleeding into the Subarachnoid space/ V.S.

Bleeding into the brain tissue and clot formation

CLINICAL MANIFESTATIONS:
MOTOR 

 Headache 
 Papiledema 
 Seizures
 Multiple cranial nerves palsies 
 Hemi paresis or hemiplegia of the side of the body opposite the side of ischemia. It
occurs due to stroke in the anterior and middle cerebral artery.
 Dysphasia
 Dysarthria: Imperfect articulation that causes difficulty in speaking. The client 
understands the language, but has difficulty in pronouncing words.
 Apraxia: A condition that affects complex motor integration. 

BOWEL & BLADDER
 Frequency, urgency & urinary incontinence 
 Constipation (related more to immobility to the physical effects of stroke) 
LANGUAGE:
 Nonfluent aphasia/ expressive- inability to express self verbally. Due to stroke in left
middle cerebral artery 
 Fluent/ Wernicke’s aphasia/ receptive- inability to comprehend speech. As result of
infarction in the temporal lobe of the brain.
 Broca’s aphasia- Affects speech production as a result an infarction in the frontal 
lobe of the brain.
 Global aphasia- Affects both speech comprehension and speech production. 
Alexia – inability to understand the written word 
SENSORY- PERCEPTUAL:
 Diminished response to superficial sensation of touch, pain, pressure, heat & cold. 
 Diminished proprioception i.e. knowledge of position of body parts in environment.
VISUAL DEFICITS: 
 Decreased acuity 
 Diplopia
  Homonymous-hemianopia: It is the visual loss in the same half of the visual
field of each eye. So the client has only half of the normal vision e.g. client

see clearly on the one side of midline but see nothing on the other side.
Unilateral Neglect occurs.Use one extremity. Orient the head and eyes to the 
one side.

 Horner’s syndrome:Sinking of the eyeball, ptosis of the upper eyelid ,slight
elevation of lower eyelid.
 Agnosia: Inability to recognize familiar objects through sight, sound & touch.
 Possible deficits in: Telling time
Judging distance 
Memory of location & objects
COGNITIVE- EMOTIONAL :

- Emotional liabiality & unpredictability 
- Behavior may be socially inappropriate e.g. Crying
- Depression
- Mental loss 
- Short attention span, easy distractibility
- Loss of reasoning ,judgement & abstract thinking ability 
-

DIAGNOSTIC EVALUATION:
- Physical examination and tests
- Arteriography
- Carotid ultrasonography.
- CT 
- MRI
- Echocardiography
MANAGEMENT:
History:
- History of warning signs
- Risk factors for atherosclerotic and cardiac disease, including hypertension, diabetes
mellitus, tobacco use,
- Physical examination
- Neurological assessment , GCS
- Vital signs 
 Contraindications :
 Symptoms suggestive of Subarachnoid hemorrhage

 Stroke or serious head trauma within 3 months
 Major surgery or serious bodily trauma within 2 weeks
 History of a prior ICH, thrombocytopenia

 Use of oral anticoagulants
Drugs commonly used: 
 Antihypertensive are given rarely to reduce the BP in acute phase as it acts as a

compensatory mech. to perfuse the brain.
 Anticoagulants: 
 Anti platelets and Anti Thrombotic e.g. Heparin, low dose aspirin × 4 to 10 days.

 Long term anticoagulants e.g. warfarin, aspirin
 Vasodilators
Surgical management:
 Craniotomy for evacuation of hematoma.
 Carotid endarterectomy 
 Anticonvulsants

 Internal to external carotid bypass
COMPLICATIONS: 
 Cerebral edema

 Seizures
 Increased ICP
 Infections
 Respiratory depression
 Coma
 DIETARY MANAGEMENT:

DO'S AND DON’TS:

 Eat a variety of foods.

 Maintain a healthy weight by balancing the calories you eat with physical activity.
 Choose more whole grains, vegetables and fruits.
 Choose foods low in fat, saturated fat and cholesterol.
 Choose foods with moderate amounts of added sugar.
 Choose foods with moderate amounts of salt and sodium.
 If you drink alcoholic beverages, do so in moderation.
 Choose healthy foods with stronger flavors, such as broiled fish and citrus fruits. Also,
spices add flavor to food and serve as a good substitute for salt.
 Choose colorful, visually appealing foods, such as salmon, carrots and dark green
vegetables.
 Cut foods into small pieces to make them easier to chew.
 Pick softer, easier-to-chew foods, such as yogurt, bananas, whole-grain hot cereals and
low sodium soups.
 If you have trouble swallowing, talk to your speech therapist or doctor. This condition
can be treated.
 If weakness in arms or hands is a problem, you might try adaptive eating utensils. Some
types of flatware have thicker handles that are easier to hold, and “rocker knives” make it possible to cut food using one hand.

