…………………………………………………………………………

…………..TABLE OF CONTENTS

TITLE PAGE NO.

I. Introduction 1-2

II. Objectives 2-3

III. Nursing Assessment

1. Personal History

1.1. Patient’s Profile 3-4

1.2. Family and Individual Information 4

1.3. Level of Growth and Development

1.3.1. Normal Development at Particular Stage 5-7

1.3.2. Ill Person at Particular Stage of Patient 8

2. Diagnostic Results 8-11

3. Present Profile of Functional Health Pattern 11-14

4. Pathophysiology and Rationale 14-22

II. Nursing Intervention

1. Care Guide of Patient 22-25

2. Actual Patient Care

2.1. Nursing Assessment 26-27

2.2. Nursing Care Plan 27-32

2.3. Drug Study 33-34

2.4. Health Teaching Plan 35-36

III. Evaluation and Recommendation 36

IV. Evaluation and Implication 36-37

V. Referral and Follow –up 37-38

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 VI. Bibliography 38-39

I. Introduction

“Cerebrovascular disorders” is an umbrella term that refers to any functional

abnormality of the central nervous system (CNS) that occurs when the normal blood
supply to the brain is disrupted. It also refers to any functional or structural abnormality
of the brain caused by a pathological condition of the cerebral vessels or of the entire
cerebrovascular system. This pathology either causes hemorrhage from a tear in the
vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the
vessel lumen with transient or permanent effects. Stroke is the primary cerebrovascular
disorder and it is the third leading cause of death after heart disease and cancer and is the
leading cause of disability among nations.

Stroke is a term used to describe neurologic changes caused by an interruption in

the blood supply to a part of the brain. The most common vessels involved are the
carotid arteries and those of the vertebrobasilar system at the base of the brain. The two
major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by a
thrombotic or embolic blockage of blood flow to the brain, with thrombosis being the
main cause of both CVA’s and transient ischemic attacks (TIAs). A thrombotic CVA
causes a slow evolution of symptoms, usually over several hours, and is “completed”
when the condition stabilizes. An embolic CVA occurs when a clot is carried into
cerebral circulation and causes a localized cerebral infarct. Ischemia may be transient
and resolve within 24 hours, reversible with resolution of symptoms over a period of 1
week (reversible ischemic neurologic deficit [RINDI]), or progress to cerebral infaction
with variable effects and degrees of recovery.

Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic
stroke. It is caused by other conditions such as a ruptured aneurysm, hypertension,
arteriovenous (AV) malformations, or other bleeding disorders. Symptoms depend on

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distribution of the cerebral vessels involved. Ischemic strokes account for
approximately 83% of all strokes. The remaining 17% of strokes are hemorrhagic.

Cerebrovascular disorder are the third leading cause of death in the United State.
And in the Philippine setting, it ranked as the second leading causes of mortality with a
62.3 rate per 100,000 population in both sexes and with a percentage of 12.5 by the year
2002. Therefore, giving emphasis in the study of this disease condition is very relevant.
Breakthroughs could happen and may help in the welfare of not just to Filipinos but to all
people at risk in this condition.

The advent of thrombolytic therapy for the treatment of acute ischemic stroke has
revolutionized the care of the client following a stroke. Before, health care professionals
could offer only supportive measures and rehabilitation to stroke survivors. New
therapies can now prevent or limit the extent of brain tissue damage caused by acute
ischemic stroke. Thrombolytic therapy must be administered as soon as possible after the
onset of the stroke; a treatment window of 3 hours from the onset of manifestations has
been established. To convey this sense of urgency regarding the evaluation and treatment
of stroke, health care professionals now refer to stroke as brain attack. Public education
is focused on prevention, recognition of manifestations, and early treatment of brain
attack.

II. Objectives

Student Nurse
General Objectives
After 2 days of giving holistic nursing care to the patient who have viral
meningitis, the nurse will be able to gain adequate knowledge, attitude and skills in
taking care of a patient who is suffering from this disease condition.

Specific Objectives
After 8 hours of giving holistic nursing care, the nurse will be able to:

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 1. relate the patients history and level of growth and development
2. explain the significance of the diagnostic results
3. review the anatomy and physiology of the brain
4. explain the disease process and organ involved
5. compare the chart in classical and clinical symptoms of the disease
process
6. formulated appropriate nursing care plan based on identified problem of
patient
7. impart health teachings to the patient and significant others on viral
meningitis

Patient and Family

General Objective
After 2 days of nurse- client interaction the client and family will be able
to acquire adequate knowledge, attitude and skills in the promotion of health and
prevention of injuries and disease as well as rehabilitation from the condition.

Specific Objective
After 8 hours of giving holistic nursing care, the patient and significant
others will be able to:
1. establish a trusting relationship with the nurse
2. verbalize feelings and thoughts to the nurse
3. share information about self and the family and life experiences to the
nurse
4. explain the disease process in their own level of understanding
5. show willingness in the implementation of planned nursing care

III. Nursing Assessment

1. Personal History

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1.1Patient’s Profile
Name: Lee, George Ang
Age: 54 years Old
Sex: Male
Civil Status: Married
Religion: Buddhist
Date of Admission: January 2, 2006
Room number: 221
Complaints: Right sided weakness and slurred speech
Impression/Diagnosis: Cerebrovascular Accident (Bleed- left basal ganglia)
Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez
Hospital Number: 782349

1.2 Family and Individual Information, Social and Health History

A case of Mr. George Ang Lee, 54 year old, male, Filipino and Buddhist.
He is a businessman living at 515 MJ Cuenco Avenue, Cebu City.
Patient is a known hypertensive for many years already with a usual blood
pressure of 140/90. He has a maintenance medication when systolic blood
pressure reaches to 170. He is non-diabetic and non-asthmatic. Inspite, his
condition, he has no previous hospitalization until January 2, 2006 when he
experienced a sudden onset of weakness at the right side of his body. Patient was
later noted to be on the floor with slurred speech and drowsiness, then was rushed
immediately to Chong Hua Hospital- Emergency Room and later transferred to
Cebu Doctor’s University Hospital after basic diagnostic procedures were taken.
CT Scan taken revealed 25 cc bleed at left basal ganglia with medial shift to the
right. BP was noted to be elevated with highest BP at 190/110 and captopril was
given.
The patient doesn’t smoke and drink alcoholic beverages. His usual diet
consist of vegetable and no meat. He also has a regular exercise schedule
everyday but he has a strong heredofamilial disease of hypertension. His wife
shared that lately his husband was under stress due to increase sales in their

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 business on the month of December and missed to have his regular exercise and
only sleeps a lesser hour per night compared to his usual sleep.

