INTRODUCTION

Many people think a stroke happens in the heart, but it happens in the brain. So what is
stroke and what does it do to our body?Researchers from the American Stroke Association
defined stroke as a disease that affects the arteries leading to and within the brain. It occurs when
a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts
(or ruptures). When that happens, part of the brain cannot get the blood (and oxygen) it needs, so
it and brain cells die.Since the brain is an extremely complex organ that controls various body
functions. If a stroke occurs and blood flow can't reach the region that controls a particular body
function, that part of the body won't work as it should.

According to the World Health Organization cerebrovascular accidents (stroke) are the
second leading cause of death and third leading cause of disability. Globally, 70% of strokes and
87% of both stroke-related deaths and disability-adjusted life years occur in low and middle-
income countries. In the Philippines, stroke is the second leading cause of death. It has a
prevalence of 0.9%; ischemic stroke compromises 70% while hemorrhagic stroke compromises
30%.Over the last four decades, the stroke incidence in low- and middle-income countries has
more than doubled. During these decades stroke incidence has declined by 42% in high income
countries.

C., a 76 yr. old woman residing in General Luna, Siargao was admitted at Surigao
Medical Center last September 24, 2019 at 8:30 am with a chief complaint of unresponsiveness
for 12 hrs, stuporous gasping and tachycardia with a pulse rate of 110. Patient C is diagnosed
with Cerebrovascular Accident.

The researcher chose the case of Patient C to gain further knowledge and experience in
the field of nursing to establish holistic approach to the S.O and to the patient promoting for
optimal health of the patient’s condition. Enhancing critical thinking and skills that can be useful
in the future as to provide appropriate nursing care to our clients.This impels the researcher to
the quest of understanding the nervous system as a whole and how it affects the entire human
body in order to achieve a healthy life and live well.This study will be useful for future purposes
related to the case Cerebrovascular Accident.

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 Review Related Literature

Cerebrovascular accident (stroke) is the sudden occurrence of a focal, nonconvulsive

neurologic deficit. Due to lack of oxygen when the blood flow to the brain is impaired by
blockage or rupture of an artery to the brain causes sudden death of brain cells. Two key steps
that will lower the risk of death or disability from stroke: control stroke’s risk factors and know
stroke’s warning sign. (SumairaNabi, MBBS, FCPS Neurology, October 2018)

Stroke is categorized in two: those caused by the blockage of blood flow and those
caused by bleeding into the brain. A blockage of a blood vessel in the brain or neck, called an
ischemic stroke, is the most frequent cause of stroke and is responsible for about 80 percent of
strokes. These blockages stem from three conditions: the formation of a clot within a blood
vessel of the brain or neck, called thrombosis; the movement of a clot from another part of the
body such as the heart to the brain, called embolism; or a severe narrowing of an artery in or
leading to the brain, called stenosis. Bleeding into the brain or the spaces surrounding the brain
causes the second type of stroke called hemorrhagic stroke. It is further classified into two
subtypes: intracerebral and subarachnoid, depending on the site of blood leakage. (American
Heart Association/American Stroke Association, October 2016)

An established ischemic stroke is signaled by hypodensity on the CT of the brain. The

specific neurologic deficit in an ischemic stroke depends on the artery that is occluded and the
area if the brain that is involved. The anterior cerebral artery (ACA) supplies the medial portion
of the frontal lobes; the posterior cerebral artery (PCA) supplies the occipital lobes, the medial
temporal lobe, and part of the midbrain and thalamus; and the MCA supplies the parietal lobe,
the lateral frontal lobe, the lateral frontal and temporal lobes, the insula, the internal capsule. And
the basal ganglia. A cerebral hemorrhage (bleeding in the brain), as from an aneurysm (a
widening and weakening) of a blood vessel in the brain, also causes stroke.(Andrew Danziger,
October 2018)

According to the American Heart Association Statistics Committee and Stroke Statistics
Subcommittee, there are symptoms that are similar to stroke. Just because a person has slurred
speech or weakness on one side of the body does not necessarily mean that person has had a
stroke. There are many other nervous system disorders that can mimic stroke including a brain
tumor, a subdural hematoma (a collection of blood between the brain and the skull) or a brain

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abscess (a pool of pus in the brain caused by bacteria or fungus. Virus infection of the brain
(viral encephalitis) can cause symptoms similar to those of a stroke, as can an overdose of certain
medications. Dehydration or an imbalance of sodium, calcium, or glucose can cause neurologic
abnormalities similar to a stroke.

The National Institutes of Health (NIH) Stroke Scale (NIHSS) was devised to facilitate
objective quantification of the deficit caused by a stroke in a standardized manner. It has 11
components, each of which grades a specific ability on a numerical scale. Typically, 0 indicates
normal function, whereas higher numbers denote degrees of functional impairment. The points
for the 11 components are summed to yield the patient’s total NIHSS score, with 0 being the
minimum possible score and 42 the maximum possible score.

Signs and Symptoms:

It depends on the area of the brain affected. The most common symptom is weakness or
paralysis of one side of the body with partial or complete loss of voluntary movement or
sensation in a leg or arm. There can be speech problems and weak face muscles, causing
drooling. Numbness or tingling is very common. A stroke involving the base of the brain can
cause affect balance, vision, and swallowing, breathing and even unconsciousness. (William C.
Shiel Jr., MD, FACP, FACR, August 2016)
Other danger signs that may occur include double vision, drowsiness, and nausea or
vomiting. Sometimes the warning signs may last only a few moments and then disappear. These
brief episodes, known as transient ischemic attacks or TIAs, sometimes called “mini strokes”.
Although brief, they identify an underlying serious condition that isn’t going away without
medical help. Unfortunately since they clear up, many people ignore them. (Medical Surgical
Nursing, Volume 2)

Risk Factors:

As stated by the National Institute of Neurological Disorders and Stroke, having a risk
factor for stroke doesn’t mean you’ll have a stroke. On the other hand, not having a risk factor
doesn’t mean you’ll avoid a stroke. But your risk of stroke grows as the number and severity of
risk factors increases.

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 The major risk factors include:

 High blood pressure. This is the primary risk factor for a stroke.

 Diabetes.

 Heart diseases. Atrial fibrillation and other heart diseases can cause blood clots lead to
stroke.

 Smoking. When you smoke, you damage your blood vessels and raise your blood
pressure.

 A personal or family history of stroke or TIA/

 Age. The risk of stroke increases as a person gets older.

 Race and ethnicity. African Americans have a higher risk of stroke.

There are also other factors that are linked to a higher risk of stroke, such as

 Alcohol and illegal drug use

 Not getting enough physical activity

 High cholesterol

 Unhealthy diet

 Obesity

Complications:

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Pneumonia.Pneumonia is an infection that inflames the air sacs in one or both lungs. The air
sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever,
chills, and difficulty breathing. (Mayo Foundation for Medical Education and Research
(MFMER), 2018)

Myocardial infarction (MI).Also called as heart attack is the irreversible death (necrosis) of heart
muscle secondary to prolonged lack of oxygen supply (ischemia). (A Maziar Zafari, MD, PhD, FACC,
FAHA, 2019)

Urinary tract infection.An infection in any part of the urinary system such as the kidneys,
ureters, bladder and urethra. Most infections involve the lower urinary tract; the bladder and the
urethra. (Mayo Foundation for Medical Education and Research (MFMER),2019)

Extracranial bleeding.It is a collection of blood (hematoma) outside the cranium (skull). (Mayo
Foundation for Medical Education and Research (MFMER),2019)

Pulmonary embolism (PE). When a blood clot (thrombus) becomes lodged in an artery in the
lung and blocks blood flow to the lung. (Mayo Foundation for Medical Education and Research
(MFMER),2019)

Pressure sores (Bed sores). These are injuries to the skin and underlying tissue resulting from
prolonged pressure on the skin. Bedsores most often develop on the skin that covers bony areas
of the body, such as heels, ankles, hips and tailbone. (Mayo Foundation for Medical Education
and Research (MFMER),2019)

Prognosis

Prognosis depends of the type of stroke, the degree and duration of obstruction or
hemorrhage, and the extent of brain tissue death.

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 Approximately 70% of ischemic stroke patients are able to regain their independence and
10% recover almost completely. Approximately 25% of patients die as a result of stroke. The
location of a hemorrhagic stroke is an important factor in the outcome, and this type generally
has a worse prognosis than ischemic stroke. ( Stanley J. Swierzewski, III, M.D., 2014)

According to a scientific statement published by the American Heart Association (AHA)

in the journal Stroke (May 2014), exercise is a valuable part of post-stroke care and recovery and
can help reduce disability and improve the prognosis for many stroke patients. AHA also
recommends minimizing bed rest in the days following a stroke, having patients sit or stand
intermittently if possible and using stroke rehabilitation programs that emphasize aerobic
exercise, strength training, flexibility, and balance.

Prevention

According to Centers for Disease Control and Prevention stroke can be prevented by
making healthy lifestyle choices such as:

 Healthy Diet. Eating foods low in saturated fats, trans fat, and cholesterol and high in
fiber can help prevent high cholesterol. Limiting salt (sodium) in your diet can also lower
your blood pressure.

 Healthy Weight. Being overweight or obese increase the risk for stroke.

 Physical Activity. It helps stay at a healthy weight and lower the cholesterol and blood
pressure levels. For adults, 2 hours and 30 minutes of moderate-intensity aerobic physical
activity such as brisk walk, each week is recommended while children and teens should
get 1 hour of physical activity each week.

 No smoking. Cigarette smoking greatly increases your chances of having a stroke.

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  Limited alcohol. Drinking too much alcohol can raise blood pressure.

