JMJ MARIST BROTHERS

Notre Dame of Dadiangas University

Marist Avenue, General Santos City
College of Health and Sciences

A CASE STUDY ON ACUTE ISCHEMIC STROKE

Submitted to

Jules Alexis B. Dajay, RN, MAN

Presented By
Abdullah, Sandra, SN
Abrea, Reginne Mae, SN
Boyles, Andrei Ysabelle, SN
Cerna, Louchelle, SN

October, 2021

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 Table of Contents

Title Page

Title Page i
ii
Table of Contents
iii

Chapter I Introduction 4

Etiology, Incidence and Epidemiology of the Case 5

Chapter II Objectives 6

Chapter III Anatomy and Physiology 8

Chapter IV Pathophysiology 10

Chapter V Medical & Nursing Management 14

Laboratory and Diagnostic Studies 14

Medical Management 19

21
Drug Studies

40
Nursing Management

42
Prognosis

Chapter VI Gordon’s Functional Health Pattern 45

Prioritization of Problems 70

2ii
 75
Nursing Care Plans
97
Health Teachings
99
Bibliography
101
Curriculum Vitae

3iii
 Chapter I

INTRODUCTION

This chapter presents the definition of the disease, the signs and symptoms of the

present, the cause, and as well as the review of related literature and studies of the topic.

Etiology, Incidence, and Epidemiology of the Case

Ischemic stroke, often known as a "brain attack" or "cerebrovascular disease," is

an abrupt loss of function caused by a disturbance in the blood flow to a portion of the

brain. The term "brain attack" has been used to imply to health care providers and the

general public that a stroke, like a heart attack, is a serious health problem that requires

immediate attention (Hinkle & Cheever, 2017). It is usually caused by a blood clot that

blocks or plugs a blood vessel in the brain. This keeps blood from flowing to the brain.

Within minutes, brain cells begin to die. Another cause is stenosis, or narrowing of the

artery.

Ischemic stroke are subdivided into five different types based on the case: large

artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%),

cardiogenic embolic strokes (20%), cryptogenic strokes (30%, and others (5%). Small

penetrating artery thrombotic strokes affect one or more vessels and are a common type

of ischemic stroke. Cardiogenic embolic strokes are associated cardiac dysrhythmias,

usually atrial fibrillation. Ant the last two classifications which are cryptogenic strokes,

which have unknown cause, and strokes from other causes such as illicit drugs (cocaine),

coagulopathies, migraine/vasospasm, and spontaneous dissection of the carotid or

vertebral arteries (Hinkle & Cheever, 2017).

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 In the United States, almost 800,000 people have a stroke each year; 82–92

percent of these strokes are ischemic. Stroke is the fifth greatest cause of adult mortality

and disability, with an annual cost of more than $72 billion. Total direct medical stroke-

related expenditures are expected to quadruple between 2012 and 2030, reaching $184.1

billion, with people aged 65 to 79 accounting for the bulk of the estimated rise in costs.

Each year, 15 million individuals worldwide suffer from a stroke, according to the World

Health Organization (WHO) (Jauch, 2020). Five million people die, and another five

million are permanently crippled. In 2017, 11.9 million stroke incidents (95 percent UI

11.1–12.8), 104.2 million prevalent (98.6–1102), 6.2 million fatal (6.0–6.3) cases, and

132.1 million stroke-related DALYs (126.5–137.4) were reported (Krishnamurthi, 2017).

Modifiable and nonmodifiable diseases are both risk factors for ischemic stroke.

The identification of risk factors in each patient can provide information about the etiology

of the stroke as well as the best therapy and subsequent prevention strategy.

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 Chapter II

OBJECTIVES

This chapter presents the general and specific objectives for this case study.

General Objectives:

The ultimate goal of this study is to elevate the level of knowledge, awareness and

have a thorough understanding with regards to Acute Ischemic Stroke; its nature, causes,

clinical manifestations, management and prognosis in order to increase competency in

health, preventing disease and rehabilitating patients through a case presentation.

Specific Objectives:

After the case presentation, the student nurses will be able to:

● Present an introduction of Chronic Kidney Disease;

● State the general and specific objectives of the study;

● Enumerate the obtained initial database;

● Discuss the past and present illness of the patient;

● Discuss the basic background of the anatomy and physiology of the system

involved;

● Trace the pathophysiology of the Chronic Kidney Disease through the

schematic diagrams;

● Compare the clinical manifestations of the Chronic Kidney Disease based

on the theories and actual observations;

● Explain the assessment and diagnostic findings;

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● Interpret the laboratory results and the nurses’ responsibilities;

● Discuss the medical and nursing management of Chronic Kidney Disease;

● Outline the drug study from the patient’s medication;

● Develop the discharge planning of the patient;

● Explain the Gordon’s Functional Health Pattern of the Patient; and

● Construct an individual nursing care plan for a patient with Chronic Kidney

Disease

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 Chapter III

ANATOMY AND PHYSIOLOGY

This chapter includes the anatomy and physiology of the system involved in the

case of Acute Ischemic Stroke to better understand the case study and its affected parts

of the system being discussed.

Anatomy and Physiology of the Central Nervous System

Depending on the kind, severity, location, and number of strokes, the effects differ

from person to person. The brain is a complicated organ. Each part of the brain is in

charge of a certain function or skill. When a

section of the brain is destroyed by a stroke,

it is possible that a component of the body will

lose its usual function. This could lead to a

handicap. The central nervous system (CNS)

is in charge of the majority of bodily and

mental activities. It is divided into two

sections: the brain and the spinal cord. The

brain is the seat of our ideas, the interpreter of Figure 1. Brain

our surroundings, and the source of body movement control.

The brain is the body's most metabolically active organ. It requires 15–20 percent

of the entire resting cardiac output to provide the necessary glucose and oxygen for its

metabolism, although accounting for only 2% of the body's mass.

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 The anterior, middle, and posterior cerebral arteries are three paired main arteries

that supply the cerebral hemispheres. The anterior and middle cerebral arteries, which

come from the supraclinoid internal carotid arteries, carry the anterior circulation. The

anterior cerebral artery (ACA) nourishes the medial and parietal lobes, as well as the

basal ganglia and anterior internal capsule, with blood.

The lateral regions of the frontal and parietal lobes, as well as the anterior and

lateral portions of the temporal lobes, are supplied by the middle cerebral artery (MCA),

which also gives rise to perforating branches to the globus pallidus, putamen, and internal

capsule. The MCA is the hemispheres' primary source of circulatory supply.

The basilar artery gives birth to the posterior cerebral arteries, which carry the

posterior circulation. The perforating branches of the posterior cerebral artery (PCA)

nourish the thalami and brainstem, whereas the cortical branches supply the posterior

and medial temporal lobes and occipital lobes.

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 Chapter IV

PATHOPHYSIOLOGY

This chapter presents the pathophysiology and textual discussion of Ischemic Stroke for better understanding of the case study.

Figure 2. Pathophysiology of Acute Ischemic Stroke

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Textual Discussion:

Acute ischemic stroke occurs when blood flow to the brain is blocked by a clot,

which is a mass of thickened blood that forms in a brain artery. Clots are classified as

either thrombotic or embolic, depending on where they form in the body and how large

they are. It is the most frequent type of stroke, occurring when a blood clot forms within

an artery in the brain, that causes the condition. Embolic stroke happens when a little

piece of plaque (fatty deposit) breaks off from somewhere else in the body, such as the

heart, and travels through the bloodstream before becoming lodged in a narrower channel

in the brain, which causes the person to have a transient loss of consciousness

(Penumbra, 2021).

As a result of decreased blood flow to the brain region, significant stress and

untimely cell death can occur in the brain region (necrosis). Necrosis is followed by the

breakdown of the plasma membrane, the enlargement of organelles and the leakage of

cellular contents into the extracellular space, as well as the loss of neuronal function.

Aside from inflammation and energy failure, loss of homeostasis and acidosis, increased

intracellular calcium levels, excitotoxicity, free radical-mediated toxicity, cytokine-

mediated toxicity, complement activation, impairment of the blood–brain barrier,

activation of glial cells, oxidative stress, and infiltration of leukocytes are all important

factors in the pathogenesis of stroke (Xiao & Kuriakose, 2020).

An ischemic stroke is presented through a sudden loss of blood circulation to an

area of the brain which can cause corresponding loss of neurologic function depending

on which areas are affected. Acute ischemic stroke is caused by a thrombotic or embolic

occlusion of a cerebral artery. This can cause ischemia which results in cell hypoxia and

11
depletion of adenosine triphosphate in cells (ATP). The loss of AT, the energy to maintain

ionic gradients across the cell membrane and cell depolarization. The influx of sodium

and calcium ions and passive inflow of water into cells which leads to cytotoxic edema

(Jauch, 2021).

When brain perfusion is below <5% for 5 minutes, some neurons die. The extent

of damage will depend on how severe the ischemia is. It is considered as mild if damage

proceeds slowly. Even 40% of normal perfusion may result in complete brain tissue in the

span of 3 to 6 hours. If severe ischemia persists within >15 to 30 minutes all of the affected

tissues will die or also called as infarction. In patients who have hyperthermia damage

occurs more rapidly and slowly for patients with hypothermia (Chong, 2020).

Symptoms will differ depending on the area affected. When the middle cerebral

artery which involves the lateral hemisphere, parietal and temporal lobes and basal

ganglia. The symptoms that may arise when this area is affect are contralateral

hemiparesis, hemiplegia, unilateral neglect, altered consciousness, homonymous

hemianopsia, inability to turn eyes toward side, vision changes, dyslexia, dysgraphia,

aphasia, agnosia memory deficits and vomiting. For patients where the anterior cerebral

artery is affected, it mostly affects the frontal lobe. Patient may experience contralateral.

hemiparesis, foot and leg deficits greater than the arm, foot drop, gait disturbances,

contralateral hemisensory alterations, and deviation of eyes toward affected side,

expressive aphasia, confusion, amnesia, flat affect, apathy, and shortened attention span,

loss of mental acuity, apraxia, and incontinence. Areas such as the occipital lobe, anterior

and medial portion of temporal lobe are involved when the posterior cerebral artery is

affected, the patient may feel mild collateral hemiparesis, intention tremor, diffuse sensory

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loss, pupillary dysfunction, loss of conjugate gaze, nystagmus, loss of depth perception,

cortical blindness, homonymous hemianopsia, preservation, dyslexia, memory deficits,

and visual hallucinations. For patients who have contralateral hemiparesis with

asymmetry, contralateral sensory alterations, homonymous hemianopsia, ipsilateral

periods of blindness aphasia if dominant hemisphere is involved, Mild Homer’s syndrome,

and carotid bruits, the affected area is the internal carotid artery. The cerebellum and

brain stem are affected when the vertebrobasilar system is involved, symptoms such as

alternating motor weakness, ataxic gait, dysmetria, contralateral hemisensory

impairments, double vision, homonymous hemianopsia, nystagmus, conjugate gaze,

paralysis, dysarthria, memory loss, disorientation, drop attacks tinnitus, hearing loss,

dysphagia, and coma may be observed. For the anterior cerebellar affected area,

ipsilateral ataxia, facial paralysis, ipsilateral loss of sensation in face, sensation changes

on trunk and limbs, nystagmus, Homer’s syndrome, tinnitus, and hearing loss may be

experienced by the patient. And lastly, if the posterior cerebellar region is affected, patient

may be observed with ataxia, paralysis of the larynx and soft palate, ipsilateral loss of

sensation of the face, contralateral on body, nystagmus, dysarthria, Homer’s syndrome,

hiccups and coughing, vertigo, nausea, and vomiting (Heiyu, 2018)

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 Chapter V

MEDICAL AND SURGICAL MANAGEMENT

This chapter presents the medical and surgical management of the disease, the

laboratory and diagnostic tests, as well as the drug studies, ideal nursing management

and the prognosis of the disease.

