Central Philippine University

College of Nursing and Allied Health Sciences

Jaro, Iloilo

A CASE PRESENTATION ON
CEREBROVASCULAR ACCIDENT/STROKE

Atty. Salex Espinosa Alibogha, RN, MAN, LLB

Lecturer, N423 (Competency Appraisal), 4th Year, 2nd Semester

Submitted By:
Aqruiola, Ryan
Barrido, Marifer Paola
Bearnod, Sharmaine Gay
Berondo, Claudette
Catequista, Claudine
Chua, Sabrina Anne
Dalipe, Cheffe April
Darroca, Estee Marie
BSN-4B
 TOPIC/TASK PRESENTOR
I. Pre-test formulation Ms. Sharmaine Bearnod
II. Case scenario of the disease Ms. Marifer Paola Barrido
III. Mini-Lecture and Pathophysiology Ms. Cheffe April Dalipe
IV. Levels of care
A. Promotive Ms. Claudine Catequista
B. Preventive Ms. Claudine Catequista
C. Curative Ms. Claudine Catequista

V. Core Competency Application

A. Patient care competency
a. Safe and Quality Care Ms. Estee Marie Darroca
b. Communication Mr. Claudette Berondo
c. Health Education Mr. Ryan Arquiola
d. Collaboration and Teamwork Ms. Sabrina Anne Chua

B. Enhancing Competencies
a. Research Proposal Ms. Sharmaine Gay Bearnod &
b. Ms. Claudette Berondo
c. Quality improvement
i. Structure Ms. Claudette Berondo
ii. Processes
iii. Outcome

C. Enabling competencies
a. Records management Ms. Estee Marie Darroca
b. Management of resources and environment Ms. Marifer Paola Barrido

D. Empowering competencies
a. Ethico-Moral Mr. Ryan Arquiola
b. Legal Responsibilities Ms. Marifer Paola Barrido
c. Personal and Professional Growth and Development Ms. Sabrina Anne Chua

VI. Insights and Implications to

A. Nursing Education Ms. Sharmaine Bearnod
B. Nursing Practice
C. Nursing Management

VII. Post-test formulation Ms. Claudine Catequista

VIII. Bibliography/References Ms. Cheffe April Dalipe
 PRE-TEST:
Instructions: Write the letter of your choice in CAPITAL FORM using black pen only! No erasure,
retracing and changing of answer.

1. Which client would the nurse identify as being most at risk for experiencing a CVA?
A. A 39-year-old pregnant female.
B. An 84-year-old Japanese female.
C. A 55-year-old African American male.
D. A 67-year-old Caucasian male.

2. What is the expected outcome of thrombolytic drug therapy?

A. Increased vascular permeability.
B. Vasoconstriction.
C. Prevention of hemorrhage
D. Dissolved emboli.

3. What is a priority nursing assessment in the first 24 hours after admission of the client with a
thrombotic stroke?
A. Cholesterol level
B. Vowel sounds
C. Pupil size and papillary response
D. Echocardiogram

4. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which
medication would the nurse anticipate being ordered for the client on discharge?
A. An anti-hyperuricemic medication. - Given
B. A beta-blocker medication.
C. A thrombolytic medication.
D. An oral anticoagulant medication.

5. A 78 year old client is admitted to the emergency department with numbness and weakness of the
left arm and slurred speech. Which nursing intervention is priority?
A. Schedule for A STAT computer tomography (CT) scan of the head.
B. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
C. Notify the speech pathologist for an emergency consult.
D. Discuss the precipitating factors that caused the symptoms.

6. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic
stroke?
A. The presence of bronchogenic carcinoma.
B. A blood pressure of 220/120 mm Hg.
C. A right-sided carotid bruit.
D. A blood glucose level of 480 mg/dl.

7. In promoting health maintenance for prevention of strokes, the nurse focuses teaching toward?
A. African Americans
B. Women who smokes
C. Individuals with hypertension and diabetes
D. Those who are obese with increased dietary intake to fat

8. Which of the following is the best treatment for acute ischemic stroke?
A. Heparin
B. LMWH
C. Alteplase
D. Eptifibatie

9. Is the most common form of stroke, accounting for around 85% of strokes?
A. Ischemic Stroke
B. Stroke
C. Hemmorrhagic stroke
D. TIA

`10. An acronym is a way to remember the signs of stroke, and can help identify the onset of stroke
more quickly?
A. FOUR
B. FSST
C. FAST
D. FATS
 Case Scenario

A.G. is a 74 year old female who is a retired public accountant; she had worked 35 years in a
government office. Later this morning, she was rushed to the E.R. after a sudden fall. The nurse then
interviewed her for to find out what was the cause of the fall. The patient verbalized “Ga lingin gid ang
ulo ko sang pag bugtaw ko kag daw ga panulom ang panan-awan ko.” Then she tried to explain that she
was trying to get a glass of water at the kitchen for her to drink because she was thirsty but then when
she was almost at the door, she suddenly fell but fortunately her husband was there trying to catch her
then after that, she was rush to the hospital.

The patient showed slurring of speech as she tries to clarify the incident and right-sided weakness upon
examining her range of motion (ROM). The folks then explained to the nurse that the day before she
was brought to the hospital the patient ate one plate of roasted pork during Christmas celebration with
the family and she forgot to take her medications which were served as her maintenance.

The physician then ordered for laboratory test and CT scan to find if there’s any contusion or
hemorrhage and it was revealed that her head was not injured. She has history of hypertension and is
continuously taking an antihypertensive drug. Her cholesterol level is 250mg/dl which is high and her
Low Density Lipid (LDL) is 161mg/dl which is passed the borderline. The patient also admitted that
during in her middle adulthood she had history of smoking. Upon further assessment, the patient was
diagnosed of Ischemic stroke. Her vital signs are T- 36.2°C, P- 78bpm, R- 20cpm, BP- 150/100mmHg. The
folks also mentioned that after the patient retired from her work, she has a sedentary lifestyle which is
always watching TV every afternoon and doesn’t eat nutritious food.

Mini-Lecture

What is Cerebrovascular Accident/Stroke?

