CEREBROVASCULAR DISEASE -

INFARCT, COMMUNITY- ACQUIRED

PNEUMONIA - MODERATE RISK, PRESENTORS:
Catubig, Ritchel
NON-ULCER DYSPEPSIA, DEMENTIA Castro, John Andre
Ceniza, Angel Reanne
MS- CASE STUDY II Demillo, Alessandra
Escalante, Anna May
Florita, Niño
Gabian, Audrey
Gador, Mikhaela
Garcia, Getzel
Gonzalez, Teereze
Lumosad, Jovelle Mae
PRESENTED TO: Orcullo, Job
DR. JAKE CUMPANAPOLES, MAN,RN, BIO,DPE Padillos, Jezzanine
Associate Professor I
 GENERAL OBJECTIVES

Being aided with the concept of Care of Clients

with Problems in Nutrition and Gastrointestinal Metabolism
and Endocrine, Perception and Coordination Acute and
Chronic, we will be able to acquire the exact knowledge,
enhance our nursing skills and develop positive attitude
towards the care
of the clients.
 SPECIFIC OBJECTIVES
1. Briefly present patient’s demographic profile/data, history and genogram
2. Present comprehensive introduction that will provide an overview of the diagnosis
including its signs and symptoms.
3. Discuss the anatomy and physiology of the affected organs
4. Present patient’s laboratory results, its significance, and interpretation.
5. Present the drugs that were prescribed to the patient and discuss its mechanism of
action, indications, and nursing responsibilities.
6. Provide priority nursing care plan in regards to the problem experienced by the
patient.
7. Provide sample comprehensive discharge plan of the patient to ensure the
continuation of the management of the disease even after discharge.
 PATIENT’S PROFILE
Patient C.S.N, an 87-year-old male, was born on July 20, 1933.
He is a Filipino, Roman Catholic, Married, from Punta Princesa,
Cebu City. The patient came to Sacred Heart Hospital on August
21, 2020, at 10:52 with vital signs of BP: 150/100 mmHg, HR: 64
bpm, RR: 24 cpm, body temperature: 36.3 C, and O2 sat: 95%.
The patient is admitted under Dr. Yu, co-manage with Dr.
Hermogenes and Dr. Pizarra with a diagnosis of Cardiovascular
disease Infarct, Community-Acquired Pneumonia at moderate
risk, Non-ulcer Dyspepsia, and Dementia.
 HISTORY OF PRESENT ILLNESS
The patient was admitted to SWU Medical Center. During his
admission, it was reported that the patient complains of vomiting,
elevated blood pressure, weakness, and cough. The patient was
admitted to the COVID unit under the service of Dr. Yu, co-manage
with Dr. Hermogenes and Dr. Pizarra.
The patient’s condition is guarded with monitoring of vital signs every
4 hours and neurological monitoring since the patient has
deterioration of sensorium. The patient started with venoclysis with
PNSS 1L @ KVO rate. He was undergone diagnostic tests and the
doctor ordered medications needed for the patient.
 PAST HEALTH HISTORY:
The patient stated that he had previous hospitalization due to a
hypertensive crisis. Patient C.S.N has been diagnosed with Chronic
Hypertensive Cardiovascular Disease. The patient’s immunizations
were incomplete, he only had BCG, Hepatitis B vaccine, and DPT.
According to the patient, he had no known allergies to food and
medicines
 FAMILY HISTORY
Patient C.S.N has two siblings, and he is the oldest child. One of
the siblings of the patient has hypertension. It is stated that the
mother of the patient was diagnosed with cardiovascular disease
infarction and dementia, while the father has hypertension.
GENOGRAM

LEGEND
 PSYCHOSOCIAL HISTORY
Patient C.S.N spends most of his time outside of the house and engages with the people
around the neighborhood. He is a heavy drinker of alcohol, and he drinks with his friends
during adulthood, but recently he’s been drinking alone. The patient also is a smoker and
usually, he can smoke 3 times a day. The patient loves to eat a lot of spicy and fatty foods. He
does not engage with any type of exercise considering his age. His daughter already had her
own family while his oldest son is the one who provides for his needs.
Patient C.S.N is currently in Integrity Vs. Despair, the eight stages of Erik Erikson’s theory of
psychosocial development. The most important event at this stage is coming to accept one's
whole life and reflecting on that life in a positive manner. According to Erikson, achieving a
sense of integrity means fully accepting oneself and coming to terms with death. Accepting
responsibility for your life and being able to undo the past and achieve satisfaction with
yourself is essential. The inability to do this results in a feeling of despair.
DISEASE DEFINITION
 CVD- INFARCT
Cerebrovascular diseases are a broad term for a functional abnormality of the central nervous system (CNS)
caused by a disruption in the brain's blood supply. An ischemic stroke, also known as a cerebrovascular disease or
a brain attack, is a type of stroke that occurs when blood vessels in the brain get blocked. Large artery thrombosis,
tiny penetrating artery thrombosis, and cryptogenic stroke are all possible causes of stroke. CVD infarct is a form of
ischemic stroke in which a plaque blocks cerebral blood flow, resulting in an abrupt loss of brain function.