Test and Diagnosis

The first to do in assessing a stroke patient is to determine whether the patient is
experiencing an ischemic or hemorrhagic stroke so that the correct treatment can begin. The first
test is a CT scan or MRI of the head. ( Mayo Foundation for Medical Education and Research
(MFMER), 2014)
 Computed Tomography (CT) of the head. This is to detect a stroke from a blood clot or
bleeding within the brain.
 MRI of the head. It is used to assess brain damage from stroke.
To help determine the type, location, and cause of stroke and to rule out other disorders,
physicians may use:

 Hematology- Hematology is the science or study of blood, blood-forming organs and

blood diseases. In the medical field, hematology includes the treatment of blood disorders
and malignancies, including types of hemophilia, leukemia, lymphoma and sickle-cell
anemia. Hematology is a branch of internal medicine that deals with the physiology,
pathology, etiology, diagnosis, treatment, prognosis and prevention of blood-related
disorders. (Ramanan, 2013)

 Electrocardiogram (ECG/EKG). This checks the hearts’ electrical activity, can help
whether heart problems caused the stroke.

 Carotid ultrasound/Doppler ultrasound: To check for narrowing and blockages in the

body’s two carotid arteries, which are located on each side of the neck and carry blood
from the heart to the brain. Doppler ultrasound produces detailed pictures of these blood
vessels and information of blood flow.

 Cerebral angiography. It is a medical test with one of the three imaging technologies; x-
rays, CT or MRI and in some cases a contrast material, to produce pictures of major
blood vessels in the brain. Cerebral angiography helps physicians detect or confirm
abnormalities such as blood clot or narrowing of the arteries.

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Medication/Treatment:

Treatment depends on the severity and type of stroke. Treatment will focus on restoring
blood flow for an ischemic stroke and on controlling bleeding and reducing pressure on the brain
in a hemorrhagic stroke.

If a stroke is caused by a blood clot, the patient may be able to receive a clot-busting drug
such as tissue plasminogen activator (t-PA) to dissolve the clot and help restore blood flow to the
damaged area of the brain. Clot-busting drugs, which can only be given within the first few hours
of stroke onset, are typically delivered intravenously by emergency medical personnel or in the
hospital emergency department.

Patients may also receive blood-thinning drugs such as aspirin or warfarin (also called by
the brand name, Coumadin), heparin or clopidogrel (also called by the brand name Plavix).

Other stroke treatments include:

 Surgery to remove blood from around the brain and repair damaged blood vessels.

 Intracranial vascular treatments: Endovascular therapy is a minimally invasive

procedure used to improve blood flow in the brain's arteries and veins. In endovascular
therapy, an image-guided catheter is navigated through the body's blood vessels to the
brain to deliver:

 Medications to dissolve blood clots.

 Devices such as balloons, which are used to open markedly narrowed blood vessels, and
stents, small tubes used to keep blood vessels open. In this procedure, which is used to
improve blood flow in the carotid arteries that supply blood to the brain, a balloon-tipped
catheter is guided to where the artery is narrow or blocked and inflated to open the vessel.
A small wire mesh tube called a stent may be placed in the artery to help keep it open.

 Tiny metal coils to repair a ruptured aneurysm in a cerebral artery

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Following a stroke, many patients will receive post-stroke rehabilitation to overcome disabilities
may occur as a result of the stroke. Post-stroke treatment may also include effortsto prevent
another stroke by controlling or eliminating risk factors such as high blood pressure, high
cholesterol and diabetes.

Prevalence

According to the World Health Organization cerebrovascular accidents (stroke) are the
second leading cause of death and third leading cause of disability. Globally, 70% of strokes and
87% of both stroke-related deaths and disability-adjusted life years occur in low and middle-
income countries. Over the last four decades, the stroke incidence in low- and middle-income
countries has more than doubled. During these decades stroke incidence has declined by 42% in
high income countries.

In the Philippines, stroke is the second leading cause of death. It has a prevalence of
0.9%; ischemic stroke compromises 70% while hemorrhagic stroke compromises 30%. Age-
adjusted hypertension prevalence is 20.6%, diabetes 6% dyslipidemia 72%, smoking 31%, and
obesity 4.9%. The neurologists-to-patient ratio is 1:330,000, with 67% of neurologists practicing
in urban centers.

Epidemiology

Although age-standardized rates of stroke mortality have decreased worldwide, the

absolute number of people who have a stroke every year, stroke survivors, related deaths, and the
overall global burden of stroke are great and increasing. Further study is needed to improve
understanding of stroke determinants and burden worldwide, and to establish causes of
disparities and changes in trends in stroke burden between countries of different income levels.

Stroke has already reached epidemic proportions. 1 in 6 people worldwide will have a
stroke in their lifetime. 15 million people worldwide suffer stroke each year and 5.8 million
people die from it. It is the second leading cause of death for people above the age of 60, and the
fifth leading cause of death in people aged 15 to 59. It affects children as well as both men and
women. From 2000 to 2008, the overall stroke incidence rates on low- and middle- income
countries exceeded that of incidence rates seen in high-income countries by 20%. Today, 2 out of

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every 3 people who suffer from a stroke live in low-and middle-income countries. (World Health
Organization, September 2016)

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 NURSING HEALTH HISTORY

BIOGRAPHIC DATA

Hospital : Surigao Medical Center

Case Number : 89236

Room : Intensive Care Unit

Name : Patient C

Age : 76 years old

Sex : Female

Address : Brgy. 5, General Luna, Surigao City

Civil Status : Widowed

Date of Birth : April 12, 1943

Birthplace : General Luna, Surigao Del Norte

Nationality : Filipino

Religion : Catholic

Height : 5’4”

Weight : 54kg

Health Financing and

Source of Medical Care : Philhealth

Source and Reliability

of data gathered : Patient’s Significant other and patient’s chart

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Admission data

Hospital : Surigao Medical Center

Admission Date : September 24, 2019

Time : 8:34 am

Mode of Transmission : Ambulatory

Admitting Vital Signs : Temperature – 36.5 ℃

Respiratory Rate – 21cpm

Pulse Rate – 110bpm

Blood Pressure – 130/80 mmHg

Admitting Physician : Dr. Stephanie Grace D. Edrial, MD

Attending Physician : Dr. Manolito C. Go, MD

Impression : CVA

Final Diagnosis : Cardiovascular Accident

Chief Complaint : 12 hrs. prior to admission, patient noted to be unresponsive,

stuporous gasping and tachycardia with a pulse rate of 110
bpm.

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History of Present Illness

12 hours prior to admission patient was noted to be unresponsive with stupouros gasping
and tachycardia so her daughter decided to seek medical attention at Surigao Medical Center at
8:34am which was where she was admitted.

PAST HEALTH HISTORY

Childhood Illness: Patient has a history of chickenpox and measles when he was in grade
school.

Childhood Immunization: Patient was immunized with DPT, OPV and BCG but was not able
to recall the dates when it was given.

HISTORY OF HOSPITALIZATION

Patient was hospitalized in 1992 due to back injury because she slipped on a chair. She
was also diagnosed with Hypertension and Diabetes MellitusII.

SURGICAL HISTORY

Accidents and Injuries

Patient had a history of spinal cord surgery in 1992.

Allergies

Patient has no known food allergies and drug allergies.

OBSTETRICAL HISTORY

At 9 years of age, patient had already her first menstruation (menarche). She claimed that
her usual menstruation last about 2 weeks and irregular with a color of red blood. She could
consume 3 pcs of pad/day. She did not experience menstrual discomfort.
Her LMP was on September, 1989. She had a miscarriage with her first child and
delivered her 2nd child through normal delivery as well as her third child. MultiGravida-3 Term-2
Preterm-0 Abortion-1 Living-2 and did not use any contraceptive.
Family Health History

Patient’s parents died of natural death and one of her siblings died of a hypertension and
the other died because of drowning. Her sibling was diagnosed with diabetes mellitus.

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Personal and Social History

Nutritional Pattern
Before hospitalization, patient stated that her usual meals are a mix of fish, fruits and
vegetables with a high fiber and low sugar diet. Before she was admitted, she would eat her
breakfast at 5am in the morning, lunch at 11am, and dinner at 6pm and drinks up to 10 glasses of
water per day.
During hospitalization, patient eats a liquidized meal in a glass using straw. She eats at
6am, have lunch at 11 and dinner at 8pm.
Sleep/Rest Pattern
She sleeps at 10 pm and wakes up at 3am and does her daily routine. She has insomnia
and does not take any remedies to relieve it.

At the hospital, her sleeping pattern was interrupted due to constant monitoring of vital
signs and giving prescribed medications.
Elimination Pattern
Patient defecates once a day with soft and form stool and urinates at least 5 times a day
with clear yellow urine. He does not have current problems like dysuria, hematuria and nocturia.

Activity of Daily Living

Patient arises at 3am in the morning and stays in for an hour then starts to water her
plants. His daughter assists her in dressing. Eats breakfast at 5am and does some stretching.
Doesn’t have chest pain, fatigue, wheezing, stiffness, cramps, or joint pain or swelling with an
activity. During evening she would have dinner with his family at 6pm and she sleeps at 10pm.
Recreation/Hobbies
Patient water’s her plants, sweep the floor and folds clothes. She also watches the
television as her past time activity.

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SOCIAL DATA

Family Relationship

Her relationship with her children is close and when there are any problems, they talk
about it as a way to fix it.