Ideal Laboratory Tests

Complete blood count (CBC)

● A group of tests that evaluate the cells that circulate in blood, including red blood

cells (RBCs), white blood cells (WBCs), and platelets (PLTs). The CBC can

evaluate your overall health and detect a variety of diseases and conditions, such

as infections, anemia and leukemia (Lab Tests Online, 2021). Commented [1]: Complete Blood Count (CBC). (2021,
June 18). Labtests Online. Retrieved November 7,
2021, from https://labtestsonline.org/tests/complete-
● A CBC measures the overall health of the blood and helps diagnose infection, blood-count-cbc

anemia, clotting problems, or other blood problems.

Table 1. Complete Blood Count Normal Values

Values Interpretation

Male Female

RBC Count 4.35 - 5.65 trillion 3.92 - 5.13 trillion Normal

cells/ L cells/L
(4.35-5.65 million (3.92 - 5.13
cellsmcL) million cells/mcL)

Hemoglobin 13.2 - 16.6 11.6-15 grams/ dL Normal

grams/dL (116-150
(132-166 grams grams/L)
L)

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 Hematocrit 38.8 - 48.6 % 35.5 - 44.9 % Normal

WBC Count 3.4 - 9.6 billion cells/L Normal

(3,400 to 9, 000 cells/mcL)

Platelet Count 135-317 billion/L 157-371 billion/L Normal

(135, 000 to (157,000 to
317,000 mcL) 371,000 mcL)

Serum electrolytes

● Is a blood test that measures levels of the body's main electrolytes (Medline

Plus, n.d). Commented [2]: Electrolyte Panel. (n.d.). Medline

Plus. Retrieved November 7, 2021, from
https://medlineplus.gov/lab-tests/electrolyte-panel/
● This test looks at substances in the blood that carry an electric charge, called

electrolytes. An electrolyte problem can cause stroke-like symptoms such as

confusion or muscle weakness. Electrolytes also show whether the patient is

dehydrated, which can cause confusion or tiredness. This test can also show

whether the patient has kidney problems, which can change the stroke tests and

treatments.

Table 2. Serum Electrolytes Normal Values

Electrolyte Values Interpretation

Sodium 135-145 mEq/L Normal

Potassium 3.5-5.0 mEq/L Normal

Chloride 98-106 mEq/L Normal

Bicarbonate 24-31 mEq/L Normal

Calcium 8.5-10.5 mg/dL Normal

Phosphorus 2.5-4.5 mg/dL Normal

Magnesium 1.8-3.0 mg/dL Normal

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Coagulation Test

● These tests measure how quickly blood clots. It is also called a coagulation

panel. If the blood clots too quickly, the stroke may have been caused by a clot

(ischemic stroke). If the blood clots too slowly, the stroke may have been caused

by bleeding (hemorrhagic stroke). It may take longer if you take blood thinners

Partial thromboplastin time (PTT) determines if the blood-thinning therapy is

effective and International normalized ratio (INR) ensures that results from a PT

test are the same from one lab to another. (Pietrangelo, 2018). Commented [3]: Pietrangelo, 2018. Coagulation tests.
Retrieved on November 07, 2021 from
https://www.healthline.com/health/coagulation-tests

Table 3. Coagulation Tests Normal Values

Coagulation Tests Values Interpretation

Prothrombin Time 10-12 seconds Normal

(PT)

Partial Thromboplastin 30-45 seconds

Time (PTT)

International 1 to 2 Normal
Normalized Ratio
(INR)

Thyroid tests

● The doctor may measure the patient's thyroid hormone levels with a blood test.

Having hyperthyroidism raises the risk of atrial fibrillation, which can lead to

stroke.

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Blood glucose

● This test measures the glucose (sugar) in the blood. Low blood sugar is a

common complication of diabetes treatments. Low blood sugar can cause

symptoms of a stroke, even when it's not a stroke.

Cholesterol tests

● This test examines whether high blood cholesterol might have led to stroke.

Table 4. Cholesterol Range of Values

Amount Total LDL HDL Triglycerides

(mg/dL)

Ideal <200 <100 >60 <150

Borderline 200-239 130-159 F: 40-59 150-199

M: 50-59

Too high or >240 High: 160- F: <40 High: 200-

low 189 M: <50 499
Very high:
Very high: >500
>190

C-reactive protein test and blood protein test

● These tests look for substances in the blood that the body releases in response

to swelling or inflammation. Damage to arteries is one cause of inflammation.

The doctor might order these tests to understand stroke risk better and to

determine how to treat your stroke.

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Figure 3. C-Reactive Protein Range

Ideal Diagnostic Tests

Physical examination. The doctor will do many tests that the patient is acquainted

with, including listening to the heart and monitoring blood pressure. A neurological exam

may be performed on the patient to see how a probable stroke is impacting his nervous

system (Mayo Clinic, 2021).

Non-contrast computed tomography (CT) scan. A CT scan creates a detailed

image of your brain by using a sequence of X-rays. A CT scan can reveal brain

hemorrhage, an ischemic stroke, a tumor, or other issues. This is the initial diagnostic test

for a stroke and should be performed within 25 minutes or less from the time the patient

presents to the emergency department to determine if the event is ischemic or

hemorrhagic as the type of stroker determines treatment (Hinkle & Cheever, 2017).

12 - Lead Electrocardiogram (ECG). This is to identify the source of the thrombi

or emboli. Sound waves are used in an echocardiography to obtain detailed pictures of

the heart. An echocardiography can detect clots in the heart that have migrated from the

heart to the brain, resulting in a stroke (Hinkle & Cheever, 2017).

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 Other studies may include CT angiography o CT perfusion; magnetic resonance

imaging (MRI) and magnetic resonance angiography of the brain and neck vessels;

transcranial Doppler Flow studies; transthoracic or transesophageal echocardiography;

xenon-enhanced CT scan; and single photon emission CT scan (Mayo Clinic, 2021).

Ideal Medical Management

The goal of treatment after an ischemic stroke is to restore blood flow to the

afflicted part of the brain as soon as possible, preferably during the first few hours after

the onset of stroke symptoms.

Antiplatelets. If thrombolytic therapy is not possible, antiplatelet therapy is

generally used immediately, or it may be given after thrombolytic therapy. Antiplatelet

therapy is useful in the treatment of acute ischemic stroke because it helps prevent new

clots from forming.

Anticoagulants. Anticoagulants, also known as anti-clotting drugs, are often

referred to as "blood thinners," but they don't really thin the blood; instead, they make it

less likely to clot. Anticoagulants such as heparin and low molecular weight heparin are

administered via injection or infusion (through a vein).

Intravenous Tissue Plasminogen Activator (tPA). Is a blood clot-dissolving

drug. A thrombolytic agent, sometimes known as a "clot buster," is an intravenous (IV)

medicine that is administered using a catheter put into a vein in the arm ithin the first three

hours. tPA can be given up to 4.5 hours after the onset of stroke symptoms.

Lifestyle Changes. Lifestyle changes, in addition to drug therapy, are an

important aspect of preventing recurrent stroke. Quitting smoking, avoiding or reducing

19
alcohol consumption, eating a nutritious diet, and exercising frequently are just a few

examples.

Rehabilitation. Based on a person's age, overall health, and degree of stroke

disability, a doctor will recommend the most intense therapy regimen that they can take.

begin as soon as you are released from the hospital. Following release, a person may

continue treatment at the same hospital's rehabilitation unit, another rehabilitation unit or

skilled nursing facility, as an outpatient, or at home.

Ideal Surgical Management

Mechanical Embolectomy. It is a cutting-edge, minimally invasive surgical

procedure for removing a blood artery obstruction. Mechanical embolectomy devices can

be utilized up to six hours (sometimes even 12 hours) following the onset of stroke

symptoms, but each hour that passes diminishes the advantages of treatment while

raising the hazards.

Cerebral Revascularization. If a stroke or mini-stroke was caused by

"cerebrovascular insufficiency," or a deficit in oxygen to the brain owing to a blocked or

restricted carotid artery, bypass surgery may be employed. Cerebral revascularization

surgery restores blood flow to the brain, which can help avoid strokes and transient

ischemic attacks.

Carotid Endarterectomy. The carotid arteries are the blood vessels that run down

each side of your neck and feed blood to your brain. This procedure clears the plaque

from a carotid artery, perhaps lowering your risk of ischemic stroke. A carotid

20
endarterectomy is not without danger, especially for those who have heart disease or

other medical problems.

Angioplasty and Stents. An angioplasty is a procedure in which a surgeon

threads a catheter through an artery in your groin to your carotid arteries. After that, a

balloon is inflated to widen the narrowed artery. Then, to support the opening artery, a

stent might be put.

Drug Study 1. warfarin (Coumadin)

Date Ordered N/A

Generic Name warfarin

Brand Name Coumadin

Classification Anticoagulants

Dosage and 2-5 mg/day with dosage adjustments based on the results of INR
Frequency and/or PT ratio determinations.

Rationale for Drug For treatment of acute MI, atrial fibrillation and pulmonary
Order embolism.

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 Prophylaxis and treatment of thromboembolic complications
Indications
associated with atrial fibrillation (AF) and/or cardiac valve
replacement; Reduction in the risk of death, recurrent myocardial
infarction (MI), and thromboembolic events such as stroke or
systemic embolization after myocardial infarction.

Contraindications ● Patients hypersensitivity to the drug and with bleeding

from GI, GU, or respiratory tract

● Patients with after recent surgery involving large open

areas, eye, brain or spinal cord.

Mechanism of Inhibits vitamin K-dependent activation of clotting factors II, VII,,

Action and X, formed in the liver. Also inhibits anticoagulant proteins C
and S.

Adverse Effects CV: vasculitis

GI: abdominal pain, diarrhea, flatulence

Hematologic: hemorrhage

Hepatic: Hepatitis

Respiratory: tracheal or tracheobronchial calcification

Skin: alopecia, pruritus,rash

Others: chills, hypersensitivity, anaphylactic reaction

● Severe bleeding, including heavier than normal menstrual

Side Effects bleeding.
● Red or brown urine.
● Black or bloody stool.
● Severe headache or stomach pain.
● Joint pain, discomfort or swelling, especially after an
injury.

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 ● Vomiting of blood or material that looks like coffee
grounds.
● Coughing up blood.

1. Obtain daily INR determinations upon initiation until stable

Nursing
Responsibilities in the therapeutic range, every 1 to 4 weeks.
2. Avoid all I.M injections.
3. Regularly inspect patient for bleeding gums, bruises on
arms or legs, nosebleeds, and such.
4. Stress the importance of complying with prescribed
dosage and follow-up appointments and evaluation.
5. Warn patient to avoid OTC medications containing aspirin,
other salicylates, or drugs that may interact with warfarin
unless ordered by the prescriber.
6. Instruct patient to observe behavior that prevents risk of
bleeding such as using a soft toothbrush.
7. Modify the patient's dietary intake with the dietician's
recommendation. Tell patient to read food labels because
food, nutritional supplements, and multivitamins that
contain vitamin K may impair anticoagulation.
8. Informt patient and the significant other to immediately call
the attention of the health care providers when adverse
reactions occur.