-A disruption in the normal blood supply to the brain, occurring suddenly and produces focal neurologic
deficits.
- Primary cerebrovascular disorder in United States
- Fourth leading cause of death after heart disease, cancer, chronic lower respiratory diseases.
- Approximately 795, 000 people experience a stroke each year in the United States. Approximately 610,
000 of these are new strokes, and 185, 000 are recurrent strokes. (Roger, Go, Lloyd-Jones, et al., 2012).

What are the Types of CVA/Stroke?

1. Ischemic Stroke- also known as a cerebrovascular accident or “brain attack”. It is a sudden loss of
function resulting from the disruption of the blood supply to a part of the brain.

Ischemic Strokes are subdivided into five different type based on the cause:

 Large Artery Thrombotic Strokes

- are caused by atherosclerotic plaques in the large blood vessels of the brain.
 Small Penetrating Artery Thrombotic Stroke
- also called Lacunar strokes which affect one or more vessels and are the most common type of
ischemic stroke.
 Cardiogenic “Embolic” Strokes
- Are caused by a thrombus or a clump of a matter that travels through the cerebral vessels and lodge in
a vessel too narrow to permit a movement.
-Often associated with cardiac dysrhythmias.
 -Frequent sites: Bifurcation of vessels, particularly those of the carotid and middle cerebral arteries.
-Onset: Sudden; Immediate deficits
-If the embolus breaks up into smaller fragments and absorbed by the body, symptoms will disappear in
a few hours to a few days.
-When embolus is not absorbed-symptoms persists.
-Even if absorbed weakness of the vessel wall increasing the potential for cerebral hemorrhage.
 Cryptogenic Stroke
-Unknown etiology
 Stroke of Other Causes
-Such as elicit drug use, coagulopathies, migraine and spontaneous dissection of the carotid or vertebral
arteries.

2. Hemorrhagic Stroke- primarily caused by intracranial or subarachnoid hemorrhage; occurs suddenly

often when the person is engaged in some activity; most fatal of all types of CVA.

Causes

 Uncontrolled Hypertension
 Ruptured Intracranial Aneurysms
 Embolic CVA
 Cerebral Amyloid Angiopathy
 Arteriovenous Malformation
 Intracranial Neoplasm
 Certain Medications e.g., anticoagulants, amphetamines

Transient Ischemic Attack- is a brief period of localized cerebral ischemia neurologic deficits lasting for
less 24 hours.

Causes
Inflammatory Artery Disorders
Sickle Cell Anemia
Atherosclerosis changes in cerebral vessels, thrombosis and emboli; and subclavian steal syndrome

Clinical Manifestation and Complication of CVA/Stroke

Changes in LOC
Motor Deficts
 Hemiplegia-paralysis of the right or left half of the body
 Hemiparesis- weakness of the right or left half of the body
 Flaccidity- absence of muscle tone (Hypotonia)
 Spasticity-increased resistance to the stretching of the extremities, with resistance increasing as the
extremity is stretched.
 Rigidity- increased resistance to stretching of the extremity that is uniform throughout the stretching
 Ataxia- uncoordinated movement, unsteady gait
 Dysarthria- Difficulty in forming words, slurring of speech
 Dysphagia- Difficulty in swallowing

Complications of Motor Deficits

 Orthostatic Hypotension
 Increased Thrombus Formation
 Decreased Cardiac Output
 Impaired Respiratory Function
 Osteoporosis
 Renal Calculi
 Contractures and Decubitus Ulcer Formation

Sensory-Perceptual Deficits
 Hemianopia- Loss of half of the visual field one or both eyes; when the same half is missing in each eye-
Homonymous Hemianopia
 Agnosia- inability to recognize previously familiar objects perceived by one or more of the senses
 Apraxia- inability to carry out some motor pattern
 Paresthesia- numbness, tingling, difficulty with proprioception

Complication: Elimination Disorders e.g. Disorders of Bladder and bowel

Language Disorders
 Aphasia- inability to use or understand language
 Expressive Aphasia- A motor speech problem in which one can understand what is being said but unable
to respond or can respond verbally only in short phrases; also called Broca’s Aphasia
 Receptive Aphasia- A sensory speech problem in which one cannot understand the spoken and (often
written) word. Speech may be fluent but with inappropriate content; also called Wernicke’s Aphasia
 Mixed or Global Aphasia- Language dysfunction in both understanding and expression.
 Alexia- inability to understand written words
 Agraphia- inability to express oneself in writing

Cognitive and Behavioral Changes

 Changes in LOC- mild confusion to coma

Behavioral Changes
 Emotional lability (in which the client may laugh or cry inappropriately)
 Loss of Self-Control (Manifested by behaviour such as swearing or refusing to wear clothes)
 Decreased tolerance for stress
 Feeling of Isolation

Cognitive or Intellectual Changes

 Memory Loss- short or long term
 Decreased attention span
 Impaired ability to concentrate
 Poor abstract reasoning
 Altered Judgement

Hemorrhagic CVA Manifestations

 Vomiting
 Early: Sudden changes in LOC
 Focal Seizures
 Sudden Unusual Severe Headache/Loss of Consciousness
 Nuchal Rigidity/Stiffness of the neck
 Visual disturbances e.g Visual Loss, Diplopia, Ptosis
 Tinnitus, Dizziness, and Neuro Deficits similar to Ischemic stroke

Complications
 Vasospasm
- Frequently occurs 3-14days after initial hemorrhage
- S/sx worsening headache, decreased LOC, new focal neuro deficits.
 Cerebral Hypoxia
 Decreased Blood Flow

Comparison of Left and Right Hemispheric Strokes

Left Hemispheric Stroke Right Hemispheric Stroke
 Paralysis or weakness on right side of the body  Paralysis or weakness on left side of body
 Right visual field deficit  Left visual field deficits
 Aphasia (expressive, receptive, or global)  Spatial-perceptual deficits
 Altered intellectual ability  Increased distractibility
 Slow, cautious behavior  Impulsive behaviour and poor judgement
 Lack of awareness of deficits

Risk Factors

Nonmodifiable

 Age-people older than 55 year old

 Gender- Men have a higher age-adjusted rate of stroke than that of women
 Race- African-American is almost twice that in Caucasian American

Modifiable
 Hypertension-
 Diabetes Mellitus
 Sickle Cell Disease
 Substance Abuse
 Atherosclerosis
 Previous History of CVA
 Obesity
 Sedentary Lifestyle
 Hyperlipidemia
 Cardiac Disease
 Polycythemia
 Oral Contraceptive Use
 Periodontal Disease
 Chronic Inflammatory Disorders
 Smoking
 PATHOPHYSIOLOGY