CAP- MR
Pneumonia is an inflammation of the lung parenchyma caused by bacteria, mycobacteria, fungi, and viruses, among
other pathogens. One of the four types of pneumonia is community-acquired pneumonia (CAP). CAP is a frequent
infectious condition that can occur in the community or within the first 48 hours of being admitted to the hospital.
Adults are diagnosed with CAP at a rate of 5.16 to 6.11 cases per 1000 people per year.

S. pneumoniae (pneumococcus) is the most common cause of CAP in people younger than 60 years without
comorbidity and those 60 years old with comorbidity. Elderly people and those with comorbidity are more vulnerable
to H. influenza. M. pneumoniae is the cause of mycoplasma pneumonia. Infected respiratory droplets spread
Mycoplasma pneumonia through person-to-person contact. Antibodies to mycoplasma might be tested on the
patient.
 DEMENTIA
Dementia is characterized by cognitive, functional, and behavioral abnormalities that gradually ruin a person's capacity
to operate. The symptoms are usually mild at first, and they grow steadily until they become visible and dangerous.
Alzheimer's disease (AD) is the most common type of dementia, accounting for up to 70% of dementia cases in older
persons. Dementia is caused by damage to brain cells. This damage interferes with the ability of brain cells to
communicate with each other. When brain cells cannot communicate normally, thinking, behavior and feelings can be
affected.

NON-ULCERATIVE DYSPEPSIA
Dyspepsia is a common occurrence that is defined as persistent or recurrent upper abdomen pain or nausea. Non-ulcer
dyspepsia (dyspepsia without an ulcer) is diagnosed in at least twice as many people as peptic ulceration.
Gastroesophageal reflux disease, biliary tract illness, chronic pancreatitis, and irritable bowel syndrome are all diseases
that can cause comparable symptoms. An accurate diagnosis is usually reached after a thorough history and physical
examination, which is complemented by certain testing. The cause of non-ulcer dyspepsia is yet unknown. Infection with
Campylobacter pylori and gastritis are common in non-ulcer dyspepsia, although their etiologic function, as well as the
importance of chronic duodenitis, is debatable.
SIGNS AND SYMPTOMS
CEREBROVASCULAR DISEASE

ASSESSMENT OF SIGNS AND SYMPTOMS

Warning signs of a trans ischemic attack or stroke may include the
sudden onset of some or all the following symptoms:

Dizziness, nausea, or vomiting

Unusually severe headache
Confusion, disorientation, difficulty with comprehension, memory loss
Numbness or weakness of an arm or leg
Facial weakness or droop, especially on one side
Abnormal or slurred speech
Loss of vision or difficulty seeing
Loss of balance, coordination, or the ability to walk 
Community Acquired Pneumonia – Moderate Risk

ASSESSMENT OF SIGNS AND SYMPTOMS

• Shortness of breath
• Coughing
• Heavy sputum
• Fever and chills
• Chest pain that is worse when you breathe or cough
• Nausea and vomiting (less common)
• tachycardia
NON-ULCER DYSPEPSIA
Symptoms of non-ulcer dyspepsia include:
· abdominal pain
· bloating
· indigestion
· nausea
· Abdominal bleeding
· Loss of appetite