Table 5. Drug Study of warfarin (Coumadin)

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Drug Study 2. dabigatran (Pradaxa)

Date Ordered N/A

Generic Name dabigatran

Brand Name Pradaxa

Therapeutic:
Classification anticoagulants
Pharmacologic:
thrombin
inhibitors

Dosage and 150 mg twice daily

Frequency

Rationale for Drug To prevent stroke and harmful blood clots.

Order

Indications Indicated to reduce the risk of stroke and systemic embolism in

patients with non-valvular atrial fibrillation.

Contraindications ● History of a serious hypersensitivity reaction to Pradaxa

● Mechanical prosthetic heart valve
● Active pathological bleeding

Mechanism of Reversibly binds to the active site on the thrombin molecule,

Action preventing thrombin-mediated activation of coagulation factors. It
may have less of an antagonistic effect on thrombin-mediated
platelet aggregation
● black, tarry stools.
Adverse Effects ● bloody stools.
● stomach discomfort, upset, burning, or pain.

● Acid or sour stomach.

Side Effects ● belching.
● pain or burning in the throat.

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 ● vomiting of blood or material that looks like coffee
grounds.
1. Inform the patient about the information of the medication
Nursing and its importance.
Responsibilities 2. Instruct patient to not stop taking dabigatran unless
directed by the physician. Inform the patient if she/he
stops taking this medication early, she/he might have a
higher risk of forming a serious blood clot (such as a
stroke, blood clot in the legs/lungs).
3. Instruct patient to immediately report signs of Gi bleeding,
including abdominal pain, vomiting blood, blood in stools,
or black, tarry stools.
4. Emphasize to the patient and significant others to get
medical help right away if she/he has experience
weakness on one side of the body, trouble speaking,
sudden vision changes, confusion, chest pain, trouble
breathing, pain/warmth/swelling in the legs.
5. Educate patient on what to do when adverse effects
occur and report immediately to health care
professionals.

Table 5. Drug Study of Dabigatran (Pradaxa)

Drug Study 3. aspirin (Aggrenox)

Date Ordered N/A

Generic Name aspirin

Brand Name Aggrenox

25
Classification Antiplatelet
Agents

Dosage and 25mg/200mg; 1 capsule given twice daily - one in morning and
Frequency one in evening

Rationale for Drug Used to treat stroke

Order

Indications Indicated to reduce the risk of stroke in patients who have had
transient ischemia of the brain or completed ischemic stroke due
to thrombosis.

Contraindications Contraindicated to patients who are hypersensitive to any of its

drug components

Mechanism of Aggrenox is an aspirin/extended-release dipyridamole

Action combination that acts on multiple mechanisms of the platelet-
aggregation process to prevent clumping and clotting.

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Adverse Effects Body as a Whole: Hypothermia, chest pain, allergic reaction,
syncope

Cardiovascular: Angina pectoris, hypotension

CNS: Cerebral edema, dizziness, cerebral hemorrhage,

intracranial hemorrhage, subarachnoid hemorrhage

Immune System Disorders: Hypersensitivity, acute anaphylaxis,

laryngeal edema

Liver and Biliary System Disorders: Hepatitis, hepatic failure,

cholelithiasis, jaundice, hepatic function abnormal

Musculoskeletal: Rhabdomyolysis, myalgia

Metabolic and Nutritional Disorders: Hypoglycemia, dehydration

Skin Disorders: Rash, alopecia, angioedema, skin hemorrhages

such as bruising, ecchymosis, and hematoma, pruritus, urticaria,
and drug reaction with eosinophilia and systemic symptoms
(DRESS)

Urogenital: proteinuria, renal insufficiency and failure, hematuria

Side Effects CNS: headache

GI: nausea, vomiting, diarrhea, abdominal pain, dyspepsia

Nursing 1. Take Aggrenox exactly as it was prescribed for you. Follow

Responsibilities all directions on your prescription label and read all
medication guides or instruction sheets.
2. You may take Aggrenox with or without food. Do not stop
taking it unless the physician tells or orders you to.
3. Do not chew, break, or open an extended-release capsule.
Swallow the capsule whole.
4. Aggrenox may cause headaches when you first start
taking it. Call your doctor if these headaches are severe.
5. Educate the patient about his medicine since it makes it
easier for the patient to bleed, even from a minor injury
such as a fall or a bump on the head. Contact a doctor or

27
 seek emergency medical attention if experienced fall or hit
the patient’s head, or have any bleeding that will not stop.

Table 6. Drug Study of aspirin (Aggrenox)

28
Drug Study 4. simvastatin (Zocor)

Date Ordered None

Generic Name simvastatin

Brand Name Zocor

Classification HMG-CoA
inhibitors (statin);
antihyperlipidemic

Dosage and
Frequency 20-40 up to 80 mg PO daily in the evening

Rationale for Drug To treat hyperlipidemia

Order

Indications ● To reduce the risk of coronary disease

● Treatment of patients w/ isolated hypertriglyceridemia
● Treatment of type III hyperlipoproteinemia

Contraindications Hypersensitivity to the drug; active liver disease, pregnancy and

lactation

Mechanism of Inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA)

Action reductase; similar in action to lovastatin but more potent. HMG-
CoA reductase inhibitors increase HDL cholesterol, and decrease
LDL cholesterol, and total cholesterol synthesis.

29
Adverse Effects CNS: asthenia, headache

CV: edema, atrial fibrillation

EENT: sinusitis

GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence,

nausea, vomiting

GU: UTI

Musculoskeletal: myalgia

Respiratory: URI, bronchitis

Skin: eczema

● Headache, difficulty sleeping, flushing of the skin, muscle

Side Effects ashes, tenderness or weakness, drowsiness, dizziness,
nausea or vomiting, abdominal cramping, bloating or gas,
diarrhea, constipation, rash, low levels of blood levels of
blood platelets

Nursing 1. Obtain baseline and periodic (q6mo) liver function during

Responsibilities the first year and yearly thereafter. Monitor cholesterol
levels throughout therapy.
2. Monitor coagulation studies with patients receiving
concurrent warfarin therapy. PT may be prolonged.
3. Assess for and report unexplained muscle pain. Determine
CPK level at onset of muscle pain.
4. Instruct patients to report unexplained muscle pain,
tenderness, or weakness, especially if accompanied by
malaise or fever, to the physician.
5. Instruct the patient to report signs of bleeding to physician
promptly when taking concurrent warfarin.
6. Advise the patient to have moderate intake of grapefruit
juice while taking this medication.
7. Advise the patient not to breastfeed while taking this drug.

Table 7. simvastatin (Zocor)

30
Drug Study 5. metformin hydrochloride (Glucophage)

Date Ordered N/A

Generic Name metformin

hydrochloride

Brand Name Glucophage

Classification Antidiabetics

Dosage and 500 mg P.O

Frequency

Rationale for Drug To lower the glucose level of the patient with acute ischemic
Order stroke associated with type 2 diabetes.

Indications Adjunct to diet to lower glucose level in patients with type 2

diabetes

Contraindications 1. Patients hypersensitivity to the drug

2. Patient with hepatic or metabolic acidosis

Mechanism of Decreases hepatic glucose production and intestinal absorption

Action of glucose and improves insulin sensitivity (increases peripheral
glucose uptake and use).

31
Adverse Effects CNS: asthenia, dizziness, headache

CV: chest discomfort, palpitations, HTN

EENT: rhinitis

GI: diarrhea, nausea, vomiting, abdominal bloating

Metabolic: hypoglycemia

Musculoskeletal: myalgia

Respiratory: URI

Skin: flushing, diaphoresis

● physical weakness (asthenia)

Side Effects ● diarrhea.
● gas (flatulence)
● symptoms of weakness, muscle pain (myalgia)
● upper respiratory tract infection.
● low blood sugar (hypoglycemia)
● abdominal pain (GI complaints), lactic acidosis (rare)
● low blood levels of vitamin B-12

Nursing 1. Before therapy and at least annually thereafter, assess a

Responsibilities patient's renal function and risk for renal impairment.

2. Monitor a patient's glucose level regularly to evaluate the

effectiveness of therapy. Notify the prescriber if glucose
level increases despite therapy.

3. Monitor patient’s vital signs and interpret laboratory result,

immediately report the to the attending physician if any
changes occur.

4. Instruct the patient about the nature of diabetes and the

importance of following therapeutic regimen, adherence to
specific diet, losing weight, getting exercise, following
personal hygiene programs, and avoiding infection.

32
 5. Instruct the patient and the significant others to
immediately report if adverse reactions occur such as
unexplained hypoventilation, dizziness, malaise, muscle
pain and such.

6. Advise patient or the significant others not to cut, crush or

chew extended-release tablets; instruct patient to swallow
them whole.

7. Advise patient not to take other drugs, including OTC

drugs, without first checking it with the prescriber.

8. Instruct the patient to carry medical identification at all

times.

9. Tell the patient and the significant others not to change

drug dosage without the physician’s knowledge. Educate
the patient to follow instructions when taking the
medication.

10. Administer medication as prescribed by the physician.

Table 8. Drug Study of metformin hydrochloride (Glucophage)

33
Drug Study 6. losartan potassium (Cozaar)

Date Ordered N/A

Generic Name losartan

Potassium

Brand Name Cozaar

Classification Angiotensin II
receptor
antagonists

Dosage and PO: Hypertension- 50 mg/day initially (range 25-100 mg/day as a

Frequency single daily dose or divided into 2 doses)

Rationale for Drug Used to treat high blood pressure and heart failure
Order

Indications Indicated for the treatment of hypertension

● Hypersensitivity
Contraindications ● Pregnancy or lactation

Mechanism of Blocks vasoconstrictor and aldosterone producing effects of

Action angiotensin II at receptor sites, including vascular smooth muscle
and the adrenal glands.

CNS: Fatigue
Adverse Effects
GI: Diarrhea, drug induced hepatitis
GU: Renal failure

Side Effects CNS: Dizziness, headache

CV: Hypotension

34
 1. Assess blood pressure and pulse periodically during
Nursing therapy
Responsibilities 2. Monitor intake and output ratios and daily weight.
3. Encourage patient to comply with additional interventions
for hypertension such as weight reduction, low sodium
diet, discontinuation of smoking, regular exercise and
stress management.
4. Instruct patient and SO on proper technique for
monitoring blood pressure. Advise them to check blood
pressure at least weekly and to reprt significant changes
to the health care professionals.
5. Instruct patient to avoid sudden changes in position to
decrease orthostatic hypotension.
6. Advise patient to consult health care professionals before
taking any OTC or herbal cough, cold or allergy remedies
or other medications.
7. Emphasize the importance of follow-up exams to
evaluate effectiveness of medication
8. Emphasize the importance of continuing to take as
directed even if feeling well.
9. Emphasize the importance of continuing to take as
directed, even if feeling well. Tak missed doses as soon
as remembered if not almost time for the next dose; do
not double doses.
10. Educate patient that this medication may cause dizziness.
Caution patient to avoid activities requiring alertness until
response to medication is known.

Table 9. Drug Study of losartan potassium (Cozaar)

35
Drug Study 7. rivaroxaban (Xarelto)

Date Ordered N/A

Generic Name rivaroxaban

Brand Name Xarelto

Classification Anticoagulants;
Factor XA
inhibitors

Dosage and 20 mg PO qDay with evening meal

Frequency

Rationale for Drug Used to treat and prevent stroke by reducing blood clots
Order

Indications Indicated to reduce the risk of stroke and systemic embolism in

patients

Contraindications Contraindicated to patients who are hypersensitive to its drug

components

Mechanism of Rivaroxaban inhibits free FXa and prothrombinase activity.