Predisposing Factor Precipitating Factor

Age: 74 y.o Hypertension
Gender: Female Sedentary Lifestyle
Hypercholesterolemia
Hyperlipidemia
Smoking
 Narrowing of blood vessels

Formation of plaque deposit

Occlusion of major vessels

Increase pressure in the blood vessels

Due to thrombosis, some neurons die because of lack of oxygen and nutrients

CVA (Stroke)

Cerebral Ischemia

Initiation of Ischemic Cascade

Anaerobic metabolism of mitochondria, which generates a large amount of lactic acid

Transient Ischemic Attack (weakness of the face, fingers, hands, arms)

Altered Cerebral Metabolism and decrease cerebral perfusion

Damage of the hemisphere of the brain

Increased intracranial pressure

Impaired perfusion and function

Numbness on the left side of the brain

 Trouble speaking
Difficulty of walking, dizziness
Sudden severe headache

If not managed If manage

Space occupying blood clot put more Palliative Care

pressure on the brain tissue Frequent vital sign and
neuro vital sign

The ruptured cerebral vessels may constrict to Good cerebral perfusion

limit blood loss, however, this vasospasm
will result to further ischemia and necrosis of brain Good improvement
tissue
Good Prognosis

Brain Death

Levels of care

Promotive

The following should be practiced to reduce the risks of patients with stroke.

 Get regular exercise.

 Keep blood pressure in normal range
 Do not smoke and drink alcoholic beverages
 Keep blood sugar in the normal range
 Keep cholesterol levels in normal range
 Limit sodium (salt) intake
 Stay active and maintain a healthy weight
 Eat healthy

Preventive

Primary Prevention

 Healthy Lifestyle- leading a healthy lifestyle which includes not smoking, maintaining a healthy weight,
following a healthy diet, and daily exercise can reduce the risk of having a stroke a stroke.
 DASH (Dietary Approaches to Stop Hypertension) diet- diet is high in fruits and vegetables, moderate in
low-fat dairy products, and low in animal protein and can lower the risk of stroke.
 Stroke risks screenings- are an ideal opportunity to lower stroke risk by identifying people or groups of
people who are at high risk for stroke.
 Education- Patients and the community must be educated about recognition and prevention of stroke.
 Low-dose aspirin- Research findings suggest that low-dose aspirin may lower the risk of stroke in
women who are at risk.

Secondary Prevention

The following tests may aid with early detection of stroke:

 Carotid Ultrasound- is a painless imaging test that uses high-frequency sound waves to create pictures
of the inside of your carotid arteries.
 CT angiography- is a computed tomography technique used to visualize arterial and venous vessels
throughout the body. This ranges the arteries serving the brain to those bringing blood to the lungs,
kidneys, arms, and legs.
 Transthoracic or transesophageal echocardiography- is a test that produces pictures of your heart. Uses
high-frequency sound waves to make detailed pictures of your heart and the arteries that lad from it.
 Single-photon emission computed tomography scan- is a type of nuclear imaging test that shows how
blood flows to tissues and organs. Is used to view how blood flows through arteries and veins in the
brain and to evaluate blood flow during seizures. It is also used to detect stress fractures, infections, and
tumors in the spine.
 CT scan- demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. May not
reveal all changes, e.g., ischemic infarcts are not evident on CT for 8-12hrs; however, intracerebral
hemorrhage is immediately apparent; therefore emergency CT is always done before administering
tissue plasminogen activator (t-PA)
 PET scan- provides data on cerebral metabolism and blood flow changes.
 MRI- shows areas of infarction, hemorrhage, AV malformations, and area of ischemia.
 Cerebral Angiography- Helps determine specific cause of stroke
 Lumbar puncture- Pressure is usually normal and CSF is clear in cerebral thrombosis, embolism, and TIA.
Pressure elevation and grossly bloody fluid suggest subarachnoid and intracerebral hemorrhage. CSF
 total protein level may be elevated in cases of thrombosis because of inflammatory process. LP should
be performed if septic embolism from bacterial endocarditis is suspected.
 Transcranial Doppler ultrasonography- Evaluates the velocity of blood flow through major intracranial
vessels.
 EEG- identifies problems based on reduced electrical activity in specific areas of infarction; and can
differentiate seizure activity from CVA damage.
 Skull X-ray- May show a shift of pineal gland to the opposite side from an expanding mass; calcifications
of the internal carotid may be visible in cerebral thrombosis; partial calcification of walls of an aneurysm
may be noted in subarachnoid hemorrhage.
 ECG and Echocardiography- to rule out cardiac origin as source of embolus.
 Recombinant tissue plasminogen- would be prescribed unless contraindicated, and there should be
monitoring for bleeding.
 Hemodynamic Monitoring- continuous hemodynamic monitoring should be implemented to avoid
increase in blood pressure.
 Neurologic Assessment- to determine if the stroke is evolving and if other acute complications are
developing

Curative

Pharmacotherapy

The goal of pharmacotherapy is to reduce morbidity and to prevent complications in patients with CVA
or stroke

 Warfarin (Coumadin). Those with atrial fibrillation or cardioembolic strokes are treated with dose-
adjusted warfarin (Coumadin) with a target international normalized ratio (INR) of 2 to 3.
 Other, newer anticoagulants that may be prescribed as alternative drugs include:
 Dabigatran (Pradaxa) or rivaroxaban (Xarelto), unless they are contraindicated.
 Platelet-inhibiting medications, including aspirin, Ticlopidine (Ticlid) extended-release dipyridamole
plus aspirin (Aggrenox), and clopidogrel (Plavix) decrease the incidence of cerebral infarction in
patients who have experienced TIAs and stroke from suspected embolic or thrombotic causes.
 Simvastatin (Zocor) to include secondary stroke prevention. After the acute stroke period,
antihypertensive medications are also used, if indicated for secondary stroke prevention.
 Ca Channel blocker- such as Nemodipine to prevent vasospasm
 Hyperosmolar solutions
 Diuretics such as Furosemide and Mannitol to decrease ICP in the subarachnoid space
 Anticonvulsants such as phenytoin

Surgery

Surgical management may include prevention and relief from increased ICP.