DEMENTIA
Early signs vary, common early symptoms of dementia include:
• memory problems, particularly remembering recent events
• increasing confusion
• reduced concentration
• personality or behavior changes
• apathy and withdrawal or depression
loss of ability to do everyday tasks.
ANATOMY AND PHYSIOLOGY
 BRAIN
The brain is divided into the cerebrum,
cerebellum, and the brain stem. At the base of the
skull is the foramen magnum, an opening through
which the spinal cord forms a continuous
connection with the brain. The brain has 3
coverings. They are the pia mater (the innermost
layer), the arachnoid (the middle), and the Dura
mater (the outermost, tough layer).
 CEREBRUM
The cerebrum is the largest part of the brain and
is divided into 2 hemispheres and consists of 4
lobes: frontal, parietal, temporal, and occipital.
On its surface, or cortex, are located the centers
from which motor impulses are carried to the
muscles and to which sensory impulses come
from the various sensory nerves. It contains an
area in its inner core referred to as the thalamus.
 CEREBELLUM AND BRAIN STEM
The cerebellum regulates coordinated activities such as gait and performance of motor tasks. The brain stem
includes the midbrain, pons, and medulla oblongata. The midbrain connects the pons and the cerebellum with
the cerebral hemispheres. The cerebellum is located below and behind the cerebrum. The pons is located in
front of the cerebellum between the midbrain and the medulla.
Cerebrospinal Fluid
Each cerebral hemisphere has a central cavity, a ventricle that is filled with clear cerebrospinal fluid. It traverses
from the ventricle through narrow tubular openings to the subarachnoid space to bathe the entire surface of the
brain and spinal cord. The average amount of cerebrospinal fluid (CSF) is 150 mL.
 Anterior Cerebral Artery
The anterior cerebral artery extends upward and forward from the internal carotid artery. It supplies the frontal
lobes, the parts of the brain that control logical thought, personality, and voluntary movement, especially of the
legs. Stroke in the anterior cerebral artery results in opposite leg weakness. If both anterior cerebral territories are
affected, profound mental symptoms may result (akinetic mutism).
 Middle Cerebral Artery
The middle cerebral artery is the largest branch of the internal carotid. The artery supplies a portion of the frontal
lobe and the lateral surface of the temporal and parietal lobes, including the primary motor and sensory areas of
the face, throat, hand and arm, and in the dominant hemisphere, the areas for speech. The middle cerebral artery is
the artery most often occluded in stroke.
 Posterior Cerebral Artery
The posterior cerebral arteries stem in most individuals from the basilar artery but sometimes originate from the
ipsilateral internal carotid artery. The posterior arteries supply the temporal and occipital lobes of the left cerebral
hemisphere and the right hemisphere.
 Lenticulostriate Arteries
Small, deep penetrating arteries known as the lenticulostriate arteries branch from the middle cerebral artery
Occlusions of these vessels or penetrating branches of the Circle of Willis or vertebral or basilar arteries are
referred to as lacunar strokes.
The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many
other animals, including several invertebrates. The stomach has a dilated structure and
functions as a vital digestive organ. In the digestive system the stomach is involved in the
second phase of digestion, following chewing. It performs a chemical breakdown by means
of enzymes and hydrochloric acid.
The cardia is where the contents of the esophagus
empty into the stomach.
The fundus (from Latin 'bottom') is formed in the
upper curved part.
The body is the main, central region of the stomach.
The pylorus (from Greek 'gatekeeper') is the lower
section of the stomach that empties contents into
the duodenum.
Mouth and nose - Openings that pull air from outside your body into your respiratory system.
Nostril- air comes into the body through the nose and smells to the olfactory nerve. It is where the microorganisms enter and travel
to the lower respiratory tract of the patient.
Pharynx (throat) - Tube that delivers air from your mouth and nose to the trachea (windpipe). Its main function is to warm and
humidify air before it enters the lungs.
Larynx (voice box) - Hollow organ that allows you to talk and make sounds when air moves in and out. It also protects the trachea.
Oropharynx - is the most critical region in swallowing and joins the oral cavity and nasopharynx with the larynx and hypopharynx.
Trachea - Passage connecting your throat and lungs.
Bronchi - are the airways that lead from the trachea into the lungs.
Bronchial tubes - Tubes at the bottom of your windpipe that connect into each lung.
Lungs - Two organs that remove oxygen from the air and pass it into your blood.
Diaphragm - Muscle that helps your lungs pull in air and push it out
Alveoli - Tiny air sacs in the lungs where the exchange of oxygen and carbon dioxide takes place. If a person has pneumonia, the
alveoli in one or both lungs become inflamed and fill with pus and fluids (exudate), which interferes with the gas exchange.
Bronchioles - Small branches of the bronchial tubes that lead to the alveoli.
Epiglottis - Tissue flap at the entrance to the trachea that closes when you swallow to keep food and liquids out of your airway.
Carina - a ridge at the base of the trachea (windpipe) that separates the openings of the right and left main bronchi.
ANATOMY AND PHYSIOLOGY OF DEMENTIA
• THE CEREBRAL CORTEX
The cerebral cortex is a thin layer of cells covering the outside surface of the brain. It is responsible for memory, reasoning,
decision-making, language, social skills. It controls actions such as moving around or talking, as well as processing sight,
hearing, taste, smell, touch and pain.
The cerebral cortex can be divided into four ‘lobes’ (regions). These are the:
∙ Frontal lobes
∙ Temporal lobes
∙ Parietal lobes
∙ Occipital lobes.
• The frontal lobe of the brain is important for planning, organization, and regulating inappropriate behavior. When
Dementia attacks the frontal lobes, the patient may be unable to control these symptoms such as:
- Loss of motivation or lack of interest in activities
- Fatigue, lethargy, and sleepiness
- Repetitive behavior without purpose, such as folding something more than once, or taking shoes off and on for no reason
- Bizarre or inappropriate behavior, including aggression, swearing, removing clothing, eating inedible items, uninhibited
sexual behavior, or urinating in public
• Frontal lobe dementia- is a form of dementia that occurs when the frontal lobes of the brain begin to shrink (or “atrophy”).
The frontal lobes are responsible for helping inhibition and behavior regulation, so people with frontal lobe dementia will
often exhibit strange or unusual behaviors and personality changes. In fact, personality changes and behavior problems
are hallmarks of the disorder. Personality changes that can occur because of frontal lobe dementia include: impulsiveness,
apathy and indifference and socially inappropriate behavior.
• The temporal lobes are on either side of the brain, nearest to the ears. The temporal lobes are essential to memory,
especially episodic memory. In order to intake new knowledge and remember where we set down the car keys, we must
encode new information and retrieve it later. Dementia commonly damages the temporal lobes, making it difficult to store
and recall a recent “episode.” In the early stages of memory loss, visual cues like photographs or verbal reminders may
help in the retrieval of stored events. Patients with dementia often retain semantic memory, which allows them to
remember how to talk and perform a task like baking a cake, but, without episodic memory, it is impossible to recall the
people and events surrounding a celebration.
• ⮚ Left temporal lobe helps to understand language, and usually stores facts and the meanings of words.
• ⮚ Right temporal lobe deals with visual information, such as recognizing familiar objects and faces.