Ethnic Affiliation
Patient was born and raised in General Luna, Siargao, SDN and he is a pure Siargaonon.
Educational History
Patient is a college graduate of Bachelor of Science in Education.
Occupational History
Patient is a retired teacher for 16 years.
Economic status
Patient is currently receiving her pension monthly at SSS and has a Philhealth that
support her hospital bills.

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 PHYSICAL EXAMINATION

General Survey

Properly groomed, awake with eyes open and looking at the examiner. Lying on
bed in a semi-fowler’s position and appears fatigue. Hooked with an IVF of PLR 1000ml
at 30gtts/min at right cephalic vein with nasal cannula attached running at 3 liters/min of
oxygen concentration. Oriented to time and place and also oriented to the people around.
Able to recall when and who visits a while ago for immediate memory. Has short term
memory. Ht: 5’4” Wt: 61 kg, Apical pulse: 72bpmResp: 20 cpmTemp: 36.0 ℃ Blood
Pressure: 110/70 mmHg O2 Saturation: 96%
Skin
Inspection
Skin is fair in color and wrinkled. No scalp lesions and edema upon inspection.
Palpation
Skin has a normal temperature of 36.0 ℃ when touched. No edema noted. Has a
poor skin turgor upon palpation.
Head and Face
Inspection
No scalp lesions or flaking. Central facial palsy noted.Smiles, frowns, shows
teeth, blows cheeks, and raises eyebrows as instructed.
Palpation
Patient identifies light touch and sharp touch to forehead, cheek and chin.Head
symmetrically rounded upon palpation.
Eyes

Inspection

Eyebrows sparse with equal distribution.No scaliness noted. Lids brown without
lesions. Sclera without increased vascularity or lesions noted. Palpebral and bulbar
conjunctiva pale without lesions noted. Irises uniformly black. Pupils are round and react
to light and accommodation.

Palpation

No edema noted. No masses noted.

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Ears and Nose

Inspection

Auricle without deformity, lumps or lesions. Auricle aligned with outer canthus
of eye about 10 degrees from vertical. Nares patent. No redness, swelling, and abnormal
discharge on the nasal mucosa. Whisper test: Patient is unable to hear whispered words or
watch tick.

Palpation
Auricles and mastoid processes are non-tender. Pinna recoils after it is folded.
Nose is symmetrical and straight upon palpation.

Mouth and Throat

Inspection

Lips are moist pink, smooth and with no lesions. Central facial palsy noted. Use
of dentures on the incisors noted. Tonsils appear to be normal.

Palpation
No palpable nodules noted.
Neck

Inspection

Neck is symmetrical. Trachea is in center placement in midline of neck.

Palpation

Lymph nodes are non-palpable.

Arms, Hands, and Fingers

Inspection

Arms are equal in size and symmetry bilaterally. Skin is fair in color. Three
flexion creases present in palm. Fingernails are finely cut, clean and clear. No clubbing.
Hands are wrinkled.

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Palpation

Poor skin turgor and elasticity. Normal temperature when touched. No edema

Thorax and Lungs

Inspection

Posterior lateral diameter is 1:2 ratio. Anterior lateral diameter is 1:2 ratio.
Symmetrical expansion on posterior thorax. Chest symmetry is equal. Shape and
position of sternum is level with ribs. Position of trachea is in midline.

Palpations

No pain or tenderness in the anterior and posterior thorax.No masses noted.

Auscultation

Lungs clear to auscultation on inspiration and expiration.

Breasts (Female)
Inspection
Pendulous breast noted.
Palpation
No palpable nodules noted.
Abdomen
Inspection
Abdomen is uniform in color. No rashes or lesions. No evidence of enlargement of liver
and spleen.
Palpation

Abdomen is soft. No evidence of enlargement of liver and spleen upon palpation

Auscultation

Bowel sounds are normal (15-30 sounds/min).

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Legs, Feet and Toes
Inspection
Minor scar located at the anterior fibula. Toenails are finely cut, clean, and clear.
No clubbing. Feet are wrinkled.
Palpation

No edema noted.

Genitalia (Female)

Inspection

Decrease in size and elasticity of labia. Decrease elasticity of vaginal walls.

Muskoloskeletal and Neurologic examination

Inspection

Muscle strength 2/5. No edema noted at both lower extremities. Passive range of motion;
pt. has poor range of motion. No deviations, inflammations, or bony deformities. Hemiplegia
noted. Pt. is weak but awake with eyes open and looking at the examiner; client responds
appropriately. Oriented to time and place and also oriented to people around. Able to recall when
and who visits a while ago for immediate memory. Can recall her name.She has trouble
regaining his memory on what he was doing from the past days. Takes incoming information
appropriately. Right hand: Alternates finger to nose with eyes closed; occasionally tends to hit
opposite side of nose. Rapidly opposes fingers to thumb bilaterally without difficulty. Alternates
pronation and supination of hands rapidly without difficulty.Heel to shin intact bilaterally. Left
hand: has difficulty in moving. Has difficulty in opposing fingers to thumb bilaterally. Cannot
fully alternate pronation and supination of hands rapidly. Pt. cannot walk at the moment as she
is still regaining her strength.

Palpation

Pt. cannot feel sense of touch on the left side of her body.

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Cranial Nerve Assessment

Cranial Nerve Name Result

I Olfactory Can smell and can identify what it
is.
II Optic Pt. is far sighted.
III Occulomotor Pupils are round and react to light
and accommodation.

IV Trochlear Both eyes are well coordinated

and moves in unison without
tenderness felt when left and right
eyes moves. Patient lids close
symmetrically.
V Trigeminal Has difficulty moving due to
stroke.
VI Abducens Can move left and right eyeballs
in a moderate manner.
VII Facial Raises her left and right eyebrows
whenever you say something to
her. Can close his both eyes.

VIII Acoustic Pt. clearly hears normal voice

tone.
IX Glossopharyngeal Positive gag reflex
X Vagus Positive swallowing reflex
XI Spinal Accessory Patient can move his neck
XII Hypoglossal Can protrude tongue

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Glasgow Coma Scale

Patient result:

 Best eye response: 1

 Best verbal response: 2
 Best motor response: 2

Total: GCS 6 (severe)

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 REVIEW OF SYSTEMS

General Survey

The usual weight of the client is 63kg. , upon hospitalization, the patient’s weight
decreased to 61kg. , appears fatigue upon assessment.

Integumentary System

Skin is fair in color and wrinkled. No scalp lesions and edema.Skin has a normal
temperature when touched. No edema noted. Has a poor skin turgor. Has no history of
any skin allergies. Has a history of chicken pox and measles.

Head, Eyes, Ears, Nose, and Throat (EENT)

No scalp lesions or flaking. No history of any head injuries.Patient is far

sighted.Patient is able to hear whispered words or watch tick. Patient had no history of
otitis media.No problems upon disseminating various scents.He had a history of
tonsillitis.

Gastrointestinal System

Patient had no complaints of constipation. Patient had no abnormality in

defecating. No abnormal bowel sounds. He had no history of hemorrhoids and rectal
bleeding.

Musculoskeletal System

Patient has hemiplegia.

Neurologic System

Patient is conscious to time, place and people. Has no history of seizure.

Urinary System

Patient urinates 5 times a day. Patient does not experience pain upon voiding.
Color of the urine is amber. Urine transparency is hazy. There is protein trace in
urinalysis.

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Reproductive System (Female)

Patient is satisfied with her sex life. Pt. had no history of of any STDs,
HIV/AIDS.

Hematologic

Patient has diabetes mellitus II and hypertension.

Endocrine
Patient had no history of polyuria and nocturia. No thyroid problem. He had a history of
tonsillitis.
Psychiatric

No signs depression. No history of attempted suicides. Has a short term memory.

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 LABORATORY RESULTS

HEMATOLOGY

COMPLETE BLOOD COUNT

September 25, 2019

TEST RESULT NORMAL UNIT SIGNIFICANT RATIONALE

VALUES
HEMOGLOBIN 10.6 12.0-17.0 g/dL Normal
HEMATOCRIT 36.8 37-54 % Normal
RBC 3.43 4.0-6.0 10^12/L Decreased Normal
MCV 107.4 87± 5 fl Increased Normal
MCH 30.9 29 ± 2 pg Increased Normal
MCHC 28.8 34 ±2 g/dL Decreased Normal
RDW 13.5 11.6-14.6 Normal
PLATELET 164 150-450 x10^9/L Normal
COUNT
WBC 7.9 x10^9/L Normal
DIFFERENTIA RESULT NORMAL UNIT
L COUNT VALUES
SEGMENTERS 91.2 50-70 % Increased Neutrophilia
LYMPHOCYTE 5.5 20-40 % Decreased Lymphocytopenia
MID CELL 3.3 %

ANALYSIS:
The result of the exam with decreased RBC and MCHC are considered normal as well as
the increased MCV and MCH since the patient is already old in age. Increased segmenters
indicatesneutrophilia and decreased lymphocytes indicates lymphocytopenia.

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 URINALYSIS

September 25, 2019

TEST RESULT NORMAL SIGNIFICANT RATIONALE

VALUES
COLOR Amber Normal
TRANSPARENCY Hazy Normal
PROTEIN 1+ Increased Proteinuria
pH 5.0 4.5-8.0 Normal
SPECIFIC GRAVITY 1.030 1.010-1.030 Normal
GLUCOSE Negative Normal
BACTERIA None

ANALYSIS:
Urinalysis shown normal urine color amber and hazy. A presence of protein in the urine
indicates proteinuria that resulted from diabetes mellitus and hypertension.