 NURSING MANAGEMENT :
1. Nursing assessment
 Neurological assessment
 Vital signs
 Careful history
 CAB
 Ongoing Monitoring
Nursing Goals:
Long term goals:
 To improve gait and performance of activities.
 To maintain the nutritional status.
 To minimize the signs of depression.
 To improve speech for clarity and pace.
 To maintain family dynamics and support system.

Short term goals:-

 To rehabilitate the patient.
 To make the patient independent.
 To relieve anxiety.
 To give health education for home care.
 To encourage the patient for follow up after discharge.
 NURSING CARE PLAN
Nsg .Diagnosis Goal Interventions
To improve the
Altered tissue perfusion  ICP monitoring
r/t increased ICP,
tissue
perfusion.  Neurological assessment
infarcted brain area.
 Avoid causes of restlessness,
e.g. full bladder
 Temperature regulation
 Activities like Straining at
stool should be avoided
 Proper positioning
Altered Physical mobility To improve the  Provide proper positioning to
r/t paralysis the patient.
physical
mobility.  Change the position 2 hrly
 Allow him to sit upright for
short duration only
 Do not place a pillow under
the affected knee
 Avoid acute hip flexion
 Position him in prone
position for 10-15 mins.
 Prevent foot drop by using
footboard
 At night use night splints
Implementation Evaluation
 ICP monitoring is done. Tissue perfusion
 Neurological assessment including temperature
including glasgow coma scale regulation was
has been done. maintained.
 Bladder has been emptied time
to time to prevent restlessness.
 Thermoregulation has been
maintained.
 Activities leading to straining
has been avoided.
 Patient is provided with proper
positioning i.e prone position. Physical mobility of the
patient was improves to
some extent.
 Position of the patient is being
changed every 2 hrly.
 He is made to sit upright for 5-7
min only.
 Pillow has been removed from
under the affected knee.
 Hip flexion is being avoided.
 Patient is provided with prone
position for 10-15 mins.
 Footboard is provided to
prevent footdrop.

 Prevent the adduction of the
affected shoulder by placing
a pillow in the axilla to keep
the arm abducted at 600
 Keep the arm in slightly in a
neutral position
 Place the forearm on another
pillow in a modified “statue
of liberty” position
 Trochanter roll is provided to
the to the patient .
 Leg is supported while
changing the position.
 Night splints are provided to
use at night.
 Pillow has been placed under
the axilla.

 Place the affected hand in a  Arm has been placed in neutral

position of function, slight position.
supination with fingers
flexed and thumb in
opposition.  Forearm has been placed in a
specified position.
 Use a handroll or splint to
prevent finger flexion and  Affected hand has been placed
thumb adduction in a position of function.
 ROM exercises
 Give a ball or something to  paralyzed arm and advised not
squeeze in the hand of the to use affected arm everytime.
patient.
 Patient is encouraged to use
affected limb .
 Help them in using paralyzed
arm as much as possible and
avoid a tendency to do
everything with affected
arm.
 Eyes have been covered with
patch in the pt.
 To improve the Patient is able to
Self care deficit r/t self care  When they can sit up,  Eyes have been irrigated with perform self care
paralysis activities of encourage them to use the activities by himself.
saline.
affected limb
patient.  Bed side rails have been raised.
 Skin is being frequently
inspected for any kind of
 Eyes : lesions.
 Cover them with an eye  Patient is provided safe
patch over one eye in pt with environment.
Diplopia  Eye care and mouth care of the
patient has been done.
High risk for injury r/t To decrease  Irrigate the eyes with saline  Patient's activities is being Pt. is safe from the risk
paralysis the risk for supervised. of injury.
injury  Keep bed side rails up
 Frequent skin inspection  Breath sounds are assessed
every 2-4 hrly.
 Safe environment
 Eye care  Tracheobronchial suctioning
has been done.
 Mouth care
 Supervise their activities  Patient's head is turned to one
side during mouth care.
 Assess for breath sounds
every 2-4 hrs

 Teach technique for Sucking

 Teach about Tongue  Patient is assisted in mouth
movements and Swallowing opening and closing.