1.3 Level of Growth and Development

1.3.1 Normal Development at Particular Stage

Physical
Appearance Changes
Hair begins to thin, and gray hair appears. Skin turgor and
moisture decreases, subcutaneous fat decreases and wrinkling occurs.
Fatty tissue is redistributed, resulting in fat deposits in the abdominal
area.
Cardiovascular Changes
Blood vessels lose elasticity and become thicker.
Gastrointestinal Changes
Gradual decrease in tone of large intestine may predispose the
individual to constipation.
Sensory Perception Changes
Visual acuity declines, often by the late forties, especially for near
vision (presbyopia). Auditory acuity for high-frequency sounds
(presbycusis) also decreases, particularly in men. Taste sensation also
diminish.
Metabolism Changes
Metabolism slows, resulting in weight gain.
Urinary changes
Nephron units are lost during this time, and glomerular filtration
rate decreases.
Sexuality Changes
Hormonal changes takes place.
Musculoskeletal Changes

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 Skeletal muscle bulk decreases at about age 60. Thinning of the
intervertebral disks causes a decrease in height of about 1 inch. Calcium
loss from bone tissue may occur. Muscle growth continues in
proportion to use.
Psychosocial
Erickson viewed the development tasks of middle-aged adult as
generativity versus stagnation. Generativity is defined as the concern
for establishing and guiding the nest generation. In other words, there is
concern about providing for the welfare of humankind that is equal to
the concern of providing for self. In middle age, the self seems more
altruistic, and concepts of service to others and love and compassion
gain prominence. These concepts motivate charitable and altruistic
actions, such as church work, social work, political work, community
fund-raising drives, and cultural endeavors. Marriage partners have more
time for companionship and recreation; thus, marriage can be more
satisfying in the middle years of life. Generative middle-aged persons
are able to feel a sense of comfort in their life-style and receive
gratification form charitable endeavors.
Erickson believes that persons who are unable to expand their
interests at this time and who do not assume the responsibility of middle
age suffer a sense of boredom and impoverishment, that is, stagnation.
These persons have difficulty accepting their aging bodies and become
withdrawn and isolated. They are preoccupied with self and unable to
give to others. Some may regress to younger patterns of behavior.

Cognitive

The middle-aged adult’s cognitive and intellectual abilities change

very little. Cognitive processes include reaction time that stays much
the same or diminishes during the later part of the middle years,
perception, learning that continues and can be enhanced by increased

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 motivation oat the time in life, memory and problem solving that are
maintained through middle adulthood, and creativity.
Middle-aged adults are able to carry out all the strategies described
in Piaget’s phase of formal operations. Some may use post-formal
operations strategies to assist them in understanding the
contraindications that exist in both personal and physical aspects of
reality. The experiences of the professional, social and personal life of
middle-aged persons will be reflected in their cognitive performance.
Thus, approaches to problem solving and task completion will vary
considerably in a middle-aged group. The middle-aged adult can
“reflect on the past and current experiences and can imagine, anticipate,
plan and hope”

Moral

According to Kohlberg, the adult can move beyond the

conventional level to the postconventional level. Kohlberg believes that
extensive experience of personal moral choice and responsibility is
required before people can reach to postconventional level. Kohlberg
found that few of his subjects achieved that highest level of moral
reasoning. To move from stage 4, a law and order orientation, to stage
5, a social contract orientation, requires that the individual move to a
stage in which rights of others take precedence. People in stage 5 take
steps to support another’s right.

Spiritual

Not all adults progress through Fowler’s stages to the fifth, called
the paradoxical-consolidative stage. At this stage, the individual can
view the “truth” from a number of viewpoints. Fowler’s fifth stage
corresponds to Kohlberg’s fifth stage of moral development. Fowler

8
 believes that only some individuals after the age of 30 years reach this
stage.
In middle age, people tend to be less dogmatic about religious
beliefs, and religion often offers more comfort to the middle-aged person
than it did previously. People in this age group often rely on spiritual
beliefs to help them deal with illness, death and tragedy.
1.3.2 The Ill Person at a Particular Stage of Patient
The three most common causes of death in older adults are heart
disease, cancer and stroke. Other frequently reported causes of death are lung
disease, accidents/falls, diabetes, kidney disease, and liver disease. Heart
disease is the leading cause of death in older adults. Common cardiovascular
disorders are hypertension and coronary artery disease. Cancer or malignant
neoplasms are the second most common cause of death among older adults.
Cerebrovascular accidents, the third leading cause of death, occurring as brain
ischemia or brain hemorrhage. Cigarette smoking has been recognized as a risk
factor in the four most common cause of death for older adults: heart disease,
cancer, stroke and lung disease. Dental carries, gingivitis, broken or missing
teeth and ill-fitting or missing dentures may affect nutritional adequacy, cause
pain, and lead to infection.

2. Diagnostic Results

Diagnostic Test Normal Values Patient’s Significance

Result
Hematology
Hemoglobin 11.5-16 g/dl 11.5 g/dl Normal
Hematocrit 35-49 vol % 35 vol % Normal
RBC 4.5-5.3x10^6/dl 4.73x10^6/dl Normal
Elevated in acute
WBC 4.5-15.0x10^3/dl 12.2x10^3/dl disease.
Source: Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G., p.1954

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MCV 72-98 fl. 91 fl. Normal
MCH 25-35 pg 30.3 pg Normal
MCHC 30-37 g/dl 33.3 g/dl Normal
Platelets 150,000-450000 361,000 cu/mm Normal
cu/mm
Segmenters 54-62% 84% Elevated in acute
disease.
Source: Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G., 1953
Eosinophils 1-3% 01% Normal
Lymphocytes 25-33% 10% Normal
Urinalysis
Macroscopic
Color Yellow Yellow Normal
Appearance Clear Slightly cloudy Not normal
Reaction 5.5-7.5 6.0 Normal
Specific gravity 1.001-1.045 1.020 Normal
Protein Negative Trace Not normal
Glucose Negative Negative Normal
Ketones Negative Negative Normal
Blood Negative Negative Normal
Macroscopic
RBC <3 RBC’s/HFF 0-1 Normal
WBC 0-5 WBC/ HPF 3-5 Normal
Epithelial Cells Rare Few Normal
Mucus Threads Rare Rare Normal
Bacteria None Negative Normal
Leukocytes Negative Negative Normal
Nitrites Negative Negative Normal
Urobilinogen Trace Normal Normal
Bilirubin Negative Negative Normal
Serum
Glucose 65-110 142 Increased in infections
Source: Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G., 1960
Creatinine .7-1.5 .9 Normal
Sodium 137-145 137 Normal
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Potassium 3.6-5.0 4.6 Normal
Chloride 98-107 103 Normal
Calcium 8.4-10.2 8.8 Normal

ELECTROCARDIOGRAPHIC REPORT
Atrial Rate: 120/min.
Ventricular: 120/min.
PR Interval: 0.14 sec.
QRS Complex: Transition zone in V3-V4
ST Segment: Isoelectric
T-wave: Upright
QRS: 0.08 sec.
AXIS: 0 degree
P-wave: upright
Interpretation: Sinus tachycardia with non specific ST-T wave changes