• The parietal lobes help interpret sensory input, which is essential to reading and recognizing faces. When the parietal
lobes are damaged throughout the course of the disease, patients may lose the ability to:
- Perform simple mathematical calculations
- Read and understand instructions
- Tell left from right
- Write legibly or coherently
- Draw, sketch, or paint
- Recognize faces, places, or objects (visual agnosia)
- Locate and pick up items (constructional apraxia)
• The occipital lobes are located at the back of the brain and mostly deal with visual information.
This region processes visual information and makes sense of it, including recognizing colors and
shapes. The resulting information can then be passed on to other areas of the brain. Damage to
the occipital lobes eventually occurs in most types of dementia, although not generally during the
early stages. When the occipital lobes become damaged, a person may experience difficulty
working out what they see in front of them. Severe difficulties with visual perception can also
contribute to visual hallucinations. As well as making visual information more difficult to
understand, damage to the visual cortex can contribute to deteriorating eyesight.
• The sub-cortex is any part of the brain below the cerebral cortex. This region allows fast
communication between the different parts of the brain. It also contains some areas that are
important for movement, thinking and emotion such as:
• ∙ The basal ganglia
• ∙ The limbic system
• ∙ The cerebellum
• ∙ The brainstem.
• The basal ganglia are a group of small structures located deep within the sub cortex. They are mostly
involved in the control of movement. Damage to this part of the brain is common in types of dementia that are
also movement disorders, such as Parkinson’s disease dementia, dementia with Lewy bodies and
Huntingdon’s disease dementia. In dementia with Lewy bodies and Parkinson’s disease movement can
become very difficult, resulting in very slow movements or a person not being able to move at all sometimes.
It can also cause involuntary movements, such as a tremor in the hands.
• The limbic system is a collection of regions in the brain that are involved in processing emotions. It includes
the amygdala, hippocampus, hypothalamus and thalamus. Damage to the limbic system is common in most
forms of dementia. It may change the way a person feels or would normally react to things. A person may feel
more excited, anxious, sad or apathetic than before they developed dementia. It can also lead them to have
delusions (strongly believing things that aren’t true) – for example believing that a stranger is in the house, or
that someone is stealing things from them.
• Amygdala- plays a major role in the processing and memorizing of emotional reactions. The amygdala of AD
patients shows a considerable shrinkage, distortion and loss of neurons, and widespread gliosis. The
amygdala is affected early in AD and results by neuropsychiatric symptoms leading to functional deficits that
greatly contribute to the disability associated with this disease. Due to the early damage to the amygdala,
neuropsychiatric symptoms are very common in mild stages of AD. Eventually, approximately 80% of the
patients with AD present neuropsychiatric symptoms, such as hallucinations, delusions, paranoia, anxiety,
agitation, and affective disturbances during the course of them illness. Other symptoms such as dysphoria,
irritability, disinhibition and apathy are also common.
• Hippocampus- Within each temporal lobe is a region called the hippocampus, which processes memories to
allow them to be stored and found when needed. Damage to the hippocampus makes it difficult to learn new
things. The hippocampus also sends important information to be stored in other parts of the cerebral cortex. It
is important for memory of events and experiences (episodic memory). Dementia often starts in and around
the hippocampus, before it spreads to other parts of the brain. This is why one of the first symptoms many
people notice is memory loss.
• Hypothalamus- the hypothalamus controls levels of hunger, thirst, body temperature, many of the hormones
that control the body’s metabolism. Damage to the hypothalamus may lead to changes in a person’s appetite
and eating behavior, particularly in frontotemporal dementia. These changes can include craving sweet foods,
overeating, or becoming obsessed with particular foods. In some cases, people may try to eat inedible
objects.
• Thalamus- just above the hypothalamus is the thalamus, which works as an important ‘information hub’. It
sends useful information to the cerebral cortex. It is heavily involved in consciousness, perception, attention,
memory and movement. The thalamus is affected to some extent in most types of dementia.
• Corpus Callosum- is the part of the mind that allows communication between the two hemispheres of the
brain. It is responsible for transmitting neural messages between both the right and left hemispheres.
Alzheimer's disease (AD) has been shown to be associated with shrinkage of the corpus callosum.
• The cerebellum co-ordinates movements, balance and posture, and helps the eyes to work together.
Research has shown that inhibited transmission of dopamine, a neurotransmitter, in this area is associated
with the lack of smooth coordinated movements in disease such as dementia.