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 CT SCAN
EXAM: Non- contrast enhanced CT-Scan of the brain.
Technique: Non- contrast 64-multislice CT- Scan of the brain
Findings:
 There is no evidence of an acute infarct/ intracranial hemorrhage at the time of the
examination. There are small and lacunar infarcts at the right insula and bilateral basal
ganglia. No edema or discrete mass lesion. No abnormal calcifications seen.
 The ventricles, cisterns and sulci are within limits. Midline structures are in place.
 The cavernous sinuses are in symmetrical. The sella and suprasellar regions are intact.
There is atherosclerosis of both internal carotid arteries.
 The brainstem and cerebellum are preserved. The cerebellopontive angles are clear.
 The paranasal sinuses and mastoids are clear. The orbital structures are remarkable.
 The osseous structures are intact.
IMPRESSION:
 Negative evidence of an acute infarct or intracranial hemorrhage.
 Negative for edema, discrete mass lesion or abnormal calcifications.
 Small and lacunar chronic infarcts at right insula and bilateral basal ganglia.
 Atherosclerosis of both internal carotid arteries.

26
 ANATOMY AND PHYSIOLOGY

The Central Nervous System

ANATOMY OF THE BRAIN


The brain is divided into three major areas: the cerebrum, the brain stem, and the cerebellum.
o The cerebrum is composed of two hemispheres: the thalamus and the
hypothalamus, and the basal ganglia.
 Additionally, connections for the olfactory (cranial nerve I) and optic
(cranial nerve III) nerves are found in the cerebrum.
o The brain stem includes the midbrain, pons, medulla, and connections for cranial
nerves II and IV through XII.
o The cerebellum is located under the cerebrum and behind the brain stem.
 The brain accounts for approximately 2% of the total body weight; it weighs
approximately 1,400g in an average young adult.
 In the elderly, the average brain weighs approximately 1,200 g.

27
Cerebrum
 The cerebrum consists of two hemispheres that are incompletely separated by the great
longitudinal fissure. This sulcus separates the cerebrum into the right and left
hemispheres.
 The two hemispheres are joined at the lower portion of the fissureby the corpus
callosum.
 The outside surface of the hemisphereshas a wrinkled appearance that is the result of
manyfolded layers or convolutions called gyri, which increase the surfacearea of the
brain, accounting for the high level of activity carriedout by such a small-appearing
organ.
 The external or outer portion of the cerebrum (the cerebral cortex) is made up of
graymatter approximately 2 to 5 mm in depth; it contains billions ofneurons/cell bodies,
giving it a gray appearance.
 White matter makes up the innermost layer and is composed of nerve fibers and
neuroglia (support tissue) that form tracts or pathways connecting various parts of the
brain with one another (transverse and association pathways) and the cortex to lower
portions of the brain and spinal cord (projection fibers).
The cerebral hemispheres are divided into pairs of frontal, parietal, temporal, and occipital lobes.
 Frontal—the largest lobe. The major functions of this lobe are concentration, abstract
thought, information storage or memory, and motor function. It also contains Broca’s
area, critical for motor control of speech. The frontal lobe is also responsible in large part
for an individual’s affect, judgment, personality, and inhibitions.
 Parietal—a predominantly sensory lobe. The primary sensory cortex, which analyzes
sensory information and relays the interpretation of this information to the thalamus and
other cortical areas, is located in the parietal lobe. It is also essential to an individual’s
awareness of the body in space, as well as orientation in space and spatial relations.
 Temporal—contains the auditory receptive areas. Contains a vital area called the
interpretive area that provides integration of somatization, visual, and auditory areas and
plays the most dominant role of any area of the cortex in cerebration.
 Occipital—the posterior lobe of the cerebral hemisphere is responsible for visual
interpretation.

28
Corpus callosum.
 A thick collection of nerve fibers that connects the two hemispheres of the brain and is
responsible for the transmission of information from one side of the brain to the other.
 Information transferred includes sensation, memory, and learned discrimination.
 Right-handed people and some left-handed people have cerebral dominance on the left
side of the brain for verbal, linguistic, arithmetical, calculating, and analytic functions.
 The non-dominant hemisphere is responsible for geometric, spatial, visual, pattern, and
musical functions.
Basal ganglia.Masses of nuclei located deep in the cerebral hemispheres that are responsible for
control of fine motor movements, including those of the hands and lower extremities.
Thalamus.lies on either side of the third ventricle and acts primarily as a relay station for all
sensation except smell. All memory, sensation, and pain impulses also pass through this section
of the brain.
Hypothalamus.located anterior and inferior to the thalamus.
 The hypothalamus lies immediately beneath and lateral to the lower portion of the wall of
the third ventricle.
 It includes the optic chiasm (the point at which the two optic tracts cross) and the
mamillary bodies (involved in olfactory reflexes and emotional response to odors).
 Plays an important role in the endocrine system because it regulates the pituitary
secretion of hormones that influence metabolism, reproduction, stress response, and urine
production.
 It works with the pituitary to maintain fluid balance and maintains temperature regulation
by promoting vasoconstriction or vasodilatation.
 Site of the hunger center and is involved in appetite control.
 It contains centers that regulate the sleep–wake cycle, blood pressure, aggressive and
sexual behavior, and emotional responses (ie, blushing, rage, depression, panic, and fear).
 The hypothalamus also controls and regulates the autonomic nervous system.
Pituitary gland.located in the sellaturcica at the base of the brain and is connected to the
hypothalamus.

29
  Common site for brain tumors in adults; frequently they are detected by physical signs
and symptoms that can be traced to the pituitary, such as hormonal imbalance or visual
disturbances secondary to pressure on the optic chiasm.
Brain Stem.
 The brain stem consists of the midbrain, pons, and medulla oblongata.
 The midbrain connects the pons and the cerebellum with the cerebral hemispheres; it
contains sensory and motor pathways and serves as the center for auditory and visual
reflexes.
 Cranial nerves III and IV originate in the midbrain.
 The pons is situated in front of the cerebellum between the midbrain and the medulla and
is a bridge between the two halves of the cerebellum, and between the medulla and the
cerebrum
o Cranial nerves V through VIII connect to the brain in the pons.
o The pons contains motor and sensory pathways. Portions of the pons also control
the heart, respiration, and blood pressure.
 The medulla oblongata contains motor fibers from the brain to the spinal cord and
sensory fibers from the spinal cord to the brain.
o Most of these fibers cross, or decussate, at this level.

o Cranial nerves IX through XII connect to the brain in the medulla.

Cerebellum.
 The cerebellum is separated from the cerebral hemispheres by a fold of dura mater, the
tentorium cerebelli.
 The cerebellum has both excitatory and inhibitory actions and is largely responsible for
coordination of movement. It also controls fine movement, balance, position
sense(awareness of where each part of the body is), and integration of sensory input.
Strucures Protecting the Brain
 The brain is contained in the rigid skull,
which protects it from injury.
 The major bones of the skull are the frontal,
temporal, parietal, and occipital bones.

30
The meninges (fibrous connective tissues that cover the brain and spinal cord) provide
protection, support, and nourishment to the brain and spinal cord.
 Dura mater—the outermost layer; covers the brain and the spinal cord. It is tough, thick,
inelastic, fibrous, and gray.
 Arachnoid—the middle membrane; an extremely thin, delicate membrane that closely
resembles a spider web (hence the name arachnoid).
o It appears white because it has no blood supply.

o The arachnoid layer contains the choroid plexus, which is responsible for the
production of cerebrospinal fluid (CSF).
o The subdural space is between the dura and the arachnoid layer, and the
subarachnoid space is located between the arachnoid and pia layers and contains
the CSF.
 Pia mater—the innermost membrane; a thin, transparent layer that hugs the brain closely
and extends into every fold of the brain’s surface.
Cerebral Circulation
Major Blood Vessels

 Blood is supplied to the brain, face, and scalp via two major sets of vessels: the right and
left common carotid arteries and the right and left vertebral arteries.
 The external carotid arteries supply the face and scalp with blood.
 The internal carotid arteries supply blood to most of the anterior portion of the cerebrum.
 The vertebrobasilar arteries supply the posterior two-fifths of the cerebrum, part of the
cerebellum, and the brain stem.
 Any decrease in the flow of blood through one of the internal carotid arteries brings about
some impairment in the function of the frontal lobes. This impairment may result in
numbness, weakness, or paralysis on the side of the body opposite to the obstruction of
the artery.
 Occlusion of one of the vertebral arteries can cause many serious consequences, ranging
from blindness to paralysis.

31
Circle of Willis

 At the base of the brain, the carotid and vertebrobasilar arteries form a circle of
communicating arteries.

 From this circle, other arteries—the anterior cerebral artery (ACA), the middle cerebral
artery (MCA), the posterior cerebral artery (PCA)—arise and travel to all parts of the
brain. Posterior Inferior Cerebellar Arteries (PICA), which branch from the vertebral
arteries, are not shown.

 Because the carotid and vertebrobasilar arteries form a circle, if one of the main arteries
is occluded, the distal smaller arteries that it supplies can receive blood from the other
arteries (collateral circulation).

Middle Cerebral Artery

 The middle cerebral artery is the largest branch of the internal carotid.

 The artery supplies a portion of the frontal lobe and the lateral surface of the temporal
and parietal lobes, including the primary motor and sensory areas of the face, throat, hand
and arm, and in the dominant hemisphere, the areas for speech.

 The middle cerebral artery is the artery most often occluded in stroke.

Posterior Cerebral Artery

 The posterior arteries supply the temporal and occipital lobes of the left cerebral
hemisphere and the right hemisphere.
 When infarction occurs in the territory of the posterior cerebral artery, it is usually
secondary to embolism from lower segments of the vertebral basilar system or heart.