ECHOCARDIOGRAPHY REPORT
1. Quality of study- Optimal
2. Sinus Tachycardia- 107 beats/ min
3. Cardiac Measurements- IVSd= 1.05 cm
LVIDd= 5.75 cm
LVPWd= 1.67 cm
LVIDs= 3.89 cm
Ejection Fraction= 61%
Ao rest= 2.97 cm
LA diameter= 3.40 cm
4. Cardiac Values: normal
5. Color and Doppler exam- Normal Pulmonic Valve/ Aortic/ left ventricular outflow
tract velocities. Normal mitral inflow pattern.
6. Left Ventricular Systolic Function- preserved global and regional with visual ejection
fraction estimate 70%.
7. Right Ventricular Systolic Function- preserved

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8. No pericardial Effusion
CONCLUSION:
1. Well preserved biventricular systolic function.
2. Left ventricular hypertrophy.
3. Mild diastolic dysfunction.

CT SCAN
IMPRESSION: (as compared to the previous study done January 6, 2006.)
1. Further interval decrease in volume and density of the intraparenchymal
(hemorrhage in the left putamen/ left external capsule now measuring
approximately 34cc in volume (previous was 39cc), as described above.
2. Slight further decrease in the small amount of intraventricular hemorrhage
(extension) within the lateral ventricular.
3. No change in the subfalcine deviation (midline shift) to the right, still by 0.6 cm.
4. Chronic lacunar infarct in the right thalamus.

3. Present Profile of Functional Health Patterns

3.1 Health perceptions/ Health management

According to Mr. Lee’s wife, his husband take a great deal with regards to
his health. He disciplined his self well to achieve an optimum health cause he
believes in the saying “health is wealth”. He values it well enough since it’s
something that gives him greater favor in his business. Whenever he
experiences sickness he manages it using Chinese herbal medications. Mrs. Lee
believes that her husband will recover gradually because he is a determined and
disciplined person who strongly value his health. As of the moment, the family
religiously follows the doctor’s instruction in restoring Mr. Lee’s health.

3.2 Nutritional/Metabolic pattern

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 According to Mrs. Lee, prior to admission, patient usually eats 3 meals a
day which usually consist of vegetables and fruits, rice, and less meat but more
on fish. He usually drinks tea every after meal or whenever he feels drinking.
He has no allergies to foods. His water consumption is replaced with tea. He has
Chinese drug supplements and has a maintenance medication for his
hypertension. Currently, he is on nasogastric tube feeding (blenderized) with
1800 calories in 1800 u volume. He is also allowed to take sip of water with
strict aspiration precaution.

3.3 Elimination Patterns

According to Mrs. Lee, before her husband’s admission, Mr. Lee voids
and defecates normally and has no problems/complaints in defecating and
urinating. He defecated about once a day usually at the morning. In the hospital
he is on diaper and lactulose is given to soften his stool. His skin is dry and
rough because he can’t take a bath but lotion is given to prevent further dryness.

3.4 Activity/ Exercise Pattern

According to Mrs. Lee, before her husband’s admission, his usual activity
is managing and supervising his own wholesale business of different stuffs. He
helps in transferring boxes from the truck to the stock rooms, without any
complaint of dyspnea or fatigue after. Every morning he takes time to go to his
gym and exercise. And during breakfast he reads newspaper or watch news
from television. Currently, in the hospital passive exercise is done by Mrs. Lee
or the Private Nurse. Turning on the television whenever he is awake is
recommended by the doctor to rehabilitate his senses.

3.5 Cognitive/Perceptual Pattern

According to Mrs. Lee, her husband manages to read newspaper without

the aid of eye glasses, he still has a 20/20 vision and can also hear clearly prior

13
 to admission. He was also able to comprehend well. But at the moment, he
doesn’t respond to any questions asked of him, he can’t speak yet. But he can
show some facial expressions like grimacing his face whenever he feels pain at
some parts of his body.

3.6 Rest/ Sleep Pattern

According to Mrs. Lee, he sleeps about 7 hours a day, usually goes to bed
early around 9 PM and arises early as well around 4 AM. He has no problems
or difficulty in sleeping. Before sleeping he usually pray with his Buddha beads.
In the hospital he sleeps most of the time, waking up occasionally. He is
drowsy.

3.7 Self- Perception Pattern

According to Mrs. Lee, he is a very responsible father to his children as

well as a good husband to her. She believes that Mr. Lee is also cooperating for
his quick recovery since he is looking forward to visit his relatives in China as
soon as he gets well.

3.8 Roles- Relationship Pattern

According to Mrs. Lee, he speaks Bisaya and Mandarin. He can’t speak at
the moment yet. He has 3 children. The two has a family of their own already
and is presently residing in China. One son ,the eldest who is still single, is left
in Cebu with them who’ll take care of him at the hospital. In time of needs he
usually turns to his wife

3.10 Coping- Stress Management Pattern

According to Mrs. Lee, whenever problems occur especially with business

matters, both of them are solving it but most of the time his decision influenced
a lot. He also have his friends and relatives who’ll listen and advices him. He

14
 also has a strong faith that he always pray whenever he has problems. Mrs. Lee
decided to have a private nurse to monitor his husband closely.

3.11 Values- Belief System

According to Mrs. Lee, they are Buddhist. They are religious in the
practices and faith of the Buddhist. Most spare time of Mr. Lee is spend in
prayers. They have their prayer room at the house. They are also active in their
temple activities and tries not to miss it. In the hospital they requested to play a
Buddhist chant which they believe could help him recover early. They also
have incenses that can soothe or make him sleep well.

4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ System Affected

The Nervous system is the body’s most organized and complex
structural and functional system. It profoundly affects both psychological and
physiologic function.
The brain is the largest and most complex part of the nervous
system. It is composed of more than 100 billion neurons and associated
fibers. The brain tissues have a gelatin-like consistency. This semi-solid
organ weighs about 1400 g in the adult. It is divided into three major areas:
the cerebrum, the brain stem and the cerebellum. The cerebrum is composed
of two hemispheres, the thalamus, the hypothalamus and the basal ganglia and
connections of the olfactory and optic nerves. The brain stem includes the
midbrain, pons, medulla, and connections of cranial nerve II, IV and VII. The
cerebellum is located under the cerebrum and behind the brain stem.
The BASAL GANGLIA consist of several structures of subcortical
gray matter buried deep in the cerebral hemisphere. These structures include
the caudate nucleus, putamen, globus pallidus, substantia nigra, and
subthalamic nucleus. The basal ganglia serve a processing stations linking the

15
 cerebral cortex to thalamic nuclei. Almost all the motor and sensory fibers
connecting the cerebral cortex and the spinal cord travel through the white
matter pathways near the caudate nucleus and putamen ganglia. These
pathways are known as the internal capsule. The basal ganglia, along with the
corticospinal tract, is important in controlling complex motor activity.
CEREBRAL CIRCULATION. The cerebral circulation receives
approximately 15% of the cardiac output, or 750 ml per minute. The brain
does not store nutrients and has a high metabolic demand that requires the
high blood flow. The brain’s blood pathway is unique because it flows
against gravity; it’s arteries fill from below and the veins drain from
above. In contrast to other organs that may tolerate decreases in blood
flow because of their adequate collateral circulation, the brain lacks
additional collateral blood flow, which may result in irreversible tissue
damage when blood flow is occluded for even short periods of time.