• The brainstem is at the bottom of the brain where it meets the spinal cord. It deals with survival functions,
such as controlling heartbeat, breathing rate, blood pressure, sleep cycle, swallowing and states of
consciousness (being awake, asleep and dreaming, or unconscious). Several types of dementia affect the
brainstem. However, people with dementia with Lewy bodies are particularly affected during the early stages.
They may experience severe sleep problems for several years before being diagnosed (for example acting
out their dreams while asleep), as well as fluctuating levels of consciousness, slowness of movement and
visual hallucinations. They can also have problems regulating their blood pressure –
• causing dizziness and fainting, which can lead to falls.
• A region of the brainstem is responsible for making an important chemical called dopamine. Dopamine is
essential for many different functions in the brain, including movement and feelings of pleasure and reward.
People with Parkinson’s disease, Parkinson’s disease dementia and dementia with Lewy bodies often have
low levels of dopamine, which can make movement difficult. It can also affect their mood, causing
depression or apathy.
PATHOPHYSIOLOGY
CVD- INFARCT
COMMUNITY- ACQUIRED PNEUMONIA
COMMUNITY- ACQUIRED PNEUMONIA
COMMUNITY- ACQUIRED PNEUMONIA
NON-ULCER DYSPEPSIA
DEMENTIA
LABORATORY TEST
RESULTS
DATE LABORATORY TESTS RESULT REFERENCE RANGE INTERPRETATION
High-Sensitivity C- 20.70mg/dL ( elevated ) 0-5 mg/dl A high level of high
Reactive ProteinCRP- sensitivity- CRP in the
HS(QUANTITATIVE) blood has been linked to
an increased risk of heart
attacks.
LDH 425.21 U/L <480 U/L Indicates no form of tissue
damage.
PROCALCITONIN 0.302 ng/mL 0.3ng/mL Indicates low risk of
sepsis.
HGT 119mg/dL 70-100 mg/dL Indicates diabetes
(slightlyelevated)
Complete Blood *13.4x10^3/mm^3 * May indicate presence
Count:WBCNEULYM (high)*11.74 #(high)*7.6 *4.4-11.0x10^3/mm^3*37. of infection, inflammation,
%;1.02 #(low) 0-80.0% 1.80-7.80 #*10.0- bodily injury, and immune
50.0 % 1.00-4.80 # system disorders.*
Indicates that a patient
has infection.* Maybe
temporarily low after an
infection.
DATE LABORATORY TESTS RESULT REFERENCE RANGE INTERPRETATION