 Carotid endarterectomy. This is the removal of atherosclerotic plaque or thrombus from the carotid
artery to prevent stroke in patients with occlusive disease of extracranial cerebral arteries.
 Hemicraniectomy. May be performed for increased ICP from brain edema in severe cases of stroke.

Rehabilitative
 Thrombolytic therapy

Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that is blocking blood
flow to the brain. Recombinant t-PA is a genetically engineered form of t-PA (a thrombolytic substance
made naturally by the body). It works by binding to fibrin and converting plasminogen to plasmin, which
stimulates fibrinolysis of the clot. Rapid diagnosis of stroke and initiation of thrombolytic therapy (within
3 hours) in patients with ischemic stroke leads to a decrease in the size of the stroke and an overall
improvement in functional outcome after 3 months. The goal is for intravenous (IV) t-PA to be given
within 60 minutes of the patient arriving to the ED. Intra-arterial delivery of t-PA is an alternative to IV
administration. This type of administration can allow for higher concentrations of the drug to be given
directly to the clot, and the time window for treatment may be extended up to 6 hrs. Those not eligible
for IV delivery may be eligible for intra-arterial delivery, and these methods may also be combined.

Physical Therapy

Stroke often causes paralysis on one side of the body, which means patients lose function in one arm
and one leg. In the first weeks and months of recovery, physical therapists work with stroke survivors to
keep these muscles toned and stimulated – even before they regain voluntary movement. If and when
function does return, physical therapy allows patients to relearn everyday skills and retrain their healthy
brain cells to control the affected body parts.

Speech Therapy

The speech therapy used a technique called constraint-induced aphasia therapy or CIAT, which
combines intense verbal communication training with language games that build simple as well as
complex language skills. The technique encourages stroke patients to speak rather than using gestures
as their primary means of communication.

Occupational Therapy

Practitioners address the physical, cognitive, and mental challenges brought on by a stroke, and can help
stroke survivors regain their ability to engage in daily activities through a variety of evidence-based
methods. Occupational therapy views the stroke survivor holistically, taking into account their needs,
desires, activities, environment, and new limitations. They can recommend equipment for the home
that can aid a person in completing tasks, evaluate the home for safety hazards, build a person’s
physical endurance and strength, help compensate for vision and memory loss, and provide activities to
rebuild self-confidence. The goal of occupational therapy, as a part of the rehabilitation process, is to
enable the individual to return to the highest level of performance in his or her valued occupations.

11 Key Areas of Responsibilities or Competencies

A. Patient Care Competencies

Safe and Quality Care - NCP

Communication
  Making observation. The nurse can verbalize what he/she observed in the client so that the client
can recognize and compare her own observations.
Nurse: “You seem distress. What seem to be the cause?”
Patient: “I’m uncomfortable every time I eat my meal because my stomach gets hurt and I feel I had to
throw up.”
Nurse: “Don’t worry sir, we’ll do the best we can to help you get better.”
Patient: “Thank you.”
 Ask open-ended questions. This lets the client feel in control of the direction of the conversation and
enhances his/her role in the interaction.
Nurse: “How are you today?”
Patient: “My stomach keeps hurting and I can’t eat much in any of my meals.”
Nurse: “Okay so how do you rate your pain in a scale of 1-10?”
Patient: “From 1-10, I rate it 8 and it’s like a gnawing pain.”
 Acceptance. Gives the client the feeling of being regarded and recognized.
Nurse: “Do you want share something?”
Patient: “I’m worried that this stomach ache won’t last and I keep on vomiting what I eat every after
meal. I’ve learned my lesson that I should be taking care of myself by taking my meals properly and
especially not to skip breakfast and avoid drinking softdrinks.”
Nurse: (Nodding) “I understand.”
 Providing Information. To minimize patient’s anxiety and to educate patient.
Patient: “Why do I have to drink this medicine and what is it for?”
Nurse: “It is an H2-Blocker it will help prevent heartburn associated with acid indigestion and sour
stomach brought on by eating or drinking certain foods and beverages.”
 Providing Silence. This gives the client time to organize and collect his/her thoughts.
 Nurse: “…….”

Health Education

 Lesson Plan for Patient Education

 Explain clearly to the patient/ patient folks the dangers of the disease.
 Direct or guide patient folks to resources of the community where this service is available as in health
centers, private physicians and health clinics.
Objectives Content Outline Teaching Strategies Time Allotment
After a 1 hour
discussion, the
patient’s folks/patient
will be able to:
1. Understand the The sudden death of brain Discussion 20 minutes
definition and cause of cells due to lack of oxygen,
Stroke. caused by blockage of blood
flow or rupture of an artery
to the brain. Sudden loss of
speech, weakness, or
paralysis of one side of the
body can be symptoms. A
 suspected stroke can be
confirmed by scanning the
brain with special X-ray tests,
such as CAT scans. The death
rate and level of disability
resulting from strokes can be
dramatically reduced by
immediate and appropriate
medical care. Prevention
involves minimizing risk
factors, such as controlling
high blood pressure and
diabetes. Abbreviated CVA.
Also known as
cerebrovascular accident.
3. Know the  Hypertension. Discussion 10 minutes
complications of  Cerebral amyloidosis.
Stroke.  Coagulopathies.
 Anticoagulant therapy.
 Thrombolytic therapy for
acute myocardial infarction
(MI) or acute ischemic stroke
(can cause iatrogenic
hemorrhagic transformation)

4. Learn the You can help prevent stroke Lecture 15 minutes

preventive measures by making healthy lifestyle
of Stroke. choices. A healthy lifestyle
includes the following:

 Eating a healthy diet.

 Maintaining a healthy
weight.
 Getting enough exercise.
 Not smoking.
 Limiting alcohol use.


5. Know the treatment Endovascular procedures. Discussion of 15 minutes
and management of Endovascular procedures treatment and one-
Stroke. may be used to treat certain on-one instruction
hemorrhagic strokes. These
procedures are less invasive
and less dangerous for the
patient than surgical
treatments. The doctor
 inserts a long tube through a
major artery in the leg or arm
and then guides the tube to
the site of the weak spot or
break in a blood vessel. The
tube is then used to install a
device, such as a coil, to
repair the damage or prevent
bleeding.
 Surgical treatment.
Hemorrhagic strokes may be
treated with surgery. If the
bleeding is caused by a
ruptured aneurysm, a metal
clip may be put in place to
stop the blood loss.