Action Rivaroxaban has no direct effect on platelet aggregation, but
indirectly inhibits platelet aggregation induced by thrombin.

36
 Blood and lymphatic system disorders: Agranulocytosis,
Adverse Effects
thrombocytopenia
GI: Retroperitoneal hemorrhage
Hepatobiliary disorders: Jaundice, cholestasis, hepatitis
(including hepatocellular injury)
Immune system: Hypersensitivity, anaphylactic reaction,
anaphylactic shock, angioedema
CNS: Cerebral hemorrhage, subdural hematoma, epidural
hematoma, hemiparesis
Skin/Dermatologic: Stevens-Johnson syndrome, drug reaction
with eosinophilia and systemic symptoms (DRESS)

Side Effects Bleeding more easily than normal

GI: bleeding gums, abdominal pain, vomiting

Respi: nose bleed

CNS: dizziness, insomnia,

Musculoskeletal: back pain

Dermatologic: unusual brusing

Nursing 1. Monitor patients frequently for signs and symptoms of

Responsibilities neurologic impairment; if a neurologic compromise is
noted, urgent treatment is necessary
2. Premature discontinuation of anticoagulants, including
rivaroxaban, places patients at increased risk for
thrombotic events
3. If anticoagulation with rivaroxaban must be discontinued
for a reason other than pathologic bleeding, consider
administering another anticoagulant
4. Educate patient about the risk for thrombotic events
increased with premature discontinuation.
5. Continue to take rivaroxaban even if you feel well. Do not
stop taking rivaroxaban without talking to your doctor. If

37
 you stop taking rivaroxaban, your risk of a blood clot may
increase.

Table 10. Drug Study of rivaroxaban (Xarelto)

Drug Study 8. clopidogrel (Plavix)

Date Ordered N/A

Generic Name clopidogrel

Brand Name Plavix

Classification Antiplatelet
Agents,
Hematologic

Dosage and 75 mg, 300 mg P.O q.d.

Frequency

Rationale for Drug This decreases the ability of platelet adhesion and aggregation
Order

Indications ● To reduce the rate of myocardial infarction and stroke in

patients with acute ST-elevation myocardial infarction
(STEMI) who are to be managed medically. Plavix should
be administered in conjunction with aspirin.

Contraindications ● In patients with active pathological bleeding such as peptic

ulcer or intracranial hemorrhage.
● In patients with hypersensitivity (e.g., anaphylaxis) to
clopidogrel or any component of the product.

Mechanism of Inhibits the binding of ADP to its platelet receptor, impeding ADP-
Action mediated activation and subsequent platelet aggregation, and
irreversibly modifies the platelet ADP receptor.

38
Adverse Effects CNS: Confusion, hallucinations, fatal intracranial bleeding,
headache

CV: hypotension, hemorrhage at any site

EENT: epistaxis, rhinitis, taste disorder

GI: hemorrhage, abdominal pain, constipation, diarrhea,

dyspepsia, gastritis, ulcers

GU: UTI, hematuria

Hematologic: thrombotic thrombocytopenic purpura

Musculoskeletal: arthralgia, myalgia, arthritis

Respiratory: bronchospasm, interstitial pneumonitis

Skin: rash, pruritus, bruising, eczema, urticaria

● Chest pain
Side Effects ● Headache
● Flu Like syndrome
● Joint pain
● Pain
● Dizziness
● Diarrhea
● Rash
● Runny or stuffy nose
● Depression
● Urinary tract infection
● Increased bleeding
● Nosebleeds
● Itching
● Bruising

Nursing 1. Carefully monitor for and immediately report S&S of GI

Responsibilities bleeding, especially when coadministered with NSAIDs,
aspirin, heparin, or warfarin.
2. Lab tests: Periodic platelet count and lipid profile.
3. Evaluate patients with unexplained fever or infection for
myelotoxicity.

39
 4. Advise patients that it may take longer than usual to stop
bleeding and to refrain from activities in which trauma and
bleeding may occur.
5. Inform patient that drug may be taken without regard to
meals
6. Drug effectiveness depends on the drugs activation to an
active metabolite.
7. Consider alternative treatment for patient identified as poor
metabolizers.

Table 11. Drug Study for clopidogrel (Plavix)

Nursing Management

1. Manage main complications of ischemic stroke such as stroke, cranial nerve

injuries, infection or hematoma, and carotid artery disruption. Therefore, it is

necessary to maintain blood pressure levels and vital signs.

2. Assess the patient’s level of consciousness from time to time and mental status

(memory, attention span, perception, orientation, affect/speech/language),

sensation/perception, motor control, swallowing ability, nutritional and bowel

function.

3. Conduct a continuous assessment on the patient’s daily activities, because the

quality of life with stroke and CV diseases is closely related to the patient’s

functional status.

4. Administer prescribed medications and provide instructions that can be easily

understood by the patient and the significant other during intake of the said

therapeutic drugs.

5. Conduct a close monitoring because the patient may frequently have concomitant

coronary artery disease.

40
6. Prepare a patient if a surgical procedure is necessary. Check the patient's history

particularly the medication chart of the patient to see if there is a need to withhold

the surgery and notify the patient immediately.

7. Focus on the assessment of cranial nerve functions such as the facial, vagus,

spinal accessory, and hypoglossal nerves. The patient may have difficulty in

swallowing, hoarseness, or other signs of cranial nerve dysfunction.

8. Provide a modified dietary plan in collaboration with the dietician to prevent

complications and blood flow disruption.

9. Also, necessary to ensure a safe and comfortable environment for the patient to

rest; avoid stressors and other modifiable risk factors.

10. Improve mobility and prevent joint deformities through frequent changing of

position with assistance if necessary. Physical movement could help improve

blood circulation and well-being. Correct positioning is important to prevent

contractures and relieve pressure.

11. Assist the patient if necessary in enhancing self-care through setting realistic

goals; if feasible, a new task is added. The first step is to carry out all self-care

activities on the unaffected side where stroke occurs.

41
Prognosis

CRITERIA POOR FAIR GOOD JUSTIFICATION

Duration of Illness ✓ The condition of the patient was

diagnosed on November 2, 2021. He
experienced symptoms such as
facial droop on his left hand side with
weakness in left side upper and
lower extremities; slurred speech
and uncoordinated balance and
movement. After observing changes
on his body, he rushed to go to
hospital with his wife.

Onset of Illness ✓ 5 years ago, patient was diagnosed

with hypertension and a few years
back he was diagnosed with
prediabetes. He has also had
asthma since 18 years old.
Diagnosis of Acute ischemic stroke
was on November 2, 2021.

Precipitating Factors ✓ Precipitating factors that lead to the

patient's condition and its worsening
include hypertension, diabetes,
unhealthy lifestyle (smoking and too
much drinking of alcohol) and lack of
regular exercise.

42
 Mood and Affect ✓
Rated as fair since the patient has

been observed being hopeless

towards himself due to his condition.

Willingness to Take ✓ Rated as fair because the patient

Medications/Complia
has been uncooperative only to his
nce with Therapeutic
wife, but in terms of treatments the
patient gives effort and takes his
medications on time.

Any Depressive ✓ Rated as fair because the patient is

Features
at risk of developing low self-esteem
because of his condition. It has been
observed that the patient is irritable,
uncooperative and always spacing
out.

Family Support ✓ Rates as good since the patient's

family, especially his wife, has been
very supportive. She helps patient in
his ADLs as well as emotional
needs.

IMPLICATION POOR( 1 x 1 ) = 1

FAIR ( 3 x 5 ) = 15

GOOD (5 x 1 ) = 5

TOTAL: 21/7 = 3

43
INTERPRETATION

Poor = 0-1.6

Fair =1.7 -3.3

Good = 3.4- 5

Fair Prognosis: Although Acute

Ischemic Stroke is medical
emergency and can be life-
threatening condition the patient
immediately give intervention when
he observed abnormalities in his
body. However, in terms of his other
disease such as diabetes and
hypertension, patient failed to
adhere to medications and
treatments due to financial problem.

44
 CHAPTER VI

GORDON’S FUNCTIONAL HEALTH PATTERN

This chapter presents the 11 Gordon’s Functional health pattern with patient’s

information, problem list, prioritization of the problems, nursing care plan designed for

the patient and health teachings.

1. Health Perception-Health Management Pattern

Prior to admission:

● 5 years ago, the patient was diagnosed with hypertension and prediabetes

a couple of years back.

● Patient continued to work in a law firm and did not take his condition

seriously.

● These past few days, the patient has been experiencing weakness and

numbness in his face, arms and legs but neglect it

Upon admission:

● Patient is 61 years old;

● Has a 30-year history of smoking;

● Is a social beer drinker with 15 standard drinks per week;

● Diagnosed with asthma at the age of 8;

● Failure to take action to reduce risk factors

2. Nutritional- Metabolic Pattern

Prior to admission:

45
 ● Patient’s wife noticed her husband began to have slurred speech and has

been experiencing difficulty swallowing

● The patient tends to eat small amounts only since he is having a hard time

chewing his food

● Some of the food remains on his mouth and some is being vomited

Upon admission:

● Slurring of speech, and stasis of food in the oral cavity are observed.

● Patient does repetitive swallowing. Reports of coughing and vomiting during

meal time were noted.

● Physical examination revealed left facial droop and altered sensation

● Ht: 5’5, Wt. 56 kg, BMI: 20.5 (normal)

● Cerebral Angiography: demonstrated Occlusive Thrombus extending from

the Right Internal Carotid Artery Origin through the Right Middle Cerebral

Artery Trunk

● MRI: demonstrated Ischemic Changes confined predominantly to the Right

Middle Cerebral Artery; Perfusion-weighted MRI showed larger perfusion

abnormality, indicating presence of a substantial volume of potentially

salvageable penumbral tissue.

● CT scan: Provisional diagnosis of Acute Ischemic Stroke secondary to

occlusion of the M1 was made

3. Elimination Pattern

Prior to admission:

● The patient has difficulty communicating with regards to his voiding.

46
 ● Has an inability to hold in urine

Upon admission:

● 350 mL if urine is excreted every time a patient urinates;

● Loss of urine before reaching the toilet;

● Amount of time required to reach toilet exceeds length of time between

sensing urge

● Uncontrolled voiding is noted.

4. Activity-Exercise Pattern

Prior to admission:

● Patient had facial droop on his left hands side with weakness in left side

upper and lower extremities; has slurred speech and uncoordinated

balance and movement

Upon admission:

● NIH stroke scale is 19, which indicates the patient has moderate to severe

stroke

● Diagnostic Tests shows

○ CT: Hyperdensity in the M1 Segment of the Right Middle Cerebral

Artery, with no other signs suggestive of an Ischemic Stroke noted.

○ MRI: Perfusion-weighted MRI showed larger perfusion abnormality,

indicating presence of a substantial volume of potentially

salvageable penumbral tissue.

47
 ■ Time-of-flight magnetic resonance angiography showed a

loss of signal in the Right Internal Carotid Artery and Middle

Cerebral Artery.

○ Cerebral angiography: demonstrated Occlusive Thrombus extending

from the Right Internal Carotid Artery Origin through the Right Middle

Cerebral Artery Trunk.

● Patient is diagnosed with Acute Thrombotic Ischemic Stroke on Nov. 02,

2021

5. Sleep- Rest Pattern

Prior to admission:

● Sleeps 6-8 hours without interruption

● Patient takes alternative rest periods after working or when feels tired

Upon admission:

● No reports of sleep and rest problem

● Normal energy level is noted during interview; participates on physical

examination and overall health evaluation

6. Cognitive-Perceptual Pattern

Prior to admission:

● Patient had a sudden onset of slurred speech, facial drooping and

weakness on the left side of both upper and lower limbs.