Clinical Chemistry 4.08X10^6/mm^3 (low) 13.0 4.50-5.9014.9-17.5 41.5- * May signify bleeding, kidney disease or
RBCHGBHCTMCV RDW SODIUM g/dL(low)39.4 % 50.480-9611.6-14.8136-145 malnutrition.* May signify anemia or blood
(low)97μm^3(high)11.14% loss.* May signify blood loss or Iron and
(low)131.0 mmol/L(low) vitamin deficiency. * May signify vitamin
B12, or folic acid deficiency.* May signify no
hematologic disorders are associated. RBC are
uniform in size.* May signify poor
hydration/too little sodium consumption, too
much fluid consumption, or kidney disorders.
Potassium(K) 4.50 mmol/L 3.5-5.1 NORMAL
Creatinine 0.82mg/dL 0.51-0.95 NORMAL
BUN 12.699mg/dL 6.0-20.0 NORMAL
BUA 5.19mg/dL 2.4-5.7 4 NORMAL
HBA1C 5.70% .9-6.0 NORMAL
ALT(SGPT) 30.44 U/L 0-41 NORMAL
Thyroid Studies TSHFT4 3.400μIU.mL 10.06pmol/L 0.25-5.0 12.0-20.0 NORMALMay indicate an underactive
(low) thyroid gland or problems with its stimulation
by the pituitary gland.
DATE LABORATORY TESTS RESULT REFERENCE RANGE INTERPRETATION
CT Scan BP a. There is no parenchymal Brainstem and cerebellum a.
hemorrhage nor acute infarction without evidence of focal Chroniclacunarinfarctintherightco
seen lesions.Lateral ventricles of rona radiatab.
b. ACSF-like hypodense focus is normal volume.Third and fourth Moderatemicrovascularischemicc
noted in the right corona radiatac. ventricles in midline.Basal hanges in both centrum semiovale
Confluent low densities are seen subarachnoid cisterns normal and periventricular white matterc.
in both centrum semiovale and configuration.Focal abnormalities Age-compatiblecerebro-
periventricular white matterd. are not observed in the brain cerebellar volume
Therestofthe brain parenchyma is parenchyma.Adequate gray lossd.Rightmaxillarysinusitis
intact, with no focal mass lesion matter-white
nor abnormalcalcification seene. matterdifferentiation.
Thereisnormalgray-white matter
demarcation. The midline
structures are undisplaced.f. The
ventricles, sulci, sylvian fissures,
andcerebellar folia arewidened.g.
Thebrainstemandcerebellum
areunremarkableh.
Thevisualizedsellar/suprasellar
regions, both orbits and mastoids
are unremarkable.i. There is
mucosal thickening in the right
maxillary sinus. The rest of the
paranasal sinuses are aerated.j.
The calvarium and basal
skullstructures are unremarkable.
DRUG STUDY
NURSING CARE PLAN
 ASSESSMENT NURSING SCIENTIFIC ANALYSIS GOAL OF CARE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE: Decreased cerebral Regardless of the cause of a Short Term: Initial assessment focuses on After immediate
“Nikalit raman siya blood flow due to stroke, After immediate airway patency, • May be compromised interventions the client
ug kahiwi iyaha increased ICP the underlying event is nursing interventions cardiovascular status by loss of gag or cough received interventions
nawong” as related to deprivation of the client will be (including blood pressure, reflexes and altered that has improved
verbalized by the inflammatory oxygen and nutrients to the able receive cardiac rhythm and rate, respiratory pattern survival. The client was
SO. response tissues of adequate carotid bruit); and gross also able to maintain
secondary to the brain. Some of the interventions to neurologic deficits. sufficient motor and
Cerebrovascular neurons served by the achiveve survival sensory status, and was
Disease Infarction occluded vessel die needs from the Check vital signs and An impending stroke may free of potential
OBJECTIVE: as evidenced by from lack of oxygen and stroke. neurologic produce a sudden rise in complications and
Vomiting temporary nutrients. status, record observations, blood pres_x0002_sure, willfullhy adhered to the
Cough neurologic This results in infarction, in and report rapid and bounding pulse, rehabilitation program.
Weakess symptoms, which tissue injury triggers Long Term: significant changes to the and the patient may
hemiplegia and an inflammatory response After 8 hours of physician. Monitor blood complain of a headache.
Vital Signs: hemiparesis. that in turn increases nursing interventions pressure, LOC, If the
BP: 150/100 mmHg intracranial pressure (ICP). the client will be pupil_x0002_lary changes, patient is unresponsive,
HR: 64 bpm Initially, the ruptured blood able to maintain motor function (voluntary and monitor his respiratory
RR: 24 cpm vessels sufficient motor and involuntary movements), status often and alert the
Temp: 36.3 degrees may constrict to limit the sensory status, be sensory function, speech, skin physician to
Celcius blood loss. free of other color temperature, signs of increased PaCO2 or
O2 Sat: 95% This vasospasm further potential increased ICP, and nuchal decreased partial
compromises complications, and rigidity or flaccidity. pressure of arterial
blood flow, leading to more be able to oxygen.
ischemia accomplish
and cellular damage. rehabilitation
Damage to the corona program. Correct positioning is
radiata disconnects the Position the patient and align important to prevent
functional circuitry between his contractures; measures
the frontal cortex and brain extremities correctly. Use are
stem, disturbing voluntary high-topped used to relieve pressure,
emotional expression. sneakers or other devices to assist in maintaining
prevent good
footdrop and contracture
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC GOAL OF CARE NURSING RATIONALE
ANALYSIS INTERVENTION

and a convoluted body alignment, and

foam, flotation, or prevent compressive
pulsating neuropathies,
mattress or especially of the
sheepskin to prevent ulnar and peroneal
pressure ulcers. nerves.

4.The patient’s To promote venous

position should be return and prevent
changed every 2 edema, the upper
hours. To place a thigh should not be
patient in a lateral acutely flexed.
(side-lying) position, a The patient may be
pillow is placed turned from side to
between the legs side, but if sensation
before the patient is is impaired,
turned. the amount of time
spent on the affected
side should be
limited.
5. After assessment
that delineates the After a stroke, the
patient’s deficits, the patient may have
neuropsychologist, in problems with
collaboration with the cognitive, behavioral,
primary provider, and emotional
psychiatrist, nurse, deficits related to
and other brain damage.
professionals, However, in many
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC GOAL OF CARE NURSING RATIONALE
ANALYSIS INTERVENTION

orientation, damaged; some

and cueing remain more intact
procedures to and functional than
compensate for others.
losses.