Brain: Basal ganglia

Coronal slices of human brain showing the basal ganglia, globus pallidus: external segment (GPe),
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 subthalamic nucleus (STN), globus pallidus: internal segment (GPi), and substantia nigra (SN).

Coronal section of brain immediately in front of pons. (Not all basal ganglia are visible, but caudate nucleus
and substantia nigra are labeled. Subthalamic nucleus would be between thalamus and internal capsule.)

4.2 Schematic Drawing on Pathophysiology of Disease

Predisposing Factors Precipitating Factors

Heredity
Age – 54 years old High sodium diet
History of stroke High blood pressure
Stress

Etiology

Plaque formation

Thrombi formation

Bloodstream is loaded
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 High blood pressure

Dislodgment of thrombi

Emboli

Occlusion of cerebral vessels and

Rupture of arteriosclerotic hypertensive vessels

Hemorrhage

Cerebral anoxia

CVA

Clinical symptoms Classical symptoms

Facial asymmetry Facial asymmetry
Slurring of speech Slurring of speech
Aphasia Aphasia
Hemiparesis Hemiparesis
Apraxia
Hemiplegia
Confusion

4.3 Disease process and Effects on Different Organ System

Stroke, ischemic damage of the brain owing to a blockage in blood flow,
or to a hemorrhage of blood vessels in the brain. Without blood, sections of brain
tissue quickly deteriorate or die, resulting in paralysis of limbs or organs controlled
by the affected brain area. Most strokes are associated with high blood pressure
(hypertension), atherosclerosis (development of fatty plaques in artery walls), or both.
Some of the signs of major stroke are facial weakness, inability to talk, loss of
bladder control, difficulty in breathing and swallowing, and paralysis or weakness,
particularly on one side of the body. Stroke is also called cerebral apoplexy and
cerebrovascular accident.

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 The majority of stroke cases are due to arterial blockage caused by either
thrombosis or embolism. Thrombosis involves the clotting of the surface of an
atherosclerotic plaque, in a branch of one or more of the four main arteries leading to
the brain. As these arteries become narrowed, a potential stroke victim often
experiences recurrent warnings, which take the form of transient paralysis (such as in
one arm or leg or on one side of the face), or discovers impairments in speech, vision,
or other motor functions. At this stage, deposits in the linings of the cerebral arteries
can often be treated by surgical removal or bypass of blockages.
Embolism occurs when a cerebral artery suddenly becomes blocked by
material—such as clotted blood, air, or fat—coming from another part of the
bloodstream. Such masses, known as emboli, often form as clots in a diseased or
malfunctioning heart, but can also come from dislodged fragments of atherosclerotic
plaque or even an air bubble. Treatment is largely preventive, consisting of
monitoring of the diet, and, if possible, use of anticoagulants.
Hemorrhaging of cerebral blood vessels, a less frequent but usually more
serious cause of stroke, can occur where aneurysms, or blister-like bulges, develop on
the forks of large cerebral arteries on the brain surface. The rupture of aneurysms
causes brain damage, owing to the seepage of blood into brain tissue or to the reduced
flow of blood to the brain beyond the point of rupture.

4.4 Comparative Chart

Classical Symptom Clinical Symptom Rationale

a. Motor changes:
contralateral hemiparesis or hemiplegia - affectation in the middle
hemiplegia; cerebral artery
Sensory changes: contralateral contralateral hemisensory
hemisensory alterations; alterations
neglect of involved
extremities;

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Visual changes:
homonymous hemianopia;
inability to turn eyes toward
the affected side;
Speech changes: dyslexia, Dysphagia, aphasia
dysgraphia, aphasia;
Others: vomiting may occur

b. Motor changes:
contralateral hemiparesis, foot Footdrop, contralateral - affectation in the anterior
and leg deficits greater than hemiparesis cerebral artery
arm, footdrop gait
disturbances;
Sensory changes: contralateral Contralateral
hemisensory alterations; hemisensory alteration
Visual changes: deviation of
eyes toward affected side;
Speech changes: expressive Expressive aphasia
aphasia;
Mental changes: confusion, Amnesia, shortened
amnesia; flat affect, apathy; attention span
shortened attention span; loss
of mental acuity;
Others: apraxia (inability to
carry out purposeful
movements in nonaffected
areas)

c. Motor changes: mild

contralateral hemiparesis (with Memory deficit - affectation of the
thalamic or subthalamic posterior cerebral artery
involvement); intention

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tremor;
Sensory changes: diffuse
sensoryloss (thalamic);
Visual changes: papillary
dysfunction (brain stem); loss
of conjugate gaze, nystagmus;
loss of depth perception;
cortical blindness;
homonymous hemianopia;
Speech changes:
perseveration; dyslexia;
Mental changes: memory
deficits;
Others: visual hallucinations

d. Motor changes:
contralateral hemiparesis with Contralateral hemiparesis - affectation of the internal
facial asymmetry; dysarthia; dysphagia carotid artery
Sensory changes: contralateral
sensory alterations;
Visual changes: hemianopia;
ipsilateral periods of blindness
(amaurosis fugax);
Speech changes: dysphagis;
Others: mild Horner’s
syndrome; carotid bruits

e. Motor changes: alternating Dysarthia, dysphagia, - affectation of the

motor weaknesses; ataxic gait, temporary memory loss, vertebral – basilar system
dysmetria (uncoordinated disorientation
actions);
Sensory changes: numbness

21
of the tongue;
Visual changes: double
vision; homonymous
hemianopis; nystagmus,
conjugate gaze paralysis;
Speech changes: dysarthia;
dysphagia;
Mental changes: memory
loss; disorientation;
Others: drop attacks; tinnitus,
hearing loss

f. Motor changes: Ipsilateral None - affectation of the

ataxia; facial paralysis; anteroinferior cerebellar
Sensory changes: ipsilateral (lateral pontine)
loss of sensation in face,
sensation changes on trunks
and limbs;
Visual changes: nystagmus;
Others: Horner’s syndrome;
tinnitus, hearing loss

g. Motor changes: ataxia; Dysarthia, dysphagia, - affectation of the

paralysis of larynx and soft coughing, hiccoughs. posteroinferior cerebellar
palate;
Sensory changes: ipsilateral
loss of sensation on face,
contralateral on body;
Visual changes: nystagmus;
Speech changes: dysarthia;
dysphagia; dysphonia;
Others: Horner’s syndrome;