Veins

 Venous drainage for the brain does not follow the arterialcirculation as in other body
structures.
 The veins reach the brain’ssurface, join larger veins, then cross the subarachnoid space
and empty into the dural sinuses, which are the vascular channels lying within the tough
dura mater.

32
  The network of the sinuses carries venous outflow from the brain and empties into the
internal jugular vein, returning the blood to the heart.
 Cerebral veins and sinuses are unique because, unlike other veins in the body, they do not
have valves to prevent blood from flowing backward and depend on both gravity and
blood pressure.

The Peripheral Nervous System

Cranial Nerves

There are 12 pairs of cranial nerves

that emerge from the lower surface of
the brain and pass through the foramina
in the skull.
I. Olfactory nerve
 Transmits information to the
brain regarding a person's sense
of smell.
II. Optic nerve
 Transmits information to the
brain regarding a person's
vision.
III. Oculomotor nerve
 Helps control muscle movements of the eyes.
IV. Trochlear nerve
 Also involved in eye movement.
 It powers the contralateral superior oblique muscle that allows the eye to point downward
and inward.
V. Trigeminal nerve
 The largest cranial nerve and has both motor and sensory functions.
 Its motor functions help a person to chew and clench the teeth and gives sensation to
muscles in the tympanic membrane of the ear.

33
  The ophthalmic part gives sensation to parts of the eyes, including the cornea, mucosa in
the nose, and skin on the nose, the eyelid, and the forehead.

 The maxillary part gives sensation to the middle third of the face, side of the nose, upper
teeth, and lower eyelid.

 The mandibular part gives sensation to the lower third of the face, the tongue, mucosa in
the mouth, and lower teeth.

VI. Abducens nerve

 Also helps control eye movements.
 It helps the lateral rectus muscle, which is one of the extraocular muscles, to turn the gaze
outward.
VII. Facial Nerve
 Has both motor and sensory functions.
 The facial nerve is made up of four nuclei that serve different functions:
o movement of muscles that produce facial expression
o movement of the lacrimal, submaxillary, and submandibular glands
o the sensation of the external ear
o the sensation of taste
VIII. Vestibulocochlear nerve
 Involved with a person's hearing and balance.
 The vestibulocochlear nerve contains two components:
o The vestibular nerve helps the body sense changes in the position of the head with
regard to gravity. The body uses this information to maintain balance.
o The cochlear nerve helps with hearing. Specialized inner hair cells and the basilar
membrane vibrate in response to sounds and determine the frequency and
magnitude of the sound.
IX. Glossopharyngeal nerve
 Possesses both motor and sensory functions.

34
 o The sensory function receives information from the throat, tonsils, middle ear, and
back of the tongue. It is also involved with the sensation of taste for the back of
the tongue.
o The motor division provides movement to the stylopharyngeus, which is a muscle
that allows the throat to shorten and widen.
X. Vagus nerve
 Has a range of functions, providing motor, sensory, and parasympathetic functions.
o The sensory part provides sensation to the outer part of the ear, the throat, the
heart, abdominal organs. It also plays a role in taste sensation.
o The motor part provides movement to the throat and soft palate.
o The parasympathetic function regulates heart rhythm and innervates the smooth
muscles in the airway, lungs, and gastrointestinal tract.
 The vagus nerve is the longest cranial nerve as it starts in the medulla and extends to the
abdomen.
XI. Accessory nerve
 Provides motor function to some muscles in the neck:
 It controls the sternocleidomastoid and trapezius muscles that allow a person to
rotate, extend, and flex the neck and shoulders.
 The accessory nerve separates into spinal and cranial parts.
XII. Hypoglossal nerve
 A motor nerve that supplies the tongue muscles.

Spinal Nerves

 The spinal cord is composed of 31 pairs of

spinal nerves: 8 cervical, 12 thoracic, 5
lumbar, 5 sacral, and 1 coccygeal. Each spinal
nerve has a ventral root and a dorsal root.
o The dorsal roots are sensory and
transmit sensory impulses from
specific areas of the body known as

35
 dermatomes to the dorsal ganglia. The sensory fiber may be somatic, carrying
information about pain, temperature, touch, and position sense (proprioception)
from the tendons, joints, and body surfaces; or visceral, carrying information
from the internal organs.
o The ventral roots are motor and transmit impulses from the spinal cord to the
body. These fibers are also either somatic or visceral. The visceral fibers include
autonomic fibers that control the cardiac muscles and glandular secretions.
Autonomic Nervous System
 Regulates the activities of internal organs such as the heart, lungs, blood vessels, digestive
organs, and glands.
o There are two major divisions: the sympathetic nervous system, with
predominantly excitatory responses, most notably the “fight or flight” response
o The parasympathetic nervous system, which controls mostly visceral
functions.
 The autonomic nervous system has two neurons in a series extending between the centers
in the CNS and the organs innervated.
o The first neuron, the preganglionic neuron, is located in the brain or spinal cord,
and its axon extends to the autonomic ganglia.
o There, it synapses with the second neuron, the postganglionic neuron, located in
the autonomic ganglia, and its axon synapses with the target tissue and
innervates the effector organ. Its regulatory effects are exerted not on individual
cells but on large expanses of tissue and on entire organs.
Motor (efferent) division
 The motor (also known as efferent) division of the nervous system contains motor nerves. 
 These nerves conduct impulses from the CNS and PNS to the muscles, organs and glands’
effecting what happens in those tissues.

The Role of the Basal Ganglia in Movement

The basal ganglia are responsible for voluntary motor control, procedural learning, and eye
movement, as well as cognitive and emotional functions

36
Location

 The basal ganglia (or basal nuclei) are a group of nuclei of varied origin in the brains of
vertebrates that act as a cohesive functional unit. They are situated at the base of the
forebrain and are strongly connected with the cerebral cortex, thalamus, and other brain
areas.

 The basal ganglia are associated with a variety of functions, including voluntary motor
control, procedural learning relating to routine behaviors or habits such as bruxism and
eye movements, as well as cognitive and emotional functions

Action Selection

 Currently popular theories hold that the basal ganglia play a primary role in action
selection. Action selection is the decision of which of several possible behaviors to
execute at a given time.

 Experimental studies show that the basal ganglia exert an inhibitory influence on a
number of motor systems, and that a release of this inhibition permits a motor system to
become active. The behavior switching that takes place within the basal ganglia is
influenced by signals from many parts of the brain, including the prefrontal cortex, which
plays a key role in executive functions.

Function in Eye Movement

 One of the most intensively studied functions of the basal ganglia is their role in
controlling eye movements. Eye movement is influenced by an extensive network of
brain regions that converge on a midbrain area called the superior colliculus (SC).

o The SC is a layered structure whose layers form two-dimensional retinotopic

maps of visual space. A bump of neural activity in the deep layers of the SC
drives eye movement toward the corresponding point in space.

37
Neurotransmitters

 In most regions of the brain, the predominant classes of neurons use glutamate as the
neurotransmitter and have excitatory effects on their targets. In the basal ganglia,
however, the great majority of neurons uses gamma-aminobutyric acid (GABA) as the
neurotransmitter and have inhibitory effects on their targets.

 The inputs from the cortex and thalamus to the striatum and subthalamic nucleus are
glutamatergic, but the outputs from the striatum, pallidum, and substantianigra pars
reticulata all use GABA. Thus, following the initial excitation of the striatum, the internal
dynamics of the basal ganglia are dominated by inhibition and disinhibition.

 Other neurotransmitters have important modulatory effects. Dopamine is used by the

projection from the substantianigra pars compacta to the dorsal striatum and also in the
analogous projection from the ventral tegmental area to the ventral striatum (nucleus
accumbens).

 Acetylcholine also plays an important role, as it is used both by several external inputs to
the striatum and by a group of striatal interneurons. Although cholinergic cells make up
only a small fraction of the total population, the striatum has one of the highest
acetylcholine concentrations of any brain structure.

Modulation of Movement by the Cerebellum

 The cerebellum is important for motor control—specifically coordination, precision, and

timing—as well as some forms of motor learning.

 The cerebellum is a region of the brain that plays an important role in motor control. It
may also be involved in some cognitive functions such as attention and language, and in
regulating fear and pleasure responses, but its movement-related functions are the most
solidly established. The cerebellum does not initiate movement, but it contributes to
coordination, precision, and accurate timing.
 It receives input from sensory systems of the spinal cord and from other parts of the
brain, including the cerebral cortex, and integrates these inputs to fine-tune motor
activity. Because of this fine-tuning function, damage to the cerebellum does not cause

38
 paralysis, but instead produces disorders in fine movement, equilibrium, posture, and
motor learning.
 The cerebellum differs from most other parts of the brain, especially the cerebral cortex,
in regards to the ability of signals to move unidirectionally from input to output. This
feedforward mode of operation means that the cerebellum cannot generate self-sustaining
patterns of neural activity, in contrast to the cerebral cortex. However, the cerebellum can
receive information from the cerebral cortex and processes this information to send motor
impulses to the skeletal muscle.

Sensory (afferent) division

 The sensory (also known as afferent) division of the nervous system contains nerves that
come from the viscera (internal organs) and the somatic areas (muscles, tendons,
ligaments, ears, eyes and skin). 
 These nerves conduct impulses to the PNS/CNS providing information on what is
happening within and outside the body.  The senses include; hearing, sight, touch, and
proprioception (the awareness of where you are in space and what position you’re in).