Collaboration and Teamwork

 Vascular Neurologist- Are also often called 'stroke doctors.' To become proficient in these approaches
to stroke treatment, physicians must acquire a great deal of experience and training. All neurologists
have a great deal of experience in managing strokes. Vascular neurology is an additional subspecialty
after completion of neurology training that allows neurologists to receive additional training in the latest
techniques in stroke care
 Neuropsychologist-Assesses the effect on memory, thinking, personality and other aspects of brain
function. A neuropsychological assessment provides information about a patient’s intellectual and
behavioral strengths and weaknesses. These assessments are used to aid in the diagnosis of the Stroke
and may also guide therapy.
 Physiotherapist - Assesses the effect of the Stroke on movements. They plan a rehabilitation
programed, taking into consideration the patient’s general health, previous level of activity and
interests. Not all people affected by severe Stroke achieve full recovery, so the Physiotherapist sets
appropriate goals, which are adjusted after continued reassessment. Early emphasis may be on
movement such as turning over in bed, rising to the sitting position, maintaining balance in the upright
position, transferring to and from a chair, standing and walking, and developing to more complex
activities as progress is achieved. The Physiotherapist coaches people in coughing and deep breathing
exercises that can prevent chest infections.
 Speech Therapist-The Speech Therapist assists people with problems of speech, understanding, reading
and writing. Therapy may involve practice in enunciating words clearly, but more often will involve some
degree of relearning names of objects and meanings of words. The Speech Therapist also assists patients
with chewing and swallowing and if necessary and in association with the Dieticians advises on diet.
 Physical Therapist - Physical therapists can teach patients how to prevent or manage their condition so
that they will achieve long-term health benefits. PTs examine each individual and develop a plan, using
treatment techniques to promote the ability to move, reduce pain, restore function, and prevent
 disability. Physical Therapist (PT). Helps stroke survivors with problems in moving and balance; suggests
exercises to strengthen muscles for walking, standing and other activities.
 Registered Nurses - As a caregiver, the nurse provides hands-on care to patients. As a decision maker,
she uses critical thinking skills to make decisions, set goals, and promote outcomes for a patient.
The Nurse’s role is very important. They develop an understanding of the person’s condition while in
hospital and assist the person to eat, bath and dress. The Nurse’s regular observations of the patient’s
conditions provide valuable information to medical staff. Arrangements can be made for a Community
Nurse to call on the person affected by Stroke once they return home and assist with bathing, to
administer medication and to check their progress.
 Dietician - It is the dietitian’s task to identify nutrition problems and assess the nutritional status.
Develop diet plans and counsel patients on special diet modifications; and assess, promote, protect, and
enhance the health of the general public in a community setting and provide strategies for prevention of
nutrition-related diseases.
 Medical Technologists - Medical laboratory technologists perform a variety of laboratory tests and
procedures to assist physicians in diagnosing, monitoring, treating and preventing disease.
 Pharmacists- Pharmacists prepare or supervise the dispensing of medicines, ointments and tablets,
advise patients on how their medicines are to be taken or used in the safest and most effective way in
the treatment of common ailments, and advise members of the public and other health professionals
about medicines (both prescription and over-the-counter medicines), including appropriate selection,
dosage and drug interactions, potential side effects and therapeutic effects. Develop a plan, using
treatment techniques to promote the ability to move, reduce pain, restore function, and prevent
disability.
 Significant others- for support and may assist in the care of the client

B. Enabling Competencies
Records Management

Date/Time Focus Progress Notes

1/24/17 8PM Ineffective Cerebral Tissue Data
Perfusion related to “Ga lingin gid ang ulo ko sang
interruption of blood flow. pag bugtaw ko kag daw ga
panulom ang panan-awan
ko.” as verbalized by the
client.
 Altered LOC
 Slurred speech
 right sided weakness
 Restless ness
 cholesterol level is 250mg/dl
 Low Density Lipid (LDL) is
161mg/dl
 Vital signs:
T- 36.2°C, -P- 78bpm,
R- 20cpm
BP- 150/100mmHg

Action
 Independent
 Monitor and document
neurological status
frequently and compare with
baseli ne.
 Monitor vital signs noting:
Hypertension and
Hypotension.
 Note customary baseline
data (e.g., ABGs, and other
appropriate laboratory study
values).
 Note history of brief/
intermittent periods of
confusion/black –out
 Provide a quiet environment,
limiting noxious stimuli.
Avoid jarring the bed. Try to
limit situations that can cause
client to become emotionally
upset; maintain calm and
reassuring manner.
 Encourage active/passive
ROM at thev aunaffected
side/affected extremity.
 Elevate Head of Bed to 30
degress or keep flat as
prescribed.
 Place a pillow in the axilla
when there is limited
external rotation.
 Monitor intake/output
balance.

Dependent:
 Administer oxygen as
indicated.
 Administer medication as
indicated such as;
 tissue Plasminogen Activato
o r (tPA)

 Warfarin sodium
 Aspirin
 Furosemide/ Mannitol
 Response
 Absence of signs of
increased ICP
 Vital signs are within normal
limits.

4PM

Management of Resources and Environment

EQUIPMENT NEEDED FOR CARE OF PATIENT WITH STROKE

 Thermometer-Monitor body temperature and also to identify signs of infection

 Medicine - helps to alleviate the condition and speed up recovery
 Bed (pillow and blanket) - to rest and relax patient from discomfort
 Small pillow /small towel rolls- for body support to avoid spasticity and rigidity of extremities.
 Mild soap or shampoo and water- for bathing purposes if the patient cannot perform activities of daily
living.
 Ultrasound-a device that uses sound to outline the structures within the skull.
 CT scan- creates a picture of the brain by using x-rays and a special scanner and will show if the
ventricles are enlarged or if there is obvious blockage.
 PET- a device that examines blood flow distribution and metabolism.
 Cardiac monitor- A machine that constantly displays a picture of your child's heart rhythm, and monitors
heart rate, arterial blood pressure, and other values. Also to detect arrhythmias.
 Oxygen tank- helps client to gain enough oxygen by breathing air.
 Clothes - should be thin, loose and not irritating because excessive heat may cause discomfort

ENVIRONMENT

 Maintain rest and provide a quiet environment that gives patients the opportunity to recover. It should
be free from the stresses of life and surrounded by professionals who understand the nature of what
they are going through.
 Make sure that the surrounding is clean and organized. It must be safe and must prevent risk for falls
and injuries.
 Prepare and organize the medications, equipment and machines needed by the client in order not to
delay time in performing interventions.
 All equipment must be functioning well and must be checked at all times.
  Equipment needed should be clean, organized and working in order not to delay any procedure and to
provide quality health care service.
 All emergency equipment like suction machines, oxygen and medicines should be gathered and placed
in one setting.