22
 hiccoughs and coughing

IV. Nursing Interventions

1. Care Guide of Patient with Disease Condition

IDENTIFY STROKE EARLY. A critical factor in the early intervention
and treatment of stroke is the proper identification of stroke manifestations.
The initial assessment of the client who is thought to have had a stroke includes
level of consciousness, papillary response to light, visual fields, movement of
extremities, speech, sensation, reflexes, ataxia, and vital signs. This data are
recorded and scored on the Glasgow Coma Scale. Intracranial pressure is also
monitored, the baseline pressure values and waveforms should be noted.
MAINTAIN CEREBRAL OXYGENATION. Always maintain a patent
airway. The client should be turned on the affected side if he or she is
unconscious, to promote drainage of saliva in the airway. The collar of the shift
should be loosened to facilitate venous return. The head should be elevated, but
the neck should not be flexed. Oxygen should be supplied an if the client
demonstrates poor ventilatory effort, intubation and mechanical ventilation may
be required to prevent hypoxia and increased cerebral ischemia. ECG is
performed and blood pressure is evaluated, and hypertension may be reduced
with vasodilators. Caution is exercised when treating blood pressure, as
lowering the blood pressure too far may lower cerebral perfusion pressure and
increase cerebral ischemia. Laboratory test for hematology, chemistry and
coagulation are obtained to rule out stroke-mimicking conditions and to detect
bleeding disorders that would increase the risk of bleeding during thrombolytic
therapy.
PREVENT COMPLICATION. Such as bleeding, cerebral edema, stroke
recurrence, aspiration and other potential complication.
REHABILITATION AFTER STROKE. Early premobilization efforts are
aimed at preventing the complications of neurologic deficit and immobility.
Relearning can take place even though damage in the CNS is irreversible. It is

23
 extremely important that relearning take place as soon as possible after the
injury. An interdisciplinary rehabilitation team is necessary to assist and
support clients and their families during this time. The recommended plan of
care includes using interdisciplinary services to :
 document the client’s condition and course fully, including deficits, status
of other disease, complications, changes in status, and functional status
before stroke.
 Begin physical activity as soon as the client’s medical condition is stable;
use caution with early mobilization in clients with progressing neurologic
deficit, subarachnoid or intracerebral hemorrhage, severe orthostatic
hypotension, acute myocardial infarction, or acute deep vein thrombosis
 Assist n managing general health functions throughout all stages of
treatment such as managing dysphagia, nutrition, hydration, bladder and
bowel function, sleep and rest, co-morbid conditions, and acute illnesses.
 Prevent complications, including deep vein thrombosis and pulmonary
embolism, aspiration, skin breakdown, urinary tract infections, falls,
spasticity and contractures, shoulder injury and seizures.
 Prevent recurrent strokes through control of modifiable risk factors, oral
anticoagulation, antiplatelet therapy, or surgical intervention.
 Assess throughout acute and rehabilitation stages
 Use reliable standardized instruments for evaluation
 Evaluate for formal rehabilitation during acute stage
 Choose individual or interdisciplinary program based on the client’s and
family’s needs; success of the program requires full support and active
participation of the client and family; families must be involved at the
outset
 Choose the local rehabilitation program that best meets the client’s and
family’s needs
INTERDISCIPLINARY MANAGEMENT. Physical therapy,
occupational therapy, speech therapy.

24
 PHARMACOLOGIC MANAGEMENT. Steroids and osmotic diuretics
may be used to reduce ICP. Hypertension is commonly controlled with
antihypertensives and diuretics.
Anticoagulants are commonly used initially through intravenous routes
and then orally. Monitoring of clotting times is important for preventing
overanticoagulation, which increases the risk of bleeding.
Headache and neck stiffness can usually be treated with mild analgesics,
such as codeine and acetaminophen. Stronger narcotics are usually avoided; these
agents sedate the client and can make neurologic assessment inaccurate.
If the client develops seizures, phenytoin (Dilantin) or Phenobarbital may
be used. Barbiturates and other sedative agents are avoided. If the client
develops fever, antipyretics may be prescribed.
DIETARY MANAGEMENT. Because of the high risk for aspiration;
choking, excessive coughing, and vomiting, oral food and fluids are generally
withheld for 24 to 48 hours. If the client cannot eat or drink after 48 hours,
alternative feeding routes are used, such as tube feedings or hyperalimentation.
When the swallowing mechanism has returned, the client can be fed orally.
SURGICAL MANAGEMENT. Several criteria are used to determine
candidates for rapid evacuation of hematoma in clients with hemorrhagic stroke
or bleeding on the dominant side. Another guide commonly used in the
determination of the need for surgery is ICP. Pressures below 20 mm HG are
usually managed without surgery; pressures above 30 mm Hg often require
surgery. Clients who have large areas of blood removed have been shown to
recover a substantial portion of speech. Clients with relatively large areas of
superficial cerebral bleeding or shifts may also require surgery. Likewise, clients
who suddenly deteriorate to from lethargy to unconsciousness may benefit from
surgery. Surgery is usually not performed on clients with bleeding in the basal
ganglia or thalamus.
Surgery is also performed on some intracranial aneurysms and on the
carotid arteries (carotid endarterectomy) to reduce the risk of CVA.
NURSING MANAGEMENT. The initial assessment of the client with
CVA is very important. The assessment must be complete and accurate to

25
 provide a baseline for ongoing assessments. The client who is awake and alert
should be taught about the pathologic process and instructed to inform the nurse
about any changes in sensation, movement, or function regardless of how minor
they may seem. Increasing neurologic deficits may indicate either progression of
the infarct or ischemia of the area from cerebral edema or bleeding. Changes in
neurologic assessments must be reported promptly to the physician.
A complete history of the presenting problem as well as past medical and
social history will provide data about the problem source of the CVA.
Ongoing assessments of the neurologic status and vital signs are
imperative. These assessments may be required as often as hourly for unstable
clients. Assessment of hemiplegia includes the repeated assessment of motor
function, sensation, and reflex activity.

2. Actual Patient Care

2.1 Nursing Assessment

Name of Patient: Mr. George Ang Lee
Impression/Diagnosis: Cerebrovascular accident
Attending Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez

ACTIVITY/REST

26
 Difficulty with activity due to generalized weakness, loss of sensation, or
paralysis (hemiplegia) tires easily; difficulty resting. Altered muscle tone and level
of consciousness. Incoherent.
CIRCULATORY
Electrocardiogram (ECG) changes. Elevated BP 160/100. strong
peripheral pulses.
EGO INTEGRITY
Feelings of helplessness and hopelessness, emotional liability an
inappropriate response to anger, sadness and happiness, difficulty expressing self.
ELIMINATION
Constipated.
FOOD/ FLUID
Mastication problems. Loss of sensation in tongue, cheek.
NEUROSENSORY
Weakness on the right side of the body, drowsy, sensory loss on
contralateral side (right side of body) in extremities and some part of the left face.
Disturbances in senses of taste and smell. Aphasia: defect or loss of language
function may be global.
PAIN/ DISCOMFORT
Guarding behavior on the GUT (scrutom).
RESPIRATION
On tracheostomy.