39
 PATHOPHYSIOLOGY
Precipitating factors:
Predisposing factors:
 History of Diabetes, and
 Age: 76 y/o
Hypertension
 Gender: Female
 Weak immune system
 Stress

 Small and lacunar

Narrowed blood vessel infarct at right insula
and basal ganglia
 Atherosclerosis of
both internal carotid
 Innefectivecerebral arteries
tissue perfusion r/t Decreased cerebral blood flow
interruption of blood

 Zynapse 1 gm IVTT
Q8 Decreased O2 supply

 Stuporous Neurons unable to maintain

gasping anaerobic respiration

 Fatigue r/t physiological condition

Tissue Ischemia  Tachycardia

 Administer O2 suppy via nasal (110bpm)
cannula @3L/min

Paralysis  Pt. unresponsive

 GCS- 6
 Hemiplegia

 Activity intolerance r/t

immobility Stroke  Impaired Physical Mobility
 Risk for falls r/t proprioceptive r/t neuromuscular
deficit impairment
 Impaired walking r/t
insufficient muscle strength

40
If Treated If left untreated

Management of infarcts & Brain death

Atherosclerosis

Multiple organ failure

Complete recovery

DEATH

LEGEND:

= DiseaseProcess

= Client Manifestation

= Clinical Manifestation

= Treatment/management

= Nursing Care Plan

= If Treated

= If Left Untreated

= Death

41
 PATHOPHYSIOLOGY
The predisposing factor of patient C are age, and gender. The precipitating factors are
history of diabetes and hypertension and stress.
Thesmall and lacunar infarcts to the right insula and basal ganglia and atherosclerosis of
both internal carotid arteries caused the narrowed blood vessel in which the decreased cerebral
blood flow was diagnosed of ineffective cerebral tissue perfusion r/t interruption of blood
which the medication Zynapse of 1gm IVTT q8 was given for. It resulted to decreased oxygen
supply to the brain causing the patient to experience fatigue and was administered with
oxygen via nasal cannula at 3L/min. Neurons that unable to maintain anaerobic respiration left
the patient in stupouros gasping results to tissue ischemia that caused pt. in tachycardia. As it
progresses the patient is paralyzed being unresponsive with the GCS of 6 that was diagnosed
with impaired Physical Mobility r/t neuromuscular impairment in result to stroke. Stroke
caused activity intolerance r/t immobility, risk for falls r/t proprioceptive deficit and impaired
walking r/t insufficient muscle strength.

If left untreated, this would result to brain death which will cause multiple organ failure
and possible death.

42
 Drug Study #1

Generic Name:

Citicoline sodium

Brand Name:

Zynapse

Dosage:

1 gm

Route:

IVTT

Frequency:

Q8

Classifications:

CNS stimulant, Peripheral vasodilators, cerebral activators

Mechanism of actions:

Citicoline increases blood flow and O2 consumption in the brain. It is also involved in the
biosynthesis action.

Indications:

It is indicated in acute recovery phase of s/sx of cerebrovascular insufficiency and in-cranial

traumatism and their sequellae. Citicoline in CVA stimulates brain function.

Contraindications:

 Hypersensitivity
 Hypertonia of the parasympathetic nervous system
 Pregnancy and lactations
 Pt. with renal and hepatic damage

43
Adverse Effects:

 CV: Fleeting and discrete hypotension effect, increased parasympathetic effects, low
blood pressure
 Itching/hives
 Swelling in face/hands
 Chest tightness
 Tingling in mouth or throat

Nursing Interventions

 Taken with or without food. Take with or between meals

 Do not take late in the afternoon or night because it can cause difficulty sleeping
 Contact physician for adverse reactions
 It should be started within 24 hours of a stroke. The physician will prescribe the correct
dosage and the length of time it should be taken for a medical condition.

44
 Drug Study #2

Generic Name:

Omeprazole

Brand Name:

Frazole

Dosage:

1 amp

Route:

IV

Frequency:

Q12

Classifications:

Anti-ulcer agents

Mechanism of actions:

Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the
final transport of hydrogen ions in the gastric lumen.

Indications: GERD/ maintenance of healing in erosive esophagitis. Duodenal ulcers (with or

without anti-infectives for Helicobacter pylori).Short term treatment of active benign gastric
ulcer.

Contraindications:

 Hypersensitivity
 Metabolic alkalosis

Adverse Effects:

 CNS: dizziness, drowsiness, fatigue, headache weakness.

45
  CV: chest pain
 GI: abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea,
vomiting.
 Derm: itching, rash
 Misc: allergic reactions

Nursing Interventions

 Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the
stool, emesis, or gastric aspirate.
 Lab test considerations: Monitor CBC with differential periodically during therapy.
 May cause increased AST, ALT, alkaline phosphatase, and bilirubin.
 May cause serum gastrin concentrations to increase during 1st-2nd week of therapy. Levels
return to normal after discontinuation of omeprazole.

46
 Drug Study #3

Generic Name:

Naproxen Sodium

Brand Name:

Eprox

Dosage:

1.5gm

Route:

IV

Frequency:

Q8

Classifications:

Anti-inflammatory drug (NSAIDs)

Mechanism of actions:

Inhibits prostaglandin synthesis and suppression of fever.

Indications:

Naproxen is indicated for the relief of symptoms of rheumatoid arthritis, both of acute flares and
long term management of the disease. It is also used in the diseases of rheumatoid osteoarthritis
(degenerative arthritis), ankylosing spondylitis, juvenile rheumatoid arthritis, tendinitis, brusitis,
acute gout, acute musculoskeletal disorders (such as sprains, direct trauma and fibrositis),
migraine and dysmenorrhoea.

Contraindications:

 Hypersensitivity; cross sensitivity may occur with other NSAIDs including aspirin
 Active GI bleeding

47
  Ulcer disease
 Lactation: passes into breast milk and should not be used by nursing mothers.
 Use cautiously in: Severe cardiovascular, renal or hepatic disease.

Adverse Effects:

 Gastro-intestinal discomfort: nausea, diarrhea and occasionally bleeding and ulceration.

 Hypersensitivity reactions: notably with bronchospasm, rashes and angioedema.
 CNS side effect: drowsiness, headache, fluid retention, vertigo, hearing disturbances such
as tinnitus and photosensitivity.
 A few instances of jaundice, impairment of renal function, thrombocytopenia, and
agranulocytosis have been reported.

Nursing Interventions

 Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk
for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.
 Pain: Assess pain prior to and 1-2 hr following administration
 Arthritis: Assess pain and range of motion prior to and 1-2 hr following administration
 Fever: Monitor temperature; note signs associated with fever.

48
 Drug Study #4

Generic Name:

Glucobest

Brand Name:

Glucobest

Dosage:

200cc

Route:

Oral

Frequency:

Q6

Classifications:

 Enteral/Nutritional Products

Mechanism of actions:

Fat/carbohydrates/proteins/minerals/vitamins, combinations ; Used as general nutrients.

Indications:

Nutritional supplement for the dietary management of protein-energy malnutrition associated w/

type II diabetes.

Contraindications:

 Not for parenteral (IV) use

 Not for use in children unless recommended by physician

Adverse Effects:

 Gastro-intestinal discomfort: nausea, diarrhea

49
Nursing Interventions

 Add 200 mL of water to a glass & 4 level scoops of powd or 1 sachet (52 g). Stir
vigorously until the powd is totally dissolved. Recommended intake: 1-2 servings/day.

50
 Drug Study #5

Generic Name:

Carvedilol

Brand Name:

Carvid

Dosage:

6.25 mg/ 1 tab

Route:

Oral

Frequency:

BID

Classifications:

 Anti-hypertensives

Mechanism of actions:

Blocks stimulation of beta1 (myocardial) and beta2 (pulmonary, vascular, and uterine) –
adenergic receptor sites. Also has alpha1 blocking activity, which may result in orthostatic
hypotension.

Indications:

Hypertension.CHF (ischemic or cardiomyopathic) with digoxin, diuretics, and ACE

inhibitors.Left ventricular dysfunction after myocardial infarction.

Contraindications:

 Pulmonary edema
 Cardiogenic shock
 Bradycardia, heart block, or sick sinus syndrome (unless a pacemaker is in place)

51
  Uncompensated CHF requiring IV inotropic agents (wean before starting carvedilol)
 Severe hepatic impairment
 Asthma and other bronchospastic disorders.

Adverse Effects:

 CNS: Dizziness, fatigue, weakness, anxiety, depression, drowsiness, insomnia, memory

loss
 EENT: blurred vision, dry eyes, nasal stuffiness
 Resp: bronchospasm, wheezing
 CV: Bradycardia, CHF
 GI: diarrhea, constipation, nausea
 GU: erectile dysfunction
 Derm: Itching, rashes
 Neuro: parasthesia

Nursing Interventions

 Monitor BP and pulse frequently during dose adjustment period and periodically during
therapy.
 Monitor I&O ratios and daily weight. Assess for fluid overload
 Hypertension: Check frequency of refills to determine adherence

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 NURSING CAREPLAN #1

Assessment
Subjective: “Mag lisod pa pag adjust saginhawasi mama sugodadtonahitabo” as
verbalized by the pt. significant other.

Objectives:
 Hemiplegia
 Muscle strength test: 2/5
 Presence of nasal cannula attached to O2. O2 saturation: 96%
 Restlessness
 Altered LOC
 CT Scan result: Atherosclerosis of both internal carotid arteries
 VS: BP- 110/70 mmHg
PR- 89 bpm
RR- 23 cpm
Temp- 36 ℃

Nursing Diagnosis

Ineffective cerebral tissue perfusion related to interruption of blood flow

Planning

After 4 hours of nursing interventions, patient will be able to display decrease signs of
ineffective tissue perfusion as evidence by gradual improvement of vital signs.