Upon admission

● Patient described/reported feeling that the left side of his body sometimes

does not belong to his own self; S/O verifies what the patient had described.

48
 ● Failure to fully move the left side both upper and lower limbs to the extent;

patient has difficulty using the neglected side to dress himself when asked;

appears unaware of positioning of neglected limb.

7. Self-Perception – Self-Concept Pattern

Prior to admission:

● Uncooperative to his wife when changing clothes

● Spacing out was also observed

Upon admission:

● Reports non-cooperative to his wife

● Irritability is noted.

● Patient shows helplessness and inability to deal with the situation.

8. Role-Relationship Pattern

Prior to admission:

● Allows his wife to explain the current situation of the patient

Upon admission:

● Assisted by wife during admission;

● Patient is dependent to wife due to onset of slurred speech;

● Allows his wife to explain the current situation of the patient;

● Irritable to his wife; uncooperative; unable to communicate

9. Sexuality-Reproductive Pattern

Prior to admission:

● No problems of sexual reproductive pattern;

49
 ● Has two adult children; who are now both married and has their own

children - one lives close by; one lives overseas;

Upon admission:

● Due to patient’s slurred speech, wife explained that patient has no problems

with regards to sexual reproductive pattern

10. Coping-Stress Tolerance Pattern

Prior to admission:

● Experienced stress due to 50-60 working hours at a Law Firm but were able

to reduce the working hours into 20-30 hours per week since being

diagnosed with hypertension 1 and prediabetes. Although the patient was

able to manage stress due to work, the patient still experiences stress about

small things.

Upon admission:

● Has an adequate family and social support says wife;

● Willingness to do better in stress management more as stated by the

patient’s wife.

11. Values-Belief Pattern

Prior to admission:

● Strong believer of having good relationship with God;

● Prays everyday and goes to Church with family every Sunday

Upon admission:

● Acknowledges the sovereignty of God;

50
● If he were to have normal speech ability right now, he would start praying

and would ask for healing and fast recovery as stated by the patient's wife.

51
 GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Cue Cluster Interference Diagnosis Priority Rationale

Health
Pattern
1. Health “5 years ago my
Perception/H husband was Ineffective Ineffective Moderate 2 This is rated as mod 2
ealth diagnosed with health health because the occurrence of
Management hypertension and management management r/t acute ischemic stroke can be
prediabetes a altered prevented through lifestyle
couple of years perceived modifications and managing
back. But my seriousness or preventing risk factors to
husband continued and become severe by following
to work in a law firm susceptibility of the treatment regimen. In the
and did not take his condition amb case of the patient he has
condition seriously. ineffective neglected the prevailing risk
These past few choices in daily factors and was not able to
days, he’s been living for take action thus, leading to an
experiencing meeting health acceleration of illness
weakness and goals, symptoms. Health education
numbness in his unexpected must be rendered to the
face, arms and legs acceleration of patient about the disease
but neglect it, illness itself and what basic health
instead he chooses symptoms and practices and modification in
to go to work” as failure to take health behaviors should be
stated by the action to reduce implemented.
patient’s wife. risk factors

O: Patient is 61
years old; has a 30-
year history of

52
 smoking; is a social
beer drinker with 15
standard drinks per
week; diagnosed
with asthma at the
age of 8; failure to
take action to
reduce risk factors.
2. Nutritional “I have noticed that
Metabolic my husband began Impaired Impaired High 2 This is rated as high 2 since
Pattern to have slurred swallowing swallowing impaired swallowing cannot
speech and has neuromuscular cause imbalanced nutrition
been experiencing impairment less than body requirement
difficulty swallowing secondary to but as well as can lead to food
and because of this, acute ischemic and drinks getting into the
he tend to eat small stroke amb lungs and the patient may
amounts only since slurring of experience aspiration. If this
he is having a hard speech, stasis happens, it can lead to
time chewing his of food, infections and pneumonia
food, thus, some of coughing and which has a very serious
the food remains on vomiting impact on the patient’s health
his mouth and some thus, must be managed.
is being vomited” as
stated by the
patient’s wife.

O: Slurring of
speech, and stasis
of food in the oral
cavity are observed.
Patient does
repetitive

53
swallowing. Reports
of coughing and
vomiting during
meal time were
noted. Physical
examination
revealed left facial
droop and altered
sensation

Ht: 5’5, Wt. 56 kg,

BMI: 20.5 (normal)

Lab Results:
Cerebral
Angiography:
- Demonstrate
d Occlusive
Thrombus
extending
from the
Right Internal
Carotid
Artery Origin
through the
Right Middle
Cerebral
Artery Trunk.

MRI:
- demonstrate
d Ischemic
Changes

54
 confined
predominantl
y to the Right
Middle
Cerebral
Artery
- Perfusion-
weighted
MRI showed
larger
perfusion
abnormality,
indicating
presence of
a substantial
volume of
potentially
salvageable
penumbral
tissue.

CT scan:
Provisional
diagnosis of Acute
Ischemic Stroke
secondary to
occlusion of the M1
was made
3. Elimination S: “Since my
Pattern husband has Functional Functional Moderate 1 This pattern is rated as
slurred speech, he Urinary Urinary moderate 1 because urinary
has difficulty Incontinence Incontinence r/t incontinence is a symptom of

55
 communicating with neuromuscular urinary dysfunction. The
regards to his limitation amb pelvic floor muscle weakness
voiding. There are uncontrolled is a common cause of these
times that he voiding, loss of symptoms. Changes to the
senses the need to urine before nerves controlling the
void and I would get reaching the bladder, bowel or pelvic floor
the bedpan for him toilet and can also result in loss of
but he suddenly senses need to control. If incontinence is not
peed in his pants. void is late managed well, the person
My husband has an with incontinence may
inability to hold in experience feelings of
urine” as stated by rejection, social isolation,
the patient. dependency, loss of control
and may also develop
O: 350 mL if urine is problems with their body
excreted every time image.
a patient urinates;
loss of urine before
reaching the toilet;
amount of time
required to reach
toilet exceeds
length of time
between sensing
urge, and
uncontrolled voiding
are noted.
4. Activity S: “My husband This is given a high 1 priority
Exercise suddenly Ineffective Ineffective High 1 because the patient is at risk
Pattern experienced a Cerebral Cerebral Tissue for a decrease in cerebral
sudden onset Tissue Perfusion r/t tissue circulation due to the
slurring of speech, Perfusion Occlusive presence of thrombus which
had facial droop on Thrombus occludes the blood vessels in

56
his left hand side extending from the brain, affecting the blood
with weakness in the Right circulation. Thrombosis is a
left side upper and Internal Carotid condition in which blood clots
lower limbs that is Artery as develop within blood arteries
why I immediately manifested by and block blood flow. That
called an left sided body might spell disaster. A clot in
ambulance to rush weakness an artery that breaks loose
him to the hospital. I associated with and travels through the
was really worried uncoordinated circulatory system can
because it became balance and obstruct the heart, lungs, and
sudden and I don’t movement, other organs, potentially
know what to do” as slurred speech, shutting them down (Yales
verbalized by the and facial droop Medicine, 2020).
wife.
The patient is at risk for
O: VS taken shows: ineffective tissue perfusion
BP - 140/90 mmHg because of the clot formation
Pulse - 75 that hinders blood circulation.
Though this is considered an
Patient has immediate condition, it still
uncoordinated could be managed and
movement and improve the blood flow
balance through medical and nursing
management and
NIH stroke scale is intervention. If this case is not
19, which indicates being managed immediately,
the patient has then the patient may possibly
moderate to severe have complications
stroke considering the fact that there
is not enough oxygen supply
Diagnostic Tests to the nearby cells and body
shows tissues which is necessary for

57
CT: Hyperdensity in normal body and ADL
the M1 Segment of function.
the Right Middle
Cerebral Artery,
with no other signs
suggestive of an
Ischemic Stroke
noted.
MRI: Perfusion-
weighted MRI
showed larger
perfusion
abnormality,
indicating presence
of a substantial
volume of
potentially
salvageable
penumbral tissue.

Time-of-flight
magnetic
resonance
angiography
showed a loss of
signal in the Right
Internal Carotid
Artery and Middle
Cerebral Artery.

58
 Cerebral
angiography:
demonstrated
Occlusive
Thrombus
extending from the
Right Internal
Carotid Artery
Origin through the
Right Middle
Cerebral Artery
Trunk.

Patient is diagnosed
with Acute
Thrombotic
Ischemic Stroke on
Nov. 02, 2021

5. Sleep/Rest Patient has no sleep Not a problem This is described as not a

Pattern and rest related Not a problem Not a problem problem because there is no
problems according sleep and rest disruption that
to his significant happened to the patient
other; also sleepers despite and prior to health
6-8 hours after work conditions. This should be
or if needed. maintained by the nurse and
with the participation of the

59
 O: patient is significant other to promote a
participative during conducive environment
physical
assessment and
health evaluation;
no sleepiness or
tiredness is noted.
6. Cognitive S: “There are times Risk for Risk for This is given a high 3 priority
Perceptual that I cannot feel a Unilateral Unilateral High 3 because the patient is at risk
Pattern specific part of my Neglect Neglect related to have impairment in sensory
body, particularly on to and motor response mental
this left side…” as Cerebrovascula and spatial attention to body
verbalized by the r Impairment and corresponding
patient with assisted environment characterized by
use of non-verbal intention to one side and
cues to overattention to the opposite
demonstrate his side. Also, left side neglect is
thoughts because of more severe and persistent
having slurred than right-side neglect. The
speech. risk of having this condition
may be prevented or
lessened through
“My husband encouraging the patient to
sometimes cannot use the affected side of the
feel the other side of body during ADLs and as
his body, he points much as possible through
out to me that movement and activity. This
something is really could still be managed
bothering him” through physical therapies
with adherence to medication
O: Patient and nursing intervention.
described/reported
feeling that left side

60
 of his body
sometimes does not
belong to his own
self;

Failure to fully move

the left side both
upper and lower
limbs to the extent;
patient has difficulty
using the neglected
side to dress himself
when asked;
appears unaware of
positioning of
neglected limb.

7.Self- This is rated as low 1

Perception/S S: “Ever since he Risk for Risk for Low 1 because stroke impacts the
elf-Concept had a stroke, he situational Situational Low brain and brain is the one
Pattern always seems to be self-esteem self -esteem r/t who controls behavior and
irritated, and functional emotions. Although
sometimes he impairment personality changes are
doesn't cooperate common mostly in stroke
when I dress him. I patients, this can be
also noticed he was managed through the
always looking at support of significant others.
the window while Low self-esteem has
sitting in his negative feelings about self,
wheelchair. Even believing that they are not
though he can’t worthy of love, happiness or
speak because of success. With research
his condition, as a linking low self-esteem to

61
 wife I can feel that mental health issues and
he is gradually poor quality-of-life, this is a
losing hope and potentially dangerous way to
self-confidence. I live.
always find ways to
make him smile and
lessen his feelings
right now. I want him
to feel that he is not
alone, me and his
children are always
right here for him.”
as verbalized by the
wife

O: Reports non-
cooperative to his
wife and is irritated
sometimes. Patient
shows helplessness
and inability to deal
with the situation.
8. Role-
Relationship S: “My husband and Impaired Impaired verbal Moderate 3 This is rated as moderate 3
Pattern I have had our ups Verbal communication because impaired expressive
and downs with our Communicati related to communication is common in
relationship on alteration of patients who had strokes and
because he was central nervous could lead to irritability and
having vices while I system as hopelessness when one finds
am doing work. Now manifested by it difficult to produce words
he has a stroke and slurred speech, and even communicate
is sometimes irritability, and properly. Being unable to
irritated by me left facial droop communicate may also lead
because I am just to alteration of how they view
62
 trying to help him. I themselves as well as they
don’t even know may feel discouraged and
what he wants to down if not treated
say to me since he immediately or undergone
can’t talk properly therapy. People with stroke
and I am just might develop mental
worried about that. ” disorders such as depression.
as stated by the
patient’s wife.