SAFETY
Swallowing difficulty, inability to meet own nutritional needs. Diminish
response to heat and cold.
SOCIAL INTERACTION
Speech problems, inability to communicate.
TEACHING/LEARNING
Family history of hypertension, strokes. Requires medication regimen/
therapeutic treatments.

27
 2.2 Nursing Care Plan

Name of Patient: Mr. George Ang Lee Age: 5 4

Room/Ward: 221 Sex: Male
Chief Complaints: Right sided weakness and slurred speech
Needs/
Nursing Scientific Objectives Nursing
Problems/ Rationale
Diagnosis Basis of Care Intervention
Cues
NCP 1
Subjective: Cerebral After eight Independent
Altered
no infarction hours of 1. Determine factors 1. Influences choice of
subjective cerebral is nursing related to individual interventions.
cues deprivation interventions, situation/ cause for Deterioration in
tissue
of blood the patient decreased cerebral neurologic signs and
Objective: perfusion supply to a will be able perfusion, and symptoms or failure to
-on semi- localized to maintain potential for improve after initial
related to
Fowler’s area of the usual/ increased ICP. insult may require
position interruption brain. The improved surgical intervention
extent of level of and/or that the patient
of blood
-with NGT infarction consciousnes be transferred to critical
in place flow depends on s, cognition, care area for monitoring
factors and motor of ICP.
(occlusive
-with such as the sensory (Doenges,p293)
D5NSS 1L disorder / location function.
@ 20 and the size Specifically, 2. Monitor/ 2. Assesses trends in
hemorrhag
gtts/min of an he shall be document neurologic LOC and potential for
e) occluded able to: status frequently and increased ICP and is
-with O2 vessel and 1.demonstrat compare with useful in determining
@ 2LPM the e stable vital baseline. location, extent, and
adequacy signs and progression/ resolution
-with of absence of of CNS damage. May
FBC-UB collateral any signs of also reveal presence of
circulation increased TIA, which may warn
-lethargy to the area ICP. of impending
noted supplied by thrombotic CVA.
the (Doenges p293)
2.displays no
-slurring occluded
further
of speech vessel. 3. Monitor vital 3. Variations may
deterioration/
noted If cerebral signs, note: occur because of
recurrence of
circulation - Hypertension / cerebral pressure /
deficits.
-with the is hypotension, compare injury in vasomotor area
ff. V/S: interrupted BP readings in both of the brain.
BP – extensively arm. Hypoertension or
170/100 , cerebral postural hypotension
mm Hg anoxia may have been a
28
PR – 90 develops, precipitating factor.
bpm that is, lack Hypotension may occur
of oxygen because of shock
RR – 24 to the (circulatory collapse).
cpm brain. Increased ICP may
T – 37.5*C (Black:199 occur (tissue edema,
clot formation).
3,p707)
Subclavian artery
blockage may be
revealed by difference
in pressure readings
between arms.
- Heart rate and - Changes in rate
rhythm, auscultate for especially bradycardia
murmurs. can occur because of
the brain damage.
Dysrhythmias and
murmurs may reflect
cardiac disease, which
may have precipitated
CVA.
- Respirations, - Irregularities can
noting patterns and suggest location of
rhythm, e.g., periods cerebral insult/
of apnea after increasing ICP and need
hyperventilation. for further intervention,
including possible
respiratory support.
(Doenges,p293)

4. Document 4. Specific visual

changes in vision. alterations reflect are of
brain involved, indicate
safety concerns, and
influence choice of
interventions.
(Doenges,p293)

5. Assess higher 5. Changes in cognition

functions, including and speech content are
speech, if patient is indicator of location/
alert. degree of cerebral
involvement and may
indicate deterioration /
increased ICP.
(Doenges,p293)

6. Position with head 6. Reduces arterial

slightly elevated and pressure by promoting
in neural position. venous drainage and
may improve cerebral

29
 circulation/ perfusion.
(Doenges,p293)

7. Maintain bed rest; 7. Continual

provide quiet stimulation/ activity can
environment. increase ICP. Absolute
Provide rest periods rest and quiet may be
in between care needed to prevent
activities, limit rebleeding in the case of
duration of hemorrhage.
procedures.

8. Prevent straining 8. Valsalva maneuver

at stool, holding increases ICP and
breath. potentiates risk of
rebleeding.
(Doenges,p293)

9. Assess for nuchal 9. Indicative of

rigidity, twitching, meningeal irritation,
increased especially in
restlessness, hemorrhagic disorders.
irritability, onset of Seizures may reflect
seizure activity. increased ICP/ cerebral
injury, requiring further
evaluation and
intervention.
(Doenges,p293)
Collaborative
1. Administer 1. Reduces hypoxemia,
supplemental oxygen which can cause
as indicated. cerebral vasodilation
and increase pressure/
edema formation.
(Doenges,p293)

2. Administer 2. Preexisting / chronic

medications hypertension requires
(Antihypertensive) as cautious treatment,
indicated. because aggressive
management increases
the risk of extension of
tissue damage.
(Doenges,p293)

3. Monitor lab 3. Provides information

studies as indicated, about drug
e.g., PT/PTT time. effectiveness/
therapeutic level.
(Doenges,p293)
NCP2

30
Subjective: Impaired Hemiplegia After eight
-no results hours of Independent
physical
subjective from nursing 1. Assess functional 1. Identifies strengths/
cues mobility damage to interventions, ability/ extent of deficiencies and may
the motor the patient impairment initially provide information
related to
Objective: area of the will be able and on a regular regarding recovery.
-on semi- paralysis cortex or to maintain basis. Assist in choice of
Fowler’s pyramidal optimal interventions, because
position tract fibers. position of different techniques are
Hemorrhag function. used for flaccid or
-with NGT e or clot in Specifically, spastic paralysis.
in place the brain’s he shall be (Doenges,p296)
left side able to:
-with causes 1.demonstrat 2. Change position at 2. Reduces risk of
D5NSS 1L right-sided e absence of least every two hours tissue ischemia/ injury.
@ 20 hemiplegia, contractures, and possibly more Affected side has poorer
gtts/min and vice- footdrop. often when place on circulation and reduced
versa. This affected side. sensation and is more
-with O2 is because 2.maintain/ predisposed to skin
@ 2LPM the nerve increase breakdown / decubitus.
fibers cross strength and (Doenges,p296)
-with over in the function of
FBC-UB pyramidal affected or 3. Minimizes muscle
tract as compensator 3. Begin atrophy, promotes
-lethargy they pass y body part active/passive ROM circulation, helps
noted from the to all extremities on prevent contractures.
brain to the 3. maintain admission. Reduces risk of
-slurring spinal cord. in integrity. Encourage exercises hypercalciuria and
of speech (Black:199 such as squeezing osteoporosis if
noted rubber ball, extension underlying problem is
3,p709)
of fingers and legs/ hemorrhage.
-inability feet. (Doenges,p296)
to
purposely
move
noted