C. Enriching Competencies
Research Proposal
A. ENRICHING COMPETENCIES
Research Proposal
Research Title: “Long term outcomes of stroke that contributes to the frailty of elderly patients’ in
Iloilo City”

BACKGROUND AND RATIONALE

Cerebrovascular accident (CVA) is the medical term for a stroke. A stroke is when blood flow to a part of your
brain is stopped either by a blockage or the rupture of a blood vessel. Every two seconds someone has a
stroke, and one in six people will suffer a stroke in their lifetime. Stroke is the third leading cause of
death worldwide, with over 6 million people dying from strokes each year. With an aging global
population, the incidence of stroke is set to rise. These sobering statistics demonstrate its huge global
impact, and emphasize how essential it is that we continue to further our understanding of stroke, with
the aim of better prevention, treatment and management. Cognitive impairment, impaired motor
function and balance, and visual and communication problems have all been reported as long-term
outcomes of stroke. Around one third of people who survive are left with a permanent disability.
Another interesting aspect of the meeting was an update on some of the research taking place into
rehabilitation and recovery, and what we could do to improve the lives of those who have had a stroke.

Objectives of the Study

This study was conducted to determine the Long term outcomes of stroke that contributes to the frailty
of elderly patient's.
Specifically, this study aims to:

1.) describe the selected characteristics of elderly stroke patients’ in terms of age, gender, and civil status.
2.) determine the long term outcomes of stoke among elderly stroke patients’.
3.) determine the frailty among elderly stroke patients’.
4.) determine if there is a significant relationship between the selected characteristics in terms of age,
gender, and civil status and long term outcomes of stroke.
5.) determine if there is a significant relationship between the selected characteristics in terms of age,
gender, and civil status and frailty of elderly patients’.
6.) If there is a significant relationship between long term outcomes of stroke that contributes to frailty of
elderly stroke patients’.

Hypotheses
Based on the stated objectives, the following hypotheses were tested:
1.) There is no significant relationship between the selected characteristics and their long term outcomes
of stroke.
2.) There is no significant relationship between the selected characteristics and that contributes to the
frailty of elderly patients’.
3.) There is no significant relationship between the selected characteristics and their long term outcomes of
stroke that contributes to the frailty of elderly patients’ in Iloilo City.

Theoretical and Conceptual Framework

The self-care deficit theory proposed by Orem is a combination of three theories, i.e. theory of self-care,
theory of self-care deficit and the theory of nursing systems. In the theory of self-care, she explains self-
care as the activities carried out by the individual to maintain their own health. The self-care agency is
the acquired ability to perform the self-care and this will be affected by the basic conditioning factors
such as age, gender, health care system, family system etc. Therapeutic self-care demand is the totality
of the self-care measures required. The self-care is carried out to fulfill the self-care requisites. There are
mainly 3 types of self-care requisites such as universal, developmental and health deviation self-care
requisites. Whenever there is an inadequacy of any of these self-care requisite, the person will be in
need of self-care or will have a deficit in self-care. The deficit is identified by the nurse through the
thorough assessment of the patient. Once the need is identified, the nurse has to select required nursing
systems to provide care: wholly compensatory, partly compensatory or supportive and educative
system. The care will be provided according to the degree of deficit the patient is presenting with. Once
the care is provided, the nursing activities and the use of the nursing systems are to be evaluated to get
an idea about whether the mutually planned goals are met or not. Thus the theory could be successfully
applied into the nursing practice.

Antecedent Variable Independent Variable Dependent Variable

 Age Long Term

Frailty of
 Gender Outcomes:
elderly
 Civil Status  Cognitive patients’
Impairment
 Impaired Motor
Function and
Balance.
 Visual and
Communication
problems.
Fig 1. Schematic presentation of the assumed flow of relationship among variables

Operational definitions of variables

For the purpose of clarity and understanding, the following terms are defined conceptually and
operationally;
Antecedent variables
Gender- the behavioral, cultural, or psychological traits typically associated with one sex. in the study it refers
to either of the two main categories (male or female) into which human and many other living things are
divided on the basis of their reproductive functions
Age- this refers to the number of years the person has lived since he or she was born. In this study, it refers to
the age of respondent as he or her last birthday.
Civil status- refers to whether the respondents is single, married, separated or widowed.

Independent Variables
Long term outcomes- can be less directly attributed to the program. Outcomes are measured a year or
several years after program completion and include changes in conditions, policies, or organizational
structure.

Dependent Variable
Frailty- the condition of being weak and delicate.

Significance of the study

This study determine long term outcomes of stroke that contributes to the frailty of elderly patients’ in Iloilo
City. It is the researcher intention that the findings of this study will be useful and viable to a number of
individuals and groups such as the following:
Elderly adults- people who are aged 65 years and above.

Scope and Limitations

This study will be conducted in Iloilo City. This city was selected because it has dense population of elder
adult who has experience CVA stroke. The respondents chosen were elder adults greater than 65 years
old. Only respondents living in the said city will be included in the study, which examine the personal
characteristics of the respondents.

Research Design
This is a descriptive-relational study when employed a one-shot survey design and will be used a structured
interview as a means of collecting data. This instrument utilize an interview schedule.

Population Sampling
This study involved samples from the population in Iloilo City. The inclusion criteria from the respondents
were older adults. This sampling technique involves taking 30 in the said city who match the inclusion
criteria to be included in the study sample.

Instrumentation
This study will be using a structured interview as a means of collecting data. This instrument utilizes an
interview schedule.

Ethical consideration
Before the interview will be conducted the researchers will explain the nature, purpose and objective of the
study. The respondents will be assured that any information that they provided will be treated with
confidentiality. The researchers will also inform them that they can refuse anytime that they feel like
they don't want to join them.