 Teach technique of sucking and

 Observe the pt. to identify
 characteristics of voiding
pattern (e.g. freq., amount,
Altered nutrition less To improve the constant dribbling)
than body requirement r/t nutritional
status of the  Maintain intake/output
inability to swallow
patient.  Whenever possible try to
keep him catheter free by:
 Offering bedpan or urinal
frequently
 Take pt to commode freq.
 Develop a bowel training
program
 Give foods known to
stimulate defecation
 Initiate a suppository and
Altered elimination To improve the
laxative regimen
pattern r/t urinary urinary
incontinence. elimination.  Institute a bowel programme.
 Enemas are avoided in
presence of increased ICP.
 Explain all the procedures
before carrying out them.
 Do not whisper at the bed
side.
 Never shout or blame the
patient
swallowing.
 Patient is observed for
characteristics of voiding.
Nutritional status of the
pt. has been improved to
some extent.
 Intake output is maintained.
 Keep the patient catheter free.
 Patient has been offered bedpan
or urinal frequently.
 Patient is taken to commode
frequently.
 Bowel training power is
developed for the patient.
 Foods which stimulate
defecation has been given.
 Suppository and laxative
regimen is initiated.
Elimination pattern of
 Bowel programme has been the pt. has been
instituted for the patient. maintained.
 Patient is not provided with
enemas.
 All the procedures are explained
before performing them.
Altered bowel  Don’t discuss about the
To improve  Silence is maintained at the bed
elimination pattern r/t hydration patient’s condition with the
dehydration, immobility of the patient.
status and relative at the bed side
and deterioration in LOC. mobility of  Be calm , gentle and patient  Patient is handled with patience
patient. and calmness.
 Help the family members to
communicate with the Bowel elimination
patient and encourage them pattern of the pt. has
to talk effectively. been established.
 Prevent intellectual
regression and disorientation
To improve the  Family members are
Impaired communication
communication encouraged and helped to
r/t aphasia secondary to
CVA. Pattern of  Position a calendar and a communicate with the patient.
patient. clock in his room
 Approach the client from
side that is not impaired
Pt.is able to
 Teach him to position the communicate by sign
head to increase the visual language.
 Calendar and clock are
field
positioned in the room.
 Avoid a busy environment
 Client is approached from the
 Do not blame the client side that is not impaired.
 Give supportive statements
Altered thought process To improve the  Head of the patient is
r/t impaired cerebral thought  Praise all success even when positioned. Thought pattern of the
blood flow. process of the small. pt. has been improved to
patient.  Provided with calm some extent.
environment.
  The patient is supported
physically as well as mentally.
To improve the  Pt. is appreciated and
Altered sensory and perception of encouraged.
perception r/t physiologic the patient.  Environment of the pt. is
changes of CVA modified to reduce the stress Perception of pt. has
level. been improved to some
extent.

To improve the
coping
Ineffective individual mechanism of
coping r/t physiologic patient. Pt. is able to cope up
changes slightly to the situation
to some extent.

HEALTH EDUCATION:-
1. Encourage pt. receiving anticoagulants to comply with follow up monitoring of prothrombin time and partial thromboplastin
time and to report any signs of bleeding.
2. Encourage the use of electric razors and tooth brushes
3. Provide information on smoking cessation
4. Encourage low fat diet, birth control alternatives and exercise
5. Stress the need to change lifestyle to halt the disease and prevent strok
BIBLIOGRAPHY:
 Wilkins and Williams; “Lippincott manual of nursing practice” published by Wolters kluwer, 10th edition Pp 472-474.
 Adams and Victors; “principles of neurology” published by Ropper Brown, 8th edition Pp 540-542.
 Black and Joyce; “Medical surgical nursing” published by Saunders, 8th edition Pp 1902-1906.
 Suddarth’s and Brunner; Medical surgical nursing” published by Saunders, 10th edition Pp1979-1986
 American Heart Association/American Stroke Association. Nutrition Tips for Stroke Survivors. Accessed 5/30/2013.
 Corrigan ML, Escuro AA, Celestin J, Kirby DF. Nutr Clin Pract. 2011;26(3):242-52. Nutrition in the stroke patient. Accessed 5/30/2013.
 NutritionMD. Consumer’s Section: Stroke: Nutritional Considerations. Accessed 5/30/2013.
 Centers for Disease Control and Prevention. What you can do: How to prevent stroke. Accessed 5/30/2013.