-impaired
coordinati 4. Promotes venous
on noted 4. Elevate arm and return and helps prevent
hand. edema formation.
-limited (Doenges,p296)
ROM
noted 5 Maintains functional
5. Place knee and hip position.
-decreased in extended position. (Doenges,p296)
muscle
strength
and Collaborative 1. Promotes even
control 1. Provide egg crate weight distribution
observed mattress, as indicated. decreasing pressure on
bony points and helping

31
 -with the prevent skin
ff. V/S: breakdown/ decubitus
BP – formation.
170/100 (Doenges,p296)
mm Hg
PR – 90 2. Individualized
bpm 2. Consult with program can be
RR – 24 physical therapist developed to meet
cpm regarding active, particular needs/ deal
T – 37.5*C resistive exercises, with deficits in balance,
and patient coordination and
ambulation strength.
(Doenges,p296)

NCP3 Self-care

Subjective: deficit Hemiplegia After eight

results hours of Independent 1. Aids in anticipating
-no (inability to
from nursing 1. Assess abilities for meeting individual
subjective
perform damage to interventions, and level of deficit needs.
cues
the motor the patient for performing (Doenges,p302)
ADLs) ADLs.
Objective: area of the will be able
related to cortex or to perform 2. These patients may
-on semi-
pyramidal self-care 2. Avoid doing become fearful and
Fowler’s paralysis.
tract fibers. activities things for the patient dependent, and although
position
Hemorrhag within level that the patient can assistance is helpful in
e or clot in of own do. preventing frustration, it
-with NGT
the brain’s ability. is important for the
in place
left side Specifically, patient to do as much as
causes he shall be possible for self to
-with
right-sided able to: maintain self esteem
D5NSS 1L
hemiplegia, 1.demonstrat and promote recovery.
@ 20
and vice- e techniques/ (Doenges,p302)
gtts/min
versa. This lifestyle
is because changes to 3. May indicate need
-with O2
the nerve meet self- for additional
@ 2LPM
fibers cross care needs. 3. Be aware of interventions and
over in the impulsive behaviors/ supervision to promote
-with
pyramidal actions suggestive of patient safety.
FBC-UB 2. identify
tract as impaired judgment. (Doenges,p302)
personal/
-lethargy they pass
community 4. Patients will need
noted from the
resources that empathy but need to
brain to the
can provide 4. Maintain a know caregivers will be
-slurring spinal cord.
assistance as supportive, firm consistent in their
of speech When
needed attitude. Allow assistance.
noted voluntary
muscle patient sufficient time (Doenges,p302)
control is to accomplish tasks.
-inability
to destroyed,
strong 5 Enhances sense of
purposely
flexor self-worth, promotes
move
muscles 5. Provide positive independence, and
noted
32
 overbalanc feedback for efforts/ encourages patient to
-impaired e the accomplishments. continue endeavors.
coordinati extensors. (Doenges,p302)
on noted This can
cause
-limited serious 1. May be necessary at
ROM deformities Collaborative first to aid in
noted . 1. Administer establishing regular
(Black:199 suppositories and bowel function.
-decreased stool softeners. (Doenges,p302)
3,p709)
muscle
strength 2. Provides expert
and assistance for
control 2. Consult with developing a therapy
observed physical / plan and identifying
occupational special equipment
-inability therapist. needs. (Doenges,p302)
to perform
ADLs
observed

-inability
to perform
oral care
noted

-with the
ff. V/S:
BP –
170/100
mm Hg
PR – 90
bpm
RR – 24
cpm
T – 37.5*C

2.3 Drug Therapy Record

Hospital No.:782349 Service: Medical
Physician: Dr. M. Lim, Dr. W. Briones, Impression:Cerebrovascular
Dr. G. Lim, Dr. E. Hernandez Accident

Drug/ Classification/ Indications/ Principles Treatment Evaluation

Route/ Mechanism of Contraindications/ of Care
Frequency/ Action Side Effects

33
 Route
Ranitidine Histamine2 Indicated for Have regular Take drug Continually
(Zantac) Antagonist duodenal ulcer medical with meals given to
150 mg (short-term follow-up to and at prevent
1 tab BID treatment), evaluate your bedtime. further
Competitively pathologic response. Therapy may complication
inhibits the hepersecretory continue for
action of conditions, Use 4–6 wk or
histamine at the maintenance therapy cautiously in longer.
histamine2 (H2) for duodenal or patient with
receptors of the gastric ulcer, erosive hepatic If you also are
parietal cells of esophagitis, dysfunction. on an antacid,
the stomach, heartburn and take it exactly
inhibiting basal gastroesophageal Drug may as prescribed,
gastric acid reflux dse. cause false- being careful
secretion and positive of the times of
gastric acid Contraindicated for results in administration
secretion that is patients urine protein .
stimulated by hypersensitive to test using
food, insulin, drugs. Multistix. Adjust dosage
histamine, in patients
cholinergic CNS: vertigo, May be added with impaired
agonists, malaise, headache to total renal function
gastrin, and EENT: blurred vision parenteral
pentagastrin. Hepatic: jaundice. nutrition Assess patient
(Karch,p1039) solutions. for abdominal
pain. Note
presence of
blood in
emesis, stool
or gastric
aspirate
Continually
Ciprofloxacin Inhibits Indicated for mild to Obtain given to
(ciprobay) bacterial DNA moderate urinary Use prevent
cautiously specimen for
500 mg 1 tab synthesis, tract infections, culture and further
q 12H mainly by severe or with patients complication
with CNS sensitivity test
blocking DNA complicated UTI’s, before giving
gyrase; mild to moderate disorders
the first dose.
bactericidal bone infections,
chronic bacterial Food doesn’t
delay Monitor
prostatitis,
absorption but patient’s
may delay intake and
Contraindicated in
peak serum output and
patients sensitive to
levels observe for
fluoroquinolones.
signs of
Tendon crystalluria.
CV: edema, chest
pain rupture has
CNS: headache, been reported Give oral
restlessness and in patients forms 2 hours
tremor receiving after a meal or
2 hours before
34
 GI: abdominal pain
or discomfort, quinolones. or after taking
constipation, antacids.
flatulence Lon g-term
Musculoskeletal: therapy may Discontinue in
arthralgia, joint result in pain,
inflammation, joint overgrowth of inflammation,
or back pain organism or tendon
resistant to rupture occurs.
Indicated to control ciprofloxacin.
for tonic-clonic and
complex partial
seizures, for patient
requiring a loading
dose, status
epilecticus.