Preventing skin and The patient who has

tissue breakdown had a stroke may be
requires frequent at risk for skin and
assessment of the tissue
skin, with emphasis breakdown because
on bony areas and of altered sensation
dependent parts of and inability to
the body. respond to
pressure and
discomfort by turning
and moving.

Provide psychological Interventions both

support. Set medical ang
realistic short-term therapeutics are not
goals. Involve the enough to attain
patient’s family in his
optimal recovery if
care when
the patient does not
pos_x0002_sible, and
have the will to go on.
explain his deficits and
strengths. Stroke patients are
Begin your often subject to
rehabilitation of the socialisolation due to
pa_x0002_tient with a the deficits that
 ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS GOAL OF CARE NURSING RATIONALE EVALUATION
INTERVENTION

Subjective: Ineffective airway Inability to clear secretions Short Term: Position head midline To open or maintain airway in After administration of nursing
“ Muana siya basta clearance related to or obstructions from the After immediate nursing with flexion appropriate at-rest and compromised interventions the client
mutukar na nga mura daw copious tracheobronchial respiratory tract to intervention the client will for age/condition. client to maintain adequate, achieved and maintained a
ug gi sak2 iyag dughan secretions Secondary to maintain a clear airway. be able to have a patent airway. patent airway free of
nga sakit”, as verbalized Community- Acquired maintained airway patency secretions and obstructions.
by the SO. Pneumonia as evidenced and readily To identify Upon auscultation breath
by pleuritc-chest pain. expectorate/clear Assist with appropriate causative/precipitating factors. sounds was clear, expirations
secretions. testing. are noiseless, and Oxyge
To clear airway from Saturation is now 99%.
Objective: secretions that are blockng the
Fatigue Long Term: Suction airway.
Use of accessory muscles After 8 hours of nursing naso/tracheal/oral prn.
for intervention the client will Irritants cause inflammatory
breathing, be able to demonstrate response which can stimulate
Cough absence/reuction of secretion production.
Purulent congestion with breath Keep environment
sputum. sounds clear, expirations allergen free according Because adequate hydration
noiseless, improved to individual situation. thins and loosens
Vital Signs: oxygen exchange. pulmonary secretions.
BP: 150/100 mmHg The respiratory rate of patients
HR: 64 bpm The nurse encourages with pneumonia increases
RR: 24 cpm hydration (2 to 3 L/day). because of the
Temp: 36.3 degrees MOnitor for signs and increased workload imposed
Celcius symptoms of by labored breathing and
O2 Sat: 95% congestive heart fever. An
failure. increased respiratory rate
leads to an increase in
insensible fluid loss
during exhalation and can lead
to dehydration.
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS GOAL OF CARE NURSING
INTERVENTION
Coughing can be initiated
either voluntarily or
by reflex. Lung expansion
maneuvers, such as deep
breathing with an
incentive spirometer, may
induce a cough.
Auscultate breath sounds
and assess air movement.
The nurse encourages the
debilitated patient to rest
and avoid
overexertion and possible
exacerbation of symptoms.
Monitor, mange, and report
any potential
complications.
RATIONALE
To improve airway patency,
the nurse encourages the
patient to perform an
effective, directed cough,
which includes
correct positioning, a deep
inspiratory maneuver,
glottic
closure, contraction of the
expiratory muscles against
the closed glottis,
sudden glottic opening,
and an explosive
expiration.
To ascertain status and
note progress.
The patient should
assume a comfortable
position to promote rest
and breathing (e.g.,
semi_x0002_Fowler’s
position) and should
change positions
frequently to enhance
secretion clearance and
pulmonary ventilation and
perfusion.
The quiker the intervention
the better prognosis.
 ASSESSMENT
SUBJECTIVE:
‘’ limtanon naman kayo ni
siya ma’am, dali kayo
kalimot mura ug ge ango-
ango’’ as verbalized by the
significant other.
OBJECTIVE:
Inability to recall if a
behaviour is performed
Inability to learn/retain
new skills or information
Inability to perform a
previously learned skill
Forgets to perform a
behaviour at a scheduled
time.
V/S as Follows:
BP- 150/100
T: 36.3
HR: 64
RR: 24
O2sat: 95%
NURSING DIAGNOSIS
Impaired memory related
to central nervous changes
secondary to degenerative
brain disease as evidence
by reported experiences
of forgetting and inability to
recall recent events.
SCIENTIFIC ANALYSIS
Dementia is a chronic
disturbance involving
multiple cognitive deficits
including memory
impairment. It is
characterized by chronicity
and deterioration of
selective mental functions,
therefore giving the client
impaired memory.
GOAL OF CARE
SHORT TERM:
After 4 hours of nursing
interventions the patient
will be able to:
Verbalize awareness of
memory problems
LONG TERM:
After 8 hours of nursing
interventions the patient
will be able to:
Establish methods to
help in remembering
essential things when
possible.
Accept limitations of
condition and use
resources effectively.
Family members will
exhibit an understanding of
required care and
demonstrate appropriate
coping skills and utilize
community resources.
NURSING RATIONALE
INTERVENTION
INDEPENDENT: 
• Monitor client’s • To reduce boredom and
behaviour and assists in enhance enjoyment of
use of stress life.
management techniques
(music therapy,
television, socialization.
• Encourage patient to • To diminish feelings of
vent out feelings. powerlessness and
hopelessness
• Orient/reorient client • To enhace
as needed. comfortability and avoid
patient from stress
 to understand the
patient's concerns,
experiences, and opinions.
• Provide patient a • To improve the healing
quiet, and consistent process and help
environment patients feel safe and
more empowered with
managing their own
recovery.
• Communicate with the • For effective
patient in a calm and management of the
supportive way even if illness/disease, slowed
the patient is upset. progression of the
disease, and improved
patient outcomes
• Provide emotional • To Support wellbeing
support to the patient and independence and
and his family. gives purpose to our
lives. 
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS GOAL OF CARE NURSING RATIONALE
INTERVENTION
DEPENDENT:
Administer ordered
medications.
Implement memory
training techniques