O: Patient was
assisted and
dependent on his
wife to explain the
current situation.
Slurred speech, left
facial droop,
decreased tone was
observed. Irritability
was also observed.

9. Sexuality S: “My husband Not A Not A Problem Not A Problem This is considered as not a
Reproductive doesn’t have any Problem problem since both
Pattern problems regarding understands that they are
sexuality and contented with their family
reproductive and their two children, as well
patterns. We were as they have understood that
happy that we were it is okay to them to lay low or
able to raise our abstain from doing or
own children who engaging with sexual
now have their own activities due to their age and
families too and we as well as to the past medical
are content with it. history of the patient.
We do not engage
63
 in sexual activities
anymore because
of my husband’s
medical history and
we are okay with it.”
as stated by the
patient’s wife.

O: Patient was
assisted and
dependent on his
wife to explain the
current situation.
Due to patient’s
slurred speech, wife
explained that the
patient has no
problems with
regards to sexual
reproductive pattern
S: “He has
10. Coping experienced a lot Risk for Risk for Low 2 This pattern is considered as
Stress way back when he Compromised compromised low 2 because the patient has
Tolerance still did not have a Resilience resilience difficulty in sustaining a
Pattern stroke since he related to pattern of having positive
works at a Law Firm presence of an responses to his current
and works 2-30 additional new condition. Patient is unable to
hours per week. crisis (illness; adapt to life's misfortunes and
Now, he is irritated stroke) as setbacks which makes him
with me, he doesn’t manifested by feel helpless and hopeless
even want to talk to irritability, regarding the self-
me, and he just staring on the perception/self-concept
wants to be alone wall, and pattern. Unable to have
resilience in life might dwell
64
 and just gaze on the wanting to be the patient deeper onto his
wall for so long. ” as alone condition, he might feel
stated by the overwhelmed or might return
patient’s wife. the patient into engaging in
unhealthy coping
O: Irritability; staring mechanisms such as alcohol
on the wall most of drinking and smoking.
the time; wants to
be alone. Patient
was assisted and
dependent on his
wife to explain the
current situation.

11. Values S: “We are all Not A Not A Problem Not a problem This pattern is considered as
Belief Pattern believers of God Problem not a problem since the
and his ways in life. patient and wife is a firm
I believe that we are believer of God, and that they
able to have a have created a strong
strong relationship relationship with Him. Also,
with God as an there are no alterations in the
individual and as a values-belief pattern of the
family. We also go patient.
to the Church every
Sunday together
with the families of
my children.” as
stated by the
patient’s wife.

O: Patient was
assisted and
dependent on his
wife to explain the
65
current situation.
Due to the patient's
slurred speech, the
wife explained that
the patient
acknowledges the
sovereignty of God
as well as portraying
a strong relationship
with Him.

66
 Problem List

Problem (PES) Date Identified Time Date Resolved

November 7, 2021 6:00 PM Ongoing

1. Ineffective Cerebral

Tissue Perfusion r/t

Occlusive Thrombus

extending from the Right

Internal Carotid Artery as

manifested by left sided

body weakness

associated with

uncoordinated balance

and movement, slurred

speech, and facial droop

November 7, 2021 6:10 PM Ongoing

2. Impaired swallowing

neuromuscular

impairment secondary to

acute ischemic stroke

amb slurring of speech,

stasis of food, coughing

and vomiting

67
 November 7, 2021 6:20 PM Ongoing
3. Risk for Unilateral Neglect

related to

Cerebrovascular

Impairment

November 7, 2021 6:30 PM Ongoing

4. Functional Urinary

Incontinence r/t

neuromuscular limitation

amb uncontrolled voiding,

loss of urine before

reaching the toilet and

senses need to void is late

November 7, 2021 6:40 PM Ongoing

5. Ineffective health

management r/t altered

perceived seriousness

and susceptibility of

condition amb ineffective

choices in daily living for

meeting health goals,

unexpected acceleration

of illness symptoms and

68
 failure to take action to

reduce risk factors

November 7, 2021 6:50 PM Ongoing

6. Impaired verbal

communication related to

alteration of central

nervous system as

manifested by slurred

speech, irritability, and left

facial droop

November 7, 2021 7:00 PM Ongoing

7. Risk for Situational Low

self -esteem r/t functional

impairment

November 7, 2021 7:10 PM Ongoing

8. Risk for compromised

resilience related to

presence of an additional

new crisis (illness;stroke)

as manifested by

irritability, staring on the

wall, and wanting to be

alone

69
 Prioritization of Problem
Problem
Ineffective Cerebral Tissue
Perfusion r/t Occlusive
Thrombus extending from
the Right Internal Carotid
Artery as manifested by
left sided body weakness
associated with
uncoordinated balance and
movement, slurred speech,
and facial droop
Priority Rationale
This is given a high 1
High 1 priority because the patient
is at risk for a decrease in
cerebral tissue circulation
due to the presence of
thrombus which occludes
the blood vessels in the
brain, affecting the blood
circulation. Thrombosis is a
condition in which blood
clots develop within blood
arteries and block blood
flow. That might spell
disaster. A clot in an artery
that breaks loose and
travels through the
circulatory system can
obstruct the heart, lungs,
and other organs,
potentially shutting them
down (Yales Medicine,
2020).
The patient is at risk for
ineffective tissue perfusion
because of the clot
formation that hinders
blood circulation. Though
this is considered an
immediate condition, it still
could be managed and
improve the blood flow
through medical and
nursing management and
intervention. If this case is
not being managed
immediately, then the
patient may possibly have
complications considering
the fact that there is not
enough oxygen supply to
the nearby cells and body
70

Impaired swallowing
neuromuscular impairment High 2
secondary to acute
ischemic stroke amb
slurring of speech, stasis
of food, coughing and
vomiting
Risk for unilateral neglect High 3
related to cerebrovascular
Impairment
tissues which is necessary
for normal body and ADL
function.
This is rated as high 2 since
impaired swallowing cannot
cause imbalanced nutrition
less than body requirement
but as well as can lead to
food and drinks getting into
the lungs and the patient
may experience aspiration.
If this happens, it can lead
to infections and
pneumonia which has a
very serious impact on the
patient’s health thus, must
be managed.
This is given a high 3
priority because the patient
is at risk to have
impairment in sensory and
motor response mental and
spatial attention to body
and corresponding
environment characterized
by intention to one side and
over attention to the
opposite side. Also, left
side neglect is more severe
and persistent than right-
side neglect. The risk of
having this condition may
be prevented or lessened
through encouraging the
patient to use the affected
side of the body during
ADLs and as much as
possible through
movement and activity.
This could still be managed
through physical therapies
with adherence to
medication and nursing
intervention.
71
 Functional Urinary
Incontinence r/t Moderate 1
neuromuscular limitation
amb uncontrolled voiding,
loss of urine before
reaching the toilet and
senses need to void is late
Ineffective health Moderate 2
management r/t altered
perceived seriousness and
susceptibility of condition
amb ineffective choices in
daily living for meeting
health goals, unexpected
acceleration of illness
symptoms and failure to
take action to reduce risk
factors
Impaired verbal Moderate 3
communication related to
alteration of central
This pattern is rated as
moderate 1 because
urinary incontinence is a
symptom of urinary
dysfunction. The pelvic
floor muscle weakness is a
common cause of these
symptoms. Changes to the
nerves controlling the
bladder, bowel or pelvic
floor can also result in loss
of control. If incontinence is
not managed well, the
person with incontinence
may experience feelings of
rejection, social isolation,
dependency, loss of control
and may also develop
problems with their body
image.
This is rated as mod 2
because the occurrence of
acute ischemic stroke can
be prevented through
lifestyle modifications and
managing or preventing
risk factors to become
severe by following the
treatment regimen. In the
case of the patient he has
neglected the prevailing
risk factors and was not
able to take action thus,
leading to an acceleration
of illness symptoms. Health
education must be
rendered to the patient
about the disease itself and
what basic health practices
and modification in health
behaviors should be
implemented.
This is rated as moderate 3
because impaired
expressive communication
72
 nervous system as
manifested by slurred
speech, irritability, and left
facial droop
Risk for Situational Low
self -esteem r/t functional
impairment
Risk for compromised
resilience related to
presence of an additional
new crisis (illness; stroke)
as manifested by irritability,
staring on the wall, and
wanting to be alone
is common in patients who
had strokes and could lead
to irritability and
hopelessness when one
finds it difficult to produce
words and even
communicate properly.
Being unable to
communicate may also
lead to alteration of how
they view themselves as
well as they may feel
discouraged and down if
not treated immediately or
undergone therapy. People
with stroke might develop
mental disorders such as
depression.
Low 1 This is rated as low 1
because stroke impacts the
brain and brain is the one
who controls behavior and
emotions. Although
personality changes are
common mostly in stroke
patients, this can be
managed through the
support of significant
others. Low self-esteem
has negative feelings about
self, believing that they are
not worthy of love,
happiness or success. With
research linking low self-
esteem to mental health
issues and poor quality-of-
life, this is a potentially
dangerous way to live.
Low 2 This pattern is considered
as low 2 because the
patient has difficulty in
sustaining a pattern of
having positive responses
to his current condition.
Patient is unable to adapt to
73
life's misfortunes and
setbacks which makes him
feel helpless and hopeless
regarding the self-
perception/self-concept
pattern. Unable to have
resilience in life might dwell
the patient deeper onto his
condition, he might feel
overwhelmed or might
return the patient into
engaging in unhealthy
coping mechanisms such
as alcohol drinking and
smoking.