Phenytoin Unknown. A Contraindicated for Continually

(dilantin) 100 hydantoin hypersensitivity and Use given to
mg I tab TID dereivative that in those with sinus cautiously in Divided doses prevent
probably bradychardia, SA patients with given with or further
stabilizes block, second or third hepatic after meals complication
neuronal degree AV block, dysfunction, may decrease
membranes and and Adam-Strokes hypotension adverse GI
limits seizure syndrome. reactions.
activity by Elderly
either CNS: ataxia, slurred patient tends Stop drug if
increasing speech and dizziness to metabolize rash appears.
efflux or CV: periarteritis phenytoin
decreasing nodosa slowly and Don’t
influx of EENT: nystagmus, may need withdraw drug
sodium ions diplopia, blurred reduced suddenly
across cell vision dosages. because
membranes in GI: nausea, vomiting seizures may
the motor cortex and constipation Use only clear worsen
during Hapatic: toxic solution for
generation of hepatitis injection.
nerve impulse.
2.4 Health Teaching Plan
Patient’s Name: Mr. George Ang Lee
Impression: Cerebrovascular Accident
Complaints: Right sided weakness and slurred speech
Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez

Objectives Content Methodology Evaluation

After the period of nursing The family
care, the patient and family were able

35
shall be able to acquire basic to
knowledge, positive attitude, assimilate
and beginning skills in the
rendering wholistic care to the information
patient post hospitalization. given.

Specifically, the patient and

family shall be able to:
1. be reminded of medication Medication should be Interaction
schedule. administered as ordered. (discussion)
15-20 mins
2. establish exercise Provide basic ROM exercises Demonstration
routine. to prevent contractures.
3. adhere to dietary Low salt, low fat diet should
management. be facilitated
4. provide psychological It is always important to
support to patient. maintain an open
communication with the
patient to relieve patient’s
anxiety.
5. visit the attending Usually when CVA patient is
physician post discharged, constant medical
hospitalization to consultation should be
provide continuity of maintained.
care.

V. Evaluation and Recommendation

After rendering holistic care, the patient and the nurse were able to
achieve the specific objectives.

36
 The degree of outcome attainment should be evaluated on an ongoing
basis. After CVA, some outcomes are achieved early (e.g., cerebral perfusion);
others may require rehabilitation (e.g., self-care deficit). It is important to
monitor progress toward outcomes, working with both the client and the family.
Continuing medications even after symptoms abate is recommended.
Continue encouraging the client to verbalizes and express his feelings, this
would always be effective and therapeutic to the client. Emotional support must
be provided to both the client and family members. If the client is to be
discharged home, the family needs clear understanding of the residual deficits.
The family and client need to have realistic expectations about the client’s
abilities; yet encourage independence when the client is able.

VI. Evaluation and Implication of This Case Study To:

Nursing Practice

This case study would make a contribution to the practice of medical

nursing as it would serve as a documentation that would then contribute to the
appropriate plan of care in patients with cerebrovascular accident (CVA). This
would also provide information about cerebrovascular accident (CVA) and
nursing interventions and therapeutic techniques used with patients who have this
disorder. It also provides information about the plan of care for patients who have
this condition for efficient nursing care.

Nursing Education
To nursing education, this case study would help by providing information
about the disease condition, cerebrovascular accident (CVA). The student nurses,
as well as the clinical instructors could gain additional information about this
disorder that ranks 2nd in the ten leading causes of death in the Philippines, so that
it could better equip them for efficient nursing care in the future. This study

37
 would explain the future nurses’ adequate background knowledge regarding
medical nursing before one is to be exposed to the clinical setting. This would
help expand knowledge regarding the disease and would correct misconceptions
toward this case. It would then promote awareness.

Nursing Research
Research is now an integral part of nursing. Through research, betterment
or improvement of nursing education to be practiced competitively in the clinical
setting will be achieved. In Nursing Research, this case study may broaden the
scope or extent of research done previously for cerebrovascular accident (CVA).
This may lead to another breakthrough study in the details of the condition. This
can also contribute in upgrading and updating the interventions made for this
condition.

VII. The Referral and Follow-up

Rehabilitation from stroke requires specialized help from neurologists,

physiotherapists, physical therapist, occupational therapist and speech therapists

—especially during the first six months, when most progress is made. Passive

stretching exercises and thermal applications are used to regain motor control of

limbs, which become rigidly flexed after a stroke has occurred. A patient may

recover enough to do pulley and bicycle exercises for the arms and legs and,

through speech therapy, may regain the language abilities often lost following a

stroke; the degree of recovery varies greatly from patient to patient.

38
VIII. Bibliography

Black, Joyce M., Hawks, Jane Hokanson, and Keene, Annabelle. Medical-Surgical
Nursing Clinical Management for Positive Outcomes. 6th Edition. Philadelphia,
PA: W.B. Saunders Company. 2001

Doenges, Marilynn, Moorhouse, Mary Frances and Geissler-Murr, Alice. Nursing Care
Plans Guidelines for Individualizing Patient Care. 6th Edition. Philadelphia: F.A
Davis Company. 2002

Deglin, Judith and Vallerand, April. Davis’s Drug Guide for Nurses. 5th Edition.
Philadelphia, Pennsylvania: 1997

Kozier, Barbara, ET. Al. Fundamentals of Nursing: Concept, Process and Practice. 5th
Edition. USA: Addison-Wesley Longman, Inc., 1998.

Potter, Patricia and Perry, Anne Griffin. Fundamentals of Nursing.5th Edition. St. Louis,
Missouri: Mosby, Inc., 2001

Smeltzer, Suzanne and Bare, Brenda. Textbook of Medical Surgical Nursing. 10th
Edition. Philadelphia, PA: Lippincott Williams and Williams, 2004.

Nettina, Sandra M. Manual of Nursing Practice. 7th Edition. Philadelphia: Lippincott,

1996

Bates, Barbara, MD. A Guide to Physical Examination. 2nd Edition. Philadelphia:

Lippincott, 1996

Positive Outcomes. Vol. 2, 6th Edition. Philadelphia: W. B. Saunders Company, 2001.

Doenges, Marilyn E. et al. Nurses Pocket Guide. 8th Edition F. A. Davis Company, 2002

Porth, Carol Matson. Pathophysiology, Concepts of Altered Health States. 6th Edition.

Lippincott Williams and Wilkins, 2002

MIMS, Philippines Index of Medical Specialties Established Since 1968, 100th Ed., 2004.

39
Oxford Reference. Dictionary of Nursing, Published by Oxford Melbourne, Oxford

University Press, Market House Books Ltd. 1990.

40