Data Collection
The data were collected from the respondents answer through the structured interview. Any discrepancies,
inconsistency or omission in the responses would immediately clarify with the respondents. All gathered
instrument will encode for computer processing.

Data Processing Analysis

The SPSS software will be used to process and analyze the data. The following statistical method or tools will
be utilize in the analysis. Frequency distribution will be used to describe the personal characteristics of
the respondents such as age, gender and civil status. In determining the relationship between each of
the personal characteristics and contribute to the frailty of elderly patients’. Gamma and Chi square will
be used. Relationship will be established at a five level of significance. All statistical results will be
computer generated.

Quality Improvement

To improve the quality of care, the following must be present: structures, processes, and outcome
evaluation which are all related to the care of a client with Cholecystitis.

Structures

• Tertiary Hospital – for the overall treatment or management of the disease and prevention of possible
complications

• Laboratory Department - where tests are usually done on clinical specimens in order to obtain
information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of
disease.
• Pharmacy Department – provides medications prescribed by the physician which are essential to the
treatment of the disease and recovery of the patient.
• Nutrition and Dietary Department - responsible for providing the right type and amount of food
appropriate for the patient’s condition.
• Emergency Department – for the acute care of patients.
• Operating Department- Special equipped room where surgical procedures are performed
• Dietary Department- To arrange right type and amount of food for the client. To promote good
nutrition
• Anesthesiology Department – concerned with the pharmacological, physiological and clinical basis of
anaethesia, including resuscitation, intensive respiratory care and pain management
• X-Ray department- uses imaging such as X-ray and CT scan to diagnose and treat diseases within the
body.
• Neurologic Department- concerned with the diagnosis and treatment of disorders of the nervous
system, which includes the brain, the spinal cord, and the nerves.

b. Equipment
• Monitoring equipment- such as thermometer, stethoscope, and sphygmomanometer to monitor the
patient’s vital signs which may indicate complications.
• Pulse oximeter- it provides continuous monitoring of oxygen saturation of hemoglobin in arterial blood.
• CT Scan equipment- A padded movable table, on which the patient lies, slides in and out of the donut
hole. A large movable ring inside the donut houses the x-ray and detector equipment. This ring spirals
around the patient during the test to create specific “slices” or pictures of anatomy.

c. Process
Before Procedure:
• The doctor will explain to the patient the procedure, including the possibility and CT scan and the risks
of surgical procedures.
• The doctor will ask the patient to sign consent from agreeing to the procedure at the same time, he or
she must inform the neurologic team of any medications, allergies, or reactions to previous procedures
or tests.
• Take off some or all of your clothing and wear a hospital gown
• Remove metal objects, such as a belt, jewelry, dentures and eyeglasses, which might interfere with
image results.
• Refrain from eating or drinking for a few hours before your scan.
During Procedure:
• While positioning you on the exam table, the technologist will explain your procedure and answer any
questions you may have.
• If contrast dye is being used, it will be injected through your IV.
• During the injection, you may experience a warm sensation all over your body and a metal taste in your
mouth. This is normal.
• If you experience any itching, sneezing, nasal congestion, scratchy throat or swelling of your face, please
notify the technologist immediately.
• You will be asked to lie flat on your back. Your arms will be positioned at your sides.
• Your head will be placed in a holder and you will be asked to hold very still. Only your head will be
covered by the scanner. The scanner is open at the back and the front, allowing you to see out.
• People who fear small, close places (claustrophobic) usually do not have problems with this procedure.
• The technologist will always be able to see and hear you during your exam.
• This procedure usually takes approximately 15 to 30 minutes.
After Procedure:
• There are no restrictions placed on you after this procedure. You may eat and drive as normal.
• If you received an injection of contrast dye, you should drink six to eight glasses of water to flush it out
of your system.
• Your study will be read by a neuro-radiologist (imaging physician) and the results sent to your physician,
usually within 48 hours.
• Your physician will discuss these results with you and explain what they mean in relation to your health.

Outcome
• The client has gained knowledge about his condition, management of signs and symptoms and
complications.
• Request for patient satisfaction feedback from all aspects of the health care system.

D. Empowering Competencies
Ethico-Moral
 Confidentiality
Duty to respect priviledge information.
Example: As a nurse assigned, you are not supposed to disclose any information regarding patient’s
condition to anyone who is not an authorized member of health care team.
 Veracity
Right of the guardian to be informed with everything regarding to the condition and medical treatment
of the client.
Example: The nurse informs the patient and her folks regarding her coondition and the possible
complications and any procedures to be performed. Nurse PJ must also answer the clients questions
regarding the treatment of her condition based on medical standards.
 Justice
The nurse must give equal quality and quality of nursing care to patients regardless of their status in life,
age, gender, religion, and disabilities.
Example: You have to be fair in giving care to your patient, you must considerate about his/her
economic status, age, gender, religion.

Legal Responsibilities
 Republic Act 9994
“AN ACT GRANTING ADDITIONAL BENEFITS AND PRIVILEGES TO SENIOR CITIZENS, FURTHER AMENDING
REPUBLIC ACT NO. 7432, AS AMENDED, OTHERWISE KNOWN AS “AN ACT TO MAXIMIZE THE
CONTRIBUTION OF SENIOR CITIZENS TO NATION BUILDING, GRANT BENEFITS AND SPECIAL PRIVILEGES
AND FOR OTHER PURPOSES”

 Republic Act 9502

SECTION 1. Short Title. - This Act shall be known as the “Universally Accessible Cheaper and Quality
Medicines Act of 2008”.
SECTION 2. Declaration of Policy. - It is the policy of the State to protect public health and, when the
public interest or circumstances of extreme urgency so require, it shall adopt appropriate measures to
promote and ensure access to affordable quality drugs and medicines €or all. Pursuant to the
attainment of this general policy, an effective competition policy in the supply and demand of quality
affordable drugs and medicines is recognized by the State as a primary instrument. In the event that full
competition is not effective, the State recognizes as a reserve instrument the regulation of prices of
 drugs and medicines, with clear accountability by the implementing authority as mandated in this Act, as
one of the means to also promote and ensure access to quality affordable medicines.