74
 Nursing care plan for Ineffective Cerebral Tissue Perfusion

Health Desired Evaluation

Cues Diagnosis Intervention Rationale Evaluation
Pattern Outcome Modification

S: “My Activity- After 8 hours Intervention: Goal partially 1. Continuity of

husband Exercise Ineffective of nursing met. Patient care and
suddenly Pattern Cerebral intervention 1. Monitor and 1. Assesses was able to evaluation are
experienced a Tissue necessary to
Perfusion r/t patient will be document trends in LOC slowly and
sudden onset maintain/identify
slurring of Occlusive able to: neurological and potential progressively improvements.
speech, had Thrombus status frequently for increased demonstrate
facial droop on extending General: and compare ICP and is behaviors and 2. Continuous
his left hand from the with baseline. useful in lifestyle health education
side with Right Internal 1. Display no determining changes to towards the
weakness in Carotid patient to
further location, improve
left side upper Artery as maintain better
manifested deterioration extent, and circulation.
and lower limbs understanding
that is why I by left sided or recurrence progression or However and promote
immediately body of deficits resolution of treating acute efficient
called an weakness CNS damage. ischemic stroke adherence to the
ambulance to associated 2. and achieving treatment
rush him to the with Demonstrate 2. Document 2. Specific the normal regimen.
hospital. I was uncoordinate
stable vital changes in visual functioning of
really worried d balance 3. Continuous
and signs, vision, such as alterations the patient
because it monitoring and
became movement, progressive reports of blurred reflect the area takes time and noting of
sudden and I slurred increase in vision and of the brain it cannot be neurological
don’t know speech, and perfusion as alterations in involved, done within 8 status, vital
what to do” as facial droop individually visual field or indicate safety hours or nursing signs, and
abnormal

75
verbalized by appropriate depth concerns, and care. The need laboratory
the wife. and absence perception. influence for continuous results.
of signs of choice of assessment
O: VS taken Background 4. Continuous
Knowledge: deficits interventions. and supervision
shows: involvement and
BP - 140/90 of the patient to
Due to the participation of
mmHg Specific: 3. Position with 3. Reduces prevent further
existence of the family
Pulse - 75 head slightly arterial deterioration
thrombus, members is
1. Maintain elevated and in pressure by and deficits is
Patient has which necessary.
obstructs the usual or neutral position. promoting still ongoing.
uncoordinated improved LOC venous Treatment and
movement and blood vessels
in the brain in cognition, drainage and therapies are
balance
and affects and motor, may improve needed for the
NIH stroke blood and sensory cerebral patient to
scale is 19, circulation, function circulation and restore tissue
which indicates there is a
perfusion. perfusion and
the patient has decrease in
cerebral 2. get back to
moderate to Demonstrate 4. Maintain bed 4. Continual normal
severe stroke tissue
circulation. behaviors and rest, provide a stimulation can functioning.
Insufficient lifestyle quiet increase ICP.
Diagnostic
arterial blood changes to environment, Absolute rest
Tests shows flow results in improve and restrict and quiet may
inadequate
circulation visitors or be needed to
CT: nutrition and
oxygenation. activities, as prevent
Hyperdensity in
Reduced indicated. recurrence of
the M1
tissue Provide rest bleeding, in the
Segment of the
perfusion periods between case of
Right Middle might be care activities, hemorrhagic
Cerebral temporary,
limiting duration stroke.
Artery, with no with little or

76
other signs no of procedures.
suggestive of ramifications
an Ischemic to the 5. Assist or 5. This is to
patient's
Stroke noted. instruct the minimize the
health, or it
MRI: Perfusion- can be more patient to patient's risk of
weighted MRI acute or long- change position skin
showed larger term, with at timed intervals breakdown,
perfusion potentially rather than using contractures
abnormality, harmful presence of pain and chest
indicating consequence as a signal to complications.
s. When
presence of a change
tissue
substantial perfusion is positions.
volume of reduced for
potentially an extended 6. Assess 6. Changes in
salvageable period of higher functions, cognition and
penumbral time, it can including speech speech content
tissue. cause tissue when the client are an
or organ
is alert. indicator of
damage, as
well as death. location and
Time-of-flight degree of
magnetic Ineffective cerebral
resonance tissue involvement
angiography perfusion – and may
showed a loss Nursing
diagnosis & indicate
of signal in the increased ICP.
care plan.
Right Internal (2019,
Carotid Artery February 12). 7. Examine 7. Assesses
and Middle Nurseslabs. motor response overall

77
Cerebral to basic awareness and
Artery. commands, ability to
noticing both respond to
Cerebral intended and external
angiography: unintentional events.
demonstrated movement. Damage to the
Occlusive Record limb motor tracts in
Thrombus movement and the opposite
extending from make separate cerebral
the Right notes for the hemisphere is
Internal Carotid right and left indicated by
Artery Origin sides. the absence of
through the spontaneous
Right Middle movement on
Cerebral Artery one side of the
Trunk. body.

8. Examine 8. Patients can

Patient is modifiable risk benefit from
diagnosed with factors such as information.
Acute hypertension make well-
Thrombotic and diabetes. informed
Ischemic As noted, decisions on
Stroke on Nov. smoking, food, risk factors that
02, 2021 physical activity, need to be
excessive addressed,
alcohol use, and and
illicit drug use. Commit to

78
 making proper
lifestyle
changes.

9. Monitor vital 9. Fluctuations

signs noting: in pressure
Hypertension or may occur
hypotension; because of
compare blood cerebral
pressure (BP) pressure or
readings in both injury in the
arms vasomotor
area of the
brain.

10. Respirations, 10.

noting patterns Irregularities
and rhythm— can suggest
periods of apnea location of
after cerebral insult
hyperventilation, or increased
Cheyne-Stokes ICP and need
respiration for further
intervention,
including
possible
respiratory
support

79
Dependent:

1. Administer - May be
medications as used to
indicated and improve
prescribed. cerebral
blood flow
- Anticoagu and prevent
lants further
(warfarin) clotting
when
embolism
or
thrombosis
is the
problem

- Antiplatel - Antiplatelet
et agents agents are
(clopidogr used
el & following an
simvastati ischemic
n) stroke

80
Collaboration:
1. Consult - An
an occupation
occupatio al therapist
nal can
therapist analyze the
or a patient's
physical home
therapist. environmen
t and
provide
recommend
ations to
help them
become
more
independen
t and
maintain
functional
ability to do
ADLs.
- A program
of physical
therapy
may be
beneficial,
whether it

81
 takes place
in the home
or in an
outpatient
program.

2. Consult - To provide
with a specific
neurologis tests,
t assessmen
ts, and
therapies
for the
patient after
the
occurrence
of stroke.

82
 Nursing care plan for Impaired Swallowing

Health Desired Evaluation

Cues Diagnosis Intervention Rationale Evaluation
Pattern Outcome Modification

“I have noticed Nutritional After 8hrs Independent: Goal partially -Continuity of

that my /Metabolic Impaired of nursing met. care and
husband Pattern swallowing interventio 1. Have suction 1. Timely reiteration of
began to have neuromusc n, the equipment intervention may After 8 hrs of demonstrated
slurred speech ular patient will available at the limit the nursing strategies and
and has been impairment be able to: bedside, untoward effects intervention, methods are
experiencing secondary especially during of aspiration. the patient was necessary to
difficulty to acute early feeding able to ensure
swallowing ischemic General: efforts. understand the continuous
and because stroke amb 1. Pass different performance
of this, he tend slurring of food and alternative to prevent
to eat small speech, fluid from 2. Promote 2. Promotes techniques and impaired
amounts only stasis of the mouth effective optimal muscle methods to swallowing
since he is food, to stomach swallowing: function, helps compensate for and
having a hard coughing safely. Schedule to limit fatigue. the difficulty associated
time chewing and activities and and impaired manifestation.
his food, thus, vomiting medications to swallowing. He
some of the Specific: provide a was able to -Stroke
food remains minimum of 30 know and requires a
on his mouth 1. min rest before initially long term
and some is Background Understan eating. demonstrate management
being vomited” Knowledge: d and the said and therapy
as stated by Demonstra techniques with from
The patient
the patient’s te 3. Assist patient 3. Assists in the the nurse and collaborative
has
wife. alternative with head control prevention of SO’s team
abnormal
techniques and position aspiration and participation to approach of

83
 functioning of methods based on specific improves the support the nurses,
of the appropriate dysfunction. capacity to patient and his doctors,
O: Slurring of swallowing to swallow by development. therapists and
speech, and mechanism individual reducing Also, the need dietician in
stasis of food caused by situations hyperextension. for order to
in the oral impaired with Head back for collaborative provide the
cavities are function of aspiration less posterior approach from needs of the
observed. the mouth, prevented. propulsion of the therapists patient with
Patient does tongue, and tongue, head and dietician to regards to
repetitive larynx due 2.Maintain tilted to the meet the nutritional
swallowing. to desired weak side for metabolic intake
Reports of cerebrovas body unilateral demands of the
coughing and cular weight pharyngeal patient has
vomiting impairment paralysis, lying already been
during meal and down on either discussed.
time were problem. side for reduced
noted. pharyngeal
Physical contraction are
examination all positions that
revealed left Reference: can help with
facial droop Nurses intake and lower
and altered Pocket the risk of
sensation Guide 12th aspiration.
Edition
Ht: 5’5, Wt. 56
kg, BMI: 20.5 4. Place the 4. By using
(normal) patient in an gravity to
upright position promote
Lab Results: during and after swallowing, the
Cerebral feeding as risk of aspiration
Angiography: appropriate. is reduced. As
the patient
swallows,

84
 encourage them
- demons to sit up straight
trated and tuck their
Occlusi chin towards
ve their chest.
Thromb
us 5.Provide oral 5. The patient
extendi care based on may have a dry
ng from individual needs mouth as a
the before a meal result of
Right difficulty
Internal swallowing or
Carotid moving the
Artery mouth, which
Origin necessitates the
through use of
the moisturizing
Right products such
Middle as alcohol-free
Cerebr mouthwashes
al before and after
Artery meals. The use
Trunk of drying agents
MRI: before meals
- demons and moisturizing
trated agents
Ischemi thereafter will
c aid patients with
Change excessive
s saliva.
confine
d 6. Within dietary 6. Increases
predom restrictions, salivation,

85
 inantly season meals improves bolus
to the with herbs, formation and
Right spices, lemon swallowing
Middle juice, etc., effort.
Cerebr according to the
al patient's
Artery preferences.
- Perfusi
on-
weighte 7. Food should be 7. Foods and
d MRI served at room fluids should be
showed temperature, and served cold or
larger water should warm as
perfusio always be cold. appropriate
n since lukewarm
abnorm temperatures
ality, are less likely to
indicati encourage
ng salivation. The
presenc hardest to
e of a swallow is
substan water.
tial
volume
of 8. If necessary, 8. Helps in
potentia use gentle sensory
lly pressure on the retraining and
salvage lips or beneath muscle control.
able the chin to seal or
penum manually open
bral the mouth.
tissue.

86
 9. Place food with 9. Enhances
the proper intake by
CT scan: consistency on providing
Provisional the side of the sensory
diagnosis of mouth that is not stimulation
Acute impacted. (including
Ischemic flavor), which
Stroke increases
secondary to salivation and
triggers
occlusion of swallowing
the M1 was attempts.
made

10. Apply ice to 10. It can help

the weak mouth with tongue
and use a tongue mobility and
blade to touch control (which is
portions of the important for
cheek. swallowing)
while also
preventing
tongue
protrusion.

11. Feed slowly, 11. Rushing can

giving the patient raise tension
30–45 minutes for and frustration,
meals. increase the
danger of
aspiration, and
cause the

87
 patient to stop
eating early.

12. At separate 12. It keeps the

periods, serve patient from
solid meals and ingesting food
drinks. that hasn't been
chewed
completely.
Liquids should
generally be
given only after
the patient has
completed
eating.

13. Encourage 13. Tastes and

the SO to bring preferences are
the patient’s familiar
favorite meals. therefore it
could stimulate
salivation and
swallowing and
intake may be
improved.

14. Instruct the

patient to keep 14. Reduces the
the head up for risk of
45–60 minutes regurgitation by
after eating. assisting the
patient in

88
 managing oral
secretions.

Dependent:

1. Prescribe IV 1. If the patient

fluids and tubing’s is unable to take
if necessary. anything orally,
it may be
essential for
fluid
replacement
and
nourishment
and to maintain
adequate body
weight.
Collaborative:

1. Coordinate a 1. Dietitians,
multidisciplinary speech
approach to therapists, and
develop a occupational
treatment plan therapists can
that meets all help to
individual needs. improve the
success of long-
term strategies
and lower the
risk of silent
aspiration.