COLLABORATIVE:
• Refer for
rehabilitations services
that are matched to the
strengths, needs, and
capacities of individual
needs, and capacities of
individual and modified
as needs change over
time- if needed.
• Refer for follow-up with
counsellors..
DISCHARGE PLANNING
Medications Advise patient to take medication accordingly to the prescription and must adhere
to the treatment regimen given in relation to the duration of time as advised. SO is
encourage to actively participate in the regimen. Educate the patient on the strict
adherence to the medication given, at the right time and the right frequency.
Instruct patient or SO that if symptoms persist or adverse effect manifest, patient
should report to physician accordingly; Educate patient with the purpose of each
drug and its side-effects; instructed not to take other medications without
consulting with the physician to prevent harmful drug-drug interactions. Instructed
patient and SO to comply strictly with the following prescribed medications:
1. Sultamacillin 750 mg/tab, 1 tab BID for 7 days
2. Clopidogrel 75 mg/tab 1 tab OD PO
3. Memantine 10 mg/tab ½ tab OD PO
4. Citicoline 1 gm/tab BID PO for 3 months
5. Atorvastatin 40 mg/tab OD
6. Losartan 50 mg/tab OD PO

Environment Encourage patient and SO to provide a safe, stress free and clean environment that
is conducive to healing as much as possible; Instruct family member and SO to
oversee proper hygienic practices and disinfection; An environment of proper social
support should also be upheld.

Treatment Instruct the patient to continue practice of deep breathing exercise as necessary to
promote lung capacity and optimize oxygenation. Patients diet and fluid intake
should be according to the prescribed restrictions and recommendations made by
the physicians. Encourage SO to accommodate patient needs as needed and to
promote a calm and safe environment. Institute measures for fall and other elderly
related complications. Instruct patient and family about the need for prompt
medical evaluation when mental status changes occur. Emphasize the importance
of home medications prescribed by the physician.
Health Teaching Encourage patient to keep a fatigue diary. Include anything that makes you feel
more tired or less tired. Bring the diary with you to follow-up visits with your
provider; Instruct patient about medicine adherence; Instruct patient to avoid
strenuous activities; Encourage patient to keep the practice of proper hand hygiene
and to keep one’s self clean all the time; Encourage patient to perform oral hygiene
accordingly and to perform good grooming.
Outpatient Instruct patient and SO to continue follow-up check up on continuous basis and
Referral should report any of the symptoms that may persist; Encourage patient as well as
the SO to observe and monitor for the continuous deterioration or alleviation of the
patients symptoms; Contact physician as soon as possible if emergency distress
occur.
Diet Instruct patient and SO to adhere and maintain low fat, low sodium diet; Encourage
to eat nutritious foods and avoid foods that may aggravate respiratory distress;
Encourage patient to stop the intake of liquors and drink enough of water as
prescribed.
Spiritual Emphasize the importance of hope for longevity of life and pray accordingly to
patient spiritual needs; Maintain spiritual relationship towards belief and to balance
that belief with family relationship and to engage in acts that may convey a sense of
fulfillment.
Evaluation Patient and SO verbalized understanding with the implemented intervention.
THANK YOU SIR JC!