Intervention

Nursing intervention Rationale

 INDEPENDENT
Monitored vital signs To have a baseline data, assess changes in
neurologic status
Checked capillary refill and conjunctiva for To determine blood circulation

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 paleness

Reviewed pulse oximetry or arterial blood gases.
Closely assessed and monitored neurological
status frequently and compared with baseline.
Positioned with head slightly elevated and in
neutral position.
 DEPENDENT/COLLABORATIVE
Restored/maintainde fluid balance (PLR, 1L
@30gtts)
Administered medications as indicated ( Zynapse
1 gm IVTT q8)
Hypoxia is associated with reduced cerebral
perfusion.
Assesses trends in level of consciousness (LOC)
and potential for increased ICP and is useful in
determining location, extent, and progression of
damage.
Reduces arterial pressure by promoting venous
drainage and may improve cerebral perfusion.
To maximize cardiac output
To increase blood flow and o2 consumption to the
brain.

Evaluation:

Goal met. After 4 hours of nursing interventions, patient was be able to display decrease signs of
ineffective tissue perfusion as evidence by gradual improvement of vital signs.

Vital Signs:
BP- 110/70 mmHg
PR- 72bpm
RR- 20cpm
Temp- 36 ℃
O2 saturation: 96%

NURSING CAREPLAN #2

54
Assessment
Subjective:“Mag lisodnasijapaghingassawayana side saijalawas” as verbalized by the pt.
significant other.
Objectives:
 Hemiplegia
 Muscle strength test: 2/5
 Difficulty in alternating pronation and supination of hands rapidly.
 Assisted upon movement
Nursing Diagnosis

Impaired Physical Mobility related to neuromuscular impairment

Planning

After 8 hours of nursing intervention, pt. will be able to increase strength and function of
affected body part.

Intervention

Nursing intervention Rationale

 INDEPENDENT
Determined functional level classification 0-4.
Identifies strengths and deficiencies that may
(Level 3: The client requires help from another provide information regarding recovery. Assists in
person and equipment device) choice of interventions, because different
techniques are used for flaccid and spastic
paralysis.

Changed positions at least every 2 hrs (supine, Reduces risk of tissue injury. Affected side has
side lying) and possibly more often if placed on poorer circulation and reduced sensation and is
affected side. more predisposed to skin breakdown.
Positioned in prone position once or twice a day if Helps maintain functional hip extension; however,
patient can tolerate. may increase anxiety, especially about ability to
breathe.

Provided or assist with range of motion To maintain joint mobility, improve circulation,

55
 interventions.
Encouraged participation in self-care;
occupational, diversion or recreational activities
DEPENDENT
Assisted in treatment of underlying condition
causing pain/dysfunction.
Collaborated with physical medicine specialist
and occupational or physical therapies in
providing range of motion exercise, isotonic
muscle contractions.
Evaluation:
Goal partially met. After 8 hours of nursing intervention, pt. was able to increase strength and
function of affected body part.
and prevent contractures.
Enhances self-concept and sense of independence.
To maximize the potential for mobility and
function.
To develop individual exercise and mobility
program, to identify appropriate mobility devices,
and to limit or reduce effects and complications of
immobility.
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 NURSING CAREPLAN #3

Assessment
Subjective:“Lujaakolawas” as verbalized by the pt.
Objectives:
 fatigue
 body weakness noted
 Inability to maintain usual routines

Nursing Diagnosis

Fatigue related to Physiological condition

Planning

After 8 hours of nursing intervention thepatient will be able to perform activities of daily
living and participate in desired activities at level of ability.

Intervention

Nursing intervention Rationale

 INDEPENDENT
Assessed vital signs. To evaluate fluid status and cardiopulmonary response
to activity.

Evaluated aspect of “learned helplessness” that Can perpetuate a cycle of fatigue, impaired
may be manifested by giving up. functioning, and increased anxiety and fatigue.
Noted daily energy patterns. This is helpful in determining pattern/timing of
activity.

Accept the reality of fatigue and do not
underestimate effect on client’s quality of life
Encouraged the use of assistive devices (ex.
Wheeled walker. Wheelchair, Cane) as needed.
For example clients with severe disease are prone
to more frequent and severe fatigue following
minimal energy expenditure and require a longer
recovery period than the usual
To extend active time/conserve energy for other
tasks

57
  DEPENDENT/COLLABORATIVE
Referred to comprehensive rehabilitation program, To improve stamina, strength, and muscle tone
physical/occupational therapy for programmed and to enhance sense of well being
daily exercises and activities
Provided supplemental oxygen as indicated (via The presence of anemia and hypoxia reduces
nasal cannula running at 3L/min) oxygen available for cellular uptake and
contributes to fatigue.

Evaluation:

Goal met. After 8 hours of nursing intervention, client was able to perform activities of daily
living such as eating small meals by herself and walking within a certain range and participate in
desired activities at level of ability.

58
 NURSING CAREPLAN #4

Assessment
Subjective:“Mag lisodkopaghingas nan akoraisa, magpaalalaykosaakoanak” as
verbalized by the pt.
Objectives:
 Fatigue
 Observe body malaise and discomfort
 Difficulty maintain balance
 Hemiplegia
Nursing Diagnosis

Activity intolerance related to immobility

Planning

After 8 hours of nursing intervention thepatient will be able to identify techniques to

enhance activity intolerance

Intervention

Nursing intervention Rationale

 INDEPENDENT
Notedclients report of weakness, fatigue, pain, Symptoms may be a result of or contribute to
intolerance of activity
difficulty accomplishing tasks, and/ or insomnia.
Noted treatment related factors such as side Which can affect the nature and degree of activity
effects and interactions of medications intolerance
Increased exercise/activity levels gradually To conserve energy
Assisted with activities and provide/monitor To protect the client from injury
client’s use of assistive devices (e.g. crutches,
walker, wheelchair, or oxygen tank)
Provided a positive atmosphere while This helps to minimize the frustration and
acknowledging the difficulties of the situation for rechannel energy.
the client

59
  DEPENDENT/COLLABORATIVE
Provided referral to other disciplines, such as To develop individually appropriate therapeutic
exercise physiologist, psychological counselling/ regimens
therapy, occupational/physical therapies, and
recreation/leisure therapies, as indicated
Implemented a physical therapy/exercise program A collaborative program with short term
in conjunction with the client and other team achievable goals enhances the likelihood of
members. success and may motivate the client to adopt a
lifestyle of physical exercise for the enhancement
of health

Evaluation:

Goal met. After 8 hours of nursing intervention the patient able to identify techniques to enhance
activity intolerance.

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 NURSING CAREPLAN #5

Assessment
Subjective: “Dili pa nako kaya motindognanakoraisaky nag adjust pa kosaakopgka
stroke” as verbalized by the pt.

Objectives:
 Hemiplegia
 Muscle strength 2/5
 Body malaise
 Fatigue

Nursing Diagnosis

Risk for fallsrelated to proprioceptive deficit

Planning

After 8 hours of nursing intervention thepatient will be able to verbalized understanding

of individual factors that contribute to possibility of injury.

Intervention

Nursing intervention Rationale

 INDEPENDENT These affect the client’s ability to protect self
Noted the client’s age, gender, developmental and/or others, and influence choice of
stage, decision making ability, and level of interventions and teachings.
cognition/ competence.

Assessed client’s muscle strength and gross and To identify risk for falls. Note: The frequency of
fine motor coordination falls increases with age and frailty level. Risk
factors for falls lie in four categories: 1.
Biological, 2. Behavioral 3. Environmental 4.
Socioeconomic. In each of these areas, some risk

61
 factors can be modified to decrease the fall risk.
Considered hazards in the care setting and/or Identifying needs or deficit provides opportunities
home environment for intervention or intstruction.
Utilized chairs/bed alarms Alert when client is trying to get up alone
Provided seat raisers for chairs, use of stand- To prevent injury to both client and care provider.
assist, repositioning or lifting devices as indicated
 DEPENDENT To identify high risk tasks, conduct site visits;
Referred to physical or occupational therapist as select, create and modify equipment and assistive
appropriate devices; and provide education about body
mechanics and musculoskeletal injuries in
addition to providing therapies as indicated.

Encouraged participation in self-help programs, To enhance self-esteem and sense of self-worth.

such as assertiveness training, positive self-image.

Evaluation:

Goal met. After 8 hours of nursing intervention thepatient was able to verbalize understanding of
individual factors that contribute to possibility of injury.

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 NURSING CAREPLAN #6

Assessment
Subjective: “Mag pa alalayakosaakoanakpagpanawky mag lisod pa ako” as verbalized
by pt.
Objective:
 Muscle strength 2/5
 Impaired ability to walk required distances
 Half of her body is paralyzed
Diagnosis

Impaired walking related to insufficient muscle strength

Planning

After 8 hours of nursing intervention thepatient will be able move about within
environment as needed within limits of ability or with appropriate adjuncts.

Intervention

Nursing intervention Rationale

 INDEPENDENT
Assisted with or review result of mobility testing For differential diagnosis and to guide treatment
(e.g., gait, timing of walking over fixed distance, interventions.
walked over set period of time [endurance].
Implemented fall precaution for high risk clients. To reduce risk of accidental injury.
Identified appropriate resources for obtaining and To promote mobility.
maintaining appliances, equipment, and
environmental modification.
 DEPENDENT To assess client ability to ambulate safety.
Performed “Timed Up and Go (TUG)” test, as
indicated.
Consulted with physical therapist, occupational For individualized mobility program and identify and
therapist, or rehabilitation team. develop appropriate devices.
Involved client/S.O in care, assisting them to learn To enhance safety for clients and S.O/caregiver.

63
ways of managing deficits.