89
Nursing care plan for Risk for Unilateral Neglect

Health Desired Evaluation

Cues Diagnosis Intervention Rationale Evaluation
Pattern Outcome Modification

S: “There are Cognitiv After 8 Independent Goal partially Continuity of

times that I e/Perce Risk for hours of Intervention: met. Patient care.
cannot feel a ptual Unilateral nursing and - Continuous
specific part of Pattern Neglect intervention, 1. significant assessment
my body, related to patient will Progressively 1. Recovery other was of
particularly on be able to: increase the from unilateral able to: improvement.
Cerebrovas
this left patient’s neglect display no - Continuous
side…” as cular General ability to cope generally further involvement
verbalized by Impairment objectives: with unilateral occurs in the deterioration, of client and
the patient neglect by first four demonstrate SO in
with assisted 1. Display using weeks after stable vital planning of
use of non- no further assistive stroke, with a signs, activities as
verbal cues to Background deterioratio devices, much more demonstrated much as
demonstrate Knowledge: n. feedback, and gradual and used possible
his thoughts support recovery after techniques
because of Unilateral 2. during that. that can be
having slurred neglect is Demonstrat rehabilitation. used to
speech. an e stable minimize
impairment vital signs 2. Initiate fall 2. Patient with unilateral
and prevention strokes are neglect, care
“My husband in sensory absence of interventions. twice as likely for both sides
sometimes and motor signs of to fall. It is of the body
cannot feel response deficits. important to appropriately
the other side mental educate the and keep the
of his body, he representati significant affected side
points out to Specific others to free from

90
me that on and objectives: prevent harm and
something is spatial accidents. lastly free
really attention to 1.Patient from injury.
bothering him” will 3. Set up the 3. These help However this
the body,
demonstrat environment in focusing patter is
O: Patient and the e and use so that attention and partially met
described/rep correspondi techniques essential aids in the because
orted feeling ng that can be activity is on maintenance there are
that left side of environmen used to the of safety. some
his body t, minimize unaffected Place the objectives
sometimes characterize unilateral side. client’s that the
does not neglect personal items patient did
d by in
belong to his within view not meet
own self; attention to 2.Patient and the such as the
one side will care for unaffected patient not
Failure to fully and over both sides side. Position returning to
attention to of the body the bed so that the optimized
move the left the opposite appropriatel the client is functioning
side. Left- y and keep approached level possible
side both affected from the yet, and there
side neglect
side free unaffected are still signs
upper and is more from harm side. of deficits.
severe and
lower limbs to persistent 4. Educate 4. Awareness
than right- the patient to of the
the extent; 3.Patient be aware of environment
side will return to the problem decreases the
neglect. optimized
patient has and modify risk of injury as
functioning behavior and well as this will
difficulty using level environment. help patient to
slowly accept
the neglected the situation.

91
side to dress possible 5. Educate 5. This will
and increase
himself when demonstrate safety as well
to the patient as awareness
asked; 4.Patient and to the
will be free significant significant
appears from injury other to others. This
position the will give them
unaware of bed at home information on
so that the how to prevent
positioning of client gets out accidents.
of bed on the
neglected unaffected
side.
limb.

6. Encourage 6.
family Improvement
participation is seen in
in care and clients who
exercise. participated in
exercise
training with
their family
members.

7. Speak in a 7. The patient

calm, may have a
comforting, limited
quiet voice, attention span
using short or problems
sentences to with

92
the patient comprehensio
and maintain n. These
eye contact. measures can
help patients
attend to
communicatio
n. Also, nurses
can educate
the SO about
the
communicatio
n difficulty of
the patient for
them to be
aware and
understand the
condition.

8. Ascertain 8. Assists
patient’s patient to
perceptions. identify
Reorient inconsistencie
patient s in reception
frequently to and integration
the of stimuli and
environment, may reduce
staff, and perceptual
procedures. distortion of
reality.

9. Approach 9. Helps the

the patient patient to
from the recognize the

93
visually intact presence of
side. Leave persons or
the light on, objects and
position may help with
objects to depth
take perception
advantage of problems. This
intact visual also prevents
fields. patients from
being startled.

10. Stimulate 10. Aids in

a sense of retraining
touch. Give sensory
patient pathways to
objects to integrate
touch, and reception and
hold. Have interpretation
patient of stimuli.
practice Helps patient
touching walls orient himself
boundaries. spatially and
strengthens
the use of the
affected side.

11. 11. The use of

Encourage visual and
the patient to tactile stimuli
watch feet assists in the
when reintegration of
appropriate the affected
and side and

94
consciously allows the
position body patient to
parts. Make experience
the patient forgotten
aware of all sensations of
neglected normal
body parts: movement
sensory patterns.
stimulation to
the affected
side,
exercises that
bring the
affected side
across the
midline,
reminding the
person to
dress/care for
the affected
(“blind”) side.

Dependent
Intervention:

1.Administer 1.May be used

medications, to improve
as indicated, cerebral blood
for example flow and
prevent further
clotting when
embolism or
thrombosis is

95
 the problem

Anticoagulant
s such as
warfarin
sodium
(Coumadin)

Antiplatelet Antiplatelet
agents, such agents are
as aspirin and used following
simvastatin an ischemic
stroke or TIA.

Collaborativ
e
Intervention:
1. To aid and
1. Refer develop
to Vascular effective
Neurologist interventions
to the patient.

96
 Health Teachings

1. Educate the patient about the importance of exercise and maintain a healthy

weight. Moderate exercise for at least 30 minutes a day is recommended for

most adults. Instruct the patient to talk about any special considerations for

exercise plans to maintain a healthy weight.

2. Teach the patient to resume as much self-care as possible; provide assistive

devices as indicated.

3. Teach patient to maintain balance in a sitting position, then to balance while

standing (use a tilt table if needed)

4. Educate family to ensure patient’s safety at all times to prevent injury

5. Educate patient about the importance of monitoring BP, HR, RR

6. Educate the family to reposition the patient every 2 hours (Passive & active

ROM)

7. Educate family to watch for the patient pouching food in their cheek on the

affected side, as this can cause aspiration.

8. Educate the patient to tuck in chin to chest while swallowing to prevent choking.

9. Have occupational therapists make a home assessment and recommendations

to help the patient become more independent.

97
10. Coordinate care provided by numerous health care professionals; help family

plan aspects of care.

11. Advise the family that the patient may tire easily, become irritable and upset by

small events, and show less interest in daily events.

12. Make a referral for home speech therapy. Encourage family involvement.

Provide family with practical instructions to help the patient between speech

therapy sessions.

13. Discuss a patient's depression with the physician for possible antidepressant

therapy.

14. Encourage patients to attend community-based stroke clubs to give a feeling of

belonging and fellowship to others.

15. Encourage the patient to continue with hobbies, recreational and leisure

interests, and contact with friends to prevent social isolation.

16. Encourage the family to support the patient and give positive reinforcement.

17. Remind family to attend to personal health and wellbeing.

98
 Bibliography

Books

Hinkle, J. L., & Cheever, K. H. (2017). Brunner & Suddarth's textbook of medical-

surgical nursing.

Website

Aggrenox. (n.d.). RxList. Retrieved November 07, 2021 from

https://www.rxlist.com/aggrenox-drug.htm

Chong, 2020. Ischemic stroke - neurologic disorders. Retrieved November 4,

2021, from https://www.msdmanuals.com/professional/neurologic-

disorders/stroke/ischemic-stroke

Heiyu. (2018). Schematic pathophysiology cva. Retrieved November 4, 2021, from

https://www.scribd.com/doc/49703337/Schematic-pathophysiology-CVA

Ineffective tissue perfusion – Nursing diagnosis & care plan. (2019, February 12).

Nurseslabs. https://nurseslabs.com/ineffective-tissue-perfusion/

Jauch, E. C., MD. (2021, October 17). Ischemic Stroke: Practice Essentials,

Background, Anatomy. Medscape.

https://emedicine.medscape.com/article/1916852-overview#a6

Krishnamurthi, R., Ikeda, T., & Feigin, V. (2020). Global, Regional and

Country-Specific Burden of Ischaemic Stroke, Intracerebral Haemorrhage

and Subarachnoid Haemorrhage: A Systematic Analysis of the Global

Burden of Disease Study 2017. Neuroepidemiology, 54(Suppl. 2), 171-

179. doi: 10.1159/000506396

99
Penumbra, 2021. Acute Ischemic Stroke. Retrieved on November 4, 2021 from

https://www.penumbrainc.com/brain-conditions/acute-ischemic-stroke/

Stroke - Diagnosis and treatment - Mayo Clinic. (2021, February 9). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-

treatment/drc-20350119

Surgery for ischemic stroke. (2021, April 7). Weill Cornell Brain and Spine

Center. Retrieved November 06, 2021 from

https://weillcornellbrainandspine.org/condition/stroke/surgery-ischemic-

stroke

Xiao & Kuriakose, 2020. Pathophysiology and Treatment of Stroke: Present Status

and Future Perspectives. Retrieved November 4, 2021, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7589849/

100
 CURRICULUM VITAE

Sandra Talapas Abdullah

Bachelor of Science in Nursing

PERSONAL INFORMATION

Nickname: Sands
Address: Purok Masunurin, Brgy. San Isidro, General Santos City
Age: 20
Birthdate: June 24, 1999
Birthplace: Brgy. Medol, Palimbang, Sultan Kudarat
Citizenship: Filipino
Civil Status: Single
Gender: Female
Religion: Islam

EDUCATIONAL BACKGROUND

ELEMENTARY Badiangon Elementary School

Years attended: 2006-2012
SECONDARY Holy Trinity College of General Santos City
Years attended: 2012-2018

TERTIARY Notre Dame of Dadiangas Univeristy

Years attended: 2018-Present

101
CURRICULUM VITAE

Reginne Mae L. Abrea

Bachelor of Science in Nursing

PERSONAL INFORMATION
Nickname: Jing
Address: Purok Kaunlarn, Brgy. San Isidro, General Santos
City
Birthdate: September 06, 1999
Birthplace: Koronadal South Cotabato
Citizenship: Filipino
Civil Status: Single
Gender: Female
Religion: Roman Catholic

EDUCATIONAL BACKGROUND

ELEMENTARY GSC SPED Integrated School

Years attended: 2006-2012
HIGHSCHOOL Notre Dame Siena College of General Santos City
Years attended: 2012-2018
COLLEGE Notre Dame of Dadiangas University
Years attended: 2018-Present

102
CURRICULUM VITAE

Andrei Ysabelle C. Boyles

Bachelor of Science in Nursing

PERSONAL INFORMATION

Nickname: Ywai

Address: Sebastian St., Barangay City Heights, General Santos City

Age: 21

Birthdate: October 03, 1999

Birthplace: General Santos City

Citizenship: Filipino

Civil Status: Single

Gender: Female

Religion: Roman Catholic

EDUCATIONAL BACKGROUND

ELEMENTARY Glan Central Elementary School

Years attended: 2006-2012

SECONDARY Holy Trinity College of General Santos City

Years attended: 2012-2018

TERTIARY Notre Dame of Dadiangas University

Years attended: 2018-Present

103
 CURRICULUM VITAE

Louchelle C. Cerna

Bachelor of Science in Nursing

PERSONAL INFORMATION

Nickname: Chelle

Address: Purok 3, Buayan General Santos City

Age: 22

Birthdate: August 06, 1999

Birthplace: General Santos City

Citizenship: Filipino

Civil Status: Single

Gender: Female

Religion: Roman Catholic

EDUCATIONAL BACKGROUND

ELEMENTARY H. Bayan Sr. Central Elementary School

Years attended: 2006-2012

SECONDARY Notre Dame of Dadiangas University

Years attended: 2012-2018

TERTIARY Notre Dame of Dadiangas University

Years attended: 2018-Present

104