 Republic Act 6675

“An Act to Promote, Require and Ensure the Production of an Adequate Supply, Distribution, Use and
Acceptance of Drugs and Medicines Identified by their Generic Names”
SECTION 1. Short Title. – This Act shall be known as the “Generics Act of 1988”
SECTION 2. Declaration of Policy. – It is hereby declared the policy or the State:
To promote, encourage and require the use of generic terminology in the importation,
Manufacture, distribution, marketing, advertising and promotion, prescription and dispensing of drugs.
To ensure the adequate supply of drugs with generic names at the lowest possible cost and endeavour
to make them available free for indigent patients;
To encourage the extensive use of drugs with generic names through a national system of procurement
and distribution;
To emphasize the scientific basis for the use of drugs, in order that health professionals may become
more aware and cognisant of the therapeutic effectiveness; and
To promote drug safety by minimizing duplication in medications and/or use of drugs with potentially
adverse drug interactions.

 Republic Act 8344

"AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO ADMINISTER APPROPRIATE
INITIAL MEDICAL TREATMENT AND SUPPORT IN EMERGENCY OR SERIOUS CASES, AMENDING FOR THE
PURPOSE BATAS PAMBANSA BILANG 702, OTHERWISE KNOWN AS "AN ACT PROHIBITING THE DEMAND
OF DEPOSITS OR ADVANCE PAYMENTS FOR THE CONFINEMENT OR TREATMENT OF PATIENTS IN
HOSPITALS AND MEDICAL CLINICS IN CERTAIN CASES"

Personal and Professional Growth

• Identifying own learning needs and enhancing them by reading related articles, attending seminars
and trainings; and joining researches

• Taking up continuing education and advanced courses/degree in medical surgical healthcare

• Learn about effective management to achieve goals in a less stressful manner when presented with
STOKE CASES. This can be done through newsletters or online subscriptions

•Rendering appropriate action of care to clients and properly dealing with concerns and complaints
brought on to you

• Performing appropriately by adhering to the professional standards of nursing practice

• Showing professionalism by demonstrating good manners and right conduct and dressing
appropriately.
E. Implications of the Case in the Learning Insights

Nursing Education
Stroke is very serious and require the nurse to have knowledge about all that pertains to it. Through
schooling, resources, and experience, a nurse can achieve this.
While student nurses are still training, it is important to stress the different conditions that they are
likely to encounter when they become an actual nurse. Conditions relating to the disease are very
important to learn while still a student.
Colleges of nursing should have a high regard in teaching their pupils about peptic ulcer complications as
they do with other complications and diseases relating to medical surgical nursing, psychiatric nursing,
etc. In order to have better nursing service whether in the hospital, community, or clinics, nursing
schools need to live up to their responsibility of providing high quality education so the production of
first-rate nurses can be possible

Nursing Practice
As a nurse, we must take care of our own health and mental well-being to be an effective health care
provider. Our professional code of ethics requires that we must always put our patient’s health first. Our
primary concern is that our patients receive the best care; we advocate for that quality care and make
sure it is delivered appropriately. We protect the health and the privacy of our charges and avoid
conflicts that interfere with our patient care delivery. We respect our patients and their rights to dignity
and self-determination.

Nursing Management
Nurse Managers oversee a specific unit in a hospital, they’re responsible for both the clinical and
administrative aspects, including supervising nurses and addressing the concerns of patients and their
families. Nurse Managers not only require specialized nursing expertise, but they also need strong
people and communication skills and the ability to take charge. They should be able to plan, organize,
direct and control their subordinates when presented with variety of cases like CVA.
 Post test

1. Patient C.J was rushed to the ER with these main presenting symptoms: Numbness of the left side of the
face, arms, and legs. What type of stroke is this?
a. Ischemic Stroke
b. Hemorrhagic Stroke
c. Both a and b
d. None of the above

2. This type of ischemic stroke is caused by atherosclerotic plaques in the blood vessels of the brain.
a. Small penetrating artery thrombotic stroke
b. Large artery thrombotic stroke
c. Cryptogenic stroke
d. Cardiogenic embolic stroke

3. This type of ischemic stroke is associated with cardiac dysrhythmias, usually atrial fibrillation.
a. Small penetrating artery thrombotic stroke
b. Large artery thrombotic stroke
c. Cryptogenic stroke
d. Cardiogenic embolic stroke

4. Because of the cavity that is created after the death of infarcted brain tissue; Small artery thrombotic
strokes are also called?
a. Lacunar strokes
b. Lunar strokes
c. Lucanar strokes
d. Lucunar strokes

5. The acronym DASH diet stands for?

a. Dietary Approaches to Stop Hypotension
b. Dietary Approaches to Stop Hypertension
c. Dietary Approaches to Stop Hyperventilation
d. None of the above

6. This type of diagnostic test evaluates the velocity of blood flow through major intracranial vessels.
a. Transcranial Doppler ultrasonography
b. PET scan
c. CT scan
d. Cerebral angiography

7. This may show a shift of pineal gland to the opposite side from an expanding mass; calcifications of the
internal carotid may be visible in cerebral thrombosis; partial calcification of walls of an aneurysm may
be noted in subarachnoid hemorrhage.
a. Skull x-ray
b. CT scan
c. MRI
d. PET scan
8. The following statements demonstrates understanding to patients to practice to reduce the risks of
stroke. Which of the following statements need further education:
a. “ I need to stay active and maintain a healthy weight”
b. “I have to exercise regularly”
c. “I need to keep my blood pressure in a normal range”
d. “I can only smoke 4 sticks per day”

9. This is A motor speech problem in which one can understand what is being said but unable to respond
or can respond verbally only in short phrases; also called Broca’s Aphasia:
a. Expressive Aphasia
b. Receptive aphasia
c. Alexia
d. Agraphia

10. This is known as an act granting additional benefits and privileges to senior citizens, further amending
republic act no. 7432, as amended, otherwise known as “an act to maximize the contribution of senior
citizens to nation building, grant benefits and special privileges and for other purposes:
a. RA 9994
b. RA 6675
c. RA 9502
d. RA 8344

References:

Book

Brunner and Suddarth’s textbook of medical-surgical nursing 13th edition vol.2 pages 1972-1977

Online

https://healthfinder.gov/healthtopics/category/health-conditions-and-deiseases/heart-health/reduce-
your-risk-of-stroke

https://nurselabs.com/cerebrovascular-accident-stroke/

https://www.scribd.com/document/124312265/Pathophysiology-CVA