Evaluation:

Goal partially met: After 8 hours of nursing intervention thepatient was able to move about
within environment as needed within limits of ability or with appropriate adjuncts but still needs
assistance upon doing so.

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 DISCHARGE PLAN
MEDICATIONS:

 Take medication exactly as directed.

 Inform the S.O about the possible side effects of the medications.
 Continue taking the medicines prescribed by the physician such as:
 Carvedilol 6.25 mg 1 tab BID
 Amlodipine OD
 Lozartan OD
 Diamecron OD
 Advised patient don’t skip doses
 Continue taking antibiotics as directed until they are all gone.

ENVIRONMENT

 Advice patient or SO by providing quiet environment, and avoiding stressful Situation.

 Advice S.O to clean up the room regularly
 Advice S.O to encourage them to participate in rehabilitation sessions so they can learn
functional assistance techniques and communication skills, which can enhance their
ability to care for the pt.
 Advice patient smell fresh air such as: go to beach.
 Avoid polluted area.

TREATMENT

 Instructed patient to follow proper instructions medications prescribed by the

physician.
 Comply with medication.
 Increased fluid intake
 Utilized deep breathing exercise for at least twice a day.
 Observe adverse effect that need to report such as: dizziness, fatigue, headache.

65
HEALTH TEACHINGS

Activities

 Bed rest upon arrival at home from the hospital.

 Light exercise (Active and Passive ROME)
 Eventually the patient can return to its normal activities of daily living.
 Clinic appointment schedule
 Understanding and knowing what to do with side effects of medications.
 Remember that adjusting to the effects of stroke takes time.
 Appreciate each small gain as you discover better ways of doing things.

Hygiene

 Encourage personal hygiene regularly

 Proper handwashing is necessary
 Bath regularly
 Oral care
 Perineal care

OPD- FOLLOW-UP:

 Instruct patient to follow scheduled check up

 Instruct patient to seek medical attention when adverse reactions and sign and symptom
occurs.

DIETARY MANAGEMENT:

 Maintain high fiber and low fat and sugar diet

 Reduce dietary sodium intake.
 Eat more fruits and vegetables to facilitate easy bowel movement.
 Drink several glasses of water a day.
 Drink prescribed milk
 Eat a balance diet so your body can work its best and heal quickly.

66
SPIRITUAL

 Encourage patient to be more faithful and have trust in God

 Encourage SO to pray for the patient’s early recovery.
 Spiritual counseling
 Anger management
 Supportive counseling

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 APPENDICES

Summary Vital Signs

Date Time BP PR RR Temp O2

Inhalation

9-24-19 10:50 am 90/80 73 21 36.2 100%

12 nn 120/90 69 18 36.0 100%

2 pm 120/80 70 17 36.0 100%

4 pm 120/80 73 18 36.2 100%

6 pm 130/80 64 18 36.6 100%

8 pm 130/80 76 22 36 100%

12 mn 130/80 57 20 36 100%

4 am 130/80 66 20 36 100%

9-25-19 8 am 110/70 79 22 36 98%

10 am 120/80 98 23 36 98%

12 nn 110/70 89 23 36 96%
2 pm 110/70 75 22 36.0 98%
4 pm 110/70 74 23 36.6 97%
6 pm 110/70 72 20 36 96%

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 Summary of IVF

Date # of Solution Volume Additive Rate of Time

Bottle Drop
9/24/19 1 1L PLR 30gtts 8:34 am
2 1L PLR 30gtts 2:00 pm
3 1L PLR 30gtts 9:20 pm
9/25/19 4 1L PLR 30gtts 5:50 am
5 1L PLR 30gtts 12:04 noon

O2 Inhalation

Date Type Time

9/24/19 Mask valve (O2 inhalation via mask valve –full tank) 10:50 am

Mask valve (O2 inhalation via mask valve) 4:00 pm

9/25/19 Mask valve shifted via nasal cannula (3L/min) 8:00 am

69
 Intake and Output Sheet

Date Credit Consumed Oral Fluid Total Urine Vomitus Bowel Total
taken Taken Output Movemen Output
t
9/24/1
9 NH 2,000 100 2,100 400 - 1x 400
(7am- +1x
7pm)
7pm-
7am NH 1,000 NPO 1,000 400 - - 400

Total 3,100 800+

1x BM

70
 GENOGRAM

93 81
Natural Death Hypertension
(Old age)

76 71 20 42
CVA DM Drowned Accident

Legend

Female
( ) = Cause of Death

Male Client

Deceased

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Definition of Terms

Cerebrovascular accident (stroke)- sudden occurrence of a focal, nonconvulsive neurologic

deficit. Due to lack of oxygen when the blood flow to the brain is impaired by blockage or
rupture of an artery to the brain causes sudden death of brain cells.

Ischemic stroke- A blockage of a blood vessel in the brain or neck.

Hemorrhagic stroke- Bleeding into the brain or the spaces surrounding the brain.

Transient ischemic attacks or TIAs- sometimes called “mini strokes”. Although brief, they
identify an underlying serious condition that isn’t going away without medical help.
Unfortunately since they clear up, many people ignore them.

Pneumonia-Pneumonia is an infection that inflames the air sacs in one or both lungs. The air
sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever,
chills, and difficulty breathing.

Myocardial infarction (MI)-Also called as heart attack is the irreversible death (necrosis) of
heart muscle secondary to prolonged lack of oxygen supply (ischemia).

Urinary tract infection-An infection in any part of the urinary system such as the kidneys,
ureters, bladder and urethra. Most infections involve the lower urinary tract; the bladder and the
urethra.

Extracranial bleeding-It is a collection of blood (hematoma) outside the cranium (skull).

Pulmonary embolism (PE)- When a blood clot (thrombus) becomes lodged in an artery in the
lung and blocks blood flow to the lung.

Pressure sores (Bed sores)-These are injuries to the skin and underlying tissue resulting from
prolonged pressure on the skin. Bedsores most often develop on the skin that covers bony areas
of the body, such as heels, ankles, hips and tailbone.

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Computed Tomography (CT) of the head-This is to detect a stroke from a blood clot or
bleeding within the brain.
MRI of the head- It is used to assess brain damage from stroke.

Hematology- Hematology is the science or study of blood, blood-forming organs and blood
diseases. In the medical field, hematology includes the treatment of blood disorders and
malignancies, including types of hemophilia, leukemia, and lymphoma and sickle-cell anemia.
Hematology is a branch of internal medicine that deals with the physiology, pathology, etiology,
diagnosis, treatment, prognosis and prevention of blood-related disorders. (Ramanan, 2013)

Electrocardiogram (ECG/EKG) – This check the hearts’ electrical activity, can help whether
heart problems caused the stroke.

Carotid ultrasound/Doppler ultrasound- To check for narrowing and blockages in the body’s
two carotid arteries, which are located on each side of the neck and carry blood from the heart to
the brain. Doppler ultrasound produces detailed pictures of these blood vessels and information
of blood flow.

Cerebral angiography- It is a medical test with one of the three imaging technologies; x-rays,
CT or MRI and in some cases a contrast material, to produce pictures of major blood vessels in
the brain. Cerebral angiography helps physicians detect or confirm abnormalities such as blood
clot or narrowing of the arteries.

Tissue Ischemia- Ischemia or ischaemia is a restriction in blood supply to tissues, causing a

shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is
generally caused by problems with blood vessels, with resultant damage to or dysfunction
of tissue.

Paralysis- Paralysis is the loss of muscle function in part of your body. It happens when
something goes wrong with the way messages pass between your brain and
muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It
can also occur in just one area, or it can be widespread.

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 REFERENCES

Books

 Medical Surgical Nursing 10th edition by Brunner and Suddarth

 Nurse’s Pocket Guide 14th edition by Doenges, Moorhouse and Murr.
 Davis’s Drug Guide for Nurses 11thEdition
 Walsh and Hoyts Clinical Neuro- Opthalmology
Journals / Articles
 Umansky F, Gomes FB, Dujovny M, et al. The perforating branches of the middle
cerebral artery: A microanatomical study. J Neurosurg 1985;62:261–268.
 Stroke Management- Official Journal of Indian Academy of Neurology

Electronic Sources
 https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/effects-of-stroke
 https://courses.lumenlearning.com/boundless-ap/chapter/the-brain/
 https://www.christopherreeve.org/living-with-paralysis/health/causes-of-paralysis/stroke
 https://emedicine.medscape.com/article/1916852-overview?fbclid=IwAR0MWtIsAO-
8UnCaGSLcrRredn-IA1ivSSe5_Kyi0tLsBMeb_TSe3QYaMMk#a4
 http://www.strokecenter.org/professionals/stroke-diagnosis/stroke-assessment-scales-
overview/?fbclid=IwAR012K_OiSXSb-zRgqPKzliXc4kWP3a8aB2YQuqmrbaEqAYU2brKQdOhaYw
 http://www.strokecenter.org/professionals/stroke-diagnosis/stroke-assessment-scales-
overview/?fbclid=IwAR012K_OiSXSb-zRgqPKzliXc4kWP3a8aB2YQuqmrbaEqAYU2brKQdOhaYw
 http://www.strokecenter.org/professionals/stroke-management/for-pharmacists-
counseling/pathophysiology-and-etiology/?fbclid=IwAR3P-
PHFJ4BBtV8w5B0WnaebEH_ZWjZACQDtQzhdPXi3jR67pvqhAQ9II6Q
 https://www.hindawi.com/journals/crinm/2012/487080/?fbclid=IwAR2L3nlyHFVvUzj4b-
0yaEgJlLYDf_8BGOJhAthKZH3ddOKB7Eyovb_jXKc

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